Translation and application of an obesity behavior change technique training in a Spanish nursing undergraduate setting

BACKGROUND

The TEnT PEGS framework is a behavior change communication toolkit which has been shown to be useful in increasing health professional trainees' skills and knowledge about obesity-related behavior change techniques. There is no version of the behavioral change intervention toolkit in Spanish. Therefore, the objectives of this study were 1) to translate the TEnT PEGS framework into Spanish and apply it to a Spanish nursing student population; 2) To analyze whether training with the Spanish toolkit (DEPREMIO) had a positive impact on students' skills in encouraging obesi-ty-related behavioral change.

METHODS

First year nursing students (n=95) attended two face-to-face (2 hours per session) obesity management training sessions. A specifically designed pre-post test was carried out. Data were collected using an ad-hoc questionnaire of fourteen items, ten of them evaluated the student's knowledge and attitude about behavior change techniques, and four evaluated the student's perception of their skills in developing different strategies.

RESULTS

Training significantly increased most students' knowledge and attitudes with a 0.05 level of significance and effect sizes were between 0.36 and 0.77. It also increased students' skills, although not to any significant extent.

CONCLUSION

The DEPREMIO toolkit helped nursing students to acquire more knowledge, attitudes and skills in obesity management. It therefore seems that this adaptation is an acceptable and feasible training tool for the Spanish nursing student population.

Understanding the experience of sleep disturbance in psoriasis: a qualitative exploration using the Common-Sense Model of Self-Regulation

BACKGROUND

Psoriasis is associated with significant morbidity, which negatively impacts upon quality of life. Sleep disturbance is reported to be common in patients with psoriasis and is associated with physical and psychological variables, although there is little published work in this area. Understanding sleep and the factors involved in its disturbance in psoriasis is a potentially important clinical area given the role of sleep in health and disease processes.

OBJECTIVES

To explore the experience of sleep and sleep disturbance in psoriasis using the Common-Sense Model of Self-Regulation (CS-SRM).

METHODS

Semistructured interviews were conducted with adults diagnosed with psoriasis. Interview questions were informed by the CS-SRM and previous research. Framework analysis was applied, including coding data into the CS-SRM dimensions and allowing additional inductive themes to emerge.

RESULTS

Seventeen people with psoriasis (nine women, eight men; aged 19-86 years) were interviewed about sleep and sleep disturbance. Seven themes emerged, with six accounted for by the CS-SRM: characteristics of sleep disturbance, change in sleep patterns, thoughts about and symptoms of disease disturbing sleep, impact of poor sleep on daily life, attempts to improve sleep, a daily battle for control and a seventh relating to metacognitive processes. A reciprocal relationship between sleep and psoriasis was evident across themes with interactions between key sleep-related thoughts, emotions and behaviours.

CONCLUSIONS

This study showed that sleep disturbance is a persistent concern for people with psoriasis; it has a 24-h impact, and interacts with the psychological and physical aspects of psoriasis. The distress and frustration felt when managing sleep disturbance perpetuated problematic sleep. Addressing this with currently available sleep treatments may therefore confer sleep and psoriasis-related benefits for people living with this condition.

'New to me': changing patient understanding of psoriasis and identifying mechanisms of change. The Pso Well® patient materials mixed-methods feasibility study

Background

Psoriasis is an inflammatory long‐term condition involving comorbidities, unhealthy lifestyle and significant life impact. Patients’ understanding of psoriasis is limited and support lacking. The Common‐Sense Model of Self‐Regulation of Health and Illness emphasizes the role of illness and treatment beliefs on coping and self‐management. New ‘Pso Well^®’ patient materials informed by the model, addressed psoriasis as a long‐term condition, medication management and lifestyle behaviours.

Objectives

To investigate whether Pso Well^® materials (i) broaden understanding of psoriasis without increasing anxiety; (ii) are acceptable; and (iii) comprise features that appear to effect change.

Methods

The Revised Illness Perceptions Questionnaire (IPQ‐R modified) and the Hospital Anxiety and Depression Scale (HADS) were administered in patients before and after intervention. Numerical rating scales assessed perceptions of change in understanding and anxiety resulting from engagement with the materials. Qualitative interviews explored acceptability and perceived ‘active ingredients’.

Results

Fifty‐five patients completed pre‐ and postintervention questionnaires (56% female; median age 59 years). Postintervention, a large effect size was indicated in two IPQ‐R domains – illness coherence [t(55) = −3·48, P = 0·001 (two‐tailed), η² = 0·19] and personal control [t(55) = −2·98, P = 0·004 (two‐tailed), η² = 0·14] – and a medium effect in one, treatment control [t(55) = −2·08, P = 0·042 (two‐tailed), η² = 0·08]. HADS scores did not change. For numerical rating scales, 80% of participants reported increased understanding of psoriasis and none reported increased anxiety. Interviews with 19 patients indicated the materials were acceptable and usable. Factors reported to broaden understanding and promote engagement with self‐management included linking of related disease aspects, personally relevant content and high‐quality design.

Conclusions

High‐quality, theory‐based psoriasis materials are acceptable to patients and can improve understanding and sense of control without increasing anxiety.

What's already known about this topic?

Psoriasis is associated with comorbidities, unhealthy lifestyle and significant life impact.

Patients’ understanding of psoriasis is limited, self‐management support is lacking and disengagement from healthcare services is common.

What does this study add?

The new, theory‐informed Pso Well^® patient materials address psoriasis as a long‐term condition; medications management and lifestyle behaviour.

The Pso Well^® patient materials can increase understanding of psoriasis, promote feelings of self‐worth and encourage a desire to engage in self‐management and behaviour change, without increasing anxiety or depression.

What are the clinical implications of this work?

The Pso Well^® patient materials could support clinical consultations by helping patients recognize the remitting–relapsing nature of psoriasis.

This will help to improve understanding of the disease, as well as providing a clearer rationale for treatment adherence and lifestyle behaviour change.

Linked Comment: Prinsen. Br J Dermatol 2017; 177:616–617

A cross-sectional survey of the nature and correlates of sleep disturbance in people with psoriasis

BACKGROUND

Research suggests that sleep disturbance is common in psoriasis. While several sleep investigations have been conducted in psoriasis populations, many have methodological shortcomings, and no study has examined multiple dimensions of sleep-wake functioning. Moreover, research has yet to be performed comprehensively examining the range of physical and psychological factors that may affect sleep in people with psoriasis.

OBJECTIVES

To characterize sleep disturbance using validated measures and to identify physical and psychological predictors of sleep quality in people with psoriasis.

METHODS

An online survey was conducted (186 respondents; mean age 39·2 years) comprising validated measures assessing sleep [Pittsburgh Sleep; Quality Index (PSQI), Berlin Questionnaire, Pre-Sleep Arousal Scale]; chronotype (Morningness-Eveningness Questionnaire); mood (Hospital Anxiety and Depression Scale); itch (5-D Itch Scale); and psoriasis severity (Simplified Psoriasis Index). Group comparisons and regression analyses were used to examine predictors of poor sleep.

RESULTS

The mean PSQI score was 9·2 ± 4·3, with 76·3% scoring above the threshold for poor sleep (≥ 6 on the PSQI) and 32·5% scoring 'positive' for probable obstructive sleep apnoea (OSA). Poor sleep and high likelihood of OSA were associated with more severe psoriasis (P < 0·05; η = 0·07; η² = 0·005). Cognitive arousal (β = 0·26, P = 0·001), itch (β = 0·26, P < 0·001) and depression (β = 0·24, P = 0·001) were the most robust predictors of poor sleep quality, which, together with somatic arousal (β = 0·17, P = 0·022), accounted for 43% of variance in PSQI scores.

CONCLUSIONS

Poor sleep is common in psoriasis and associated with psychological and physical factors. Rates of probable OSA are also high. Given the importance of restorative sleep for health, sleep complaints should receive greater clinical attention in the management of psoriasis.

Providing lifestyle behaviour change support for patients with psoriasis: an assessment of the existing training competencies across medical and nursing health professionals

BACKGROUND

Psoriasis is associated with unhealthy lifestyle behaviours which contribute to psoriasis onset and severity. Health professionals who manage patients with psoriasis are well placed to support lifestyle change but few feel confident to do so. Little is known about the extent to which health promotion and lifestyle behaviour change (LBC) skills are included within post-qualification training curricula.

OBJECTIVES

This study aimed to systematically examine the content of post-qualification U.K. training curricula for health professionals across General Practice and Dermatology for evidence of behaviour change skills relating to the promotion of healthy lifestyles.

METHODS

Core curricula documents from professional organizations were analysed for content to examine the extent to which curricula: (1) mentioned health promotion and LBC as part of the professional role; and/or (2) included health promotion and LBC as explicit training competencies or requirements for qualification.

RESULTS

Of the 11 core curricula documents analysed, we found 67 occurrences of terms related to LBC and health promotion. Most were in the General Practitioner curriculum (n = 42; 62·7%), followed by the Dermatology Specialist Nurse curriculum (n = 14; 20·9%) and Dermatologist curriculum (n = 11; 16·4%). No occurrences were found in the General Practitioner with a Special Interest in Dermatology curriculum. LBC knowledge, skills and attitudes were not clearly specified and only basic level LBC competencies were included.

CONCLUSIONS

Development of post-qualification curricula would ensure health professionals are equipped with the necessary knowledge, skills and attitudes to support LBC for patients with psoriasis. This is of particular relevance, given the evidence linking unhealthy lifestyles with psoriasis outcomes.

Early training in tackling patient obesity: a systematic review of nurse education

OBJECTIVES

This systematic review aims to identify studies that have assessed educational interventions in undergraduate nurse training regarding obesity, and to investigate the interventions' effectiveness.

BACKGROUND

Obesity is a prominent global issue and nurses have an increased role in weight management with patients. The literature has identified various theory-based behaviour change techniques that successfully assist weight management in patients. Thus, training nurses in obesity-related behaviour change techniques is appropriate in preparing them for their future professional role. However, effectiveness of these educational interventions has not yet been assessed.

METHODS

The Centre for Reviews and Dissemination guidelines informed this systematic review. Four databases were systematically searched and articles were assessed against inclusion criteria. Data extraction and quality appraisal forms were developed and completed to identify salient features within the articles.

RESULTS

Eight studies met inclusion criteria. Only two included both baseline and outcome measures, one of which was a randomised controlled trial. Additionally, only one study included an explicitly identified behaviour change technique. Interventions were delivered through a range of methods, however, quality appraisal indicated that all of the studies had poor methodologies and had high risks of bias.

CONCLUSIONS

Studies in this area of research are sparse and are not methodologically robust. Therefore, it is not possible to identify effective educational interventions for nursing students on weight management.

IMPLICATIONS

More robust research is needed to investigate how nurses can be trained to facilitate weight management. Greater transparency of intervention descriptions, particularly around what behaviour change techniques were taught, would allow for replication and appropriate evaluation. Until then, it is not known if current teaching adequately equips nurses to manage obese and overweight patients.

Impulsivity in restrained eaters: emotional and external eating are associated with attentional and motor impulsivity

The current study examined the relationships of motor, nonplanning, and attentional impulsivity to external and emotional eating among restrained eaters. Data were collected from a female college sample of restrained eaters (N=90). Aspects of impulsivity and disordered eating were assessed using the Barratt Impulsiveness Scale, Version 11, the Attentional Control Scale and the Dutch Eating Behavior Questionnaire. Significant correlations emerged between eating disturbances and different types of impulsivity. The results indicated that restrained eating is associated with motor and attentional forms of impulsivity. Emotional eating appears to be linked to both attentional and motor impulsivity whereas external eating seems to be linked only to motor impulsivity. Future studies should explore which aspects of disinhibited eating among restrained eaters are best predicted by a tendency to act impulsively.

Asthma control with extrafine-particle hydrofluoroalkane-beclometasone vs. large-particle chlorofluorocarbon-beclometasone: a real-world observational study

BACKGROUND

The extrafine-particle formulation of hydrofluoroalkane-beclometasone (EF HFA-BDP; Qvar®) demonstrates improved total and small airway deposition compared with large-particle chlorofluorocarbon (CFC)-BDP. In some short-term studies, EF HFA-BDP provides greater effects on lung function than CFC-BDP, and hence is recommended to be prescribed at a lower dose, but whether there are differences in asthma outcomes during long-term treatment is unknown.

OBJECTIVE

To compare the effectiveness of EF HFA-BDP vs. CFC-BDP over 1 year.

METHODS

This retrospective matched cohort study examined outcomes in a large primary care database for patients aged 5-60 years with asthma receiving their first inhaled corticosteroid (ICS) prescription (initiation population) or first ICS dose increase (step-up population) by a pressurized metered-dose inhaler (pMDI) as EF HFA-BDP or CFC-BDP. Patients were matched on baseline demographic and asthma severity measures in EF HFA-BDP:CFC-BDP ratios of 1:3 and 1:2 for initiation and step-up populations, respectively. Step-up patients were matched also on ICS dose during a baseline year. Co-primary endpoints were asthma control (composite measure comprising no recorded hospital attendance for asthma, oral corticosteroids, or antibiotics for lower respiratory infection) and exacerbation rate during the outcome year.

RESULTS

For the initiation population (EF HFA-BDP n=2882; CFC-BDP n=8646), adjusted odds of achieving asthma control with EF HFA-BDP vs. CFC-BDP was 1.15 (95% CI 1.02-1.28). For the step-up population (n=258 and 516), adjusted odds of asthma control with EF HFA-BDP was 1.72 (95% CI 1.14-2.56). EF HFA-BDP was prescribed at a median dose half that of CFC-BDP.

CONCLUSION AND CLINICAL RELEVANCE

During 1 year after initiating or stepping up ICS therapy by pMDI, patients who received EF HFA-BDP were more likely to achieve asthma control than those receiving CFC-BDP. These findings suggest that ICS formulation, particle size, and deposition characteristics play important roles in real-life effectiveness of asthma therapy. This study shows that an EF-particle formulation of beclometasone can be used at half the dose of the large-particle formulation with at least as good clinical outcomes.

Cholesterol lowering effects of nuts compared with a Canola oil enriched cereal of similar fat composition

BACKGROUND AND AIM

Small quantities of nuts protect against subsequent cardiovascular risk. There is speculation that the cholesterol lowering effect associated with nut consumption arises primarily from the fatty acid composition of nuts but may be caused by some other component. To evaluate this possibility we compared the effect of various nuts, against a Canola oil based cereal with a comparable fatty acid profile, on lipids, lipoproteins and fatty acids to determine whether the fatty acid profile of nuts explains their cholesterol lowering effects.

METHODS AND RESULTS

Twenty-eight men and women with mean (s.d.) levels of total and low density lipoprotein cholesterol of 6.0 (1.1) mmol/L, and 4.1 (1.0) mmol/L, respectively and a mean body mass index (BMI) of 26.9 (3.2) kg/m2 took part in a randomised cross over trial. For two periods of six weeks, separated by a four-week washout, participants were asked to consume a low saturated fat diet, which included either 30 g/d nuts (nut diet) or one serving of a cereal containing Canola oil (cereal diet). There were no significant differences in the lipids, lipoproteins, plasma fatty acids or other variables between the two diets at the end of the study. Total cholesterol (TC) and low density lipoprotein cholesterol (LDL-C) were lower on both experimental diets than at baseline, 0.51 mmol/L and 0.40 mmol/L (p<0.001, p<0.01), respectively on the nut diet and 0.42 mmol/L and 0.37 mmol/L (p<0.001, p<0.01), respectively on the cereal diet.

CONCLUSION

A 30 g serving of nuts, or a serving of a Canola oil enriched cereal with a similar fatty acid composition reduced total and LDL cholesterol to a similar extent when consumed as part of a lipid lowering diet. Results suggest that foods with a similar fatty acid composition to nuts can produce comparable decreases in lipoprotein mediated cardiovascular risk.

Replacing cows' with sheep's dairy fat lowers plasma cholesterol concentration in participants consuming dairy fat-rich diets

OBJECTIVE

To determine the effects on plasma cholesterol concentration of replacing cows' dairy fat with sheep's dairy fat.

DESIGN

Randomised crossover dietary intervention.

SETTING

General community, Dunedin, New Zealand.

SUBJECTS

Volunteer sample of 41 healthy adults with initial plasma cholesterol concentration between 4.8 and 7.8 mmol/l.

INTERVENTIONS

Participants were asked to follow a self-selected low-fat background diet throughout the study to which, during each of the 2, 3-week dairy diets, they were asked to add sheep's or cows' dairy products.

MAIN OUTCOME MEASURES

Energy and nutrient intakes, plasma triacylglycerol fatty acids, and plasma cholesterol.

RESULTS

Energy and nutrient intakes on the sheep-dairy and cow-dairy diets were very similar, with total, saturated, monounsaturated and polyunsaturated fat contributing 34, 18-19, 9, and 3% of total energy intake, respectively. Participants consumed approximately 50 g/day of dairy fat on each diet. Replacing cows' with sheep's dairy fat led to a 0.33 (0.11-0.56, 95% CI) mmol/l decrease (6%) in plasma total cholesterol concentration, from 5.53 (0.90, s.d.) to 5.20 (0.90) mmol/l. Plasma low-density lipoprotein (LDL) cholesterol was 0.18 (0.02-0.33) mmol/l lower on the sheep-dairy diet as was the concentration of plasma high-density lipoprotein (HDL) cholesterol, 0.11 (0.02-0.20) mmol/l. The LDL to HDL cholesterol ratio at the end of the sheep-dairy diet, 2.91 (1.10), was not significantly different (P>0.05) from the cow-dairy diet, 2.73 (0.83).

CONCLUSIONS

Within the context of a diet high in dairy fat (50 g/day), replacing cows' milk fat with sheep's milk fat leads to a small reduction in plasma cholesterol concentration, but no change in the ratio of LDL to HDL cholesterol.

Plant sterol-enriched spread enhances the cholesterol-lowering potential of a fat-reduced diet

OBJECTIVE

To determine the effect of a plant sterol-enriched spread on plasma cholesterol concentrations when replacing butter or a standard polyunsaturated spread in a diet containing 30% of energy fat.

DESIGN

Parallel butter phase followed by double-blind, randomized, cross-over polyunsaturated spread phases.

SETTING

General community.

SUBJECTS

Volunteer sample of 50 free-living men and women with mean age (s.d.) 46.7 y (10.5), moderately elevated plasma total cholesterol 5.95 mmol/l (0.78), and body mass index 26.0 (3.9) kg/m(2).

INTERVENTION

Participants ate a moderately low-fat diet (30% of energy) for the 11-week intervention. During the first 3 weeks the diet included 20 g per day of butter. Participants were then randomized to replace the butter with 25 g of polyunsaturated spread with or without 2 g of plant sterols for 4 weeks, crossing over in the last 4 weeks to the alternate spread.

MAIN OUTCOME MEASURES

Plasma cholesterol and fatty acids.

RESULTS

Replacing butter with a standard polyunsaturated fat spread reduced mean plasma total cholesterol concentrations by 4.6% (from 6.09 (0.82) to 5.81 (0.77) mmol/l, P<0.01) and low-density lipoprotein cholesterol by 5.5% (from 3.98 (0.76) to 3.76 (0.74) mmol/l, P<0.05). Replacing butter with a polyunsaturated spread containing plant sterols reduced plasma total cholesterol by 8.9% (from 6.09 (0.82) to 5.55 (0.76) mmol/l, P<0.01) and low density lipoprotein cholesterol by 12.3% (from 3.98 (0.76) to 3.49 (0.72) mmol/l, P<0.01). Plasma high density lipoprotein cholesterol concentration was the same on the three diets.

CONCLUSION

In people with moderately raised plasma cholesterol concentrations consuming reduced-fat diets the reduction in plasma total and low-density lipoprotein cholesterol concentrations achieved by replacing butter with a polyunsaturated spread is enhanced by addition of plant sterols.

Assessment of three levels of folic acid on serum folate and plasma homocysteine: a randomised placebo-controlled double-blind dietary intervention trial

OBJECTIVE

To determine the minimum effective dose of folic acid required to appreciably increase serum folate and to produce a significant reduction in plasma total homocysteine (tHcy).

DESIGN

Double-blind, randomised placebo-controlled intervention trial.

SETTING

Community-based project in a New Zealand city.

SUBJECTS

Seventy free living men and women with tHcy> or =10 micromol/l. Mean age (range) was 58 (29-90) y.

INTERVENTIONS

Daily consumption over 4 weeks of 20 g breakfast cereal either unfortified (placebo) or fortified with 100, 200 or 300 microg folic acid. Dietary intake was determined by weighed diet records and consumption of commercially fortified products was avoided.

MAIN OUTCOME MEASURES

Plasma tHcy and serum folate concentrations.

RESULTS

Average serum folate concentrations (95% CI) increased significantly in the treatment groups relative to the control group by 28(9-51)%, 60(37-87)% and 79(51-114)% for supplementation with 100, 200 and 300 microg folic acid, respectively. A reduction in tHcy was observed, being 16(8-22)%, 12(4-18)% and 17(9-24)% in the three treatment groups, respectively.

CONCLUSIONS

A regular intake of as little as 100 microg folic acid per day was sufficient to lower tHcy in persons at the upper end of the normal range for tHcy. Low-level fortification may also be appropriate for lowering the risk of neural tube defects given that, when aggregated from all sources, the total intake of folic acid may be sufficiently high to adequately improve the folate status of young women.

Comparison of a vitamin E-rich diet and supplemental vitamin E on measures of vitamin E status and lipoprotein profile

OBJECTIVE

To determine whether dietary modification rather than use of supplements can raise indices of vitamin E status to potentially cardioprotective levels.

DESIGN

Eight week randomised controlled trial with parallel treatments to compare increased use of vitamin E-rich foods, supplementation with 200 IU of vitamin E, and a placebo.

SETTING

Dunedin, New Zealand.

SUBJECTS

Ninety subjects were recruited, of whom 82 non-smoking, free-living individuals aged 22-72 y with plasma cholesterol <7.5 mmol/l completed the trial.

MAIN OUTCOME MEASURES

Dietary intakes, plasma alpha tocopherol, plasma alpha tocopherol/cholesterol ratio and lipoprotein cholesterol.

RESULTS

Consumption of an additional 12 mg of vitamin E (alpha tocopherol equivalents) from dietary sources was primarily achieved through the replacement of saturated fat-rich foods with unsaturated fats rich in vitamin E, nuts and vegetables. This resulted in a 3.4 micromol/l increase in plasma alpha tocopherol at week 6 (95% CI 1.6-5.3), and 0.9 micromol/mmol in plasma alpha tocopherol/cholesterol at weeks 4 and 6 (95% CI 0.3-1.4 and 0.4-1.4, respectively) when compared with the placebo group. In the supplement group, plasma alpha tocopherol and plasma alpha tocopherol/cholesterol were significantly increased within 2 weeks and remained so throughout the 8 week intervention.

CONCLUSION

Increasing dietary vitamin E intake can increase plasma alpha tocopherol levels, although factors other than dietary intake are also important determinants. The extent of dietary modification required to achieve potentially cardioprotective levels of plasma alpha tocopherol is difficult in practice.

SPONSORSHIP

The study was supported through the Otago Medical Research Foundation Laurenson Award.

Variants in the cholesterol ester transfer protein and lipoprotein lipase genes are predictors of plasma cholesterol response to dietary change

There are no definitive explanations as to why individuals with hypercholesterolemia, a major cardiovascular risk factor, respond differently to dietary change. Fifty five free-living individuals completed a double crossover trial with two dietary regimens, a high saturated fat diet (providing 21% energy from saturated fat and 3% energy from polyunsaturated fat) and a high polyunsaturated fat diet (providing 11% energy as saturated fat and 10% energy as polyunsaturated fat), each phase continuing for 4 weeks. Extensive genotyping and several measures of dietary compliance have provided further insights regarding the determinants of extent of cholesterol response to changes in the nature of dietary fat. Individuals with the CETP B1B1 genotype and the LPL X447+ allele showed an average 0. 44 (95% CI: 0.22, 0.66) and 0.45 (95% CI: 0.18, 0.72) mmol/l greater change in total cholesterol, respectively, than those with one or more CETP B2 allele or homozygous for the LPL S447 allele when comparing diets high and low in saturated fat. Indices of dietary compliance including changes in reported saturated and polyunsaturated fat intake and change in triglyceride linoleate were not significantly different between the CETP genotypes. Change in reported saturated (r=0.36, P=0.04) and polyunsaturated (r=0.22, P=0. 05) fat intake and change in triglyceride linoleate (reflecting polyunsaturated fat intake) (r=0.21, P=0.07), also predicted total cholesterol response to dietary fat changes. In multivariate analyses, variation in the cholesterol ester transfer protein and lipoprotein lipase genes predicted response independent of measures of dietary compliance, suggesting that these two genes are important determinants of variation in cholesterol response to dietary change in free-living individuals.

Dietary strategies for lowering homocysteine concentrations

BACKGROUND

Elevated plasma total homocysteine (tHcy) concentrations are associated with increased risk of vascular disease, and there is a strong inverse association between dietary and blood folate and blood tHcy concentrations. Increased folate consumption may lower the risk of tHcy-mediated cardiovascular disease.

OBJECTIVES

The objective was to determine the most appropriate means of increasing dietary folate to reduce plasma tHcy.

DESIGN

Sixty-five free-living subjects aged 36-71 y with tHcy concentrations >/=9 micromol/L participated in a randomized, controlled trial to compare 3 approaches for increasing dietary folate to approximately 600 microg/d: folic acid supplementation, consumption of folic acid-fortified breakfast cereals, and increased consumption of folate-rich foods.

RESULTS

An intake of 437 microg folic acid/d from supplements resulted in a 27-nmol/L increase in serum folate and a 21% reduction in tHcy, relative to the change in a control group. In subjects who consumed folic acid-fortified breakfast cereal, folate intake increased by an average of 298 microg, serum folate increased by 21 nmol/L, and tHcy concentrations decreased by 24%. Increased intakes of folate-rich foods resulted in a 418-microg increase in dietary folate, a 7-nmol/L increase in serum folate, and a 9% reduction in tHcy concentrations. The decrease in tHcy was negatively correlated (r = -0.66) with the increase in serum folate.

CONCLUSIONS

Daily consumption of folic acid-fortified breakfast cereals and the use of folic acid supplements appear to be the most effective means of reducing tHcy concentrations. The reduction in tHcy was significantly negatively correlated with the increase in serum folate, which may be a useful marker for measuring dietary change.

Genetic factors associated with response of LDL subfractions to change in the nature of dietary fat

A preponderance of dense low density lipoprotein (LDL) particles is associated with an increased risk of coronary heart disease. It has been shown that dense LDL levels can be modified by diet. We investigated the contribution of polymorphisms in the genes for apolipoprotein (apo) B, apo AIV, lipoprotein lipase (LPL) and cholesterol ester transfer protein (CETP) to variation in the changes in plasma concentrations of dense LDL between a high saturated and a high polyunsaturated fatty acid diet. A total of 46 freeliving individuals (19 men and 27 women) completed a crossover trial with two dietary interventions of 4 weeks each, a high saturated fat diet (providing 21% energy from saturated fat and 3% energy from polyunsaturated fat) and a high polyunsaturated fat diet (providing 11% energy as saturated fat and 10% energy as polyunsaturated fat). Overall, the change in dense LDL between the saturated and polyunsaturated fat period was 0.17+/-0.33 mmol/L and this change was similar in men and women. Of the polymorphisms studied only variation in the apo AIV gene causing the substitution of histidine for glutamine at position 360 (Q360H) was associated with significant differences in the change in dense LDL concentration. Apo AIV Q/H individuals (n=6) showed a three-fold greater change in dense LDL cholesterol unadjusted for Lp(a) levels than Q/Q individuals (0.46+/-0.27 versus 0.12+/-0.31 mmol/L, p=0.02). The greater decrease in dense LDL cholesterol with an increase in polyunsaturated fat seen in those with the apo AIV H360 variant, who represent roughly 10% of the general population, suggests that they may benefit most from a PUFA rich lipid lowering diet.

Homocysteine levels in healthy New Zealanders and those with vascular disease

AIMS

Levels of plasma homocysteine (tHcy) have been shown to vary between populations. The aim of the present study was to determine tHcy levels in a New Zealand population to facilitate interpretation of international reference ranges.

METHODS

Fasting tHcy levels were determined in 431 volunteer men and women, aged between 17 and 83 years, from the greater Otago region. Subjects with self-reported incidences of vascular disease (n=138) were compared with healthy control subjects (n=293).

RESULTS

Mean (SD) fasting tHcy level of the entire population was 8.3(3.5) micromol/L and men had significantly higher levels than women (9.0(3.4) and 7.8(3.5) micromol/L, respectively, p<0.05). Levels increased significantly with increasing age (0.5 micromol/L for every ten years). There was a small but non-significant difference in tHcy levels between subjects with and without vascular disease (difference after excluding two outliers and adjusting for age and gender; 0.63, 95% CI, -0.03,1.29). tHcy levels were not significantly correlated with lipid or lipoprotein levels.

CONCLUSION

Levels of tHcy in a group of volunteers from the greater Otago region were similar to those reported in other populations at high risk of cardiovascular disease. Reference ranges derived from these populations would appear to be applicable for New Zealanders. tHcy measurements should be made when assessing individuals at high risk of vascular disease and intervention strategies considered.

Conservation and divergence of axon guidance mechanisms

Analysis of axon guidance mechanisms in vertebrates, Caenorhabditis elegans, and Drosophila melanogaster has led to the identification of several signaling pathways, many of which are strikingly conserved in function. Recent studies indicate that several axon guidance mechanisms are highly conserved in all animals, whereas others, though still conserved in a general sense, show strong evolutionary divergence at a detailed mechanistic level.

Variation in plasma cholesterol response to dietary change

BACKGROUND AND AIMS

Previous studies have suggested that some individuals show an appreciably larger change in total cholesterol in response to dietary change (hyper-responders) than others (minimal responders), and also that some people are more likely to respond consistently. We have examined the role of individual dietary compliance in determining total cholesterol response to changes in the nature of dietary fat.

METHODS AND RESULTS

Participants completed a randomised double dietary crossover trial with a diet high in saturated fat and a diet high in polyunsaturated fat. Each period continued for four weeks without washouts. Plasma lipoproteins were measured at the end of each period. Dietary compliance was assessed by change in the reported polyunsaturated:saturated fat ratio calculated from three-day diet records, and change in polyunsaturated fat intake, determined by change in plasma triglyceride linoleate. A wide range of individual responses was observed with no evidence of two distinct populations of hyper- and minimal responders. Variation in response to the three crossovers appeared to be due mainly to variation in compliance.

CONCLUSIONS

The results of this study do not support earlier suggestions of two separate populations of hyper and minimal responders to change in the nature of dietary fat, rather there is a graded range of response. In a free-living population, the extent to which individuals comply with dietary advice varies considerably and this contributes to the magnitude of cholesterol response as well as consistency on repeated dietary challenges.

Regulated nuclear entry of the C. elegans Pax-6 transcription factor

It is shown that the C. elegans Pax-6 locus encodes two protein isoforms. One contains a Paired DNA binding domain as well as a homeodomain; the other consists only of the carboxy-terminal portion of the locus encoding the homeodomain. These two isoforms are expressed in a variety of postembryonic cell lineages. In one set of lineages, nuclear localization of a homeodomain-only form (MAB-18 isoform) appears to be under temporal and spatial control. Nuclear localization of MAB-18 is correlated with the genetic requirement for mab-18 and with activation of a reporter gene driven by a mab-18 promoter. Reporter gene expression is dependent on mab-18 gene activity. It is hypothesized that a positive feedback loop is activated by regulated nuclear entry.

Effects of dietary coconut oil, butter and safflower oil on plasma lipids, lipoproteins and lathosterol levels

OBJECTIVE

The aim of this present study was to determine plasma levels of lathosterol, lipids, lipoproteins and apolipoproteins during diets rich in butter, coconut fat and safflower oil.

DESIGN

The study consisted of sequential six week periods of diets rich in butter, coconut fat then safflower oil and measurements were made at baseline and at week 4 in each diet period.

SUBJECTS

Forty-one healthy Pacific island polynesians living in New Zealand participated in the trial.

INTERVENTIONS

Subjects were supplied with some foods rich in the test fats and were given detailed dietary advice which was reinforced regularly.

RESULTS

Plasma lathosterol concentration (P < 0.001), the ratio plasma lathosterol/cholesterol (P=0.04), low density lipoprotein (LDL) cholesterol (P<0.001) and apoB (P<0.001) levels were significantly different among the diets and were significantly lower during coconut and safflower oil diets compared with butter diets. Plasma total cholesterol, HDL cholesterol and apoA-levels were also significantly (P< or =0.001) different among the diets and were not significantly different between buffer and coconut diets.

CONCLUSIONS

These data suggest that cholesterol synthesis is lower during diets rich in coconut fat and safflower oil compared with diets rich in butter and might be associated with lower production rates of apoB-containing lipoproteins.

Native American adolescents' views of fetal alcohol syndrome prevention in schools

Alcohol is the most commonly abused substance among adolescents in the United States. Adolescent females are recognized as one group at risk for giving birth to babies with fetal alcohol syndrome (FAS). Sixth through eighth grade Native Americans were surveyed about their attitudes toward and knowledge of FAS risk factors and prevention strategies. Data revealed that 52% of students drank alcohol prior to the survey. Though sexually active, students lacked knowledge about the relationship between alcohol and FAS. The study revealed 1) limited prevention programs in middle schools and 2) the most influential factor in determining attitudes and decisions about alcohol use was the immediate family. Students felt FAS prevention is an important topic in school health education, noting the important role peers play in teaching and role modeling. Various strategies incorporating music and communication technology such as videotape and computer-assisted interactive tools into prevention materials are discussed.

A diet rich in walnuts favourably influences plasma fatty acid profile in moderately hyperlipidaemic subjects

OBJECTIVE

To compare two low fat diets one rich in walnuts on parameters of lipid metabolism in a group of hyperlipidaemic subjects.

DESIGN

A randomised cross over study.

SETTING

Department of Human Nutrition, University of Otago, Dunedin, New Zealand

SUBJECTS

Twenty one men with mean (s.d.) levels of total and LDL cholesterol of 6.58 (0.60) and 4.63 (0.58) respectively.

INTERVENTIONS

For two periods of four weeks subjects were asked to consume two low fat diets (fat 30% total energy), one containing, on average, 78 g/d walnuts. Walnuts obtained through Lincoln University and the Walnut Growers Group (South Canterbury).

RESULTS

Participants reported a higher total fat intake on the walnut diet (38% compared with 30% on the low fat diet P < 0.01) The most consistent change in fatty acid profile of triacylglycerol, phospholipid and cholesterol ester on the walnut diet was a significant (P < 0.01) increase in linoleic acid. Triacylglycerol linolenate also increased significantly (P < 0.01). Total and LDL cholesterol were lower on both experimental diets than at baseline, 0.25 mmol/l and 0.36 mmol/l respectively on the walnut diet and 0.13 mmol/l and 0.20 mmol/l respectively on the low fat diet. High density lipoprotein cholesterol was higher on both the walnut and low fat diets when compared to baseline (0.15 mmol/l and 0.12 mmol/l, respectively). When comparing the walnut and low fat diets only apo B was significantly lower (P < 0.05) on the walnut diet.

CONCLUSIONS

Despite an unintended increase in the total fat intake on the walnut diet, fatty acid profile of the major lipid fractions showed changes which might be expected to reduce risk of cardiovascular disease. The reduction of apolipoprotein B suggests a reduction in lipoprotein mediated risk, the relatively low myristic acid content of both diets perhaps explaining the absence of more extensive differences in lipoprotein levels on the two diets.

General practitioners' views on a mental health service

AIM

This study set out to investigate general practitioners (GPs) views on a Mental Health Service. It seeks their views on how well the Trust is providing those services and suggestions for change and development of the service.

BACKGROUND

GPs are not generally regarded as consumers of services. This survey looks at GPs as both purchasers and consumers of the services provided by a NHS Trust.

METHOD

A short survey questionnaire which addressed the major services offered was sent to all GPs in the Grampian region. The data were analysed using non-parametric statistical techniques.

FINDINGS

Maybe rather surprisingly, GPs felt that the service provision overall was of a good standard. Two areas which GPs suggested required more provision were highlighted.

CONCLUSION

The survey was used to inform Trust Management of GPs views and as a basis for meetings with GPs about the service. As a result new services have been developed.

Effect on lipoprotein profile of replacing butter with margarine in a low fat diet: randomised crossover study with hypercholesterolaemic subjects

OBJECTIVE

To examine the effect on lipid and lipoprotein concentrations when butter or an unsaturated margarine is used for cooking or spreading in a reduced fat diet.

DESIGN

Randomised crossover study with two intervention periods of six weeks' duration separated by a five week washout.

SETTING

Community setting in New Zealand.

SUBJECTS

49 volunteers with polygenic hypercholesterolaemia and baseline total cholesterol concentration in the range 5.5-7.9 mmol/l.

MAIN OUTCOME MEASURES

Concentrations of total and low density lipoprotein, Lp(a) lipoprotein, high density lipoprotein, apolipoprotein B 100, and apolipoprotein A I.

RESULTS

Concentrations of low density lipoprotein cholesterol and apolipoprotein B were about 10% lower with margarine than with butter. Lp(a) lipoprotein and high density lipoprotein cholesterol concentrations were similar with the two diets.

CONCLUSION

Despite concerns about adverse effects on lipoproteins of trans fatty acids in margarines, the use of unsaturated margarine rather than butter by hypercholesterolaemic people is associated with a lipoprotein profile that would be expected to reduce cardiovascular risk.

Effects of coconut oil, butter, and safflower oil on lipids and lipoproteins in persons with moderately elevated cholesterol levels

The physiological effects of coconut oil, butter, and safflower oil on lipids and lipoproteins have been compared in moderately hypercholesterolemic individuals. Twenty eight participants (13 men, 15 women) followed three 6-week experimental diets of similar macronutrient distribution with the different test fats providing 50% total dietary fat. Total cholesterol and low density lipoprotein cholesterol were significantly higher (P < 0.001) on the diet containing butter [6.8 +/- 0.9, 4.5 +/- 0.8 mmol/l] (mean +/- SD), respectively than on the coconut oil diet (6.4 +/- 0.8; 4.2 +/- 0.7 mmol/l) when levels were significantly higher (P < 0.01) than on the safflower diet (6.1 +/- 0.8; 3.9 +/- 0.7 mmol/l). Findings with regard to the other measures of lipids and lipoproteins were less consistent. Apolipoprotein A-I was significantly higher on coconut oil (157 +/- 17 mg/dl) and on butter (141 +/- 23 mg/dl) than on safflower oil (132 +/- 22 mg/dl). Apolipoprotein B was also higher on butter (86 +/- 20 mg/dl) and coconut oil (91 +/- 32 mg/dl) than on safflower oil (77 +/- 19 mg/dl). However gender differences were apparent. In the group as a whole, high density lipoprotein did not differ significantly on the three diets whereas levels in women on the butter and coconut oil diet were significantly higher than on the safflower oil diet. Triacylglycerol was higher on the butter diet than on the safflower and coconut oil diets but the difference only reached statistical significance in women. Cholesteryl ester transfer activity was significantly higher on butter than safflower oil in the group as a whole and in women.(ABSTRACT TRUNCATED AT 250 WORDS)

Trans fatty acids: a cause for concern?

The recommendation to reduce total and saturated fat is incorporated into the dietary guidelines for the general population in many western countries. In addition, dietary modification to reduce substantially the intake of saturated fats is a cornerstone of treatment in the hyperlipidaemias. Concern has recently been expressed regarding possible deleterious effects of trans isomers of unsaturated fatty acids on the lipoprotein profiles of both normo and hypercholesterolaemic persons. This review seeks to examine recent research in this area with a view to considering possible changes in the present dietary recommendations.

The effect of dietary fat content on plasma noncholesterol sterol concentrations in patients with familial hypercholesterolemia treated with simvastatin

The effects of a low-fat, low-cholesterol diet (LFD) or a higher-fat, higher-cholesterol diet (HFD) on plasma concentrations of lipids, lipoproteins, lathosterol (an index of cholesterol synthesis rate), and plant sterols were determined in 19 patients with familial hypercholesterolemia (FH) treated with simvastatin. The study followed a randomized crossover design including two 8-week diet periods. The LFD significantly decreased plasma lathosterol (-22%), cholesterol (-6%), low-density lipoprotein (LDL) cholesterol (-6%), and high-density lipoprotein (HDL) cholesterol (-7%) levels compared with the HFD. Decreases in plasma lathosterol and LDL cholesterol concentrations in patients during the LFD were significantly correlated (r = .522, n = 19, P < .05). These results suggest that a LFD may enhance the decrease in cholesterol synthesis induced by simvastatin treatment, and in this way might contribute to the decrease in plasma cholesterol levels when the fat content of the diet is reduced in simvastatin-treated FH patients.

A homeotic gene cluster patterns the anteroposterior body axis of C. elegans

In insects and vertebrates, clusters of Antennapedia class homeobox (HOM-C) genes specify anteroposterior body pattern. The nematode C. elegans also contains a small cluster of HOM-C genes, one of which has been shown to specify positional identity. Here we show that two additional C. elegans HOM-C genes also specify positional identity and that together these three HOM-C genes function along the anteroposterior axis in the same order as their homologs in other organisms. Thus, HOM-C-based pattern formation has been conserved in nematodes despite the many differences in morphology and embryology that distinguish them from other phyla. Each C. elegans HOM-C gene is responsible for a distinct body region; however, where their domains overlap, two HOM-C genes can act together to specify the fates of individual cells.

Dietary management of patients with familial hypercholesterolaemia treated with simvastatin

The effect of diet on plasma lipids and lipoproteins was examined in 19 patients with familial hypercholesterolaemia treated with the HMGCoA reductase inhibitor, simvastatin. The study was a randomized double-blind cross-over trial of two diets: a low fat diet and a higher fat diet, and was performed to determine whether ongoing attention to diet is necessary for patients receiving this drug for the treatment of familial hypercholesterolaemia. Plasma cholesterol concentration was 6.5 per cent lower on the low fat diet than on the high fat diet. The difference was within the range predicted by the Jacobs modification of the Keys formula from the reported intake on the two diets. The fall on the low fat diet was principally accounted for by a reduction in low density lipoprotein cholesterol, although high density lipoprotein cholesterol and apolipoprotein A1 also fell. Patients taking HMGCoA reductase inhibitors for the treatment of familial hypercholesterolaemia respond to changes in dietary fat intake. They are thus likely to achieve further reduction in their coronary heart disease risk, and should remain on a low saturated fat low cholesterol diet even when taking these powerful lipid lowering drugs.

Should mono- or poly-unsaturated fats replace saturated fat in the diet?

The effects of diets differing in saturated, monounsaturated and polyunsaturated fatty acid composition (SAFA, MUFA and PUFA, respectively) on plasma lipoproteins and factor VIIc were investigated in 28 middle-aged men and women with mild to moderate hyperlipidaemia. The subjects were stabilized on a diet with a total fat content fairly typical of New Zealand, containing approximately 40% energy as fat, before entering a randomized cross-over trial of diets high in PUFA (20% energy; SAFA and MUFA 10% each) or a high MUFA diet (20% energy; SAFA and PUFA 10% each). After 6-week periods on each diet the subjects returned to a high SAFA diet. Body weight and blood pressure remained unchanged during the study. Total and LDL cholesterol, HDL cholesterol and the HDL2 subfraction were significantly lower on both the MUFA and the PUFA diet than on SAFA. However, there were no statistically significant differences in lipoprotein concentrations on the MUFA and PUFA diet. Factor VIIc concentrations were similar on the three diets. The proportion of PUFA in a MUFA diet appears to be a major determinant of the relative lipoprotein response to such a diet. In order to avoid a reduction in HDL-C when replacing SAFA with MUFA it may be necessary to ensure that PUFA does not provide more than about 8% total energy. Thus careful planning is needed to identify the most appropriate foods to replace those rich in SAFA in diets designed to reduce the lipoprotein-mediated risk of coronary heart disease.

Control of cell fate in the tail region of C. elegans by the gene egl-5

The tail region of C. elegans contains a number of blast cell and neuron types that either are found only in the tail, or are different from more anterior homologues. In egl-5 mutants, the fates of many of these tail cells are abnormal or transformed to those of anterior homologues. The affected cells are related only by position and not by ancestry. egl-5 is also required for normal development of the somatic gonad and sex muscles in males. The function of egl-5 in all these tissues is cell autonomous. By genetic mapping, egl-5 lies very close to mab-5, a gene with an analogous role in the immediately anterior body region. egl-5 and mab-5 may constitute a ‘mini-cluster’ of regional determination genes, similar to those described in other animal phyla.