The effect of the Maryland WIC 5-A-Day promotion program on participants' stages of change for fruit and vegetable consumption.

The Maryland Women, Infants and Children (WIC) 5-A-Day Promotion Program examined the effect of a multifaceted nutrition intervention on changing the fruit and vegetable consumption of low-income women in the WIC program in Maryland. The sample consisted of 3,122 participants (1,443 intervention and 1,679 control) with a mean age of 27.2. Fifty-six percent were Black/African American. This article focuses on the effect of the intervention on the stages of change of the participants. Intervention participants showed significantly greater positive movement through the stages than control participants. Stages of change were measured for two specific target behaviors: eating five servings of fruits and vegetables a day and eating more servings of fruit and vegetables a day. Results demonstrated significant differences in the stage status of intervention and control women and in movement through the stages. The effectiveness of the intervention across groups depended on which staging measure was used.

Uses of process evaluation in the Maryland WIC 5-a-day promotion program.

Using a crossover design, the authors conducted a 6-month intervention program aimed at increasing fruit and vegetable consumption among women served by the Women, Infants, and Children program in Baltimore City and six Maryland counties. The theoretical framework for the interventions was the Transtheoretical Model of Change. At 2 months postintervention, mean daily consumption had increased significantly more in intervention participants than in control participants. Extensive process evaluation data were collected to assess the quantity and quality of program services delivered. These included participant nutrition session evaluation forms and attendance logs, focus groups of attenders and nonattenders of sessions, information about peer educators, and postintervention surveys. Many lessons were learned about program delivery, factors affecting attendance, and the obstacles to dietary change. Strategies to increase participants' consumption of fruits and vegetables were modified based on these lessons and the process evaluations.

Psychosocial factors and intervention-associated changes in those factors as correlates of change in fruit and vegetable consumption in the Maryland WIC 5 A Day Promotion Program.

This study sought to examine: (a) the relative effects of baseline demographic and psychosocial factors and an intensive nutritional intervention on changes in fruit and vegetable consumption in low-income, ethnically diverse women served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program in Maryland; (b) whether this intervention, designed to modify psychosocial factors associated with fruit and vegetable consumption, was successful in changing these factors; and (c) whether changes in these factors were associated with increased consumption. The same women from 15 WIC program sites were surveyed at baseline and postintervention 8 months later. Women randomized to the intervention group showed significantly greater mean change in self-efficacy, attitudes, social support, and knowledge of national consumption recommendations than control group women. Changes in all psychosocial factors were significantly associated with nutrition session attendance and increased consumption. In a hierarchical model, changes in these factors accounted for most of the intervention effect on increased consumption.

Educational guidelines for achieving tight control and minimizing complications of type 1 diabetes.

Tight glucose control with intensive therapy in patients with type 1 diabetes (formerly known as juvenile-onset or insulin-dependent diabetes) can delay the onset and slow the progression of retinopathy, nephropathy and neuropathy. Optimal blood glucose control is defined by a target glycosylated hemoglobin level of less than 7 percent, a preprandial glucose level of 80 to 120 mg per dL (4.4 to 6.7 mmol per L) and a bedtime glucose level of 100 to 140 mg per dL (5.6 to 7.8 mmol per L). This article provides guidelines to help family physicians teach patients with type 1 diabetes how to achieve tight glucose control to help minimize complications. Guidelines include maintaining blood glucose levels at near normal by taking doses of short-acting insulin throughout the day supplemented by a nighttime dose of intermediate-acting insulin, monitoring blood glucose levels frequently, following a prudent diet, exercising regularly and effectively managing hypoglycemia, as well as empowering patients to lead their control efforts and rigorously controlling other risk factors for cardiovascular disease. Support from physicians, family members and friends is crucial to the success of a regimen of tight glucose control.

Factors associated with attendance in a voluntary nutrition education program.

PURPOSE: This paper examines factors associated with attendance in a National Cancer Institute-funded randomized trial of nutrition education to increase fruit and vegetable consumption among women served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). SETTING: The study took place at 16 WIC sites in Maryland. SUBJECTS: The participants were 1528 women who were enrolled in WIC or who had children enrolled in WIC, were > or = 18 years of age, and planned to continue enrollment at that WIC site for at least 6 months (68% of eligible women approached agreed to participate). INTERVENTION: Women received personal invitations, letters, and telephone reminders from peer educators encouraging their attendance at three bimonthly nutrition sessions. MEASURES: Demographic data were collected in a baseline survey. Attendance data and telephone and address changes were also collected. The postintervention survey included a question regarding reasons for nonattendance. Focus groups were also held to ascertain reasons for attendance or nonattendance. Chi-square tests of trend and multiple logistic regression, adjusted for within-site correlation, were used in statistical analyses. RESULTS: Fifty-four percent of enrollees attended at least one session. Multiple logistic regression analysis showed increased odds of attending with higher age, breast-feeding, and/or knowledge of the recommendation to eat five or more servings of fruits and vegetables daily. There were decreased odds of attending for pregnant women who already had children. There were nonsignificant trends toward decreased attendance among unmarried women compared with married women and among blacks compared with nonblacks. Reasons given for nonattendance included withdrawal from WIC, moving, conflicting activities, negative feelings about nutrition education, and lack of transportation or child care. CONCLUSIONS: The results suggest that numerous barriers hinder participation in nutrition programs aimed at low-income women. These barriers should be considered by health care professionals when planning intervention programs. Overcoming these barriers presents a major challenge.

Baseline fruit and vegetable intake among adults in seven 5 a day study centers located in diverse geographic areas.

OBJECTIVE: To examine baseline rates of fruit and vegetable consumption among adults in the 5 A Day research trials in order to identify any regional and sociodemographic differences associated with daily servings. DESIGN: The main outcome measure was the frequency of fruits and vegetables consumed within 1 month of the baseline survey as assessed by a 7-item food frequency questionnaire (FFQ). SUBJECTS/SETTING: Participants (N = 15,060) were from 7 study centers. Study centers included schools (N = 48), worksites (N = 60), churches (N = 50), or the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics (N = 15) in interventions to increase fruit and vegetable consumption. STATISTICAL ANALYSES: Means and standard errors, adjusting for clusters, were calculated. A mixed linear model analyzed relationships between fruit and vegetable consumption and regional center, gender, age, race, education, income, marital status, food-shopping responsibility, and whether one lives with children. RESULTS: Results indicate an overall mean intake of 3.6 daily servings of fruits and vegetables. Significant differences in mean daily servings were found among the regional study centers (low of 3.0 to high of 4.1). There were significant differences in mean daily consumption by age (< 30 years = 3.7 servings per day; 30 to 49 years = 3.4; > or = 50 years = 3.7), education (> high school = 3.4 servings per day; high school graduate = 3.4; some college = 3.5; college graduate = 3.9), race (black = 3.7 servings per day; Hispanic = 3.0; white = 3.6; other = 3.7), marital status (married = 3.6 servings per day; single = 3.5), and food-shopping responsibilities (little = 3.2 servings per day; about half = 3.6; most = 3.8). Only 17% of respondents ate 5 or more servings of fruits and vegetables per day. CONCLUSIONS: The 7 regions showed significant variability in daily fruit and vegetable consumption, suggesting that a single national message to increase fruit and vegetable consumption may not reach the population segments most in need of changing. It is advisable to spend more time understanding the food consumption habits of the population under investigation to develop messages to foster behavior change.

Stages of change for increasing fruit and vegetable consumption among adults and young adults participating in the national 5-a-Day for Better Health community studies.

Higher fruit and vegetable consumption is associated with a reduced risk of certain cancers and chronic diseases. The 5-a-Day for Better Health community studies are evaluating population-based strategies to achieving dietary behavior change using the stages-of-change model and associated theories. The authors present baseline comparisons of stages of change for fruit and vegetable consumption among adults and young adults in eight study sites representing diverse regions of the United States and diverse populations and settings. Three dominant stages, precontemplation, preparation, and maintenance, were found across sites. Women and those with college degrees were more likely to be in action/maintenance. Fruit and vegetable consumption, self-efficacy, and knowledge of the 5-a-Day recommendation were positively associated with more advanced stages of change in all study sites. The authors discuss the findings in relation to possible limitations of this and other dietary stages-of-change measures and suggest directions for future research.

Factors associated with fruit and vegetable consumption among women participating in WIC.

OBJECTIVE: The purpose of this analysis was to assess to what extent sociodemographic and psychosocial characteristics predict consumption of fruits and vegetables in women served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). DESIGN: Baseline survey data were analyzed for women enrolled in the Maryland WIC 5 A Day Promotion Program, a study sponsored by the National Cancer Institute. Sociodemographic variables included age, race, education, marital status, working status, pregnancy status, and smoking status. Psychosocial variables included self-efficacy, knowledge, attitudes, social support, and perceived barriers to consuming 5 or more servings daily of fruits and vegetables. SUBJECTS/SETTING: Analyses are based on 3,122 women enrolled at 15 WIC sites in Baltimore and 6 counties in Maryland. STATISTICAL ANALYSES PERFORMED: Because psychosocial characteristics were measured on different scales and varied in dispersion, we standardized scores for these variables. Multiple regression analyses were then performed to assess contributions of the sociodemographic variables and the standardized psychosocial variable scores to the variance in consumption of fruits and vegetables. RESULTS: Sociodemographic variables were not powerful predictors of fruit and vegetable consumption. In contrast, an increase of 1 standard deviation in self-efficacy resulted in a mean increase of 0.76 servings, and an increase of 1 standard deviation in perceived barriers resulted in a decrease of 0.50 servings. About 21% of the variance in consumption was explained by all of the variables examined. APPLICATIONS: Dietitians and intervention programs should focus on increasing clients' self-efficacy, positive attitudes, and knowledge relating to fruits and vegetables while trying to reduce perceived barriers to consumption of fruits and vegetables.

Final results of the Maryland WIC 5-A-Day Promotion Program.

OBJECTIVES: This National Cancer Institute-funded study sought to increase fruit and vegetable consumption among women served by the WIC program in Maryland. METHODS: Over a 2-year period, a multifaceted intervention program using a randomized crossover design sought to increase fruit and vegetable consumption at 16 WIC program sites in Baltimore City and 6 Maryland counties. Participants were surveyed at baseline, 2 months postintervention, and 1 year later. RESULTS: Two months postintervention, mean daily consumption had increased by 0.56 +/- 0.11 servings in intervention participants and 0.13 +/- 0.07 servings in control participants (P = .002). Intervention participants also showed greater changes in stages of change, knowledge, attitudes, and self-efficacy. Changes in consumption were closely related to number of nutrition sessions attended, baseline stage of change, race, and education. One year later, mean consumption had increased by an additional 0.27 servings in both intervention and control participants. CONCLUSIONS: Dietary changes to prevent cancer can be achieved and sustained in this hard-to-reach, low-income population. However, many obstacles must be overcome to achieve such changes.

Diet and cancer.

Unhealthy diets are a major cause of cancer. Extensive scientific research implicates three components of diet as being particularly important in the etiology of various cancers: dietary fat, fruits and vegetables, and fiber. The evidence linking these components to the incidence of numerous cancers warrants physicians making strong dietary recommendations to reduce their patients' risk of developing cancer.

A rapid and simple procedure to detect the presence of MVM in conditioned cell fluids or culture media.

During the manufacture of biopharmaceuticals, numerous adventitious agents have been detected in Master Cell Banks, end-of-production cells as well as bulk harvest fluid. Recently, a number of large-scale production bioreactors have become infected with Minute Virus of Mice (MVM) during cGMP (current good manufacturing practices) operations, and this has resulted in both the loss of product and the need for major cleaning validation procedures to be put in place. We have developed a simple DNA extraction/PCR assay to detect the presence of MVM in cell culture supernatant (conditioned cell fluids). This highly specific assay can detect 10 or fewer genome equivalents (copies) of MVM following PCR and gel electrophoresis visualization. For routine high-throughput detection, 300-100 copies could be consistently detected. The extraction procedure was shown to reliably detect MVM at a concentration of 1 TCID50/ml. The combination of the extraction/PCR procedure establishes a powerful, sensitive, specific assay that can detect the presence of MVM sequences with a 1-day turnaround time.

The NHLBI workshop on Hypertension in Hispanic Americans, Native Americans, and Asian/Pacific Islander Americans.

In June 1994, the National Heart, Lung, and Blood Institute held a workshop entitled "Epidemiology of Hypertension in Hispanic Americans, Native Americans, and Asian/Pacific Islander Americans." The studies that served as the basis for the workshop along with a summary of two workshop panel discussions are being published as a supplement by Public Health Reports. In this article, the authors present graphs that compare results across these studies with data for non-Hispanic whites, blacks, and Hispanics from the Third National Health and Nutrition Examination Survey. The graphs indicate differences in mean blood pressure levels within and among these three population groups; such differences are also apparent in comparisons of these groups with the U.S. white and black populations. Although they appear modest, these differences are sufficient to result in increased mortality rates in populations with higher levels of hypertension. Environmental influences appear to underlie most of these differences. In all of these populations, blood pressure control rates are poor. Based on these studies, hypertension prevention and control programs should be undertaken. Special emphasis should be placed on the underserved minority populations that were the focus of the workshop.

Blood pressure in minorities screened for the Multiple Risk Factor Intervention Trial (MRFIT).

THE AUTHORS PRESENT DATA FROM 361, 662 MEN ages 35 to 57, screened from 1973 to 1976 for possible participation in the Multiple Risk Factor Intervention Trial (MRFIT). Volunteers identified themselves as "white," "black," "Oriental," "Spanish American," "American Indian," or "other." They also noted if they were taking medication for diabetes. A trained technician measured blood pressure after participants had rested for 5 minutes, using the fifth Korotkoff sound to define diastolic pressure and averaging the second and third of three readings. Differences among the groups included the following: blacks had consistently higher systolic and diastolic blood pressure (SBP and DBP) than other groups; Orientals had slightly lower pressure than other nonblack groups; American Indians had somewhat higher pressure than other nonblack groups at ages 35 to 44 but lower at ages 45 to 54; Hispanics in Miami and Davis, California, had significantly higher SBP and DBP than whites in the same area; Orientals in California had significantly higher DBP (but not SBP) than whites in California.

Putting it all together: summary of the NHLBI Workshop on the Epidemiology of Hypertension in Hispanic American, Native American, and Asian/Pacific Islander American Populations.

THE AUTHORS OF THIS PAPER SUMMARIZED the major themes that emerged from a 2-day workshop entitled Epidemiology of Hypertension in Hispanic Americans, Native Americans, and Asian/Pacific Islander Americans, sponsored by the National Heart, Lung, and Blood Institute (NHLBI) in Washington, DC. Data from the papers were synthesized using seven points: similarities, variability within and between groups, lost prevention opportunities, emergence of explanatory variables, differences in types of data collected, missing or inconsistently reported data, and socioeconomic characteristics. Virtually all of the population groups demonstrated rises in blood pressure with age. These rises appear to be largely attributable to potentially modifiable risk factors, for example, high body mass index (BMI). Despite high levels of awareness, the levels of control of high blood pressure were poor in each population studied. Based on the themes that emerged from the data, we presented several recommendations to the workshop. One was that data be collected on these population groups repeatedly and in a standardized fashion. Another called for increased efforts aimed at control of high blood pressure in these groups. A third recommended major nationwide programmatic efforts aimed at the prevention and control of high blood pressure.

5 A Day for better health--nine community research projects to increase fruit and vegetable consumption.

One of the national objectives in "Healthy People 2000" is for members of the public to increase their consumption of fruits and vegetables to five or more servings daily. The National Cancer Institute (NCI) began a nationwide campaign to achieve this objective in 1991. As part of this campaign, the NCI funded nine research studies in 1993. These projects are implementing and evaluating community-based programs designed to increase fruit and vegetable consumption among different segments of the population in Alabama, Arizona, Georgia, Louisiana, Maryland, Massachusetts, Minnesota, North Carolina, and Washington. The settings for these projects include the Special Supplement Food Program for Women, Infants, and Children (WIC Programs), churches, worksites, and schools. The projects are led by multidisciplinary teams and entail extensive collaboration among academic, governmental, private sector, and voluntary agencies within each State. The projects represent a model public health paradigm for conducting this type of research.

The University of Maryland experience in integrating preventive medicine into the clinical medicine curriculum.

Lifestyle risk factors play a major role in the etiology of premature mortality, morbidity, and disability in the United States. Numerous professional groups as well as the Surgeon General of the Public Health Service have recommended that increased attention be devoted to training medical students and physicians to improve their knowledge and skills in health promotion and disease prevention. Such training is critical for attaining many of the "Healthy People 2000" objectives. For a variety of reasons, however, most medical schools have had difficulty in successfully integrating preventive medicine into their clinical curriculums. This article describes the critical elements that allowed the faculty at the University of Maryland School of Medicine to accomplish this goal through its fourth year clinical preventive medicine course. The strategies employed in this course may serve as a model for other institutions to achieve the integration of preventive medicine into their clinical curriculums.

Heart disease, cancer, and stroke in Maryland.

Maryland has higher mortality rates from heart disease, cancer, and stroke (HCS) than the United States as a whole. More than 50% of deaths from HCS are premature, occurring before age 75. The health care and indirect costs from these three diseases total approximately $4.4 billion annually, placing a major economic burden on the state. A large body of scientific literature has shown the potential for the prevention of HCS. Currently, Maryland, like virtually all states, lacks the type of systematic, well-coordinated, comprehensive intervention campaign needed to lower morbidity, mortality, and health care costs from these three diseases. Such a campaign has now been planned by the University of Maryland at Baltimore. Similar campaigns are needed throughout much of the United States.