Shape it up: a school-based education program to promote healthy eating and exercise developed by a health plan in collaboration with a college of pharmacy.

BACKGROUND: Childhood obesity is an intensifying public health problem that affects millions of U.S. children. Obesity leads to the development of health conditions such as hypertension, diabetes, gastroesophogeal reflux disease, depression, and hypercholesterolemia. The increasing prevalence of these conditions among U.S. children is reflected in increased use of medical services and medications in both childhood and adulthood. OBJECTIVE: To assess the preliminary results of the effectiveness of Shape It Up, a school-based obesity prevention program developed and implemented by the Ernest Mario School of Pharmacy at Rutgers University in conjunction with Horizon Blue Cross Blue Shield of New Jersey, with the goal of using these results to help improve the program. METHODS: Program activities and materials included an interactive workshop, an activity book and family guide, posters, a website, and educational field days. The Shape It Up program not only delivered a positive message about eating healthful food but also modeled fruit and vegetable consumption during the interactive workshops and distributed fruits and vegetables as prizes. During the 2004-2005 and 2005-2006 school years, Shape It Up was delivered to 89,736 children at 257 New Jersey elementary schools. Pre-intervention and post-intervention surveys were administered to a convenience sample of 6,421 students at 49 participating schools. Attitudes were measured using a 6-point Likert-type graphic face scale (smiles positive, frowns negative) and analyzed for statistical significance of pre-intervention to post-intervention change using paired t-tests. RESULTS: After exposure to the Shape It Up program, children reported higher levels of knowledge (P < 0.001) and positive attitudes (P < 0.001) about healthy eating and exercise compared with the baseline survey results. In a question to gauge satisfaction with the program, 54.9% of children surveyed gave the program the highest possible rating, and overall, 91.7% selected 1 of the 3 response categories toward the positive end of the 6-point scale. CONCLUSION: Shape It Up appears to have had a positive impact on children's knowledge and attitudes toward exercise and healthy eating. Additional research employing a comparison group is needed to assess the program's impact.

High-risk patients' readiness to undergo BMD testing for osteoporosis diagnosis in Pennsylvania.

The objective of this study was to better understand high-risk patients' readiness to engage in bone mineral density (BMD) testing to diagnose osteoporosis. Six hundred thirty-six participants in a randomized control trial for patients at high-risk for osteoporosis were surveyed. BMD screening readiness was measured by a three-item summative index. Multivariable linear regression examined the relationship between patients' scores on the index and constructs of osteoporosis and BMD testing knowledge, concern for developing osteoporosis and self-efficacy to engage in fall prevention behaviors. Participants had a mean age of 79 years, 96% were female and 80% were white. Greater concern for developing osteoporosis and better knowledge about BMD testing were significant predictors of a higher score on the index. Improving high-risk patients' knowledge about osteoporosis and the importance of BMD testing may enhance patients' readiness to undergo BMD testing. We found several correlates of readiness to undergo BMD screening that may be used to design effective interventions.

Osteoporosis improvement: a large-scale randomized controlled trial of patient and primary care physician education.

UNLABELLED: We conducted a randomized controlled trial within the setting of a large drug benefit plan for Medicare beneficiaries. Primary care physicians and their patients were randomized to usual care, patient intervention only, physician intervention only, or both interventions. There was no difference in the probability of the primary composite endpoint (BMD test or osteoporosis medication) or in either of its components comparing the combined intervention group with usual care (risk ratio = 1.04; 95% CI, 0.85-1.26). INTRODUCTION: Fractures from osteoporosis are associated with substantial morbidity, mortality, and cost. However, only a minority of at-risk older adults receives screening and/or treatment for this condition. We evaluated the effect of educational interventions for osteoporosis targeting at-risk patients, primary care physicians, or both. MATERIALS AND METHODS: We conducted a randomized controlled trial within the setting of a large drug benefit plan for Medicare beneficiaries. Primary care physicians and their patients were randomized to usual care, patient intervention only, physician intervention only, or both interventions. The at-risk patients were women >or=65 yr of age, men and women >or=65 yr of age with a prior fracture, and men and women >or=65 yr of age who used oral glucocorticoids. The primary outcome studied was a composite of either undergoing a BMD test or initiating a medication used for osteoporosis. The secondary outcome was a hip, humerus, spine, or wrist fracture. RESULTS: We randomized 828 primary care physicians and their 13,455 eligible at-risk patients into four study arms. Physician and patient characteristics were very similar across all four groups. Across all four groups, the rate of the composite outcome was 10.3 per 100 person-years and did not differ between the usual care and the combined intervention groups (p = 0.5). In adjusted Cox proportional hazards models, there was no difference in the probability of the primary composite endpoint comparing the combined intervention group with usual care (risk ratio = 1.04; 95% CI, 0.85-1.26). There was also no difference in either of the components of the composite endpoint. The probability of fracture during follow-up was 4.2 per 100 person-years and did not differ by treatment assignment (p = 0.9). CONCLUSIONS: In this trial, a relatively brief program of patient and/or physician education did not work to improve the management of osteoporosis. More intensive efforts should be considered for future quality improvement programs for osteoporosis.

Gaps in treatment among users of osteoporosis medications: the dynamics of noncompliance.

PURPOSE: Cyclical patterns of compliance have been observed with many health-related activities such as dieting and exercise. It is not known whether such patterns of compliance exist among users of chronic medications. We sought to estimate the percentage of patients who restart osteoporosis therapy after a prolonged lapse in medication use and to identify the factors associated with a return to compliance. METHODS: We studied 26,636 new users of an osteoporosis medication (alendronate, calcitonin, estrogen, raloxifene, or risedronate) who were age 65 or older and had an extended lapse in refill compliance, defined as a period of at least 60 days after the completion of one prescription in which no refill for any osteoporosis medication was obtained. Survival curves were used to estimate the length of time until therapy is resumed. We estimated the association between patient characteristics and the rate of resuming treatment using Cox proportional hazards analysis. We then conducted a case crossover analysis to examine whether certain events occurring during follow-up triggered a return to refill compliance. RESULTS: Of patients who stopped therapy for at least 60 days, an estimated 30% restarted treatment within 6 months, and 50% restarted within 2 years. Among patients who had at least 6 months of continuous use before their interruption in treatment (n=5863), 42% restarted therapy within 6 months and 59% within 2 years. Younger patients, women, and those with a history of a fracture were more likely to return after a break in medication use. Recent hip fractures, discharges from nursing homes, and bone mineral density testing also predicted a return to treatment. CONCLUSION: Extended gaps in treatment are common among users of osteoporosis medications. Because the effectiveness of these drugs used in an interrupted way is unknown, compliance interventions should emphasize the need for continuous medication use. Further research is needed to understand why patients often go for months without refilling prescriptions and also whether similar utilization patterns exist for other chronic medications.

Compliance with osteoporosis medications.

BACKGROUND: Long-term compliance with pharmacologic treatments for many asymptomatic conditions may be suboptimal, but little is known about compliance with medications used for osteoporosis. This study was undertaken to assess the level and determinants of compliance with drugs prescribed for osteoporosis. METHODS: This retrospective cohort study used pharmacy claims data from US Medicare and filled prescriptions from a state pharmaceutical benefits program. We included persons 65 years or older who initiated use of a medication for osteoporosis (alendronate sodium, calcitonin, hormone therapy, raloxifene hydrochloride, or risedronate) from January 1, 1996, through December 31, 2002. The outcome of interest was suboptimal medication compliance, defined as equal to or less than 66% of days with medication during a 60-day period. RESULTS: One year after initiating treatment for osteoporosis, 45.2% of the 40,002 patients were not continuing to fill prescriptions. Five years after initiation, 52.1% of patients were not continuing to fill prescriptions for an osteoporosis medication. Several characteristics independently predicted compliance: female sex, younger age, fewer comorbid conditions, using fewer nonosteoporosis medications, bone mineral density testing before and after initiating a medication, a fracture before and after initiating a medication, and nursing home residence during the 12 months before initiating a medication. However, models adjusted for the significant patient variables explained only 6% of the variation in compliance. CONCLUSIONS: Most patients who initiate a medication for osteoporosis do not continue to take it as prescribed. Although several patient characteristics significantly correlated with compliance, adjusted models explained little of the variation.

Educational outreach (academic detailing) regarding osteoporosis in primary care.

BACKGROUND: Academic detailing utilizes educators trained in social marketing to conduct one-on-one visits with physicians using evidence-based data. Academic detailing programs have improved physician's prescribing behaviors; however, the feasibility of large-scale programs across a large, geographically disperse state is unclear. METHODS: The study team collaborated with a state-run pharmacy benefits program for low-income elderly in a trial to improve osteoporosis management. Community-practicing physicians who saw a minimum of 25 patients enrolled in the benefits program were randomized to receive academic detailing or not. Fourteen educators were trained in the principles of academic detailing as well as osteoporosis epidemiology, diagnosis, and treatment. From September 2003 to January 2004, they attempted to meet with physicians or an allied health professional to discuss osteoporosis and fracture prevention. RESULTS: The physician population was 356 and 148 (41.6%) visits were completed-100 with physicians, 38 with allied health professionals, and 10 with both the physician and an allied health professional. In mixed multivariable models, there were no physician characteristics associated with completed encounters, including gender, training, geographic location, years since medical school, and number of study patients (all p-values > 0.11). The detailer's gender, professional training, and professional experience were not statistically significant correlates of completed encounters (all p-values > 0.28). Number of years since a detailer's professional training was a predictor of a completed encounter, OR = 1.43 per 5 years (95%CI 1.05, 1.96). CONCLUSIONS: A moderate rate of completed encounters was achieved. There was only one predictor of completed encounters.

Older adults' knowledge and beliefs about osteoporosis: results of semistructured interviews used for the development of educational materials.

OBJECTIVE: Although osteoporosis and associated fractures have been recognized as a significant public health problem, underdiagnosis and undertreatment are common. We investigated older adults' knowledge and beliefs regarding osteoporosis and its prevention, in order to develop effective osteoporosis health education messages and materials. These messages will be used as part of a trial that will test the efficacy of both public and doctor education to improve osteoporosis management. METHODS: We conducted semistructured one-on-one interviews with 15 older adult volunteers. A standard interview guide was developed and used for all interviews, which were audiotaped and transcribed. Key themes were extrapolated by 3 study staff using data abstraction forms. The data forms were then compared for consistency. RESULTS: We found that the term "osteoporosis" was well recognized, but many participants had only a fragmented understanding of its meaning. All participants identified osteoporosis as a serious condition, but many did not perceive themselves to be at personal risk for developing the condition. Many participants were confused about the difference between osteoporosis and osteoarthritis. Participants expressed reservations about taking prescription medications because of concerns over cost, side effects, and interactions with their current medications. CONCLUSION: Osteoporosis awareness is high, but the older adults interviewed had an incomplete understanding of the condition. This could hinder efforts to improve prevention and treatment of osteoporosis.

Skin self-examination practices in a convenience sample of U.S. university students.

BACKGROUND: Melanoma skin cancer affects many young adults, yet few practice skin self-examination (SSE). We collected detailed information about young adult SSE practices, which can be used to guide the development of SSE interventions that target this age group. METHODS: We surveyed 190 US university students to assess their SSE practices, including thoroughness of self-exams and reasons for not performing SSE. RESULTS: Just 33.2% of respondents had ever performed SSE, and only 5.8% had checked their entire body. The three most commonly cited reasons for failing to practice SSE were not knowing what to look for (55.9%), never thinking of it (54.3%), and not knowing it should be done (33.1%). CONCLUSIONS: Interventions to promote early melanoma detection must raise awareness about the importance of beginning SSE practice in young adulthood and conducting thorough self-exams. They should target all young adults, including those who already practice SSE.

Effects of adenovirus-mediated expression of p27Kip1, p21Waf1 and p16INK4A in cell lines derived from t(2;5) anaplastic large cell lymphoma and Hodgkin's disease.

We investigated the response of SUDHL-1 and L428 cells, derived from t(2;5)-anaplastic large cell lymphoma (ALCL) and Hodgkin's disease (HD), respectively, to recombinant adenoviruses expressing cyclin-dependent kinase inhibitors (CDKIs) p27Kip1 (Adp27), p21Waf1 (Adp21) and p16INK4A (Adp16). Cell cycle analysis of SUDHL-1 cells after 24 h of infection with 200 multiplicity of infection (MOI) of Adp27, Adp21, and Adp16, showed very high levels of cell debris in the subG1 area. The magnitude of cell debris-events was Adp27/Adp21 > Adp16. Cell cycle analysis of L428 cells revealed absence of cell debris and increased G2 phase in all the groups of cells tested as compared to the controls (mock and AdNull). A minimal increase in G1 phase was also evident in cells infected with Adp27 (52%) compared to uninfected cells (43%), AdNull (45%) and to cells infected with Adp21 (37%) and Adp16 (31%). The presence of significant levels of Coxsackie-adenovirus receptor (CAR) on the cell surface of L428 cells excluded the cell membrane-barrier as responsible for the differences in cell observed in response to the recombinant adenovirus-mediated CDKIs expression as compared to SUDHL-1. We also showed that the recombinant adenovirus-mediated cytotoxicity measured as apoptosis was MOI- and vector-dependent in SUDHL-1 cells at lower MOI (100). In conclusion, the therapeutic effect induced by recombinant adenoviruses expressing p27Kip1, p21Waf1 and p16INK4A is cell-dependent in cells derived from selected lymphoid malignancies. Biochemical cellular differences more than cell surface barriers seem to be responsible for differences in response to recombinant adenovirus-mediated expression of cytotoxic genes. Moreover, the cytotoxicity of recombinant adenoviruses expressing p27Kip1, p21Waf1 and p16INK4A may be further explored as a tool for gene therapy of t(2;5)-derived ALCL.

Model of inhibition of the NPM-ALK kinase activity by herbimycin A.

Anaplastic large cell lymphoma (ALCL) exhibiting the t(2;5) translocation is characterized by the resulting expression of the oncogenic fusion protein nucleophosmin-anaplastic lymphoma kinase (NPM-ALK) gene product. The ALK domain of NPM-ALK contains kinase activity, which is responsible for the autophosphorylation of tyrosine residues of the oncogenic protein and phosphorylation of SH2-protein substrates. Herbimycin A is a general protein tyrosine kinase inhibitor active as an antiproliferative compound against different types of mammalian cells. Herbimycin A inhibited the NPM-ALK-associated autophosphorylating activity in an in vitro cell-free kinase assay. The inhibition was specific when tested against other kinase inhibitors and extended to other cell lines derived from t(2;5)-ALCL. SUDHL-1 cells showed increasing percentage of cells in G(1) after 18 h of incubation with a dose of herbimycin A. NPM-ALK, Akt, and pAkt were down-regulated after 24 h of incubation with herbimycin A. Apoptosis was observed only if the dose of inhibitor was given every 12 h for prolonged time. Our results show that herbimycin A interferes with NPM-ALK and Akt pathways in SUDHL-1 cells. It seems that prolonged inhibition of these biochemical pathways may lead to cell cycle arrest and apoptosis. This study supports the idea of investigating protein kinase inhibitors as therapeutic compounds for t(2;5)-ALCL.