Implementation of Obesity Science Into Clinical Practice: A Scientific Statement From the American Heart Association.

Obesity is a recognized public health epidemic with a prevalence that continues to increase dramatically in nearly all populations, impeding progress in reducing incidence rates of cardiovascular disease. Over the past decade, obesity science has evolved to improve knowledge of its multifactorial causes, identifying important biological causes and sociological determinants of obesity. Treatments for obesity have also continued to develop, with more evidence-based programs for lifestyle modification, new pharmacotherapies, and robust data to support bariatric surgery. Despite these advancements, there continues to be a substantial gap between the scientific evidence and the implementation of research into clinical practice for effective obesity management. Addressing barriers to obesity science implementation requires adopting feasible methodologies and targeting multiple levels (eg, clinician, community, system, policy) to facilitate the delivery of obesity-targeted therapies and maximize the effectiveness of guideline-driven care to at-need patient populations. This scientific statement (1) describes strategies shown to be effective or promising for enhancing translation and clinical application of obesity-based research; (2) identifies key gaps in the implementation of obesity science into clinical practice; and (3) provides guidance and resources for health care professionals, health care systems, and other stakeholders to promote broader implementation and uptake of obesity science for improved population-level obesity management. In addition, advances in implementation science that hold promise to bridge the know-do gap in obesity prevention and treatment are discussed. Last, this scientific statement highlights implications for health research policy and future research to improve patient care models and optimize the delivery and sustainability of equitable obesity-related care.

The relationship of health activation with risk of future cardiovascular disease among rural family caregivers of patients with chronic illnesses.

BACKGROUND: Family caregivers are at higher risk for developing cardiovascular disease (CVD) than non-caregivers. This risk is worse for those who live in rural compared to urban areas. Health activation, an indicator of engagement in self-care, is predictive of health outcomes and CVD risk in several populations. However, it is not known whether health activation is associated with CVD risk in rural caregivers of patients with chronic illnesses nor is it clear whether sex moderates any association. OBJECTIVES: Our aims were to determine (1) whether health activation independently predicts 10-year CVD risk; and (2) whether sex interacts with health activation in the prediction of 10-year CVD risk among rural family caregivers (N = 247) of patients with chronic illnesses. METHODS: Health activation was measured using the Patient Activation Measure. The predicted 10-year risk of CVD was assessed using the Framingham Risk Score. Data were analyzed using nonlinear regression analysis. RESULTS: Higher levels of health activation were significantly associated with decreased risk of developing CVD (p < 0.028). There was no interaction of sex with health activation on future CVD risk. However, male caregivers had greater risk of developing CVD in the next 10 years than female caregivers (p < 0.001). CONCLUSIONS: We demonstrated the importance of health activation to future CVD risk in rural family caregivers of patients with chronic illnesses. We also demonstrated that despite the higher risk of future CVD among male, the degree of association between health activation and CVD risk did not differ by sex.

Perceived Control, Functional Status, Depressive Symptoms, and Anxiety: Mediating and Moderating Influences on Health-Related Quality of Life in Patients With Heart Failure.

BACKGROUND: Health-related quality of life (HRQoL) is poor in patients with heart failure. Psychological (ie, depressive symptoms [DS], anxiety, and perceived control) and physical (ie, functional status) factors are associated with HRQoL. The dynamic relationships among these variables and their impact on HRQoL remain unclear, limiting the ability to design effective interventions. PURPOSE: Our aim was to evaluate a moderated mediation model, in which the association between perceived control and HRQoL was hypothesized to be mediated by DS and anxiety in the presence of a moderator, functional status. METHODS: Patients (N = 426) with heart failure completed the Control Attitudes Scale-Revised to measure perceived control, Duke Activity Status Index for functional status, Patient Health Questionnaire-9 for DS, Brief Symptom Inventory for anxiety, and Minnesota Living with Heart Failure Questionnaire for HRQoL. We performed a moderated parallel mediation analysis. RESULTS: Higher levels of perceived control were associated with better HRQoL through lower levels of anxiety and DS in the presence of functional status (index of moderated mediation for DS, b = 0.029; 95% confidence interval, 0.016-0.045; for anxiety: b = 0.009, 95% confidence interval, 0.002-0.018). The effect of perceived control on psychological symptoms was stronger at low and moderate functional statuses; however, this effect diminished with increasing functional status. CONCLUSION: Functional status moderated the indirect effects of perceived control on HRQoL through DS and anxiety in patients with heart failure. Efforts to improve HRQoL by targeting perceived control may be more effective when considering DS and anxiety in patients with low to moderate levels of functional status.

Diet Quality Mediates the Relationship Between Chronic Stress and Inflammation in Patients With Metabolic Syndrome.

BACKGROUND: Chronic stress is associated with promotion of inflammation and development of metabolic syndrome, as well as deterioration of diet quality. Inflammation can be modified by changes in dietary intake. OBJECTIVE: The aim of this study was to test the hypothesis that diet quality mediates the relationship of chronic stress with inflammation in patients with metabolic syndrome. METHODS: Participants with metabolic syndrome (n = 73, 62 ± 12 years old, 71% female) completed questionnaires on chronic stress (Perceived Stress Scale-10) and diet quality (Healthy Eating Index-2020). The Perceived Stress Scale-10 was dichotomized. The Healthy Eating Index-2020 score was used as a continuous variable, and higher scores indicate better diet quality. Inflammation was assessed using plasma high-sensitivity C-reactive protein (log-transformed). We used PROCESS in SPSS to test the hypothesis. RESULTS: Patients in the higher stress group had lower Healthy Eating Index-2020 scores (worse diet quality) than those in the lower stress group (57 ± 13 vs 64 ± 10, P = .01). Diet quality mediated the relationship between chronic stress and inflammation (indirect effect, 0.211; 95% bootstrap confidence interval, 0.006-0.496). Higher stress was associated with lower diet quality (effect, -7.152; 95% confidence interval, -13.168 to -1.137) that was associated with increased inflammation (effect, -0.030; 95% confidence interval, -0.052 to -0.007). CONCLUSIONS: Our findings show the important role of diet quality in the relationship of chronic stress with inflammation in patients with metabolic syndrome. Healthcare providers should encourage patients with higher stress to improve diet quality, which can decrease inflammation.

Characterization of sleep efficiency transitions in family caregivers.

Family caregivers are at high risk of psychological distress and low sleep efficiency resulting from their caregiving responsibilities. Although psychological symptoms are associated with sleep efficiency, there is limited knowledge about the association of psychological distress with variations in sleep efficiency. We aimed to characterize the short- and long-term patterns of caregivers' sleep efficiency using Markov chain models and compare these patterns between groups with high and low psychological symptoms (i.e., depression, anxiety, and caregiving stress). Based on 7-day actigraphy data from 33 caregivers, we categorized sleep efficiency into three states, < 75% (S1), 75-84% (S2), and ≥ 85% (S3), and developed Markov chain models. Caregivers were likely to maintain a consistent sleep efficiency state from one night to the next without returning efficiently to a normal state. On average, it took 3.6-5.1 days to return to a night of normal sleep efficiency (S3) from lower states, and the long-term probability of achieving normal sleep was 42%. We observed lower probabilities of transitioning to or remaining in a normal sleep efficiency state (S3) in the high depression and anxiety groups compared to the low symptom groups. The differences in the time required to return to a normal state were inconsistent by symptom levels. The long-term probability of achieving normal sleep efficiency was significantly lower for caregivers with high depression and anxiety compared to the low symptom groups. Caregivers' sleep efficiency appears to remain relatively consistent over time and does not show rapid recovery. Caregivers with higher levels of depression and anxiety may be more vulnerable to sustained suboptimal sleep efficiency.

Sleep Deficiency by Caregiving Status: Findings From Nationally Representative Data.

OBJECTIVE: Caregiving demands may influence caregivers' sleep duration and quality, which are essential for optimal health. We aimed to examine the association between caregiving status and sleep deficiency (i.e., short sleep duration and/or poor quality) and identify factors associated with sleep deficiency among caregivers. METHODS: This secondary analysis used data from 3870 adults living in the United States, obtained from the 2019 Health Information National Trends Survey. Multinomial logistic regressions were performed to examine the association between caregiving status (i.e., caregivers vs. non-caregivers) and sleep status (i.e., normal duration-good quality [optimal sleep, reference], short duration-good quality, normal duration-poor quality, and short duration-poor quality), and to identify caregiving-related factors associated with sleep deficiency in the caregiver group. RESULTS: Compared to non-caregivers, caregivers were more likely to report short sleep duration (<7 hours) with good quality sleep (relative risk ratio [RRR] = 1.566, 95% CI [1.238, 1.980]) or poor quality sleep (RRR = 1.376, 95% CI [1.034, 1.832]) than the optimal sleep status. Caregivers providing care for ≥20 hours per week (vs. <20 hours) and providing care to individuals with dementia (vs. no dementia caregiving) were 2.8 times more likely to report normal sleep duration with poor sleep quality than optimal sleep (RRR = 2.796, 95% CI [1.125, 6.950]; RRR = 2.776, 95% CI [1.154, 6.675], respectively). CONCLUSION: The findings of a higher risk of sleep deficiency among caregivers suggest that health care providers need to assess both caregivers' sleep duration and quality status. Interventions tailored to the caregiving context are also warranted.

A Biomarker of Stress and Self-reported Caregiving Distress Predict Poor Quality of Life in Family Caregivers of Patients With Heart Failure.

BACKGROUND: Family caregivers are at a high risk for low quality of life due to caregiving-related stress. Caregivers' stress is commonly assessed using self-reported measures, which reflect relatively subjective and long-term stress related to caregiving, but objective biological markers of stress are rarely used for caregivers. The purposes of this study were (1) to determine whether caregiver characteristics were associated with stress assessed using a stress biomarker (serum cortisol) and a self-reported caregiving distress measure (Caregiver Burden Inventory) and (2) to determine the predictability of both stress measures for quality of life in caregivers of patients with heart failure. METHODS: Taiwanese family caregivers (N = 113; mean age, 54.5 years; 70.8% female) of patients with heart failure completed surveys including caregiving distress and quality of life measured by the Caregiver Burden Inventory and the Short Form-36 (physical and psychological well-being subscales), respectively, and provided blood samples for serum cortisol. Independent t tests, correlation, and hierarchical regression were conducted. RESULTS: Single caregivers had higher serum cortisol levels than married caregivers (P = .002). Men had significantly higher serum cortisol levels than women (P = .010), but men reported lower caregiving distress than women (P = .049). Both serum cortisol (ß = -0.32, P = .012) and caregiving distress (ß = -0.29, P = .018) were significant predictors of quality of life in the physical well-being scale while controlling for caregivers' characteristics and depressive symptoms. Serum cortisol (ß = -0.28, P = .026) and caregiving distress (ß = -0.25, P = .027) also predicted quality of life in the psychological well-being scale. CONCLUSIONS: Serum cortisol and self-reported caregiving distress have similar predictability for quality of life in family caregivers of patients with heart failure. Reducing stress and caregiving distress is critical to improving quality of life in this population.

Mediation by Fatalism of the Association Between Symptom Burden and Self-care Management in Patients With Heart Failure.

BACKGROUND: Clinicians and researchers often assume that symptom burden is associated with self-care management (SCM) in patients with heart failure (HF). However, that association is often not borne out in simple regression analyses and may be because another variable mediates the association. Fatalism is an appropriate candidate for mediation and is the belief that circumstances are predetermined without opportunity for control by individuals. OBJECTIVE: Our objective was to determine whether fatalism mediated the relationship of symptom burden with SCM among adults with HF. METHODS: We conducted a secondary analysis (N = 95) from a clinical trial. We used Self-care of HF Index to measure SCM, the Memorial Symptom Assessment Scale-HF for symptom burden, and the Cardiovascular Disease Fatalism Instrument to measure fatalism. We used the PROCESS macro to evaluate mediation. RESULTS: Symptom burden was not directly associated with SCM (effect coefficient [C'] = 0.0805; 95% confidence interval, -0.048 to 0.209; P = .217). There was, however, an indirect pathway between symptom burden and SCM through fatalism (ab = -0.040; 95% confidence interval, -0.097 to -0.002). Those with higher symptom burden were more fatalistic (a = 0.004, P = .015), and greater fatalism was associated with worse SCM (b = -9.132, P = .007). CONCLUSION: Symptom burden, not directly associated with SCM, is associated through the mediator of fatalism. Interventions to improve SCM should include strategies to mitigate fatalistic views. Self-care management interventions should focus on promoting internal locus of control or increasing perceptions of perceived control to decrease fatalism and improve engagement in self-care.

The moderating role of neighborhood social cohesion in the mediation effects of the loneliness between acculturation stress and post-traumatic growth among female North Korean defectors.

Loneliness negatively predicts post-traumatic growth (PTG) among North Korean defectors (NKD), one of the representative groups of refugees. Additionally, evidence also suggests that females, who account for 70% of NKDs entering South Korea, are vulnerable not only to past trauma but also to the current acculturation stress and loneliness affected by neighborhood social cohesion. This study explores whether the mediating effect of loneliness on the relationship between acculturation stress and PTG was moderated by the neighborhood social cohesion among female NKDs. In this study, the data of 166 female NKDs who completed an online survey regarding acculturation stress, PTG, loneliness, and neighborhood social cohesion were used. Moderated mediation analysis was conducted using SPSS PROCESS macro program. Loneliness was associated with PTG (B = - 1.896, p < 0.001), and mediated the association between acculturation stress and PTG (indirect effect = - 0.278, 95% LLCI - 0.403, 95% ULCI - 0.166). Neighborhood social cohesion moderated the mediation effect of loneliness on the association between acculturation stress and PTG (B = - 0.016, 95% LLCI 0.001, 95% ULCI 0.035). The indirect effect of acculturation stress on PTG through loneliness was notably high for those with low neighborhood social cohesion. Therefore, increasing neighborhood social cohesion would reduce loneliness caused by acculturation stress and support the positive growth among female NKDs. This represents the most effective approach to aiding female NKDs in achieving growth, even after suffering trauma.

Psychometric Properties of the Patient Activation Measure in Family Caregivers of Patients With Chronic Illnesses.

BACKGROUND: The Patient Activation Measure (PAM) is used clinically and in research to measure an individual's knowledge, skills, and confidence related to their health management engagement. Despite the use of "patient" in the title, the instrument can be used in nonpatient populations. A group at high risk for low activation concerning their own health is family caregivers of patients with chronic illnesses. The psychometric properties of the PAM have not been established in family caregivers. OBJECTIVES: This study aimed to examine the psychometric properties of the PAM 10-item version (PAM-10) in a sample of family caregivers of patients with chronic illnesses. Our focus was on family caregivers' health activation of their own healthcare needs. METHODS: We evaluated the internal consistency reliability of the PAM-10 in a sample of 277 family caregivers. Item-total correlations and interitem correlations were used to assess item homogeneity. Construct validity of the PAM-10 was examined using exploratory factor analysis and testing hypotheses on known relationships. RESULTS: The PAM-10 demonstrated adequate internal consistency. Item-total correlation coefficients and interitem correlation coefficients were acceptable. Construct validity of the instrument was supported. Factor analysis yielded two factors that explained 62.3% of the variance in the model. Lower levels of depressive symptoms were significantly associated with better activation, providing evidence of construct validity. Caregivers with high activation levels were significantly more likely to engage in and adhere to self-care behaviors such as regular exercise, eating a healthy diet, and engaging in stress reduction strategies. DISCUSSION: This study demonstrated that the PAM-10 is a reliable and valid measure for family caregivers of patients with chronic illnesses to measure caregivers' health activation of their own healthcare needs.

Association of disrupted sleep with 24-hour blood pressure variability in caregivers.

BACKGROUND: A growing body of research highlights the negative impact of caregiving on cardiovascular disease (CVD) risk. OBJECTIVES: This study aimed to examine associations of psychological symptoms and sleep quality with 24-hour blood pressure variability (BPV), which is an independent predictor of CVD, among family caregivers of community-dwelling individuals with chronic illness. METHODS: For this cross-sectional study, we assessed caregiving burden and depressive symptoms using questionnaires and 7-day sleep quality (i.e., number of awakenings, wake after sleep onset, sleep efficiency) using an actigraph. The participants carried out a 24-hour ambulatory BP monitoring for systolic and diastolic BPV over 24 h and during awake/sleep times. We performed Pearson's correlations and multiple linear regression. RESULTS: The analytic sample consisted of 30 caregivers (25 female; mean age 62 years). The number of awakenings during sleep was positively correlated with systolic BPV-awake (r = 0.426, p = 0.019) and diastolic BPV-awake (r = 0.422, p = 0.020). Sleep efficiency was negatively correlated with diastolic BPV-awake (r = -0.368, p = 0.045). Caregiving burden and depressive symptoms were not correlated with BPV. After controlling for age and mean arterial pressure, the number of awakenings was significantly associated with increased systolic BPV-24 h (ß = 0.194, p = 0.018) and systolic BPV-awake (ß = 0.280, p = 0.002), respectively. CONCLUSIONS: Caregivers' disrupted sleep may play a role in increased CVD risk. While these findings should be confirmed in large clinical studies, improving sleep quality would need to be considered in CVD prevention for caregivers.

Examining the Individual Response to a Low-Sodium Diet in Patients with Hypertension: Protocol for a Pilot Randomized Controlled Trial.

BACKGROUND: Excessive dietary sodium intake is an independent risk factor for hypertension and cardiovascular disease (CVD). Despite the large body of evidence concerning the effects of dietary interventions on blood pressure (BP) and CVD outcomes, trials have often reported low adherence to decreased sodium intake, likely due in part to heterogeneous BP responses. To address the challenges, recent clinical findings suggested a precise and personalized dietary approach that seeks to deliver more preventive and practical dietary advice than the "one-size-fits-all" guidelines and weighs the personal risk of developing specific diseases. OBJECTIVE: The purpose of this pilot randomized controlled trial was to test the feasibility and preliminary efficacy of integrating the use of mobile technology and metabolomics with a low-sodium diet intervention in patients with hypertension to develop personalized low-sodium diet programs. Additionally, the study will examine the associations of urine metabolites with urinary sodium levels and BP control based on the hypothesis that targeted urine metabolites. In this report, we describe the design and protocol of the pilot trial. METHODS: A total of 40 patients with hypertension will be randomly assigned to either a 8-week low-sodium diet group (n=20) or a standard care group (n=20). Each week, intervention participants went through individual sessions with an interventionist via videoconferencing to discuss low-sodium diet regimens, patients' food choices, and BP tracks on mobile apps. The control group followed their usual care for hypertension management. All participants in both groups monitored diet and BP using mobile apps for 8 weeks. A 24-hour urinary sodium excretion for the estimation of dietary sodium intake, systolic, and diastolic BPs were measured at the baseline and at 8 weeks. The primary outcomes of this study include the feasibility of conducting a randomized controlled trial (RCT) by reporting recruitment, retention, and completion statistics. The preliminary effects of intervention will be tested by a generalized estimating equation model. RESULTS: This pilot RCT study was approved by the institutional review board at the University of Texas Health San Antonio in January 2021. The first participant was enrolled in April 2021, and currently, 26 participants were enrolled. All data collection is expected to conclude by March 2023, with data analysis and study results ready for reporting by December 2023. Findings from this pilot RCT will further guide the team in planning a future large-scale study. CONCLUSIONS: The findings of this proposed study will establish a comprehensive knowledge base for future research and development of personalized dietary interventions to promote adherence to dietary strategies and self-management of chronic disease using the Precision Health approach for millions of Americans who are struggling with uncontrolled hypertension. TRIAL REGISTRATION: ClinicalTrials.gov NCT04764253; https://clinicaltrials.gov/ct2/show/NCT04764253. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/39058.

Self-reported engagement in exercise is associated with longer event-free survival in heart failure patients with poor functional capacity.

AIMS: Despite evidence-based recommendations for clinically stable patients with heart failure (HF) to engage in unsupervised exercise, the minimum cumulative dose of exercise per week associated with improvement in HF outcomes, especially in patients with poor functional capacity, has not been examined. We examined whether patients with HF and poor functional capacity who reported engagement in a guideline-recommended minimum weekly exercise had longer event-free survival than patients who did not exercise. METHODS AND RESULTS: This analysis included 310 patients with HF who had completed the Duke Activity Status Index (DASI) and reported their level of engagement in exercise. Patients were grouped into good and poor functional capacity using a DASI cut-point of ≥19 and then further stratified based on their self-reported exercise level: high (≥60 min/week) and low (<60 min/week). Cox regression modelling was used to predict event-free survival for the four groups after adjusting for covariates. Patients (mean age = 61.6 ± 11.4 years, 30.3% female, 44.2% NYHA Classes III-IV) were followed for a median of 362 days. There were eight deaths and 108 all-cause hospitalizations. Patients with poor functional capacity who reported high exercise engagement had a 36% lower risk of all-cause hospitalization or mortality compared with patients with poor functional capacity who reported low exercise engagement (hazard ratio: 0.64, P = 0.028). CONCLUSION: Self-reported engagement in a minimum of 60 min of exercise per week was associated with a significant improvement in event-free survival, even in patients with HF with low functional capacity. These results provide evidence that this dose of exercise is beneficial in patients with HF and poor functional capacity.

Improvement in Heart Failure Self-Care and Patient Readmissions with Caregiver Education: A Randomized Controlled Trial.

Caregivers support heart failure (HF) self-care with little HF education. The purpose of this study was to evaluate the effectiveness of a caregiver-only educational intervention aimed at improving caregiver self-efficacy, perceived control, and HF knowledge, as well as patient self-care and 30-day cardiac readmission. In total, 37 patients and their caregivers were randomly assigned to a control condition or a caregiver-only educational intervention with telephone follow-up. Outcomes included patient 30-day cardiac readmission, patient self-care, caregiver self-efficacy, caregiver perceived control, and caregiver HF knowledge. Linear mixed model, Kaplan-Meier, and Cox regression analyses were used to determine the effects of the intervention on outcomes. Self-care maintenance (p = 0.002), self-care management (p = 0.005), 30-day cardiac readmission (p = 0.003), and caregiver perceived control (p < 0.001) were significantly better in the intervention group. The results suggest that interventions targeting caregiver HF education could be effective in improving HF patients' 30-day cardiac readmissions, patient self-care, and caregiver perceived control.

Associations of multidimensional fatigue with the physical, psychological, and situational factors in outpatients with heart failure: a cross-sectional study.

AIMS: Fatigue, a distressing symptom in patients with heart failure (HF), is associated with progress and health outcomes. Fatigue has been identified as having multidimensions, but a few studies have used a multidimensional fatigue scale. Many factors related to HF, including physical, psychological, and situational factors, may impact fatigue. However, there is limited knowledge about how these HF-related factors are associated with multidimensional fatigue in outpatients with HF in Japan. The aim of this study was to identify HF-related factors [physical; clinical characteristics, New York Heart Association (NYHA) functional class and physical function, psychological; depressive symptoms and anxiety, situational; health literacy and perceived control] associated with the five dimensions of fatigue in outpatients with HF. METHODS AND RESULTS: Outpatients with HF (N = 165, mean age = 69.5 years, 78.8% male) completed the survey and physical assessment of gait speed. Fatigue was assessed using five dimensions of the Multidimensional Fatigue Inventory-20. Multiple linear regression analysis was conducted for each dimension of fatigue. General fatigue was predicted by age, NYHA, and perceived control. Physical fatigue was predicted by NYHA, depressive symptoms, and perceived control. Reduced activity was predicted by NYHA, gait speed, depressive symptoms, communicative health literacy, and critical health literacy. The reduced motivation was predicted by depressive symptoms and perceived control. Mental fatigue was predicted by depressive symptoms. CONCLUSION: Different factors were significantly associated with each fatigue dimension. Further research is needed to alleviate fatigue in patients with HF.

Diet variety sup the relationship between appetite and micronutrient intake in patients with heart failure.

AIMS: Eating a varied diet promotes adequate micronutrient intake. Poor appetite could decrease the desire to eat a varied diet leading to dietary micronutrient insufficiencies. The interrelationships among appetite, diet variety, and dietary micronutrient intake have not been investigated in patients with heart failure (HF). The purpose of the study was to determine whether the relationship between appetite and micronutrient insufficiency was mediated through diet variety. METHODS AND RESULTS: A total of 238 patients with HF, mean age 61 ± 12.1; 68% male, and 45% NYHA class III/IV were included in this secondary analysis. Data collection consisted of a 4-day food diary and self-reported appetite on a 10-point visual analogue scale. Micronutrient insufficiency was defined as the total number of 17 minerals and vitamins that were insufficient in the diet. Diet variety was calculated as the number of 23 food types consumed over the 4 days. Mediation analysis, controlling for covariates age, gender, NYHA class, and body mass index showed that diet variety mediated the relationship between appetite and micronutrient insufficiencies [indirect effect = -0.0828, 95% confidence interval (CI): -0.1585 to -0.0150]. There was no direct effect of appetite on micronutrient insufficiency (c´ = -0.1802; 95% CI = -0.3715 to.0111). CONCLUSIONS: Diet variety played a previously unrecognized role in the relationship between appetite and dietary micronutrient intake in patients with HF. More research is needed to validate these associations in patients with HF.

Measures of Engagement With mHealth Interventions in Patients With Heart Failure: Scoping Review.

BACKGROUND: Despite the potential of mobile health (mHealth) interventions to facilitate the early detection of signs of heart failure (HF) decompensation and provide personalized management of symptoms, the outcomes of such interventions in patients with HF have been inconsistent. As engagement with mHealth is required for interventions to be effective, poor patient engagement with mHealth interventions may be associated with mixed evidence. It is crucial to understand how engagement with mHealth interventions is measured in patients with HF, and the effects of engagement on HF outcomes. OBJECTIVE: In this review, we aimed to describe measures of patient engagement with mHealth interventions and the effects of engagement on HF outcomes. METHODS: We conducted a systematic literature search in 7 databases for relevant studies published in the English language from 2009 to September 2021 and reported the descriptive characteristics of the studies. We used content analysis to identify themes that described patient engagement with mHealth interventions in the qualitative studies included in the review. RESULTS: We synthesized 32 studies that operationalized engagement with mHealth interventions in 4771 patients with HF (3239/4771, 67.88%, male), ranging from a sample of 7 to 1571 (median 53.3) patients, followed for a median duration of 90 (IQR 45-180) days. Patient engagement with mHealth interventions was measured only quantitatively based on system usage data in 72% (23/32) of the studies, only qualitatively based on data from semistructured interviews and focus groups in 6% (2/32) of studies, and by a combination of both quantitative and qualitative data in 22% (7/32) of studies. System usage data were evaluated using 6 metrics of engagement: number of physiological parameters transmitted (19/30, 63% studies), number of HF questionnaires completed (2/30, 7% studies), number of log-ins (4/30, 13% studies), number of SMS text message responses (1/30, 3% studies), time spent (5/30, 17% studies), and the number of features accessed and screen viewed (4/30, 13% studies). There was a lack of consistency in how the system usage metrics were reported across studies. In total, 80% of the studies reported only descriptive characteristics of system usage data. The emotional, cognitive, and behavioral domains of patient engagement were identified through qualitative studies. Patient engagement levels ranged from 45% to 100% and decreased over time. The effects of engagement on HF knowledge, self-care, exercise adherence, and HF hospitalization were inconclusive. CONCLUSIONS: The measures of patient engagement with mHealth interventions in patients with HF are underreported and lack consistency. The application of inferential analytical methods to engagement data is extremely limited. There is a need for a working group on mHealth that may consolidate the previous operational definitions of patient engagement into an optimal and standardized measure.

Linkage of Optimism With Depressive Symptoms Among the Stroke Survivor and Caregiver Dyads at 2 Years Post Stroke: Dyadic Mediation Approach.

BACKGROUND: Depressive symptoms are substantial among stroke survivors and their caregivers in poststroke management. Optimism and social support are known to protect against depressive symptoms. However, little is known about how optimism and social support contribute to depressive symptoms among stroke survivor-caregiver dyads. The study's purpose was to examine actor and partner effects of optimism on depressive symptoms through perceived social support among stroke survivors and caregiver dyads in the chronic stage of rehabilitation. METHODS: Stroke survivors and caregivers (N = 105 dyads) completed the survey at 2 years of follow-up after the first stroke. Depressive symptoms, optimism, and perceived social support were assessed using the Center for Epidemiologic Studies-Depression, the Life Orientation Test, and the Interpersonal Support Evaluation List. The Actor-Partner Interdependence Model Extended to Mediation analysis was used to test the indirect effect of optimism on depressive symptoms through perceived social support. RESULTS: Higher optimism was significantly associated with lower depressive symptoms for caregivers (direct actor effect, -0.6844; 95% confidence interval [CI], -0.9844 to -0.3844) and stroke survivors (direct partner effect, -0.4189; 95% CI, -0.0789 to -0.0889). Perceived social support availability significantly mediated the association between optimism and depressive symptoms for stroke survivors (indirect effect, -0.1957; 95% CI, -0.3923 to -0.0670). Caregiver perceived social support availability was also a significant mediator between caregivers' optimism and stroke survivors' depressive symptoms (indirect effect, 0.1658; 95% CI, 0.0559-0.3128). CONCLUSIONS: Intervention improving dyad members' optimism and social support would be beneficial to improve depressive symptoms of the stroke survivors and caregivers in chronic stroke management.

Caregivers of patients with cancer: perceived stress, quality of life and immune function.

OBJECTIVES: To examine the mediating effect of quality of life (QoL) on the relationship between perceived stress and immune function in Korean family caregivers of patients with cancer. METHODS: In this cross-sectional study, 89 family caregivers of patients with cancer completed perceived stress and QoL questionnaires. Immune function was assessed using two proinflammatory biomarkers, IL-6 and tumour necrosis factor-alpha (TNF-α). Multiple parallel mediator regression was conducted using four mediators (burden, lifestyle disruption, positive adaptation and financial concern) representing the subscales of QoL related to caregiving. RESULTS: Psychological (indirect effect (ab)=-0.52, 95% CI -1.25 to -0.01) and physical (ab=-0.44, 95% CI -1.07 to -0.05) stress had a significant indirect effect on IL-6 levels attributed to lifestyle disruption associated with caregiving. Psychological (ab=-0.97, 95% CI -2.37 to -0.11) and physical (ab=-1.10, 95% CI -2.87 to -0.08) stress also had a significant indirect effect on TNF-α as a result of financial concerns owing to caregiving. Other indirect effects of psychological/physical stress on inflammation were not significant. CONCLUSION: This study demonstrated that the effects of perceived psychological and physical stress on IL-6 and TNF-α levels were mediated by the caregiver's QoL, especially lifestyle disruption and financial concerns. Stress management and improvement of caregivers' QoL related to lifestyle disruption and financial issues should be considered to reduce the negative effects of caregiving on immune function.

Use of Mobile Apps for Self-care in People With Parkinson Disease: Systematic Review.

BACKGROUND: Self-care is essential for people with Parkinson disease (PD) to minimize their disability and adapt to alterations in physical abilities due to this progressive neurodegenerative disorder. With rapid developments in mobile technology, many health-related mobile apps for PD have been developed and used. However, research on mobile app-based self-care in PD is insufficient. OBJECTIVE: This study aimed to explore the features and characteristics of mobile apps for self-care in people with PD. METHODS: This study was performed sequentially according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Web of Science, and PsycINFO were searched in consultation with a librarian on June 8, 2021. We used keywords including "Parkinson disease" and "mobile." RESULTS: A total of 17 studies were selected based on the inclusion criteria, including 3 randomized controlled trials and 14 observational studies or quasi-experimental studies. The use of mobile apps for self-care in people with PD focused on symptom monitoring, especially motor symptoms. Motor symptoms were objectively measured mainly through the sensors of smartphones or wearable devices and task performance. Nonmotor symptoms were monitored through task performance or self-reported questionnaires in mobile apps. Most existing studies have focused on clinical symptom assessment in people with PD, and there is a lack of studies focusing on symptom management. CONCLUSIONS: Mobile apps for people with PD have been developed and used, but strategies for self-management are insufficient. We recommend the development of mobile apps focused on self-care that can enhance symptom management and health promotion practices. Studies should also evaluate the effects of mobile apps on symptom improvement and quality of life in people with PD. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42021267374; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021267374.