One-year follow-up of nutrition education for hypercholesterolemic children.

OBJECTIVES: This study evaluated retention of the effect of a home-based, practitioner-initiated nutrition education model. METHODS: Children with elevated low-density lipoprotein (LDL) cholesterol levels were randomly assigned to one of two nutrition interventions or to an at-risk control group. Intervention effects were evaluated 3, 6, and 12 months postbaseline. RESULTS: The parent-child autotutorial group demonstrated significant increases in knowledge and, along with the counseling group, decreases in total and saturated fat intake. Also, the autotutorial and counseling groups retained a majority of their initial LDL cholesterol decrease. CONCLUSIONS: Knowledge of heart-healthful eating and dietary fat intake as well as dietary change can be affected and retained via home-based, practitioner-initiated nutrition interventions with hypercholesterolemic children, although some form of ongoing intervention may be necessary to produce lasting decreases in LDL cholesterol levels.

A weighted concordance correlation coefficient for repeated measurement designs.

The need to quantify agreement between two raters or two methods of measuring a response often arises in research. Kappa statistics (unweighted and weighted) are appropriate when the data are nominal or ordinal, whereas the concordance correlation coefficient is more appropriate when the data are measured on a continuous scale. We develop weighted product-moment and concordance correlation coefficients which are applicable for repeated measurements study designs. We consider two distinct situations in which the repeated measurements are paired or unpaired over time. We illustrate the methodology with examples comparing (1) two assays for measuring serum cholesterol, (2) two estimates of dietary intake, from a food frequency questionnaire and dietary recalls, and (3) two measurements of percentage body fat, from skinfold calipers and dual energy x-ray absorptiometry.

Picture-sort method for administering a food frequency questionnaire to older adults.

OBJECTIVE: To assess the validity of a picture-sort approach to administering the National Cancer Institute food frequency questionnaire to older adults. DESIGN: A picture-sort interview was conducted in each respondent's home. After the picture sort, a 24-hour recall interview was administered on the same occasion. Five additional in-home recall interviews were subsequently conducted at approximately 1-month intervals. SUBJECTS/SETTING: Forty-seven female and 49 male volunteers aged 66 to 100 years were recruited from among Cardiovascular Health Study participants from Maryland and North Carolina. MAIN OUTCOME MEASURES: Estimates from the picture sort and the recall for intakes of macronutrients, cholesterol, fiber, and selected vitamins and minerals exclusive of supplements. STATISTICAL ANALYSES: Comparison of means estimated by the two methods and correlation analyses were used. Correlations were adjusted under varied assumptions about the nature of the information contained in the six 24-hour recalls relative to respondents' usual intakes. RESULTS: After correction for attenuation, Pearson correlation coefficients for macronutrients ranged from .41 for protein to .74 for saturated fat and cholesterol. For vitamins and minerals, correlations ranged from .26 for beta carotene to .62 for calcium. APPLICATIONS: Picture-sort estimates of mean nutrient intakes were comparable with estimates based on 24-hour recalls, and correlations with reference data were similar to those reported in the literature for conventionally administered food frequency questionnaires. This dietary assessment method may, therefore, offer a way to simplify or structure responses to improve ease of administration and increase respondents' liking for the interview without loss of data quality.

The effect of calcium supplementation and Tanner stage on bone density, content and area in teenage women.

One hundred and twelve Caucasian girls, 11.9 +/- 0.5 years of age at entry, were randomized into a 24-month, double-masked, placebo-controlled trial to determine the effect of calcium supplementation on bone mineral content, bone area and bone density. Supplementation was 500 mg calcium as calcium citrate malate (CCM) per day. Controls received placebo pills, and compliance of both groups averaged 72%. Bone mineral content, bone mineral area and bone mineral density of the lumbar spine and total body were measured by dual energy X-ray absorptiometry (DXA). Calcium intake from dietary sources averaged 983 mg/day for the entire study group. The supplemented group received, on average, an additional 360 mg calcium/day from CCM. At baseline and after 24 months, the two groups did not differ with respect to anthropometric measurements, urinary reproductive hormone levels or any measurement of pubertal progression. The supplemented group had greater increases of total body bone measures: content 39.9% versus 35.7% (p = 0.01), area 24.2% versus 22.5% (p = 0.15) and density 12.2% versus 10.1% (p = 0.005). Region-of-interest analyses showed that the supplemented group had greater gains compared with the control group for bone mineral density, content and area. In particular, in the lumbar spine and pelvis, the gains made by the supplemented group were 12%-24% greater than the increases made by the control group. Bone acquisition rates in the two study groups were further compared by subdividing the groups into those with below- or above-median values for Tanner score and dietary calcium intake. In subjects with below-median Tanner scores, bone acquisition was not affected by calcium supplementation or dietary calcium level. However, the calcium supplemented subjects with above-median Tanner had higher bone acquisition rates than the placebo group with above-median Tanner scores. Relative to the placebo group, the supplemented group had increased yearly gains of bone content, area and density which represented about 1.5% of adult female values. Such increases, if held to adult skeletal maturity, could provide protection against future risk of osteoporotic fractures.

Patient attitudes toward medical student participation in a general internal medicine clinic.

OBJECTIVE: To study patient attitudes toward medical students in a faculty academic general internal medicine practice. DESIGN: Survey. SETTING: An academic general internal medicine ambulatory practice site at a university hospital. PATIENTS: Random selection of 199 patients attending the practice; 194 patients completed the survey. MAIN RESULTS: Approximately half (55.8%) of the patients had no preference regarding medical student participation, a third preferred to see the attending physician alone, and 10% preferred to see the student with the physician. Seventy-six percent were not reluctant to disclose "personal" information with the medical student, whereas 24% felt uncomfortable. Almost half (46.5%) of the patients enjoyed their encounters with medical students, 43% were neutral, and 10.3% disliked their encounters. Half of the patients desired some time alone with the attending physician. Thirty-seven percent of the patients reported that they had benefited from their interactions with the medical students. Patients who were men and older appeared to be more receptive of medical students. There was also a trend for patients who had had previous visits involving medical students to be more accepting of their participation. CONCLUSIONS: The majority of the patients in the study were receptive to medical student participation in this ambulatory setting. Patients should be adequately prepared for medical student involvement and each patient should have an opportunity to spend time alone with the attending physician. A sizable minority (a third) of patients do not desire medical student participation.

Reduction of elevated LDL-cholesterol levels of 4- to 10-year-old children through home-based dietary education.

OBJECTIVE: To assess the effects of a home-based, parent-child autotutorial (PCAT) dietary education program on the dietary knowledge, lipid consumption, and plasma low density lipoprotein-cholesterol (LDL-C) of 4- to 10-year-old children with elevated plasma LDL-C. METHODS: "At-risk" children (screening total cholesterol, (TC), exceeded 4.55 mmol/L and average LDL-C from two fasting samples was between 2.77 and 4.24 mmol/L for boys or 2.90 and 4.24 mmol/L for girls) were randomized to the PCAT program (N = 88), for dietary counseling with a registered dietitian (N = 86), or to an at-risk control group (N = 87). Dietary knowledge, diet, and LDL-C of these groups were assessed at baseline and after the educational period (3-month follow-up). The knowledge and diet of a not-at-risk (TC below 4.22 and 4.34 mmol/L for boys and girls, respectively) control group (N = 81) was also assessed and compared with that of the at-risk control group. RESULTS: At the 3-month follow-up, the PCAT children's knowledge scores had increased three times more than those of the counseling and at-risk control groups (P < .001). Mean grams of total and saturated fat consumed by PCAT and counseling groups declined while that of the at-risk control group increased slightly; these differences were significant (P < .05). The mean LDL-C decline of the PCAT group was significantly different (P < .05) from the decline of the at-risk control group (0.26 vs 0.09 mmol/L), and approached significance (P = .07) when compared with that of the counseling group (0.26 vs 0.11 mmol/L). The at-risk control group's knowledge and diet did not differ from that of the not-at-risk group. CONCLUSION: The PCAT program offers a mechanism for providing effective dietary education to children with elevated cholesterol and to their families.

Response of the magnocellular system in rats to hypovolemia and cholecystokinin during pregnancy and lactation.

To define changes in the magnocellular neuroendocrine system during lactation and pregnancy, we compared plasma levels of oxytocin (OT) and vasopressin (VP) after polyethylene glycol (PEG)-induced hypovolemia and cholecystokinin (CCK) stimulation. Conscious virgin, pregnant (day 20), and lactating (day 6) Sprague-Dawley rats were injected with either PEG (70-600 mg/ml; 35 or 70 ml/kg sc), CCK (100 micrograms/ml; 4 ml/kg ip), or vehicle and decapitated 4 h (PEG) or 5 min (CCK) later. Changes in thresholds for release of hormone and the responsiveness (slopes relating [hormone] to blood volume depletion or to plasma osmolality) of the OT and VP systems were determined using an iterative nonlinear threshold regression model. After PEG, plasma osmolality increased coincident with a decrease in blood volume, with both stimuli contributing to the rise in plasma VP and OT. Compared with virgin rats, neither the threshold nor the responsiveness of the VP system was altered by the combined stimulus, whereas the oxytocinergic system of pregnant rats was more responsive to osmotic component. Lactating rats, however, had a higher threshold for VP release and an apparent elevation of the OT threshold beyond 25% volume depletion. Regardless of the reproductive state, the threshold for VP release was always lower than that for OT. Intraperitoneal CCK elevated plasma [OT] in each reproductive state, although the response in lactating animals was attenuated. In virgin and lactating rats, plasma levels of VP also increased slightly but significantly in response to CCK. During gestation when cardiovascular volume is expanded, both the VP and OT neuroendocrine systems were reset, enabling secretion of both hormones in response to hypovolemia with hypertonicity. During lactation, both neuroendocrine systems are reset such that greater changes in fluid balance are needed to stimulate hormone release. Regardless of the reproductive state, the threshold for VP release was always lower than that for OT, indicative of preferential release of VP with less than a 5% (virgin, pregnant) or a 20% (lactating) loss in blood volume.

Calcium supplementation and bone mineral density in adolescent girls.

OBJECTIVE: To evaluate the effect of calcium supplementation on bone acquisition in adolescent white girls. DESIGN: A randomized, double-blind, placebo-controlled trial of the effect of 18 months of calcium supplementation on bone density and bone mass. SUBJECTS: Ninety-four girls with a mean age of 11.9 + 0.5 years at study entry. SETTING: University hospital in a small town. INTERVENTIONS: Calcium supplementation, 500 mg/d calcium as calcium citrate malate; controls received placebo pills. MAIN OUTCOME MEASURES: Bone mineral density and bone mineral content of the lumbar spine and total body were measured by dual-energy x-ray absorptiometry and calcium excretion from 24-hour urine specimens. RESULTS: Calcium intake from dietary sources averaged 960 mg/d for the entire study group. The supplemented group received, on average, an additional 354 mg/d of calcium. The supplemented group compared with the placebo group had greater increases of lumbar spine bone density (18.7% vs 15.8%; P = .03), lumbar spine bone mineral content (39.4% vs 34.7%; P = .06), total body bone mineral density (9.6% vs 8.3%; P = .05), and 24-hour urinary calcium excretion (90.4 vs 72.9 mg/d; P = .02), respectively. CONCLUSIONS: Increasing daily calcium intake from 80% of the recommended daily allowance to 110% via supplementation with calcium citrate malate resulted in significant increases in total body and spinal bone density in adolescent girls. The increase of 24 g of bone gain per year among the supplemented group translates to an additional 1.3% skeletal mass per year during adolescent growth, which may provide protection against future osteoporotic fracture.

Determinants of bone density in young women. I. Relationships among pubertal development, total body bone mass, and total body bone density in premenarchal females.

Bone mass accretion during puberty appears to be critical in the development of peak bone mass, which, in turn, is believed to be a major determinant of osteoporosis risk. Although genetics may be the primary determinant of peak bone mass, modifiable secondary factors, such as nutrition and hormone exposure, may significantly affect bone mass accretion during the second decade of life. As part of a longitudinal study of major determinants of bone development during puberty, we obtained cross-sectional measurements from 112 premenarchal caucasian females (mean +/- SD age, 11.9 +/- 0.49 yr at study entry). Total body bone mineral density (TBBMD) and total body bone mineral content (TBBMC) were measured by dual energy x-ray absorptiometry and compared to anthropometric, pubertal development, urinary steroid and gonadotropin levels, and nutrient intake. An integrated estrogen exposure index was developed and used to evaluate the cumulative effect of circulating estrogen levels on both development. Compared to normative reference data for adults, our subjects possessed 90% of adult height, 68% of adult weight, 83% of adult TBBMD, and 53% of TBBMC. The strongest combined predictors of prepubertal TBBMD and TBBMC were body weight, followed by height and pubertal development. Urinary estradiol levels were positively correlated with dietary intake of iron and vitamin B6.

Pulsatile oxytocin administered to ewes at 120 to 140 days gestational age increases the rate of maturation of the fetal electrocorticogram and nuchal activity.

Spontaneous, long lasting epochs of myometrial contractility, contractures, occur throughout the majority of pregnancy in sheep. Contractures are temporally related to a switch in fetal electroencephalogram (ECoG) patterns from low to high voltage. In late gestation, fetal ECoG increases in voltage. We have previously suggested that contractures may influence fetal ECoG maturation. In the present study, we hypothesized that a sustained increase in the frequency of myometrial contractures in pregnant sheep at 120-140 days gestation would accelerate maturation of the fetal ECoG. Five pregnant ewes were pulsed with oxytocin 600 microU.kg-1.min-1 intravenously for five minutes in every 30 minutes from 127.8 +/- 1.5 days gestational age for a minimum of six days. Six control ewes received pulses of saline. Fetuses of all eleven ewes were instrumented with bilateral electrodes to record fetal ECoG and nuchal muscle activity. Fetal high voltage (HV) ECoG increased in amplitude in both groups but the rate of increase was faster in the fetuses of ewes receiving oxytocin. There were no differences between the two groups in the duration of HV ECoG. The percentage increase in the amount of time the fetal nuchal muscles were active compared with the baseline day before infusion was only significant in the oxytocin infused group on the first day of oxytocin infusion. These findings support the hypothesis that myometrial activity during pregnancy has the capacity to influence fetal neural development.

Treatment of low-grade and intermediate-grade lymphoma with intensive combination chemotherapy results in long-term, disease-free survival.

To define the role of intensive combination chemotherapy in the treatment of low-grade or intermediate-grade lymphomas, the authors report results in 49 patients treated with intermediate-dose or high-dose methotrexate, bleomycin, Adriamycin (doxorubicin; Adria Laboratories, Columbus, OH), cytoxan (cyclophosphamide), vincristine, and dexamethasone (m/M-BACOD) with long-term follow-up. The complete response rate was 59% (29 of 49), including 67% (eight of 12) with low-grade and 57% (21 of 37) with intermediate-grade disease. The median survival for the entire group was 81 months. The 29 complete responders had a long median survival of 131 months. Forty-five percent (13 of 29) of the complete responders, 27% of the entire group, continue in remission with a median disease-free survival of 76 months. This includes five of 19 patients with diffuse poorly differentiated lymphoma, a disease generally characterized by early relapse. Twelve patients achieved a partial response and had a shorter median survival of 53 months, whereas nonresponders survived a median of less than 5 months. Late relapse was noted in patients with low-grade and intermediate-grade disease. Age (younger than or older than 60 years) was the only predictor of long-term survival. These data indicate very long disease-free survival can be achieved in low-grade and intermediate-grade lymphomas after attaining a complete remission. Intensive doxorubicin containing chemotherapy can be considered as an option for patients with advanced low-grade lymphoma but can only be proven to be superior to single-agent chemotherapy or no initial therapy by controlled randomized trails.