Primary care providers need a variety of nutrition and wellness patient education materials.

OBJECTIVE: To assess and document the need for nutrition and wellness patient education materials. DESIGN: The results of open-ended interviews and focus groups were used to develop a mail-type survey. The 46-item survey addressed barriers to using nutrition and wellness education materials as well as format, education/reading level, foreign languages, and topics needed. North Carolina Cooperative Extension Service (NCCES) family and consumer education agents distributed surveys to family and general practices throughout North Carolina. SUBJECTS: Of the 721 primary care providers surveyed, 303 (42%) returned usable surveys. Respondents practiced in 89 of the 100 counties of the state served by NCCES family and consumer education agents. STATISTICAL ANALYSIS PERFORMED: Descriptive statistics and independent sample t tests were used to analyze survey results. RESULTS: Limited time with patients and inability to obtain materials because of cost or being unsure of sources were most often identified as barriers to using nutrition and wellness materials. Of the 26 topics surveyed, 6 had mean levels of need greater than or equal to high need (mean score > or = 4): weight control for adults, smoking cessation, changing dietary fat intake, exercise guidelines for healthy adults, general stress management guidelines, and healthful eating for older adults. Twenty-four of the 26 topics had mean levels of need greater than or equal to moderate need (mean score > or = 3). Topics with moderate need included guidelines for overweight children and adolescents, nutrition for chronic disease prevention, and healthful eating for various stages of the life cycle. The combined mean score for topics dealing with weight control and exercise for adults, adolescents, and children was greater than the score for high need (mean score > 4). Eighty-three percent of respondents preferred 1-page, printed handouts. Forty-five percent requested materials in Spanish. APPLICATIONS: Dietitians who work in a variety of settings can use techniques similar to those described here to determine the patient education materials practitioners need for the populations they serve. The information obtained from this study will be used to develop 1-page, printed handouts. A registered dietitian and a food and nutrition specialist with NCCES will develop and pilot-test the handouts. These materials will be made available to primary care providers in North Carolina via local NCCES family and consumer education agents, many of whom are registered dietitians.

The relation between religiosity, selected health behaviors, and blood pressure among adult females.

BACKGROUND: This study examined the association between blood pressure (BP), selected health behaviors, and various dimensions of religiosity among females. METHODS: Data were obtained on 112 females who were at least 35 years of age and of Judeo-Christian faith. Resting BP measures were taken with an automated sphygmomanometer, height and weight were measured to determine body mass index (BMI), and intermediate health variables (e.g., physical activity, smoking, diet, and alcohol consumption) were measured by questionnaire. A multifactorial questionnaire was used to assess various dimensions of religiosity. Multiple regression path analyses were conducted to determine the direct and indirect effects of religiosity on BP with age and BMI controlled statistically. RESULTS: The direct effects of religiosity on SBP and DBP were more substantial than the indirect effects through the intermediate health variables, suggesting that religiosity may be associated with lower levels of BP via a direct pathway, such as improving the ability to cope with stress. In general, DBP was more influenced by religiosity than SBP and the dimensions of "intrinsic religiosity" and "religious coping" were most influential. Results also indicated that "religious experiences" may exert a greater beneficial effect on DBP in older (50-80 years) age groups. CONCLUSIONS: These results support a direct relationship between religiosity and BP, rather than an indirect effect through intermediate health behaviors.

The relation of documented coronary artery disease to levels of total cholesterol and high-density lipoprotein cholesterol.

Recommendations for identifying persons at high risk for coronary heart disease are based primarily on levels of total and low-density lipoprotein cholesterol. We examined whether, given knowledge of these levels, information on the high-density lipoprotein cholesterol level would improve the prediction of arteriographically documented coronary artery disease among 591 men. We found that even at levels of total and low-density lipoprotein cholesterol considered desirable, high-density lipoprotein cholesterol was inversely related to disease severity. For example, among the 112 men with a total cholesterol level <180 mg per dl, the mean occlusion score (representing the overall severity of disease) was 107 among men with a high-density lipoprotein cholesterol level < or = 30 mg per dl vs a mean score of 52 among men with levels > or = 45 mg per dl. Furthermore, men with low levels of both low-density lipoprotein cholesterol (< 110 mg per dl) and high-density lipoprotein cholesterol (< or = 30 mg per dl) had as much occlusive disease as did men with high levels of both lipoprotein fractions. Given information on the ratio of high-density lipoprotein cholesterol to total cholesterol, the actual levels of the lipoprotein fractions did not improve disease prediction. Our results emphasize the importance of considering high-density lipoprotein cholesterol when assessing coronary heart disease risk.

Cholesterol and coronary artery disease: age as an effect modifier.

An elevation of serum cholesterol has been one of the more frequently cited risk factors for coronary heart disease, found in both case-control and cohort studies. As a result, this country has undertaken massive screening of adults older than 20 years of age in an attempt to identify those persons with cholesterol levels greater than 200 mg/dl, and follow up with an active approach for intervention. The suggested cutpoints for borderline (200-240 mg/dl), and definite (> or = 240 mg/dl) hypercholesterolemia have been applied to all age groups despite suggestions of a diminution of risk conferred by cholesterol in the elderly. This study of 2544 white men undergoing coronary angiography shows that for all men, aged 25-84 years, plasma cholesterol levels were associated with an increase in coronary artery occlusion (rs = 0.15, p < 0.01). However, when stratified by age, this association held only for the younger men, the association diminishing to near zero in the oldest age group. The negative interaction between cholesterol levels and age in predicting coronary artery disease proved highly significant (p < 0.001) in multivariable linear regression analysis, suggesting that cholesterol levels are much less predictive of coronary artery disease in the elderly as compared to the young. These results point to the need for a more finely tuned set of criteria for the evaluation of hypercholesterolemia, one that takes into account the age of the screenee.

Treatment of multiple sclerosis with hyperbaric oxygen. Results of a national registry.

Three hundred twelve patients were entered into a long-term study of effects of hyperbaric oxygen on multiple sclerosis. The protocol called for an initial 20 treatments in either the monoplace or multiplace chamber on a daily basis followed by monthly booster treatments for 2 years. One hundred seventy neurologists and 22 institutions provided data for this study. There was no control group, but the study was based on Schumacher's postulation that a scientifically valid study to test the efficacy of a new therapy was possible by choosing patients who were definitively diagnosed with multiple sclerosis and following them up for 2 years after the imposed treatment. If the overwhelming majority of the subjects failed to get worse over the 2-year observation period, the efficacy of the treatment would be manifest. The expanded Kurtzke Disability Status Scale (EDSS) was used to assess the severity of the disease state. The dropout rate was high with only 76% (237 of 312 patients) finishing the initial 20 treatments. Twenty-two percent (69 of 312) finished 1 year of booster therapy, and 9% (28 of 312) completed 2 years of monthly boosters. The mean deterioration on the Kurtzke EDSS score was 0.93 or almost a full step from the beginning of treatment until the last evaluation. There was no difference in outcome between those who had the shortest and longest periods of time between onset of symptoms and hyperbaric oxygen treatment. Treatment pressure made no difference in outcome. Changes in the Kurtzke EDSS score bore no relationship to the use of booster treatment. Patients who were reasonably well off at the onset of treatment with initial Kurtzke EDSS scores of 1 or 2 (n = 21) deteriorated by an average of 1.7 Kurtzke points. Those patients whose initial Kurtzke EDSS scores were greater than 2 (n = 164) deteriorated on an average of 0.82 points. Of interest was that 19.5% (39 of 200) of the patients reported a temporary improvement in bladder function, but improvement was maintained in only 11 patients (5.5%) at 2-year follow-up. Fifteen patients (7.5%) indicated long-term worsening. There was no significant change in the working status of the patients following hyperbaric oxygen treatment. Although this study treated the patients in accordance with protocols reported to produce a benefit in multiple sclerosis, we were unable to substantiate any useful long-term effect of hyperbaric oxygen therapy.

Pediatric Trauma Score. Predictor of hospital resource use?

The Pediatric Trauma Score has been recommended to triage children with scores of 8 or less to a level 1 pediatric trauma center. The Injury Severity Score correlates well with the Pediatric Trauma Score. During a 36-month period ending December 31, 1985, paramedics saw 983 pediatric trauma patients (aged 17 years and younger) and intervened with advanced life support procedures in 196 (20%). One hundred forty-four patients receiving advanced life support were transported to either a level 1 adult trauma center or a pediatric community hospital. Our data confirm the correlation between Pediatric Trauma Score and Injury Severity Score and support recommendations to transport patients with Pediatric Trauma Scores of 8 or less to trauma facilities. We also conclude that Pediatric Trauma Scores may be useful in predicting hospital resource use.

Body fat distribution and male/female differences in lipids and lipoproteins.

The role of body fat distribution, as assessed by the ratio of waist-to-hip circumferences (WHR), in statistically explaining differences in levels of lipoproteins between men and women was studied using data collected in 1985-1986 from employed adults (mean age, 40 years). As compared with the 415 women, the 709 men had higher mean levels of triglycerides (+38 mg/dl) and apolipoprotein B (+11 mg/dl) as well as lower mean levels of high density lipoprotein (HDL) cholesterol (-15 mg/dl) and apolipoprotein A-I (-19 mg/dl). Additionally, men were more overweight, consumed more alcohol, and exercised more frequently than women but were less likely to smoke cigarettes. Controlling for these characteristics, however, did not alter the differences in lipoprotein levels between men and women. In contrast, adjustment for WHR (which was greater among men) reduced the sex differences in levels of apolipoprotein B (by 98%), triglycerides (by 94%), HDL cholesterol (by 33%), and apolipoprotein A-I (by 21%). Similar results were obtained using analysis of covariance, stratification, or matching; at comparable levels of WHR, differences in lipid and lipoprotein levels between men and women were greatly reduced. Although these results are based on cross-sectional analyses of employed adults and need to be replicated in other populations, the findings emphasize the relative importance of body fat distribution. Whereas generalized obesity and body fat distribution are associated with lipid levels, fat distribution (or a characteristic influencing fat patterning) can be an important determinant of sex differences in levels of triglycerides, HDL cholesterol, and apolipoproteins B and A-I.

Coping with DRGs--a nursing home's experience.

The introduction of prospective payment system (PPS) based on diagnostic related groups (DRGs) has had a significant impact on hospitals. To determine the impact of PPS on nursing homes, the authors studied the activity of a Veterans Administration teaching nursing home (admissions, acute hospital transfers, and discharges) during 1 year preceding implementation of DRGs and for 3 consecutive years following implementation of DRGs. In 1983, pre-DRGs, a total of 36 patients, were admitted to the nursing home. Following implementation of DRGs, a sevenfold increase was noted in the number of patients admitted when comparing 1983 and 1986, with the monthly average of patients admitted increasing from 3 in 1983 to 9.7, 22, and 23.8 in 1984, 1985, and 1986, respectively. Associated with the increase in patients admitted following DRGs was an increase in patients requiring transfer to the acute hospital, within 30 days of admission to the nursing home. In 1986, approximately 27% of patients admitted to the nursing home required transfer to the acute hospital within 30 days of their admission. The number of patients discharged from the nursing home also increased following DRGs. None of the patients admitted to the nursing home in 1983 were discharged within 30 days of admission. Subsequent to introduction of DRGs, an average of two patients per month were discharged within 30 days of nursing home admission.(ABSTRACT TRUNCATED AT 250 WORDS)

Cigarette smoking and non-fatal myocardial infarction in women: is the relation independent of coronary artery disease?

The relation of cigarette smoking to both coronary disease and non-fatal myocardial infarction was examined in a cross sectional study of 1053 women who underwent coronary arteriography. As compared with the 489 women who had never smoked cigarettes, ever-smokers (mean duration of smoking, 25 years) were 1.6 times as likely to have significant stenotic disease and were 1.9 times as likely to have suffered a myocardial infarction. These associations were strongest in women under 50 years of age, with odds ratios of 3.5 for coronary artery disease and 4.5 for myocardial infarction. Although the extent of stenotic disease and prior myocardial infarction were strongly associated, women who smoked cigarettes remained at increased risk of a myocardial infarction even after their increased coronary artery disease had been taken into account. For example, heavy smokers (greater than 30 pack-years) were 2.3 times as likely to have had a myocardial infarction as were non-smokers; controlling for the extent of stenotic disease (in addition to age and other risk factors) reduced the estimated relative risk to only 1.9. Stratified analyses showed that this increased risk for clinical disease among smokers was evident at all levels of occlusion, even among women with minimal stenotic disease. These results, collected at the time of arteriography, suggest that non-atherogenic mechanisms may be important in the aetiology of myocardial infarction among women who smoke cigarettes.

Risk factors and the anatomic distribution of coronary artery disease.

Differences in the importance of risk factors according to the anatomic location of coronary artery disease (CAD) were assessed in 4722 men and 1069 women who underwent arteriography. Examined characteristics included total and high-density lipoprotein (HDL)-cholesterol, triglycerides, obesity, smoking, alcohol consumption, diabetes, and hypertension. Of these risk factors, the ratio of total to HDL-cholesterol showed the highest correlation with the overall severity of CAD (r = 0.24, men; r = 0.38, women); in contrast, its relation to left main (LM) disease was much lower (r = 0.10, men; r = 0.08 women) than were correlations with stenotic disease in the left anterior descending, circumflex, and right coronary arteries. Other risk factors also showed weaker associations with LM disease than with stenoses in other vessels, and none was related to increased LM disease after controlling for disease in other vessels. For example, as compared with men who had no significant CAD, those with 1-, 2-, and 3-vessel disease had mean increases in total cholesterol of 12, 18, and 19 mg/dl, respectively. In contrast, after adjusting for disease in other vessels, LM disease (present in 293 men) was associated with only a 4 mg/dl increase in mean cholesterol levels (P = 0.20). These results indicate that the relation of risk factors to CAD differs according to the location of the stenotic disease, and that LM disease is poorly predicted by the standard risk factors.

The influence of smoking on vitamin C status in adults.

To further define the relation between smoking and vitamin C status, the dietary and serum vitamin C levels of 11,592 respondents in the second National Health and Nutrition Examination Survey (NHANES II) were analyzed. Smokers of 20 cigarettes daily had the lowest vitamin C dietary intake (79 mg, 95% CI:73, 84) and serum levels (0.82 mg/dl, 95% CI: 0.77, 0.86; 46.6 mumol/L, 95% CI: 43.7, 48.8), while smokers of 1-19 cigarettes daily had decreased vitamin C intake (97 mg; 95% CI: 90, 104 mg) and serum levels (0.97 mg/dl, 95% CI: 0.92, 1.03; 55.1 mumol/L, 95% CI: 52.2, 58.5) compared to respondents who had never smoked (109 mg, 95% CI: 105, 113 and 1.15 mg/dl, 95% CI: 1.11, 1.18; 65.3 mumol/L, 95% CI: 63.0, 67.0, respectively). This inverse association between both intake and serum levels of vitamin C and smoking was independent of age, sex, body weight, race, and alcoholic beverage consumption. Following further adjustment for dietary vitamin C intake, the negative correlation between cigarette smoking and serum vitamin C levels persisted. The risk of severe hypovitaminosis C (serum levels less than or equal to 0.2 mg/dl; 11.4 mumol/L) was increased in smokers, particularly when not accompanied by vitamin supplementation (odds ratio 3.0, 95% CI: 2.5, 3.6). These data suggest that even though smoking adversely affects preferences for vitamin C rich foods, the inverse association between smoking and serum vitamin C levels occurs independently of dietary intake.

Calcium intake and the relationship of dietary sodium and potassium to blood pressure.

Using First National Health and Nutrition Examination Survey (NHANES I) data, we studied the relationships of dietary sodium, potassium, and alcohol to blood pressure in relation to levels of dietary calcium intake. At low Ca intakes (less than 400 mg/d for men and less than 800 mg/d for women) the ratio of Na to K (Na:K) was significantly related to blood pressure (p less than 0.01) after controlling for age, body mass index (BMI), race, and gender. At higher Ca intakes neither Na:K nor any other nutrient (with the exception of alcohol) was related to either systolic or diastolic blood pressures. Na:K was more strongly related to blood pressure than either nutrient alone and low Ca intakes were necessary for the Na:K-blood pressure relationship to be evident. Interaction of these three dietary factors in relation to blood pressure was evident in all race and gender groups. Associations of age, BMI, gender, and alcohol with blood pressure were not affected by Ca levels.

Black/white differences in risk factors for arteriographically documented coronary artery disease in men.

Although the leading cause of death among black men in the United States is coronary artery disease (CAD), risk factors have not been well documented in black populations. Therefore, possible racial differences in the relation of several characteristics to the extent of CAD were assessed in 4,722 white and 169 black men who underwent arteriography. Associations between an occlusion score (ranging from 0 to 300), reflecting the severity of CAD, and levels of total and high-density lipoprotein (HDL) cholesterol, triglycerides, cigarette smoking, alcohol intake, relative weight, systemic hypertension and diabetes mellitus were examined. Most risk factors were significantly related to the extent of CAD in both races, but lipid levels showed stronger associations with CAD among blacks: correlations between CAD and total cholesterol were 0.16 (whites) vs 0.29 (blacks) and associations with HDL cholesterol were -0.22 (whites) vs -0.49 (blacks). In addition, at adverse levels of certain risk factors, blacks had more extensive CAD than did whites: mean occlusion scores were 148 (whites) and 238 (blacks) at HDL cholesterol levels less than 30 mg/dl. As assessed by multiple linear regression, however, only triglyceride levels were differentially related to CAD between whites (beta = 0) and blacks (beta = 0.47), p less than 0.01 for racial contrast. These results document the importance of risk factors in black men and indicate black/white differences in the relation of triglycerides to CAD.

Relation of triglyceride levels to coronary artery disease: the Milwaukee Cardiovascular Data Registry.

Although levels of triglycerides have consistently shown a strong association with cardiovascular disease in both case-control and cohort studies, it remains controversial whether this relation exists independently of levels of cholesterol and other risk factors. The association of arteriographically documented coronary artery disease with plasma levels of triglycerides, total cholesterol, and high density lipoprotein (HDL) cholesterol was therefore examined in 5,216 white adults (81% were male) referred to two Milwaukee hospitals between 1972 and 1986. Elevated levels of triglycerides were related to the extent of coronary artery disease (estimated using the total number and severity of stenoses) in both sexes; this association existed independently of total cholesterol, age, obesity, hypertension, smoking, and alcohol consumption. In addition, the association between triglycerides and coronary artery occlusion was strongest at total cholesterol levels less than or equal to 250 mg/dl. However, both stratified and regression analyses indicated there was no residual association between triglyceride levels and occlusion after controlling for HDL cholesterol. (Levels of HDL cholesterol and triglycerides showed a moderate inverse association: r = -0.39 to -0.51.) These results indicate that the association between coronary artery occlusion and levels of triglycerides is indirect, and that the disparate findings of earlier studies may have resulted from not controlling for HDL cholesterol.

Postmenopausal use of estrogen and occlusion of coronary arteries.

The degree of coronary artery occlusion was compared between users and nonusers of postmenopausal estrogen among 933 female patients undergoing angiography between the ages 50 and 75 years in the Milwaukee Cardiovascular Data Registry. Users (n = 154) had less occlusion than nonusers (n = 779), and a significant increase in occlusion scores with age was evident for nonusers (p less than 0.001) but not for users (p = 0.50). The age-adjusted odds ratios for use of postmenopausal estrogen among women with moderate and severe levels of occlusion of the coronary arteries were 0.59 (95% confidence interval, 0.48 to 0.73) and 0.37 (95% confidence interval, 0.29 to 0.46), respectively, which indicated a statistically significant, apparent protective effect of postmenopausal estrogen on coronary occlusion. This effect was independent of the type of menopause or other risk factors but not independent of high-density lipoprotein-cholesterol levels. Higher high-density lipoprotein-cholesterol levels among users may indicate a biologic mechanism by which postmenopausal estrogen use lowers the risk of coronary occlusion.

Diabetes mellitus and arteriographically-documented coronary artery disease.

Diabetics are at increased risk for coronary heart disease even after accounting for other risk factors, and the impact of diabetes mellitus may be particularly strong among females and at adverse levels of other risk factors. Therefore, the independent relation of diabetes to arteriographically-documented coronary artery disease (CAD) was examined in 5620 patients (18% female) referred to two Milwaukee hospitals from 1972 to 1986. As assessed by questionnaire, the prevalence of diabetes mellitus among these patients was 8% (n = 466). Diabetics had increased CAD (assessed by the number and severity of stenoses) even after accounting for levels of total and high-density lipoprotein cholesterol, triglycerides, hypertension, obesity, smoking, and alcohol consumption. In addition, regression analyses indicated that as compared with nondiabetics, female diabetics tended to have a greater increase in CAD than did male diabetics (p = 0.06 for sex x diabetes interaction). Although adverse levels of other risk factors did not increase the association between diabetes and CAD, female diabetics who were using oral hypoglycemics or insulin showed almost a two-fold increase in CAD severity (p less than 0.01). Results suggest that the higher relative risk of coronary heart disease among female (vs male) diabetics may be due to a proportionately greater increase in atherosclerosis.

Body fat distribution, plasma lipids, and lipoproteins.

The relation of body fat distribution as measured by the ratio of waist to hip circumferences (WHR) to plasma levels of lipids and lipoproteins was studied in 713 men and 520 women who were employed by two Milwaukee companies. Quetelet index (kg/m2), waist girth, hip girth, and WHR were each positively related to levels of total cholesterol, triglycerides, apolipoprotein B, and the ratio of total to high density lipoprotein (HDL) cholesterol. In addition, the anthropometric measures were inversely associated with levels of HDL cholesterol. (Controlling for age, alcohol intake, exercise level, current smoking status, and oral contraceptive use only slightly reduced the strength of the correlations.) In addition, WHR and Quetelet Index were independently related to lipid and lipoprotein levels, and the magnitudes of the associations were roughly equivalent. For example, the mean (covariate-adjusted) triglyceride level among men in the upper tertile of the Quetelet Index was 37 mg/dl higher than for men in the lower tertile of the Quetelet Index; the corresponding difference according to WHR tertiles (upper to lower) was 39 mg/dl (p less than 0.01 for both effects). These findings indicate that in healthy men and women a less favorable lipid and lipoprotein profile is associated with elevated levels of both Quetelet Index and WHR.

Risk factors among patients undergoing repeat aorta-coronary bypass procedures.

It is estimated that as many as 7% of patients who have an aorta-coronary bypass operation will require a second bypass procedure within 10 to 12 years. Using information from the Milwaukee Cardiovascular Data Registry, we matched 166 men who underwent two coronary bypass operations at least 6 months apart, between 1968 and 1981, with 428 patients who had a single procedure. Patients were matched according to date of operation and left ventricular wall motility function for analysis of risk factors for repeat operation. Elevated triglyceride levels were found to be the strongest risk factors associated with reoperation. In addition, both younger age and less complete revascularization during the first operation were significant predictive factors of repeat operation. The results suggest that efforts to reduce plasma triglyceride levels and ensure adequate revascularization may significantly reduce the need for repeat coronary bypass.