Development and cross-validation of a prediction equation for estimating resting energy expenditure in healthy African-American and European-American women.

OBJECTIVE: To develop, validate, and cross-validate a formula for predicting resting energy expenditure (REE) in African-American and European-American women. DESIGN: A cross-sectional study of REE in women. Participants were randomly assigned to one of two groups. One group served to develop and validate a new equation for predicting REE while the second was used to cross-validate the prediction equation. The accuracy of the equation was compared to several existing formulae. SETTING: University metabolic laboratory, Memphis, TN, USA. SUBJECTS: Healthy, premenopausal African-American and European-American women between 18 and 39 y of age. The validation sample included 239 women (age: 28.4 y, wt: 70.7 kg, body mass index (BMI): 25.2 kg/m(2), REE: 5840 kJ/day), while the cross-validation sample consisted of 232 women (age: 27.5 y, wt: 70.7 kg, BMI: 25.2 kg/m(2), REE: 5784 kJ/day). RESULTS: The prediction equation derived from the current sample, which included adjustments for ethnicity, was the only formula that demonstrated a high level of accuracy for predicting REE in both African-American and European-American women. The mean difference between REE predicted from the new formula and measured REE was 28 kJ/day (s.d.=668) for European-American women and 142 kJ/day (s.d.=584) for African-American women. CONCLUSIONS: Previous equations for predicting energy needs may not be appropriate for both African-American and European-American women due to ethnic differences in REE. A new equation that makes adjustments in predicted REE based on ethnicity is recommended for determining energy needs in these groups (Predicted REE (kJ/day)=616.93-14.9 (AGE (y))+35.12 (WT (kg))+19.83 (HT (cm))-271.88 (ETHNICITY: 1=African American; 0=European American)). SPONSORSHIP: Support for this study was provided by Grant #HL53261 from the National Heart, Lung, and Blood Institute.

Cigarette smoking is associated with energy balance in premenopausal African-American adult women differently than in similarly aged white women.

OBJECTIVE: To investigate the differential association of cigarette smoking with energy balance in African-American and white premenopausal women. DESIGN: Cross-sectional study of energy balance, weight, and smoking in women. SUBJECT: A total of 374 women: 191 African-American (mean age=29.8+/-6.5 y) and 183 white women (mean age=28.9+/-7.1 y). MEASUREMENTS: Weight, cigarette smoking habits, resting energy expenditure, dietary intake, and physical activity. RESULTS: There were no significant differences in dietary intake by race or smoking status. The model for physical activity was significant (P=0.0004), with body mass index (BMI) having the largest effect on activity (P<0.001). Smoking status was related to activity, with the heaviest smokers reporting more activity than nonsmokers (P=0.008) or light smokers (P=0.028). The model for resting energy expenditure (REE) was significant (P<0.0001), with the largest again being BMI (P<0.001). There was also an interaction between ethnicity and smoking status (P<0.0001) such that African-American nonsmokers and light smokers tended to have lower REE than several other groups, most often the African-American moderate heavy smokers. The model for BMI was significant (P<0.0001) with an interaction for ethnicity and smoking status (P=0.0009). African-American nonsmokers and light smokers had significantly higher BMIs than most of the other groups. CONCLUSION: African-American women who were the heaviest smokers had a lower adjusted BMI than the heaviest smoking white women. This effect, at least partially, may be related to an increased REE in the African-American smoking women. While energy intake did not appear to be important in this relationship, energy expended in physical activity appeared to be increased with smoking, as was REE.

Food sources of calcium in a sample of African-American an Euro-American collegiate athletes.

Adequate calcium intake is integral to bone health as well as for optimal athletic performance. This study was conducted to investigate: (a) food sources of calcium in a sample of collegiate athletes, (b) gender and/or ethnic differences in food sources of calcium, and (c) whether athletes that derive less of their calcium intake from dairy sources increase their calcium intake from supplements or other food sources. Participants were African-American and Euro-American NCAA Division 1-A athletes. Eighty-five men and 59 women participated. Calcium intake for the previous 7-day period was assessed with a brief calcium screen. Men consumed significantly more calcium than women (1,354 vs. 898 mg/day), with female cross-country runners exhibiting the lowest average intake (605 mg/day). Both men and women obtained the majority of their calcium from dairy products and mixed dishes, while men consumed significantly more calcium-fortified foods. Several gender and ethnic interactions for calcium intake from food groups were found. Mean total dairy calcium intake was found to vary according to total calcium intake in men, and supplemental calcium was not used to augment low dairy intakes of calcium in any group. While African-Americans and Euro-Americans athletes were consuming similar levels of calcium, the female athletes in the sample did not get adequate amounts.

Socioeconomic status, ethnicity, and health care access among young and healthy women.

This study examined: (a) the relationship between socioeconomic status (SES) and health care access among healthy women; (b) which SES variable(s) were most strongly associated with HCA; and (c) whether the SES/HCA relationship was the same for Black and White women. A total of 383 women (57.4% Whites and 42.6% Blacks) participated in the study. Independent variables included family income, education levels, occupation, median income within zip code of participants' residence, and ethnicity. Dependent variables were the total and subscale scores (accessibility, accommodation, and affordability) on a measure of health care access. Family income was the SES variable that showed the strongest positive association with total health care access, and there was a significant interaction between occupation and ethnicity for total health care access. Unique relationships were observed between each SES variable and each subscale on the health care access measure. The overall patterns between SES and health care access were similar for Blacks and Whites. Results suggest that the relationship between health care access and SES should be investigated through a multi-dimensional approach, and that an array of SES variables must be considered when designing interventions to improve health care access among healthy women.

Becoming an information master: using "medical poetry" to remove the inequities in health care delivery.

In response to the spiraling costs, the US populace, for now, has chosen to ration health care by choosing who can receive it rather than what services are provided. Changing this approach will require an organized national policy and will be difficult. Clinicians must accept that providing minimally beneficial but not absolutely necessary care to their patients increases cost without significantly improving quality, and results in more people who lack adequate health care. The public must accept that exclusively focusing health care decisions on individuals places patients in conflict with their community, their family, and, eventually, themselves. Effectively using valid Patient-Oriented Evidence that Matters (POEMs) will give family physicians the tools necessary to improve the value of health care services. Family physicians are in the unique position to guide the necessary changes in health care delivery to resolve these conflicts and to be leaders in this process.

Family physicians' use of medical abstracts to guide decision making: style or substance?

BACKGROUND: Many physicians rely on the abstracts of research articles to guide their clinical decision making. This need for expediency is one basis for many journals to reformat their abstracts. METHODS: To determine whether the format of medical abstracts affects physician decision making, we surveyed family physicians in Michigan, Pennsylvania, and Virginia. All participants were members of the American Academy of Family Physicians. The survey included three case scenarios (corneal abrasion, fibromyalgia, and hyperlipidemia) followed by structured and open-ended assessments of usual management. After assessing their usual management in each scenario, the respondents were provided with an abstract of a valid research paper. The format of abstracts (unstructured, IMRAD [introduction, methods, results, and discussion], structured, and POEM [patient-oriented evidence that matters]) were randomly assigned. After reading the abstract, we assessed changes in management of the case scenario. RESULTS: Two hundred eighty-nine family physicians responded to the survey. At baseline, 187 (65%) of physicians patched corneal abrasions. After reading the abstract, 142 (76%) would no longer use eye patches. Two hundred forty-five (83%) of physicians did not use the combination of fluoxetine and amitriptyline for managing fibromyalgia. After reading the abstract, 179 (73%) would use combination therapy. Two hundred thirty-four (84%) of physicians used "statins" when managing hyperlipidemia. After reading the abstract, 211 (90%) would continue using statins. The format of abstract had no significant effect on physicians' decision making. CONCLUSIONS: Whereas the format of abstract in this study had no effect on physician decision making, having valid information available in the context of a clinical scenario appeared to influence decisions.

Research and the clinical dietitian: perceptions of the research process and preferred routes to obtaining research skills.

The art and science of dietetics are rooted in research, yet clinical dietitians do not generally participate in the research process. Focus group methodology was used to identify clinical dietitians' perceptions about incorporating research into clinical practice and to identify potential barriers to participation in research. In a series of 9 focus group sessions with 50 registered dietitians and 3 dietetic interns, attendees recognized the importance that research findings play in their practice. Barriers such as lack of time and low comfort levels with initiating and conducting research were discussed, and possible solutions to these barriers were suggested. Collaboration with academic dietitians or with research mentors was viewed as a useful and realistic pathway to increased participation in the research process. According to participants, increased involvement in research could also be facilitated by a supportive administrative structure within the facility, clinical management that is supportive of the research process, and collaboration among members of the dietetics staff. The findings of this qualitative investigation indicate that the central tenet of successful integration of clinical practice and research is collaboration-within dietetics departments, across the strata of facilities, and in particular, between clinical and research-oriented registered dietitians.

Becoming an information master: using POEMs to change practice with confidence. Patient-Oriented Evidence that Matters.

Today's physicians are faced with identifying, evaluating, and applying a huge quantity of medical information. In addition, many stakeholders in health care, from patients to payers, are taking an active role in the previously inviolable process of physician decision making. This is the third paper in a series discussing the concept of information mastery. In the first paper we discussed using the criteria for Patient-Oriented Evidence that Matters (POEMs) to distill clinically relevant information. The second paper in the series focused on techniques for efficiently obtaining this information from the myriad resources available. In this paper we discuss the final step in the process, changing practice habits after finding new information that necessitates it. We discuss managing change, consider barriers, and present ideas to help with the process.

Socioeconomic status, ethnicity, and environmental tobacco exposure among non-smoking females.

This study examined the relationship between socioeconomic status (SES) and environmental tobacco smoke (ETS) exposure among non-smoking females, determined which SES variable(s) were most strongly associated with ETS exposure, and examined whether the relationship between SES and ETS exposure was the same for Blacks and Whites. Participants were 404 never-smoker females recruited in the community. Independent variables included income, education, occupation, median income within zip code of participants' residence, and ethnicity. Number of days per week exposed to ETS in the past year was the dependent variable. There was a significant correlation between CO levels (parts per million, ppm) and self-reported ETS exposure (r = 0.22, p < 0.001). The mean CO level exposure was 1.81 +/- 1.19 ppm, and the mean number of days per week of ETS exposure was 4.72 +/- 4.71. The most frequent source of ETS exposure was at public places (64.4%). Although Blacks tended to report higher ETS exposure than Whites (p = 0.08), this tendency disappeared when SES indicators were entered in the model. Correlations among SES indicators were either non-significant or very modest suggesting that different SES indicators may not measure the same construct. Education was the only SES variable that was significantly associated with ETS exposure in this population. The relationship between SES and ETS exposure was similar for both Blacks and Whites. These findings suggest that education may be the most important factor to be considered when designing interventions to decrease ETS exposure among young non-smoking females (e.g., public education of the hazards of ETS exposure and awareness of existing tobacco-control laws and regulations).

Teaching information mastery: creating informed consumers of medical information.

BACKGROUND: The concepts of evidence-based medicine are permeating all specialties, including family practice. This article describes a curriculum to teach residents the principles and practices of information mastery, a derivation of evidence-based medicine that is more relevant to family physicians. METHODS: The curriculum is a 2-year longitudinal experience consisting mainly of didactic presentations and demonstrations in the first year followed by small-group sessions in the second year. Residents are taught the concepts of the previously described approach of information mastery and the application of these concepts to the variety of information resources available to them. Specifically, residents are taught how to find, evaluate, and apply information available from original research literature, review articles, meta-analyses, translation (controlled-circulation) journals, continuing education lectures, experts and colleagues, pharmaceutical representatives, and clinical experience. RESULTS: Using a before-after design at two institutions, the curriculum improved residents' attitudes, confidence regarding the medical literature, their perceptions of their ability to evaluate the published literature, and their use of information sources. CONCLUSIONS: Offering a structured curriculum to family practice residents creates dynamic, confident, and independent clinicians skilled in the art of information mastery.

Finding POEMs in the medical literature.

Articles about primary care topics that measure patient-oriented outcomes (eg, morbidity, mortality, quality of life) should change practice, if the reported results are valid. We call these types of articles POEMs--Patient-Oriented Evidence that Matters. The extent and distribution of POEMs in the medical literature is unknown. We identified 85 medical journals of potential interest to primary care physicians, and counted 8085 original research articles over a 6-month period; 211 of those articles were POEMs (2.6%). Ten journals accounted for 50% of the POEMs identified during the study period: Journal of the American Medical Association, Annals of Internal Medicine, New England Journal of Medicine, Archives of Internal Medicine, Lancet, British Medical Journal, Obstetrics and Gynecology, Arthritis and Rheumatology, American Journal of Obstetrics and Gynecology, and Journal of the American College of Cardiology. Other journals with a high percentage of POEMs were: Journal of Family Practice, Journal of the American Board of Family Practice, and American Journal of Emergency Medicine. Half the journals we surveyed published 0 or 1 POEMs during the study period. Not all clinicians have the time, inclination, or access to review a large number of journals on a regular basis. By focusing on POEMs and the journals that publish them, busy physicians can avoid reading 98% of the original research published each month. This will not only drastically cut physicians' reading time, but also help them obtain the information that is most valuable for their patients.

The effect of eating out on quality of diet in premenopausal women.

OBJECTIVE: To compare the intake of women who report varying levels of frequency of consuming food at commercial facilities outside the home. DESIGN: A 1-week descriptive study of dietary intake in women. Subjects completed daily diet records that included information regarding the source of the food eaten at each meal or snack. The sample was divided on the basis of the number of meals each subject reported obtaining from a commercial establishment outside the home. Of the 129 subjects, 56% (n = 72) reported eating out 5 times or less during the week of recording (Low Eating Out group) and the remainder (n = 57) reported eating out between 6 and 13 times (High Eating Out group) SUBJECTS/SETTING: One hundred twenty-nine premenopausal women were recruited via community advertising for an investigation of health habits. This study was conducted in a midsouthern US city. STATISTICAL ANALYSES PERFORMED: Results were analyzed using independent sample t tests and chi 2 tests. RESULTS: Mean intake was compared for the groups. The High Eating Out group was found to be consuming significantly more total energy (2,057 kcal vs 1,769 kcal; P = .002), fat (79.5 g vs 60.6 g; P < .001), and sodium (3,299 mg vs 2,903 mg; P = .043) and marginally more carbohydrate (261.5 g vs 234.6 g; P = .055) and protein (71.5 g vs 65.4 g; P = .066). Total fiber or calcium intake did not differ between the groups. CONCLUSIONS: Our study demonstrates that women who report eating out a greater number of times per week report more total energy intake as well as higher fat and sodium intakes. However, the High Eating Out group did not consume significantly more fiber or calcium in the extra energy consumed.

A model for making outcomes research standard practice in clinical dietetics.

In today's rapidly changing health care environment, it is imperative that dietitians demonstrate the importance of their role as health care providers by initiating and participating in outcomes research. Patient care should be based on empirical studies, and clinical dietitians should participate in or be at the helm of such investigations. Nutrition research is usually accomplished and reported by persons with MD or PhD degrees who do not have clinical training in nutrition and does not often address situations encountered by dietitians in clinical settings. This article examines the extent to which clinical dietitians are conducting and reporting outcomes research, their attitudes about such research, and how they think they could best acquire the skills needed to incorporate outcomes research into their practice. Results indicate that clinical dietitians are not writing a substantial percentage of articles and that reports of outcomes research are not commonly included in clinical nutrition journals. Clinical dietitians appear to value the inclusion of research in clinical practice, but they are not spending a great amount of time doing research. Dietitians report being comfortable about participating in research but not about designing, conducting, and reporting research. Results from several surveys were used to develop a model for integrating research in clinical practice. This model includes the research process as a basis for clinical practice. A model for collaborative efforts between clinical and academic dietitians is also proposed and emphasizes the responsibility of academic dietetics training programs in the integration of research and clinical practice.