Is duration of psychological treatment for depression related to return into treatment?

PURPOSE: There is increasing pressure on mental health providers to reduce the duration of treatments, while retaining level of quality and effectiveness. The risk is that the population is underserved and therefore needs new treatment episodes. The primary aim of this study was to investigate whether duration of treatment and return into mental health care were related. METHODS: This study examined Dutch patients with an initial treatment episode in 2009 or 2010 in specialized mental health settings for depressive disorder (N = 85,754). Follow-up data about treatment episodes were available up until 2013. The data set included demographic (age, gender), and clinical factors (comorbidity with other DSM-IV Axis; scores on the 'Global Assessment of Functioning'). Cox regression analyses were used to assess whether duration of treatment and relapse into mental health care were related. RESULTS: The majority of patients did not return into mental health care (86 %). Patients with a shorter duration of treatment (5-250 min; 251-500 min and 751-1000 min) were slightly more likely to return (reference group: >1000 min) (HR 1.19 95 % CI 1.13-1.26; HR 1.11 95 % CI 1.06-1.17; HR 1.18 95 % CI 1.11-1.25), adjusted for demographic and clinical variables. CONCLUSIONS: The results suggest that a longer duration of treatment may prevent return into mental health care in some groups. However, because of the design of the study, no causal inference can be drawn. Further research, preferably in a RCT, is needed to determine whether the trend towards lower intensity treatments is associated with repeated mental health care use.

The contribution of epidemiology.

Epidemiologic studies directly contribute data on risk (or benefit) in humans as the investigated species, and in the full food intake range normally encountered by humans. This paper starts with introducing the epidemiologic approach, followed by a discussion of perceived differences between toxicological and epidemiologic risk assessment. Areas of contribution of epidemiology to the risk assessment process are identified, and ideas for tailoring epidemiologic studies to the risk assessment procedures are suggested, dealing with data collection, analyses and reporting of both existing and new epidemiologic studies. The dietary habits and subsequent disease occurrence of over three million people are currently under observation worldwide in cohort studies, offering great potential for use in risk assessment. The use of biomarkers and data on genetic susceptibility are discussed. The paper describes a scheme to classify epidemiologic studies for use in risk assessment, and deals with combining evidence from multiple studies. Using a matrix approach, the potential contribution to each of the steps in the risk assessment process is evaluated for categories of food substances. The contribution to risk assessment of specific food substances depends on the quality of the exposure information. Strengths and weaknesses are summarized. It is concluded that epidemiology can contribute significantly to hazard identification, hazard characterisation and exposure assessment.

Baseline recreational physical activity, history of sports participation, and postmenopausal breast carcinoma risk in the Netherlands Cohort Study.

BACKGROUND: The aim of the current study was to evaluate the relation between physical activity and breast carcinoma risk with specific emphasis on interaction with other aspects of energy balance. METHODS: The Netherlands Cohort Study on diet and cancer was conducted among 62,537 women ages 55-69 years at baseline. Information regarding baseline recreational physical activity, history of sports participation, and occupational physical activity was collected with a questionnaire in 1986. After 7.3 years of follow-up, 1208 incident breast carcinoma cases were available for case-cohort analyses. RESULTS: A summed total of baseline recreational physical activity (including walking, cycling, gardening) showed an inverse association with breast carcinoma risk. Women who were active in the above-mentioned activities for > 90 minutes a day had a rate ratio (RR) of 0.76 (95% confidence interval [95% CI], 0.58-0.99) compared with women who were active < 30 minutes a day. Women who ever participated into sports before baseline had a RR of 1.13 (95% CI, 0.94-1.37) compared with women who never participated in sports. The relation between sports participation and breast carcinoma risk did not appear to be dependent on the time window of participation (before/after menarche, before/after birth of the first child, before/after age 20 years). No interaction was found between baseline recreational physical activity, body mass index (BMI) (kg/m(2)), energy intake, and weight gain/loss during adult life in relation to breast carcinoma, although in the subgroup of women with a high BMI we found a stronger inverse relation between recreational physical activity and breast carcinoma risk independent of energy intake. Occupational physical activity was not found to be related to breast carcinoma risk. CONCLUSIONS: The current study findings support the hypothesis that recreational physical activity is associated inversely with breast carcinoma risk.

Plant sterol intakes and colorectal cancer risk in the Netherlands Cohort Study on Diet and Cancer.

BACKGROUND: Plant sterols in vegetable foods might prevent colorectal cancer. OBJECTIVE: The objective was to study plant sterol intakes in relation to colorectal cancer risk in an epidemiologic study. DESIGN: The study was performed within the framework of the Netherlands Cohort Study on Diet and Cancer in 120852 subjects who completed a baseline questionnaire in 1986. After 6.3 y of follow-up, 620 colon and 344 rectal cancer cases were detected. A case-cohort approach was used to calculate confounder-adjusted rate ratios (RRs) and their 95% CIs for quintiles of plant sterol intake. RESULTS: The total mean (+/-SD) intake of campesterol, stigmasterol, beta-sitosterol, campestanol, and beta-sitostanol was 285 +/- 97 mg/d. Major contributors to plant sterol intake were bread (38%), vegetable fats (26%), and fruit and vegetables (21%). For men, there was no clear association between intake of any of the plant sterols and colon cancer risk when age, smoking, alcohol use, family history of colorectal cancer, education level, and cholecystectomy were controlled for. Adjustment for energy did not alter the result. For rectal cancer, adjustment for energy resulted in positive associations between risk and campesterol and stigmasterol intakes. For women, there was no clear association between intake of any of the plant sterols and colorectal cancer risk. CONCLUSION: A high dietary intake of plant sterols was not associated with a lower risk of colon and rectal cancers in the Netherlands Cohort Study on Diet and Cancer.

Vegetable and fruit consumption and risks of colon and rectal cancer in a prospective cohort study: The Netherlands Cohort Study on Diet and Cancer.

The relation between vegetable and fruit consumption and colorectal cancer risk was comprehensively assessed in the Netherlands Cohort Study on Diet and Cancer using a validated 150-item food frequency questionnaire. After 6.3 years of follow-up (1986-1992), over 1,000 incident cases of colorectal cancer were registered. Using case-cohort analysis, the authors calculated rate ratios and 95% confidence intervals adjusted for age, alcohol intake, and family history of colorectal cancer. For colon cancer, no statistically significant associations with total vegetable intake or total fruit intake were found. However, among women, an inverse association was observed with vegetables and fruits combined (for the highest quintile vs. the lowest, the rate ratio was 0.66 (95% confidence interval: 0.44, 1.01)). Brassica vegetables and cooked leafy vegetables showed inverse associations for both men and women. Among women and, to a lesser extent, among men, inverse associations were stronger for distal colonic tumors than for proximal colonic tumors. For rectal cancer, no statistically significant associations were found for vegetable consumption or fruit consumption or for specific groups of vegetables and fruits; only Brassica vegetables showed a positive association in women. As in other cohort studies, the observed inverse relation between vegetable and fruit consumption and occurrence of colorectal cancer was less strong than relations reported in case-control studies.

A prospective cohort study on antioxidant and folate intake and male lung cancer risk.

Many studies have reported inverse associations between vegetable and fruit consumption and lung cancer risk. The aim of the present study was to elucidate the role of several antioxidants and folate in this relationship. In the Netherlands Cohort Study on Diet and Cancer, 58,279 men of ages 55-69 years at baseline in 1986 returned a questionnaire including a 150-item food frequency questionnaire. After 6.3 years of follow-up, 939 male lung cancer cases were registered. A new Dutch carotenoid database was used to estimate intake of alpha-carotene, beta-carotene, lutein + zeaxanthin, beta-cryptoxanthin, and lycopene, completed with the antioxidant vitamins C and E and folate. Using case-cohort analysis, rate ratios were calculated, adjusted for age, smoking, educational level, and family history of lung cancer. Protective effects on lung cancer incidence were found for lutein + zeaxanthin, beta-cryptoxanthin, folate, and vitamin C. Other carotenoids (alpha-carotene, beta-carotene, and lycopene) and vitamin E did not show significant associations. After adjustment for vitamin C, only folate remained inversely associated, and after adjustment for folate, only beta-cryptoxanthin and vitamin C remained significantly associated. Inverse associations were strongest among current smokers and weaker for former smokers at baseline. Inverse associations with carotenes, lutein + zeaxanthin, and beta-cryptoxanthin seemed to be limited to small cell and squamous cell carcinomas. Only folate and vitamin C intake appeared to be inversely related to small cell and squamous cell carcinomas and adenocarcinomas. Folate, vitamin C, and beta-cryptoxanthin might be better protective agents against lung cancer in smokers than alpha-carotene, beta-carotene, lutein + zeaxanthin, and lycopene.

Vegetable and fruit consumption and lung cancer risk in the Netherlands Cohort Study on diet and cancer.

OBJECTIVE: The purpose was to study the association between vegetable and fruit consumption and lung cancer incidence using 1074 cases after 6.3 years of follow-up in the Netherlands Cohort Study. METHODS: Dietary intake was assessed using a 150-item food-frequency questionnaire. Multivariate models were used including age, sex, family history of lung cancer, highest educational level attained, and smoking history. RESULTS: Statistically significant inverse associations were found with total vegetables and most vegetable groups. Rate ratios (RRs) based on consumption frequency showed the strongest effect of vegetables from the Brassica group (RR 0.5, 95% confidence interval (95% CI) 0.3-0.9, for consumption > or = 3 times per week versus < or = once a month). RR of highest versus lowest quintile of total vegetable consumption was 0.7 (95% CI 0.5-1.0, p-trend 0.001). Statistically significant inverse associations were found for all fruits listed in the questionnaire. RRs for quintiles of total fruit intake were 1.0, 0.7, 0.6, 0.6 and 0.8 respectively (p-trend < 0.0001). Protective effects of fruits and vegetables were stronger in current than in former smokers, and weaker for adenocarcinomas than for other types of tumors. CONCLUSIONS: Inverse associations with lung cancer are found for both vegetable and fruit intake, but no specific type of vegetable or fruit seems to be particularly responsible.

The physical condition of elderly women differing in habitual physical activity.

In a cross-sectional study, 50 elderly women (age 71.5 +/- 4.2 yr, mean +/- SD) participated in a battery of tests assessing several aspects of physical fitness. The women were selected based on tertiles of habitual physical activity as determined by a validated questionnaire 10 months ago. The tests comprised the following measurements: peak expiratory flow, flexibility of shoulder joint, flexibility of hip and spine, balance, reaction time, grip strength, manual dexterity, and endurance. Additionally, data were collected on height, body weight, and systolic and diastolic blood pressure. A questionnaire was used to evaluate subjective fitness and general subjective health. Results indicated that physically more active elderly women tend to have better results on most tests. Body weight and body mass index, flexibility of the hip and spine (assessed using a sit-and-reach test), and endurance on a walk test were significantly better in the more active women. Test results are confirmed by subjective evaluation by the participants.

Energy expenditure at rest and during standardized activities: a comparison between elderly and middle-aged women.

To estimate energy expenditure (EE) in elderly subjects, more age-specific data are required on energy costs of standardized activities. EE was assessed by using indirect calorimetry in 28 women aged 72 +/- 4 y (mean +/- SD) and in 29 middle-aged women (42 +/- 1 y) at rest (resting metabolic rate; RMR) and during sitting, sitting with standardized arm activity, and walking on a treadmill at 3 km/h. RMR and EE during sitting, and sitting with standardized arm activity did not differ significantly between the groups, although EE expressed as a ratio of arm activity to RMR (physical activity ratio, PAR) tended to be higher in the elderly subjects. Walking EE was significantly higher in the elderly women (16.4 +/- 4.0 kJ/min) than in the middle-aged women (12.7 +/- 2.3 kJ/min), also when expressed as PAR. It is suggested that elderly women walk less efficiently. Because PARs are frequently used to estimate daily EE, it is important to note that additional age-specific data might be required.

History of body weight and physical activity of elderly women differing in current physical activity.

Development of overweight and physical activity during life was studied retrospectively in a group of physically active and a group of sedentary elderly women. The two groups of elderly women were selected based on a validated physical activity questionnaire. A previous study on their current dietary intake and nutritional status showed a 12 kg higher body weight in the sedentary group compared to the physically active group, whereas body height did not differ. In order to study the relationship between development of overweight and physical activity in these elderly women, a retrospective study was carried out in 45 subjects. Information about former physical activity was collected by means of a detailed structured interview. Information about body shape and fatness, expressed as 'weight index', was obtained using silhouettes and subjective rating of obesity of subjects compared with peers. Classification of obesity was checked by old photographs rated by interviewers, sizes of clothing and recalled body weight and height. Information was collected about the situation at age 12, 25, 40 and 55 years whereas the mean current age is 71. Weight index was statistically significantly different between the active and sedentary group from age 25 onwards (P less than 0.05). Photographs proved to be useful for a valid and objective categorization. No differences were found in physical activity scores between the groups at age 12, 25, 40 and 55 years. It is concluded that the current difference in body shape and fatness between physically active and inactive elderly women was already present at age 25 and persisted throughout their adult life.(ABSTRACT TRUNCATED AT 250 WORDS)

Relative validity of different methods to assess body composition in apparently healthy elderly women.

Body composition was assessed by means of densitometry, anthropometry and bioelectrical impedance in 28 healthy, elderly females, aged 67-78 years. Underwater weighing was used as the reference method. Mean body mass index (BMI) was 26.3 +/- 3.4 kg/m2. Body fat percentage from body density was 39.6 +/- 5.6%. The fat-free mass (FFM) from body density was 41.0 +/- 5.4 kg. Mean predicted FFM using different prediction formulas from the literature ranged from 38.8 +/- 4.2 to 46.3 +/- 5.3 kg. The differences between FFM from densitometry and FFM using either prediction equation were highly correlated, thus part of the difference is probably due to an error in the reference method. The different prediction equations revealed rather good relative validity, compared to the densitometric method, with the exception of equations based on skinfold measurements developed in younger reference populations. Age-specific prediction equations based on BMI and bioelectrical impedance measurement may be used to assess body composition in the elderly. Prediction equations using skinfold thickness measurements are less appropriate for this purpose.

Are physically active elderly women in a better nutritional condition than their sedentary peers?

The generally observed decrease in physical activity with age has its influence on energy requirements and to a lesser extent on micronutrient requirements of the elderly. In this study it was hypothesized that physically active people can more easily obtain their recommended nutrient intake without becoming overweight, because of their increased energy needs. Nutritional intake, body composition and vitamin status were assessed in two groups of women aged 60-79 years. The groups showed large differences in pattern and level of physical activity as estimated by a previously described questionnaire. Dietary intake was assessed by dietary history. Body composition was assessed using anthropometric measures and bioelectrical impedance. Blood levels of haematological parameters, blood lipids and several vitamins were measured. Differences in food consumption were not statistically significant. However, the more physically active women tended to have a food pattern more in line with dietary allowances according to the Dutch guidelines. At the same body height the physically active and sedentary women had body weights of 64.9 +/- 10.9 and 77.1 +/- 12.0 kg (mean +/- SD) respectively (P less than 0.001). Percentage of body fat was higher in the sedentary women. Blood levels did not differ significantly between both groups of women except for higher beta-carotene in the active women.

A physical activity questionnaire for the elderly.

A validated physical activity questionnaire for young adults was adapted and validated for use in free living, apparently healthy people, aged 63-80 yr. Test-retest reliability of the questionnaire on 29 participants was 0.89 as determined by Spearman's correlation coefficient. Further classification by tertiles of activity resulted in 72% of the participants being correctly classified and 0% grossly misclassified on two separate occasions. In a similar group of 31 subjects, classifications based on questionnaire activity scores were compared with classifications obtained by repeated 24-h activity recalls and pedometer measurements, showing Spearman's correlations of 0.78 and 0.73, for both methods, respectively. Seventy-one and 67% of the subjects, respectively, were classified in the same activity tertile for both methods. It is concluded that the questionnaire provides a reliable and valid method for classifying elderly subjects into categories of high, medium, and low physical activity.

Energy metabolism and requirements in different ethnic groups.

Some studies on energy metabolism of men and women in Third World countries suggested that their basal metabolic rate (BMR) is lower compared to BMRs of people in Northern European and American countries. It is, however, not clear whether this results from ethnic factors, climate or adaptation to, for instance, a low energy intake. A study on energy requirements of people from Third World countries has therefore been performed. People with different ethnic backgrounds participated; they were divided into four ethnic groups: 8 African males, 7 Asian males of Mongolian origin (Asian-M), 8 Asian males of Caucasian origin (Asian-C) and 7 European males, who formed the control group. The participants from outside Europe had spent at least 3 months in the Netherlands. All participants consumed a diet (12 per cent of energy from protein, 22 per cent from fat and 66 per cent from carbohydrate) during 8 d. The dietary energy given to each individual was estimated to maintain energy equilibrium during the experiment. The last 3 nights and 2 days were spent in an indirect whole-body calorimeter. Two 24-h energy expenditure (24hEE) measurements were performed on each subject. The environmental temperature inside the calorimeter was 22.0-24.5 degrees C. Physical activity was light, mainly sedentary, with 75 min bicycling at 15 W. The Asian subjects had a significantly lower body weight and fat-free mass than the Europeans. Energy requirement (ER), 24hEE and EE during the night (8 h sleep) was lower in the Asian and African subjects compared to the Europeans, but the difference only reached significance for the Asian-C and African males. When ER, 24hEE and EE-night were expressed in relation to body weight and fat-free mass the Asian groups showed a higher ER and higher EE than the Europeans. This result is contrary to findings of others and may be caused eg, by a higher body weight and fat-free mass of the European controls. Comparison of EE-night with BMR estimated from FAO/WHO/UNU equations showed that the EE-night was consistently lower by about 9 per cent. This suggests that EE during the night may not be predicted by the BMR estimated by widely used equations. This study does not give conclusive evidence that an ethnic factor is involved in energy metabolism in humans.