A randomized, placebo-controlled trial (NCIC CTG MAP.2) examining the effects of exemestane on mammographic breast density, bone density, markers of bone metabolism and serum lipid levels in postmenopausal women.

We hypothesized that exemestane (EXE) would reduce mammographic breast density and have unique effects on biomarkers of bone and lipid metabolism. Healthy postmenopausal women were randomized to EXE (25 mg daily) or placebo (PLAC) for 12 months and followed for a total of 24 months. The primary endpoint was change in percent breast density (PD) between the baseline and 12-month mammograms and secondary endpoints were changes in serum lipid levels, bone biomarkers, and bone mineral density (BMD). Ninety-eight women were randomized (49 to EXE; 49 to PLAC) and 65 had PD data at baseline and 12 months. Among women treated with EXE, PD was not significantly changed from baseline at 6, 12, or 24 months and was not different from PLAC. EXE was associated with significant percentage increase from baseline in N-telopeptide at 12 months compared with PLAC. No differences in percent change from baseline in BMD (lumbar spine and femoral neck) were observed between EXE and PLAC at either 12 or 24 months. Patients on EXE had a significantly larger percent decrease in total cholesterol than in the PLAC arm at 6 months and in HDL cholesterol at 3, 6, and 12 months. No significant differences in percent change in LDL or triglycerides were noted at any time point between the two treatment arms. EXE administered for 1 year to healthy postmenopausal women did not result in significant changes in mammographic density. A reversible increase in the bone resorption marker N-telopeptide without significant change in bone specific alkaline phosphatase or BMD during the 12 months treatment period and 1 year later was noted. Changes in lipid parameters on this trial were modest and reversible.

Recognizing acetabular version in the radiographic presentation of hip dysplasia.

Attention to the radiographic shadow of the walls of the acetabulum seen on the anteroposterior projection of a well-centered radiograph of the pelvis is important to identify the orientation of the opening of the acetabulum. This is referred to as the acetabular version. The opening of the mouth of the acetabulum may be oriented anteriorly, which is referred to as anteverted; posteriorly, or retroverted; or when the shadow of the lips of the anterior and posterior walls terminate together on the lateral edge of the acetabular rim, neutral version. The radiographs of 153 patients with developmental hip dysplasia presenting with hip pain were reviewed to determine the frequency of retroversion of the acetabulum. In this group of patients, retroversion of the hip socket was surprisingly common, one in three hip sockets, and generally was associated with smaller values of the lateral center edge measurement. The observation is important, because it must be taken into account when planning a corrective osteotomy of the acetabulum so the abnormal horizontal orientation of socket is corrected along with the usual anterior and lateral insufficiency.

Evaluation of the impact and acceptance of a nutrition program in an HIV community clinic.

The present paper describes the evaluation of a nutrition service and research model for human immunodeficiency virus (HIV)-positive clients within a community based HIV acquired immune deficiency syndrome (AIDS) medical clinic. This program was designed to develop an effective, practical, replicable model for the delivery of nutrition services in the ambulatory HIV care setting. The objectives of evaluating the model were to define the ways that nutrition services in HIV/AIDS impacted clients, the clinic, and referral sources, and to continually refine the model by determining what services provide greatest benefit to clients, especially in view of the changing landscape of HIV therapy. Four evaluation activities completed during the study period of 5 years are described. These included a focus group and semistructured interview with clients, a semistructured interview with workers from the local network of service referral agencies and a client satisfaction survey at study "close-out." These evaluation processes confirmed or prompted programmatic modifications that improved access, confidentiality, and the relevance of specific components for clients. Providers/stakeholder's concerns were addressed through more frequent communication about clients' specific nutrition issues, clearer and easier referral and cooperation in recruiting patients. Also, the evaluation activities provided a platform for the communication of general and specific information about the program and for outreach. Although clients' and workers' priorities differed in some details of program implementation, there was strong agreement on the value of addressing nutrition concerns in HIV. Favorable feedback about the program gave impetus to continue nutrition services in the clinic after the project period ended and supports its application in other sites and settings.

Paying doctors more: use of musculoskeletal specialists and increased physician pay to decrease workers' compensation costs.

Previous studies evaluating workers' compensation care systems used retrospective controls. We performed a concurrent effectiveness study comparing a WC system that used visiting musculoskeletal specialists to assist primary care physicians with a typical discounted-fee, WC, managed-care system. In the new specialist-direct system, physicians could not profit from self-referral, but were paid 35% to 69% more per patient visit than doctors in the discounted-fee clinics. All claims filed by all employees of two hotels for 2 years were examined. Patients had self-selected either a specialist-direct or a discounted-fee clinic, and the entire cost of the claim was assigned to either system of care. Claim costs were 63% lower in the specialist-direct system (P < 0.001). Medical costs were 45% less (P < 0.014), and indemnity 85% less (P < 0.001), in this system. Claims were closed nearly 6 months faster in the specialist-direct system (P < 0.0001). Indemnity claims were more common in the discounted-fee system (P < 0.0001). Claimant and injury characteristics were not significantly different between the systems. This new care model is a cost-effective alternative to discounted WC managed care. Discounting the services of the primary treating physician may result only in cost-shifting, not cost-saving.

Hostility, dieting, and nutrition attitudes in overweight and weight-cycling men and women.

OBJECTIVE: Relationships were examined between hostility, weight status, weight cycling, dieting behaviors, and nutrition attitudes. METHOD: Data were derived from the RENO Diet-Heart Study (RDHS), a 5-year prospective natural history (descriptive) study of weight fluctuations, behavior patterns, and cardiovascular (CVD) risk factors. Overweight versus normal-weight and weight-cycling versus non-weight-cycling men and women were compared on overt and covert hostility. RESULTS: Overweight subjects scored significantly higher than normal-weight individuals on covert but not overt hostility. Similarly, subjects with a history of weight fluctuation scored significantly higher on covert hostility than subjects without a history of weight cycling. Subjects who reported more hostility scored higher on measures of eating disinhibition, hunger, and dietary helplessness. DISCUSSION: The relationships among hostility, dieting behaviors, and nutrition attitudes could not be explained on the basis of general distress alone. The findings supported the hypothesis that the relationship between hostility and health is mediated by the association between hostility and health-related behaviors.

Dietary fat consumption in a cohort of American adults, 1985-1991: covariates, secular trends, and compliance with guidelines.

PURPOSE: To examine compliance with the guideline for dietary fat (i.e., 30% of total daily colonies) and covariates of fat intake in a cohort of adults using both 24-hour recall and food frequency questionnaire (FFQ). DESIGN: Prospective, observational cohort study over 5 years. SETTING: Community-based sample in Reno, Nevada. SUBJECTS: Equal numbers of male and female, lean and overweight adults (n = 508), recruited from 1985 to 1986, of whom 348 completed all relevant surveys. MEASURES: Subjects underwent repeated anthropometric measures and completed extensive surveys on diet, weight cycling, lifestyle, and physical activity. RESULTS: Mean fat intake by 24-hour recall declined from 36.9% to 33.6% of calories between years 1 and 5 (p < .001), while calorie intake increased (p = .2). As measured by FFQ at year 2, mean fat intake was 39.1% of calories, and only 11.8% of subjects were in compliance with the guideline for dietary fat intake. Fat intake by FFQ at year 2 was statistically higher than by 24-hour recall in year 1 for lean women (p = .02) and lean men (p = .02), but not for the overweight of either gender, and was significantly higher than the year 5 24-hour recall for all categories of gender and weight (p < .001). Calorie intake, gender, and body mass index were significant in regression models that explained less than 10% of total variability in fat intake (r2 = .08; p < .01). CONCLUSIONS: Compliance with the nationally recommended level of dietary fat intake was poor in this cohort, especially as measured by FFQ. Variability in fat intake was largely unexplained by host characteristics, including education. Further study is required to corroborate secular trends in population fat intake, elucidate the determinants of such intake, and identify cost-effective strategies for reducing the consumption of dietary fat.

Adult obesity and functioning in the family of origin.

OBJECTIVE: This study investigated the relationship between eating and weight behaviors and functioning in individuals' families of origin. METHOD: Subjects were 237 women and 242 men enrolled in the RENO (Relationship of Energy, Nutrition, and Obesity) Diet-Heart Study, a prospective 5-year study of the effects of weight fluctuation on cardiovascular disease risk factors in normal weight and obese adults. Variables of primary interest included subjects' body mass index (BMI), age of onset of obesity, eating attitudes, lack of control while eating, and family functioning. RESULTS: In men, higher family cohesion was related to healthier eating attitudes and better control over eating, controlling for age, BMI, and adaptability, whereas higher adaptability (changing rules and poor leadership) was related to earlier onset of obesity and more disturbed eating attitudes. Cohesion and adaptability were not related to body weight or eating variables in women. DISCUSSION: The lower societal pressure on men to be thin may increase the importance of family factors in influencing their shape and weight.

A classification system to evaluate weight maintainers, gainers, and losers.

OBJECTIVES: To study natural weight changes and to develop a weight classification system that can identify weight maintainers, gainers, and losers. DESIGN/OUTCOME: A prospective, observational study in which weight changes over five annual measurements were evaluated. In the weight classification system used, changes greater than 5 lb defined weight maintenance, gain, or loss. SUBJECTS/SETTINGS: Subjects were healthy, normal-weight and over weight, men and women (mean age = 44.1 +/- 14.1 years) in the Relationships of Energy, Nutrition, and Obesity to Cardiovascular Disease Risk Study. Prospective data for 385 of the original 508 subjects for whom actual weights were available for each of the 5 years (1985 to 1990) were used to classify and characterize subjects by weight-change categories. STATISTICAL ANALYSES: Cross-tabulations (with chi 2 tests) and hterarchical log-linear analyses (with partial chi 2 tests) to examine the relationships of categorical variables; analyses of variance (with F tests) for continuous measures. RESULTS: Over the 4-year interval, 46% of subjects were classified as maintainers, 34% as gainers, and 20% as losers. Over shorter 1-year epochs, more subjects were maintainers (62%) and fewer subjects were gainers (22%) or losers (16%). Maintainers had fewer and smaller magnitudes of weight fluctuations and showed fewer deleterious changes in health risk factors than gainers. APPLICATIONS: Weight changes of greater than +/-5 lb can classify a person as a weight maintainer, or loser. Although annual weight changes were used in this study, a weight change of more than 5 lb between any two points in time may suggest nonmaintenance of weight or weight instability that needs further evaluation.

Dietary helplessness and disinhibition in weight cyclers and maintainers.

OBJECTIVE: The primary purpose of this study was to compare obese versus nonobese adults and weight cyclers versus maintainers on measures of dietary helplessness, nutrition concern, dietary restraint, and disinhibition. METHOD: Dietary helplessness, nutrition concern, dietary restraint, and disinhibition were assessed in 385 healthy obese and nonobese men and women in the RENO Diet-Heart Study, a 5-year prospective investigation of cardiovascular risk factors, weight cycling, and lifestyle. RESULTS: The results indicated that dietary helplessness and disinhibition were significantly greater in obese individuals, subjects with a history of weight cycling, and weight fluctuators (prospectively measured). Women were found to score significantly higher than men on measures of dietary helplessness, disinhibition, and cognitive restraint. DISCUSSION: The role of nutrition attitudes is discussed in relation to dietary self-regulation, weight fluctuation, and management of body weight.

Psychological correlates of reported physical activity in normal-weight and obese adults: the Reno diet-heart study.

This investigation assessed psychological correlates of reported physical activity in a sample of 381 normal-weight and obese adults who were enrolled in a 4-year, prospective, natural history study. The psychological measures included the Eating Self-Efficacy Scale, the General Well-Being Schedule, and the Center for Epidemiological Studies Depression Scale. Reported Physical Activity was defined as a composite measure of reported recreational physical activity and perceived importance of activity in health and recreation. Physical activity was correlated with a more positive psychological profile in obese subjects at both year 1 and year 5. Increases in reported physical activity over the four years were associated with improvements in depression and well-being in normal-weight subjects, and with improvements in eating self-efficacy and well-being in obese subjects.

Who are the weight maintainers?

To characterize people who maintain weight over long periods of time, normal weight and obese adults (n = 385) were studied over five annual visits. Subjects were classified using a +/- 5 lb change between the first and the fifth year visits to determine overall maintenance (M), with gain (G) or loss (L) being any change outside this range. This MGL status was cross-tabulated with a Fluctuation Index which counted the number of successive year-to-year weight changes of more than +/- 5 lbs (F0 through F4). True maintainers were defined as those having all weight changes within +/- 5 lbs during the 5-year period (M and F0). Nineteen percent (n = 73) of the subjects were classified as True Maintainers and included three times as many normal weight as obese subjects. Obese subjects comprised only 25% of the True Maintainer group but 60% of the Non-Maintainer group. Age had no association with Maintainer status. Standard measures of weight variability were lowest among True Maintainers and highest in Non-Maintainers. In addition, True Maintainers had lower BMI, Percent Body Fat, and Waist-Hip Ratios than Non-Maintainers. Subjects classified as Non-Maintainers were more likely to engage in dieting, by a variety of measures, than True Maintainers--this was particularly true among obese subjects. Finally, changes in total cholesterol, LDL and HDL cholesterol, and systolic and diastolic blood pressure were not reliably associated with Maintainer status, although the ordering of the group means suggested that True Maintainers had slightly healthier levels of "risk" variables. Overall, the results suggest that True Maintainers comprise a potentially important and interesting group of individuals who need further study.

Psychological correlates of weight fluctuation.

This investigation attempted to determine psychological correlates of weight fluctuation in a sample of 497 normal weight and obese adults who were enrolled in a prospective, natural history study. Subjects were stratified by gender, obesity, and age and classified as weight maintainers, gainers, or losers based on their changes in weight over a 1-year period. Subjects were further classified as either weight fluctuators or nonfluctuators based on historical self-report. Nonfluctuators reported significantly higher general well-being, greater eating self-efficacy, and lower stress than weight fluctuators, regardless of body weight. Weight maintainers had more favorable eating self-efficacy related to negative affect than weight gainers. Results suggest that weight fluctuation is strongly associated with negative psychological attributes in both normal weight and obese individuals. Future research should focus on the assessment and treatment of weight fluctuation and on weight maintenance, irrespective of weight status.

D2 dopamine receptor gene and cigarette smoking: a reward gene?

There is now growing evidence that the less prevalent allele (A1) of the D2 dopamine receptor (DRD2) gene is strongly associated with severe alcoholism. Similarly, subjects who abuse illegal drugs or who are obese also show a significantly higher prevalence of the A1 DRD2 allele compared to controls. Moreover, cigarette smokers, both past and current, demonstrate significantly higher prevalence of the A1 allele than nonsmokers. In as much as alcohol, cocaine, opiates, nicotine and food are known to increase brain dopamine levels and activate the mesocorticolimbic dopaminergic reward pathways of the brain, it is hypothesized that an inherited deficit of D2 dopamine receptor numbers in brain reward areas of A1 allelic subject predisposes them to substance abuse problems.

Valine, isoleucine, and leucine. A new treatment for phenylketonuria.

Early treatment of phenylketonuria by dietary phenylalanine restriction prevents brain damage. Behavioral and cognitive deficits occur when serum phenylalanine levels increase. Administration of valine, isoleucine, and leucine to patients with phenylketonuria may inhibit entry of phenylalanine into the brain and reduce its toxic effects on the central nervous system. Sixteen adolescents and young adults with phenylketonuria participated in double-blind trials in which a valine, isoleucine, and leucine mixture or a control mixture was given for four 3-month periods. Biochemical and neuropsychologic tests were carried out before and at the end of each period. Time to completion of a test that required substantial attention with mental processing (Attention Diagnostic Method) was faster during the valine, isoleucine, and leucine periods than during the control mixture periods. Improvement with valine, isoleucine, and leucine on a less demanding task (Continuous Performance Test) approached significance. These data lent support to the hypothesis that a regimen of valine, isoleucine, and leucine may help individuals unable to maintain low serum phenylalanine levels.

Screening asymptomatic adolescent males for chlamydia.

Ninety-seven asymptomatic 16-21-year-old sexually active adolescent males were evaluated for gonorrhea and chlamydia by culture, chlamydia enzyme immunoassay, and an analysis of a random urine sample for pyuria using centrifuged urine and urine cytometer. The incidence of gonorrhea was 5.3% and chlamydia by culture 12.3%. Immunoassay was superior in sensitivity and specificity (75% and 99%, respectively) to centrifuged urine (sensitivity 58%, specificity 92%) or urine cytometer (58% and 91%) in identifying asymptomatic chlamydia urethritis. Chlamydia enzyme immunoassay is an acceptable, more rapid, and less expensive alternative to culture. The absence of pyuria in asymptomatic males cannot be assumed to indicate the absence of a sexually transmitted disease.

A controlled study of type A behavior and psychophysiologic responses to stress in anorexia nervosa.

Adolescents and young adults meeting DSM-III criteria for anorexia nervosa (n = 13) and atypical eating disorders (n = 7) were compared with weight-recovered anorectics (n = 6) and normal weight controls (n = 11) using a type-A structured interview and a computerized stress procedure. Heart rate, blood pressure, and electrocardiographic changes were monitored. Anorexia nervosa subjects demonstrated significantly more type-A characteristics than controls. The emaciated and weight-recovered anorectics had elevated hostility scores on the type-A interview, which has been shown in recent studies of type-A behavior to be a risk factor for cardiovascular disease. This pilot study is the first to demonstrate a significant relationship between anorexia and the type-A behavioral pattern. Also the anorectic subjects showed significantly more cardiovascular reactivity than controls as measured by failure of stressed anorectic subjects to lower their systolic blood pressure to baseline levels as controls did. These results support the importance of monitoring stress reactions and personality traits as well as traditional biological measures.

Phenylketonuria and complex spatial visualization: an analysis of information processing.

Recent neuropsychological studies have suggested that patients with early-treated phenylketonuria (PKU) and normal intelligence have a specific deficiency in solving complex spatial problems. In the present study a task involving the assembly of various shapes was used to compare the performance of 16 PKU patients and 11 sibling controls. Error rates generally were higher and response times slower among the PKU patients, but greater complexity did not produce differential changes in accuracy or speed in the PKU group compared to the controls. Correlations between task performance and IQ measures were significant for the PKU patients, but when IQ was controlled for the group differences vanished. The results suggest that choice of problem-solving strategy, attention span and accuracy of mental representation may be affected in PKU patients, despite efforts to maintain well-controlled phenylalanine concentrations in the blood.

Phenylketonuria revisited: treatment of adults with behavioural manifestations.

Dietary treatment of three PKU patients with irreversible changes is described and elevated.