Theoretical Mediators of Diabetes Risk and Quality of Life Following a Diabetes Prevention Program for Latino Youth With Obesity

PURPOSE

This study tested self-efficacy and social support for activity and dietary changes as mediators of changes in type 2 diabetes related outcomes following a lifestyle intervention among Latino youth.

SETTING AND INTERVENTION

Latino adolescents (14-16 years) with obesity (BMI% = 98.1 ± 1.4) were randomized to a 3-month intervention (n = 67) that fostered self-efficacy and social support through weekly, family-centered sessions or a comparison condition (n = 69).

MEASURES

Primary outcomes included insulin sensitivity and weight specific quality of life. Mediators included self-efficacy, friend, and family social support for health behaviors. Data was collected at baseline, 3-months, 6-months, and 12-months.

ANALYSIS

Sequential path analysis was used to examine mediators as mechanisms by which the intervention influenced primary outcomes.

RESULTS

The intervention had a direct effect on family (β = 0.33, P < .01) and friend social support (β = 0.22, P < .001) immediately following the intervention (3-months). Increased family social support mediated the intervention's effect on self-efficacy at 6-months (β = 0.09, P < .01). However, social support and self-efficacy did not mediate long-term changes in primary outcomes (P > .05) at 12-months.

CONCLUSIONS

Family social support may improve self-efficacy for health behaviors in high-risk Latino youth, highlighting the important role of family diabetes prevention. Fostering family social support is a critical intervention target and more research is needed to understand family-level factors that have the potential to lead to long-term metabolic and psychosocial outcome in vulnerable youth.

Familism, Self-Esteem, and Weight-Specific Quality of Life Among Latinx Adolescents With Obesity

OBJECTIVE

Obesity is a critical public health condition affecting Latinx adolescents and contributes to health disparities across the lifespan. Childhood and adolescent obesity is associated with reduced quality of life (QoL) and decreased self-esteem. The purpose of this study is to examine the role of cultural (e.g., familism) and psychosocial (e.g., self-esteem) factors as predictors of weight-specific QoL among Latinx adolescents with obesity.

METHODS

Baseline data from 160 Latinx adolescents (ages 14-16 years) with obesity (BMI > 95th percentile for age and sex) who were recruited for a diabetes prevention intervention were used. Structural equation modeling tested the relationships between four latent constructs (familism, positive self-esteem, self-deprecation, and weight-specific QoL).

RESULTS

The model tested paths from familism to positive self-esteem, self-deprecation, and weight-specific QoL, and paths from positive self-esteem and self-deprecation to weight-specific QoL. Higher familism was positively associated with positive self-esteem but not self-deprecation. In turn, positive self-esteem was positively associated with higher weight-specific QoL, whereas self-deprecation was negatively associated. Furthermore, there was an indirect effect of familism on QoL via positive self-esteem.

CONCLUSIONS

These data shed light into specific cultural and psychosocial constructs that influence QoL among Latinx adolescents with obesity. This study suggests that familism and positive self-esteem can operate as protective factors associated with higher weight-specific QoL in Latinx adolescents with obesity; whereas self-deprecation may operate as a risk factor for lower weight-specific QoL.

Yields and costs of recruitment methods with participant phenotypic characteristics for a diabetes prevention research study in an underrepresented pediatric population

Background/aims

Prediabetes and diabetes disproportionately impact Latino youth, yet few diabetes prevention programs have prioritized inclusion of this underrepresented population. This report describes the recruitment process, yields, associated costs, and phenotypic characteristics of Latino youth with obesity and prediabetes enrolled in a randomized controlled diabetes prevention study in the USA.

Methods

Recruitment efforts included referrals from clinics, community outlets, local media, and word of mouth with the goal of enrolling 120 Latino adolescents aged 12–16 with obesity (BMI > 95th percentile) and prediabetes. Prediabetes eligibility was determined by any of the following: HbA1c between 5.7 and 6.5%, fasting glucose between 100 and 125 mg/dL, or a 2-h glucose between 120 and 199 mg/dL following a 75-g oral glucose tolerance test (OGTT), but not meeting any of the diagnostic criteria for diabetes. Eligible participants were randomized 2:1 to either a 6-month community-based lifestyle intervention that included group nutrition and health education classes (1 day/week) and group exercise classes (2 days/week) or usual care control arm. Recruitment yields were determined by review of referral source in the study screening database. Recruitment costs were determined by an after-the-fact financial review of actual and in-kind costs. Participant phenotypic characteristics (i.e., demographics, anthropometrics, and biochemical data) were compared by recruitment strategy using a one-way ANOVA.

Results

Recruitment efforts covered 160 mile² (414 km²) across 26 ZIP codes (postcode) in the Phoenix Metropolitan Area and yielded 655 referrals from clinics (n = 344), community (n = 143), media (n = 137), and word-of-mouth (n = 31). From this pool, 26% (n = 167) did not meet general, pre-screening eligibility criteria; 29% (n = 187) declined participation; and 10% (n = 64) were unable to be contacted. A total of 237 youth were invited to the clinical research unit to determine final eligibility. Following the OGTT, 52% (n = 122) met prediabetes criteria and 117 were subsequently randomized. Clinical recruitment yielded the highest number of referrals (53%; n = 344) while word-of-mouth yielded the highest proportion (35%; n = 11) of randomized participants per referred youth. There were no significant differences in anthropometric or biochemical measures among youth by recruitment strategy. Based upon final enrollment numbers, community recruitment was the costliest approach ($486/randomized participant) followed by clinical ($248/randomized participant) and media ($236/randomized participant).

Conclusions

The ability to meet enrollment goals for a clinical trial of an underrepresented population required multiple recruitment strategies. Although strategies vary in yields and costs, it appears they produce similar phenotypical risk profiles of eligible youth.

Trial registration

ClinicalTrials.gov NCT02615353. Registered on 26 November 2015

Sex as a moderator of body composition following a randomized controlled lifestyle intervention among Latino youth with obesity

BACKGROUND

Body composition differences between males and females emerge during adolescence and continue throughout adulthood; however, whether sex moderates body composition changes in adolescents with obesity after an intervention is unknown.

OBJECTIVE

To examine sex as a moderator of changes in adiposity following lifestyle intervention.

METHODS

A total of 136 Latino youth with obesity (BMI% 98.2 ± 1.3) aged 14 to 16 years old were randomized to either a 12-week lifestyle intervention (27 males/40 females) or control (35 males/34 females) group. The intervention included nutrition education (1 h/wk) and moderate-to-vigorous physical activity (3 h/wk). Anthropometric data (body mass index [BMI], BMI%, waist circumference, total body fat, and fat-free mass) were obtained pre- and post-intervention. Sex differences were examined by general linear models with significance determined at P < .05 for the F-statistic.

RESULTS

Sex did not moderate changes in BMI (F1,115 = 0.01, P = .9), BMI% (F1,115 = 0.14, P = .7), or waist circumference (F1,117 = 1.1, P = .3). Sex significantly moderated changes in body fat percent (F1,117 = 5.3, P = .02), fat mass (F1,116 = 4.5, P = .04), and fat-free mass (F1,116 = 4.3, P = .04). Intervention males compared with females had greater relative reductions in fat percent (-4.1 ± 0.8% vs -1.2 ± 0.7%, P = .02) and fat mass (-5.0 ± 1.1 kg vs -1.5 ± 0.9 kg, P = .02) and gained more fat free mass (3.6 ± 0.9 kg vs 0.5 ± 0.8 kg, P = .02) when compared with same sex controls.

CONCLUSION

Males and females exhibited a differential response to lifestyle intervention for percent fat, fat mass, and fat-free mass indicating that sex-specific improvements in body composition favours males over females.

Effects of a Community-Based Diabetes Prevention Program for Latino Youth with Obesity: A Randomized Controlled Trial

OBJECTIVE

This study examined the short- and long-term effects of a community-based lifestyle intervention among Latino youth with obesity.

METHODS

Latino adolescents (14-16 years old) were randomized to a 3-month lifestyle intervention (n = 67) or comparison control (n = 69) and followed for 12 months. The intervention included weekly nutrition and health classes delivered to groups of families and exercise sessions (3 days/week) delivered to groups of adolescents. Comparison youth received laboratory results and general health information. Primary outcomes included insulin sensitivity and weight-specific quality of life (QoL) with secondary outcomes of BMI percentile (BMI%), waist circumference, and percent body fat.

RESULTS

At 3 months, youth in the intervention group exhibited significant increases in insulin sensitivity (P < 0.05) and weight-specific QoL (P < 0.001), as well as reductions in BMI%, waist circumference, and percent body fat compared with controls. Increases in weight-specific QoL and reductions in BMI% and percent body fat remained significant at 12 months (P < 0.001), while changes in insulin sensitivity did not. In a subsample of youth with prediabetes at baseline, insulin sensitivity (P = 0.01), weight-specific QoL (P < 0.001), and BMI% (P < 0.001) significantly improved at 3 months.

CONCLUSIONS

Lifestyle intervention can improve cardiometabolic and psychosocial health in a vulnerable population of Latino adolescents at high risk for developing type 2 diabetes.

Decreased GlycA after lifestyle intervention among obese, prediabetic adolescent Latinos

BACKGROUND

Obese youth with prediabetes are at increased risk for premature morbidity and mortality through multiple mechanisms, including increased systemic inflammation. GlycA is a novel measure of systemic inflammation that predicts type II diabetes, cardiovascular events, and all-cause mortality in adults.

OBJECTIVE

The purpose of the present study was to examine changes in GlycA after lifestyle intervention among obese, prediabetic Latino youth.

METHODS

Obese, prediabetic Latino youth (n = 27; 15.5 ± 1.1 years, 13 males/14 females) completed a 12-week lifestyle intervention that included weekly nutrition education and 3 d/wk of moderate to vigorous physical activity. Prediabetes was characterized by an expanded definition of impaired glucose tolerance, using 2-hour glucose ≥120 mg/dL after an oral glucose tolerance test. GlycA was assessed at baseline and 12 weeks using nuclear magnetic resonance spectroscopy.

RESULTS

After the lifestyle intervention, GlycA was significantly reduced (445.3 ± 51.3 μmol/L to 419.0 ± 50.0 μmol/L, P = .01) (mean ± standard deviation). Additional improvements were observed in multiple cardiovascular risk factors, including body mass index (BMI; 34.8 ± 5.0 kg/m² to 34.0 ± 5.1 kg/m², P < .001), total cholesterol (154.1 ± 30.3 mg/dL to 143.3 ± 29.1 mg/dL, P = .003), and 2-hour glucose (141.0 ± 13.2 mg/dL to 115.9 ± 31.4 mg/dL, P < .001). Decreases in GlycA were associated with decreases in 2-hour glucose (r = 0.49, P = .008) and BMI (r = 0.41, P = .03).

CONCLUSION

These data are consistent with the hypothesis that lifestyle intervention might improve GlycA levels in obese, prediabetic adolescent Latinos, but randomized trial evidence is needed. Healthy lifestyle modifications among high-risk youth may decrease future risk of cardiometabolic disease through reducing systemic inflammation, in addition to improving traditional cardiovascular risk factors.

Preventing diabetes in obese Latino youth with prediabetes: a study protocol for a randomized controlled trial

Background

Obese Latino adolescents are disproportionately impacted by insulin resistance and type 2 diabetes. Prediabetes is an intermediate stage in the pathogenesis of type 2 diabetes and represents a critical opportunity for intervention. However, to date, no diabetes prevention studies have been conducted in obese Latino youth with prediabetes, a highly vulnerable and underserved group. Therefore, we propose a randomized-controlled trial to test the short-term (6-month) and long-term (12-month) efficacy of a culturally-grounded, lifestyle intervention, as compared to usual care, for improving glucose tolerance and reducing diabetes risk in 120 obese Latino adolescents with prediabetes.

Methods

Participants will be randomized to a lifestyle intervention or usual care group. Participants in the intervention group will attend weekly nutrition and wellness sessions and physical activity sessions twice a week for six months, followed by three months of booster sessions. The overall approach of the intervention is framed within a multilevel Ecodevelopmental model that leverages community, family, peer, and individual factors during the critical transition period of adolescence. The intervention is also guided by Social Cognitive Theory and employs key behavioral modification strategies to enhance self-efficacy and foster social support for making and sustaining healthy behavior changes. We will test intervention effects on quality of life, explore the potential mediating effects of changes in body composition, total, regional, and organ fat on improving glucose tolerance and increasing insulin sensitivity, and estimate the initial incremental cost effectiveness of the intervention as compared with usual care for improving glucose tolerance.

Discussion

The proposed trial builds upon extant collaborations of a transdisciplinary team of investigators working in concert with local community agencies to address critical gaps in how diabetes prevention interventions for obese Latino youth are developed, implemented and evaluated. This innovative approach is an essential step in the development of scalable, cost-effective, solution oriented programs to prevent type 2 diabetes in this and other populations of high-risk youth.

Trial Registration

NCT02615353, registered on June 8, 2016.

Preventing diabetes in obese Latino youth with prediabetes: a study protocol for a randomized controlled trial

BACKGROUND

Obese Latino adolescents are disproportionately impacted by insulin resistance and type 2 diabetes. Prediabetes is an intermediate stage in the pathogenesis of type 2 diabetes and represents a critical opportunity for intervention. However, to date, no diabetes prevention studies have been conducted in obese Latino youth with prediabetes, a highly vulnerable and underserved group. Therefore, we propose a randomized-controlled trial to test the short-term (6-month) and long-term (12-month) efficacy of a culturally-grounded, lifestyle intervention, as compared to usual care, for improving glucose tolerance and reducing diabetes risk in 120 obese Latino adolescents with prediabetes.

METHODS

Participants will be randomized to a lifestyle intervention or usual care group. Participants in the intervention group will attend weekly nutrition and wellness sessions and physical activity sessions twice a week for six months, followed by three months of booster sessions. The overall approach of the intervention is framed within a multilevel Ecodevelopmental model that leverages community, family, peer, and individual factors during the critical transition period of adolescence. The intervention is also guided by Social Cognitive Theory and employs key behavioral modification strategies to enhance self-efficacy and foster social support for making and sustaining healthy behavior changes. We will test intervention effects on quality of life, explore the potential mediating effects of changes in body composition, total, regional, and organ fat on improving glucose tolerance and increasing insulin sensitivity, and estimate the initial incremental cost effectiveness of the intervention as compared with usual care for improving glucose tolerance.

DISCUSSION

The proposed trial builds upon extant collaborations of a transdisciplinary team of investigators working in concert with local community agencies to address critical gaps in how diabetes prevention interventions for obese Latino youth are developed, implemented and evaluated. This innovative approach is an essential step in the development of scalable, cost-effective, solution oriented programs to prevent type 2 diabetes in this and other populations of high-risk youth.

TRIAL REGISTRATION

NCT02615353, registered on June 8, 2016.

Culturally-grounded diabetes prevention program for obese Latino youth: Rationale, design, and methods

BACKGROUND

Type 2 diabetes (T2D) disproportionately impacts Latino youth yet few diabetes prevention programs address this important source of health disparities.

OBJECTIVES

To address this knowledge gap, we describe the rationale, design, and methodology underpinning a culturally-grounded T2D prevention program for obese Latino youth. The study aims to: 1) to test the efficacy of the intervention for reducing T2D risk, 2) explore potential mediators and moderators of changes in health behaviors and health outcomes and, 3) examine the incremental cost-effectiveness for reducing T2D risk. Latino adolescents (N=160, age 14-16) will be randomized to either a 3-month intensive lifestyle intervention or a control condition. The intervention consists of weekly health education delivered by bilingual/bicultural promotores and 3 moderate-to-vigorous physical activity (PA) sessions/week. Control youth receive health information and results from their laboratory testing. Insulin sensitivity, glucose tolerance, and weight-specific quality of life are assessed at baseline, 3-months, 6-months, and 12-months. We will explore whether enhanced self-efficacy and/or social support mediate improvements in nutrition/PA behaviors and T2D outcomes. We will also explore whether effects are moderated by sex and/or acculturation. Cost-effectiveness from the health system perspective will be estimated by the incremental cost-effectiveness ratio using changes in insulin sensitivity at 12-months.

CONCLUSIONS

The results of this study will provide much needed information on how T2D prevention interventions for obese Latino youth are developed, implemented and evaluated. This innovative approach is an essential step in the development of scalable, cost-effective, solution oriented programs to prevent T2D in this and other high-risk populations.

Retention of Minority Participants in Clinical Research Studies

Recruitment of minority participants for clinical research studies has been the topic of several analytical works. Yet retention of participants, most notably minority and underserved populations, is less reported and understood, even though these populations have elevated health risks. This article describes two related, intervention-based formative research projects in which researchers used treatment theory to address issues of recruitment and retention of minority women participants in an exercise program to reduce obesity. Treatment theory incorporates a model of health promotion that allows investigators to identify and control sources of extraneous variables. The authors’ research demonstrates that treatment theory can improve retention of minority women participants by considering critical inputs, mediating processes, and substantive participant characteristics in intervention design.

Diabetes Prevention for Latino Youth: Unraveling the Intervention "Black Box"

The translation of research findings into sustainable health promotion and disease prevention programs in community settings remains a challenge. This report describes the process of substantiating a community-developed diabetes prevention program for Latino youth through research. Included are design considerations, measurement strategies, and the context through which the project is culturally grounded for relevance and fit within a local community. The process included (1) refining the program to include salient, stakeholder-identified behavioral components; (2) refining the collaborative effort to embrace the capacity for facilitating relevant behavior change on targeted health-related outcomes to enhance intervention effectiveness; and (3) including the accurate assessment of intervention efficacy via precise assessment of diabetes-related health outcomes. We explain the process of collaborating with community partners to enhance the cultural relevance and sustainability of intervention effects on both individuals and communities. We discuss the rationale for empirical support for academic-community collaborations that function in both a "top-down" and a "bottom-up" manner to advance the science and practice of sustainable and efficacious community health promotion.

Effects of a diabetes prevention programme on weight-specific quality of life in Latino youth

OBJECTIVE

To examine the effects of a diabetes prevention programme on weight-specific Quality of Life (QOL) in obese Latino youth.

METHODS

Fifteen obese Latino adolescents (body mass index % = 96.4 ± 1.2; age = 15.0 ± 1.0) completed a 12-week culturally grounded, community-based intervention designed to improve physical and psychosocial health. Weight-specific QOL was assessed by the Youth Quality of Life-Weight module and compared with age, sex and ethnicity-matched lean youth.

RESULTS

At baseline, intervention youth exhibited significantly lower weight-specific QOL compared with lean youth (70.8 ± 5.4 vs. 91.2 ± 2.2, P = 0.002). However, following the intervention, total weight-specific QOL increased by 21.8% among obese youth (70.8 ± 5.4 to 86.2 ± 4.3, P < 0.001) and was no longer different from lean controls. Significant increases in weight-specific QOL were noted across all subdomains including self (45.7%), social (11.9%) and environmental (36.2%) despite the fact that weight did not change (90.6 ± 6.8 to 89.9 ± 7.2, P = 0.44). The improvements in QOL were maintained for up to 12 months after the intervention.

CONCLUSION

Weight-specific QOL among obese Latino youth can be improved through lifestyle interventions to a level similar to lean peers. Further, weight loss may not be necessary to observe improvements in QOL.

Use of the Stanford Brief Activity Survey for physical activity assessment in postpartum Latinas: a validation study of a linguistically translated Spanish version

This study assessed the concurrent validity of the English and a linguistic Spanish translation of the Stanford Brief Activity Survey (SBAS) with pedometer-measured physical activity (PA) among postpartum Latinas. Latinas (n 97) completed the SBAS in either English (n 47) or Spanish (n 50) and wore pedometers 7 days at three different assessment periods. The English version demonstrated significant trends (p .01) for differentiating aerobic walking steps (AWS) and aerobic walking time (AWT) across SBAS intensity categories at two of the three assessment periods. The Spanish version showed marginally significant trends for differentiating AWS (p .048) and AWT (p .052) across SBAS intensity categories at only one assessment period. The English version of the SBAS is effective in assessing PA status among Latinas; however, the Spanish version indicates a need for research to further explore cultural and linguistic adaptations of the SBAS.

Addressing the demand for cultural relevance in intervention design

This article describes the development of a model to promote physical activity in Hispanic women that embeds a life course perspective and culture to enhance comparative effectiveness in intervention design. When working with diverse cultural groups, researchers often struggle with intervention designs and strategies to enhance cultural relevance; they do so based on the assumption that this will enhance efficacy and make interventions more sustainable. In this article, the authors discuss how the model was used in two interventions designed for younger and older Hispanic women. These interventions were guided by a life course perspective, incorporated social support, and included salient elements from the women's culture. Three considerations underpinned the development of the model: (a) infusing concepts and values of a culture and tradition into the interventions, (b) viewing participants through a life course perspective to assess how an intervention can build on developmental transitions, and (c) determining how social support operates within two groups that, although sharing history and thus some cultural practices, diverge widely in those practices. The authors propose that by incorporating elements of this model into their interventions, researchers can increase program efficacy and effectiveness.

Effects of a culturally grounded community-based diabetes prevention program for obese Latino adolescents

PURPOSE

The purpose of this study was to test the feasibility and preliminary effects of a culturally grounded, community-based diabetes prevention program among obese Latino adolescents.

METHODS

Fifteen obese Latino adolescents (body mass index [BMI] percentile = 96.3 ± 1.1, age = 15.0 ± 0.9 years) completed a 12-week intervention that included weekly lifestyle education classes delivered by bilingual/bicultural promotoras and three, 60-minute physical activity sessions per week. Participants were assessed for anthropometrics (height, weight, BMI, and waist circumference), cardiorespiratory fitness, physical activity/inactivity, nutrition behaviors, and insulin sensitivity and glucose tolerance by a 2-hour oral glucose tolerance test.

RESULTS

The intervention resulted in significant decreases in BMI z score, BMI percentile, and waist circumference; increases in cardiorespiratory fitness; and decreases in physical inactivity and dietary fat consumption. In addition to these changes, the intervention led to significant improvements in insulin sensitivity and reductions in 2-hour glucose levels.

CONCLUSIONS

These results support the feasibility and efficacy of a community-based diabetes prevention program for high-risk Latino youth. Translational approaches that are both culturally grounded and biologically meaningful represent a novel and innovative strategy for closing the obesity-related health disparities gap.

Camina por Salud: walking in Mexican-American women

Forty-six percent of older Mexican-American women report that they do not engage in leisure time physical activity (PA); 38.1% of them are obese. This study (1) evaluated a PA intervention for coronary heart disease risk reduction and (2) determined which variables affect adherence to PA. For 36 weeks, Group I members walked for 3 days a week and Group II members walked for 5 days a week. We measured the participants' total body fat, regional fat, blood lipids, and adherence to PA The walking interventions favorably affected body fat, with significant differences in body mass index reduction, F(2, 16) = 12.86, p = .001. No statistical difference was noted in the anthropometric and blood lipid results between the baseline and 36-week measures.

Factors related to overweight and risk for overweight status among low-income Hispanic children

The purpose of this research was to investigate the agent, host, and environmental factors that are related to overweight status in a sample of low-income Hispanic toddlers who were enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children in a large southwestern city in the United States. Among children at risk for overweight status, the mothers' body mass index (BMI) and the number of servings of fat in the children's daily diet were positively associated with their weight/height percentiles whereas servings of protein in the daily diet and the children's reporting of hunger were negatively associated with their weight/height percentiles. Among overweight children, age was positively associated with their weight/height percentiles. No other variable in the ecological model was associated with normal weight or overweight children and their weight/height percentiles. Different approaches to dietary counseling and health promotion may be indicated based on a child's weight/height percentile or BMI.

Comparison of two walking frequencies in African American postmenopausal women

Despite the known benefits of exercise, 60% of African American women are sedentary. The efficacy and dose-response effects of low intensity exercise performed in community settings by overweight sedentary women have not been established. The purpose of this study was to examine the effects of two intensities of walking on level of exercise maintenance and on cardiovascular risk factors in sedentary, obese African American women. A two group, randomized experimental approach was used to test 45-70 year old postmenopausal obese African American women, measuring age, self reported ethnic affiliation, height, weight, socioeconomic status, diet history, menopausal status, exercise volume, dietary restrictions, medication use, and medical conditions precluding participation. Group one walked three days/week; group 2 walked 5 days/week; both groups walked at 65% of their target heart rate reserve.

Evaluation of Selected Behavior Change Theoretical Models Used in Weight Management Interventions

Purpose: This paper evaluates selected behavior change theoretical models used in weight reduction interventions and presents recommendations for the use of theory in weight reduction research. Overweight and obesity are complex problems, requiring long-term behavioral change. Behavioral treatments for overweight and obesity are as varied as the elements of behavior, and the long-term efficacy of most approaches is poor. Because of the complexity of both the problem and its treatment, investigations must target the development of cause-effect explanations. CONCLUSIONS: Many of the behavioral change intervention studies reviewed lacked external validity, primarily due to the failure to consider salient moderators. The theoretical models reviewed in this paper were primarily tested on white, employed populations. These and other data suggest that extant theoretical approaches may not be salient in certain groups. IMPLICATIONS: Practice implications include: 1) assess indicators for readiness to engage in weight reduction efforts; 2) base interventions on multiple theories; and 3) develop context-based interventions. Future research should include a focus on innovative methods in theory development, development of theory acknowledging mediator/moderator interactions, development of theory in context, and development of theory reflecting cultural meaning and diversity.

Cultural consideration in promoting wellness

This article discusses culture as it relates to the cardiovascular health promotion needs of various cultural groups. The promotion of cardiovascular wellness among cultural groups can be facilitated by the use of culturally appropriate models, interventions, and strategies. Those major characteristics that extend across cultures that may guide cardiovascular nurses in providing culturally appropriate care include communication, family and kinship models, and access to and acceptance of medical involvement in health care matters.

Ethnic and age trends for body composition in women residing in the U.S. Southwest: I. Regional fat

The study described regional fat distribution and anthropometric variables in an ethnically diverse sample of women (N = 143) who were between 20 and 30 (premenopausal) or 40 and 50 (perimenopausal) yr of age and of normal weight for height. Measurements included 11 skinfolds (abdomen, biceps, calf, forearm, midaxillary, pectoral, subscapular, suprailiac, suprapatellar, thigh, and triceps), waist and hip circumferences, height and mass. Regional fat distribution for African American, Mexican American, and Caucasian women was described as gluteal femoral. African American women had the smallest waist-to-hip ratio, with larger absolute measures for both the waist and gluteal C than the Caucasians or Mexican Americans. Native American women had an abdominal fat distribution pattern which was explained by more fat on the abdomen rather than less fat on the gluteal-femoral area. Native Americans had a different fat distribution from the other ethnic groups. Caucasians are not a good comparison group for African Americans or Native Americans because there are large differences as indicated by effect sizes in regional fat distribution. Variation within the ethnic groups was larger than differences between the groups for most variables. The distribution within ethnic groups was biased by extreme scores; thus 50-70% of the subjects were similar regardless of ethnic group.

Ethnic and age trends for body composition in women residing in the U.S. Southwest: II. Total fat

This study assessed body density (BD) in an ethnically diverse sample of women (African American, Caucasian, Mexican American and Native American) (N = 139) who were between 20 and 30 or 40 and 50 yr of age and of normal weight for their height. BD was assessed using three methods: hydrostatically determined density (UWW), total body potassium (TBK) and the Jackson et al. (1980) sum of seven SF with gluteal circumference (SF). Ethnic differences in BD were detected by TBK and UWW. BD from SF did not detect ethnic differences, and the SEE was unacceptable. Based on multiple regression, the prediction equation was: BD = 1.1197794 - 0.000224382 (X3) + 0.006999 (e2) - 0.000320177 (X2) - 0.001892 (e1) + 0.001750 (e3) - 0.000537005 (x1) (where x1 = gluteal C, x2 = age in years, x3 = sum of 7 SF and e1, e2, and e3 describe ethnicity). This formula had a reduced SEE, a higher correlation with hydrostatically determined BD, and was sensitive to ethnic differences detected with other measures of BD. A 24-mmol decrease in potassium was found when comparing the older Caucasian women with the younger Caucasian women, while the difference for the African, Mexican, and Native American groups was 200-300 mmol.

Variables related to obesity and body fat: avenues to change

Obesity and overweight constitute major health concerns in this country today. This article provides a description of the terms overweight and obese, variables contributing to diet and exercise adherence, and practice implications for nurse practitioners.

Metabolic screening in the NICU population: a proposal for change

To be an effective preventive pediatric and public health strategy, newborn screening for hereditary metabolic disorders should include 100% of all neonates as the target population. Delaying screening for critically-ill and premature infants places the neonatal intensive care unit (NICU) population at high risk for developing devastating side effects of untreated or late-treated metabolic diseases. A clinical nursing project was undertaken in The Johns Hopkins Hospital NICU to develop specific metabolic screening criteria for this special population.

Factors contributing to perception of health in young black women

An exploratory descriptive design using interviews and open-ended questions examined factors which were associated with perceptions of health held by 22 young black women, ages 18 to 40 years. Interview findings indicated that, among these women, obesity was considered to contribute positively to perceptions of health as did eating good foods and engaging in stress-reducing activities.

Guidelines for treatment of chronic depression in the aphasic patient

This article defines the language disorder of aphasia and the motor speech disorders of apraxia of speech and the dysarthrias. Discussion includes depression and the five definable sets of behaviors related to the phenomenon: motor-expressive behaviors, affective, cognitive, motivational, and somatic, and the relationship of self-concept to both depression and visual and verbal thought. Detailed discussion of treatment of chronic depression inpatients with non-organic reactive factors is presented. These include positive reinforcement of desirable behaviors, avoidance of verbal punishment, labeling the disorder for the client and family, and time structuring or scheduling to assist in motivation. In addition, implementation of support from family, friends, and social relationships, tolerance of expressions of frustration and anger by the client, and environmental manipulation are considered therapeutic interventions.

The medical aspects of soccer injury epidemiology

In this article, the six major studies of soccer injury epidemiology are reviewed. Strengths and weaknesses of each epidemiologic design are critiqued and the crucial importance of the definition of injury is emphasized. The effect of age, sex, and intensity of play on injury rates is discussed. Our present knowledge of injury rate by anatomical site, player position, and the type of playing surface are reviewed. We examined the importance of player factors such as flexibility, joint laxity, weakness, and incomplete rehabilitation from other injuries. In addition, we reviewed the role played by inadequate equipment, field conditions, and rule violations. A successful program for soccer injury prevention is described, and guidelines for future soccer injury epidemiology research are proposed.

The medical aspects of soccer injury epidemiology

In this article, the six major studies of soccer injury epidemiology are reviewed. Strengths and weaknesses of each epidemiologic design are critiqued and the crucial importance of the definition of injury is emphasized. The effect of age, sex, and intensity of play on injury rates is discussed. Our present knowledge of injury rate by anatomical site, player position, and the type of playing surface are reviewed. We examined the importance of player factors such as flexibility, joint laxity, weakness, and incomplete rehabilitation from other injuries. In addition, we reviewed the role played by inadequate equipment, field conditions, and rule violations. A successful program for soccer injury prevention is described, and guidelines for future soccer injury epidemiology research are proposed.

A prospective, randomized study of the management of severe ankle fractures

One hundred and thirty-eight patients with a closed grade-4 supination-external rotation or pronation-external rotation ankle fracture (Lauge-Hansen classification) who were seen in the emergency room of the University of Chicago Hospitals were entered into a randomized study of the results of various methods of treatment. Ninety-six patients with satisfactory initial closed reduction were randomized between continued closed treatment in a plaster cast and open reduction with rigid internal fixation according to the techniques of the Association for the Study of Internal Fixation (ASIF). Forty-two patients with unsatisfactory closed reduction were randomized between open reduction with internal fixation of only the medial malleolus and open reduction with rigid internal fixation according to the ASIF techniques. Of the 138 patients who were admitted to the study, only seventy-one (51 per cent) could be followed for an average of 3.5 years (a typical return rate of urban trauma centers). The outcomes were evaluated by a scoring system that included clinical, anatomical, and arthritis scores. Statistical analysis of the data showed that, of the patients with initial satisfactory closed reduction, the ones treated by open reduction and rigid internal fixation had significantly higher total scores, particularly the patients who were more than fifty years old and those with a medial malleolar fracture. The small number of patients with unsatisfactory closed reduction who were treated by one of the two types of open reduction and internal fixation and were available for follow-up precluded drawing any conclusions about the superiority of one method of internal fixation over the other in that group. The difference in the talocrural angle between the injured and normal sides was the only statistically significant radiographic indicator of a good prognosis.

Advances in the understanding of knee ligament injury, repair, and rehabilitation

Knee injuries continue to present a complex set of clinical problems. The answers to these problems have recently been redefined by the application of sophisticated biomechanical research methods to the study of knee ligaments and joint function. This manuscript reviews contributions which our laboratory has made to the understanding of knee injury, highlighting those research findings which form the basis for our clinical treatment of knee ligament injuries. High strain-rate techniques for studying knee ligament failure have replaced the previous low strain-rate methods and distinguish the failure mechanism of ligaments from that of bone. Ligament function is now further defined by measuring the restraining force provided by specific ligaments, adding to the information provided by cutting studies. The development of the 6-degrees-of-freedom concept and the instrumented kinematic chain now permit precise analysis of joint position, motion, and laxity. Biomechanical evaluation of intra-articular anterior cruciate ligament substitution has emphasized the importance of selection of a high-strength graft material, meticulous surgical technique with attention to graft vascularity, precise location of graft fixation sites, judicious adjustment of graft tension, post-operative protection during tissue remodelling, and a carefully conceived rehabilitation program. Newer biomechanical research methods have provided a sound scientific foundation on which to base clinical decisions concerning the care of knee ligament injuries.

The principles of the treatment of tibial shaft fractures: a review of 10,146 cases from the literature

The tibial shaft is a common site of long bone fracture, and both nonoperative and operative treatment methods have been developed in an effort to speed union while minimizing complications. To compare the recent results of present treatment alternatives and to identify those factors of prognostic significance, a review of the 1976-1981 English literature was performed, representing a review of 10, 146 fractures. Comminution, displacement, bone loss, distraction, soft tissue injury, infection, polytrauma, and patient personality were found to be factors that place the patient with a tibial shaft fracture at risk for local and systemic complications. Fracture location, fracture configuration, and concomitant fibula fracture were found to be of no prognostic significance. The advantages and disadvantages of casts, traction, plates, intramedullary rods, and external fixation are discussed. The principles of treatment of soft tissue injury, transverse and short oblique fractures, spiral fractures, single butterfly comminution, segmental fractures, comminuted fractures, bone loss, "floating knee" injuries, bilateral tibial fractures, and brain injured patients are detailed.

Indications for open reduction of femoral neck fractures

The Garden alignment index is useful for femoral neck fractures in the aged and defines an acceptable reduction as 155 degrees-180 degrees in both views. The quality of films available in the operating room may not permit accurate measurements of the index. As a substitute, anterior and medial cortical displacement of more than 2 mm may be used as a measure of unsatisfactory reduction. Because malreduction is associated with a high incidence of nonunion and avascular necrosis, inability to achieve acceptable reduction of an adult femoral neck fracture is an indication for open reduction. Since posterior communication is also associated with a high rate of healing complications, it is another indication for open reduction. Bone grafting and careful reshaping of the distal fracture fragment at open reduction can provide stability to promote healing. The incidence of complication of femoral neck fracture is especially high in young adults and children. Anatomic reduction is essential in these age groups to minimize nonunion and avascular necrosis. Primary open reduction is advisable for displaced femoral neck fractures in patients less than 40 years of age if a single gentle closed manipulation fails to provide anatomic reduction.

Temporal orientation pre- and post-delivery of a child

17 men and 30 women were administered Roos' Time Reference Inventory during the third trimester before delivery and again at 6 wk. post-delivery to assess temporal orientation with respect to the delivery of a child. There was no significant difference in temporal orientation in terms of future, past, and present age estimate.

Preparation of cultured cells for SEM: air drying from organic solvents

Air evaporation from organic solvents of differing polarities and surface free energies was used in the preparation of cultured murine peritoneal macrophages for scanning electron microscopy (SEM). The surface structural features of these cells were compared to the surfaces of similar cells prepared by the critical-point procedure. In general, all organic solvents produced a marked collapse of cell structure resulting in an increase in surface irregularity. Fracture surfaces and sharply defined contours including numerous flaps and ridges were characteristic of the non-polar solvent dehydrated samples. Polar solvent dehydrated samples, including those dried from solvents of low surface free energy, exhibited a secondary flowing and settling of the cell membrane. Primary collapse was apparent but cell contours were smoothed and rounded. Overall cell shape and cell-to-cell relationships were retained regardless of solvent type. It is suggested that solvent evaporation may prove useful in certain cases, though investigators are advised to use caution when interpreting the results obtained by such procedures.