Behavioral risk factors among members of a health maintenance organization.

BACKGROUND: Co-occurrence of risk behaviors (RBs) substantially increases the risk of disease. This study examines the co-occurrence of four health risk behaviors (i.e., smoking, high-fat diet, sedentariness, and high-risk drinking) and demographic and psychosocial variables associated with number of RBs in a sample of members of a health maintenance organization who participated in the Seasonal Variation in Cholesterol (Seasons) study. METHODS: Seasons study baseline data were used. Subjects completed a self-administered questionnaire packet containing questions on demographics, smoking history, and leisure-time physical activity, a 7-day dietary recall instrument, and various psychosocial measures. Results presented here are based on 496 subjects with complete data on all RBs. RESULTS: Forty-three percent of participants had > or = two RBs. The most prevalent RB combination was high-fat diet/sedentariness, with 30% of subjects reporting both RBs. Associations between RBs were observed. A greater number of RBs were observed among younger and less-educated subjects, those with higher depression scores, and subjects who perceived their health as poor. CONCLUSIONS: Findings highlight the importance of designing and evaluating primary care-based screening programs and interventions for multiple RBs.

Sources of variance in daily physical activity levels in the seasonal variation of blood cholesterol study.

The authors examined sources of variance in self-reported physical activity in a cohort of healthy adults (n = 580) from Worcester, Massachusetts (the Seasonal Variation of Blood Cholesterol Study, 1994-1998). Fifteen 24-hour physical activity recalls of total, occupational, and nonoccupational activity (metabolic equivalent-hours/day) were obtained over 12 months. Random effects models were employed to estimate variance components for subject, season, day of the week, and residual error, from which the number of days of assessment required to achieve 80% reliability was estimated. The largest proportional source of variance in total and nonoccupational activity was within-subject variance (50-60% of the total). Differences between subjects accounted for 20-30% of the overall variance in total activity, and seasonal and day-of-the-week effects accounted for 6% and 15%, respectively. For total activity, 7-10 days of assessment in men and 14-21 days of assessment in women were required to achieve 80% reliability. For nonoccupational activity, 21-28 days of assessment were required. This study is among the first to have examined the sources of variance in daily physical activity levels in a large population of adults using 24-hour physical activity recall. These findings provide insight for understanding the strengths and limitations of short term and long term physical activity assessments employed in epidemiologic studies.

Seasonal variation in household, occupational, and leisure time physical activity: longitudinal analyses from the seasonal variation of blood cholesterol study.

The authors examined seasonal variation in physical activity in longitudinal analyses of 580 healthy adults from Worcester, Massachusetts (the Seasonal Variation of Blood Cholesterol Study, 1994-1998). Three 24-hour physical activity recalls administered five times during 12 months of follow-up were used to estimate household, occupational, leisure time, and total physical activity levels in metabolic equivalent (MET)-hours/day. Trigonometric models were used to estimate the peak-to-trough amplitude and phase of the peaks in activity during the year. Total activity increased by 1.4 MET-hours/day (121 kcal/day) in men and 1.0 MET-hours/day (70 kcal/day) in women during the summer in comparison with winter. Moderate intensity nonoccupational activity increased by 2.0-2.4 MET-hours/day in the summer. During the summer, objectively measured mean physical activity increased by 51 minutes/day (95% confidence interval: 20, 82) in men and by 16 minutes/day (95% confidence interval: -12, 45) in women. The authors observed complex patterns of seasonal change that varied in amplitude and phase by type and intensity of activity and by subject characteristics (i.e., age, obesity, and exercise). These findings have important implications for clinical research studies examining the health effects of physical activity and for health promotion efforts designed to increase population levels of physical activity.

Comparing physical activity assessment methods in the Seasonal Variation of Blood Cholesterol Study.

PURPOSE: This paper evaluated three measures of physical activity employed in the Seasonal Variation of Blood Cholesterol Study (Seasons), and it had two objectives: 1) To examine the laboratory validity of the Actillume activity monitor, and 2) To examine the relative validity of three 24-h physical activity recalls (24HR) in quantifying short-term physical activity behaviors. METHODS: Nineteen healthy middle-age adults completed seven activity trials (reading, typing, box moving, stepping, and walking (3.5, 4.25, 5.0 km x h(-1))) while oxygen consumption and Actillume measures were obtained. ANOVA, linear regression, and a scatter plot were employed to examine the validity of the Actillume. In relative validity analyses of the 24HR in the Seasons study, participants (N = 481) completed two or three 24HR (MET-h x d(-1)) and a modified Baecke Questionnaire. A subset of the cohort (N = 41) wore the Actillume for 3-8 d (counts x min(-1) x d(-1)). The relative validity of the 24HR method was examined by comparison to these criterion measures. RESULTS: In laboratory validation analyses, the monitor was found to discriminate between sedentary and moderate intensity activities, changes in walking speed, and to account for 79% of the variance in oxygen consumption across sedentary and walking trials. In relative validity analyses, correlations between the 24HR and the modified Baecke ranged from 0.29 to 0.52 (P < 0.01) across total, household, occupational, and leisure-time activities. CONCLUSIONS: In laboratory testing, the Actillume monitor discriminated between sedentary and moderate intensity activities and was highly correlated with oxygen consumption. Three 24HR of physical activity were observed to have a relative validity that was comparable to published data from other short-term activity assessments that also employed the Baecke Questionnaire and activity monitors as criterion measures.

Comparing food intake using the Dietary Risk Assessment with multiple 24-hour dietary recalls and the 7-Day Dietary Recall.

The Dietary Risk Assessment (DRA) is a brief dietary assessment tool used to identify dietary behaviors associated with cardiovascular disease. Intended for use by physicians and other nondietitians, the DRA identifies healthful and problematic dietary behaviors and alerts the physician to patients who require further nutrition counseling. To determine the relative validity of this tool, we compared it to the 7-Day Dietary Recall (an instrument developed to assess intake of dietary fat) and to the average of 7 telephone-administered 24-hour dietary recalls. Forty-two free-living subjects were recruited into the study. The 7-Day Dietary Recall and DRA were administered to each subject twice, at the beginning and the end of the study period, and the 24-hour recalls were conducted during the intervening time period. Correlation coefficients were computed to compare the food scores derived from the 3 assessment methods. Correlations between the DRA and 7-Day Dietary Recall data were moderate (r = .47, on average, for postmeasures); correlations between the DRA and 24-hour recalls were lower. The ability of the DRA to assess dietary fat consumption and ease of administration make it a clinically useful screening instrument for the physician when counseling patients about dietary fat reduction.

Seasonal variation of blood cholesterol levels: study methodology.

This manuscript provides a description of the methodology used in the Seasonal Variation of Blood Cholesterol Levels (SEASON) study, with the intent of informing the scientific community of the available data sets and to invite a dialogue with scientists in complementary fields. The primary aim of the SEASON study is to describe and delineate the causes of seasonal variation of blood lipid levels in the general population. This research project is designed specifically to systematically collect and analyze a number of important variables necessary to study the role of seasonality in blood lipids and relevant covariates.

A dietitian-delivered group nutrition program leads to reductions in dietary fat, serum cholesterol, and body weight: the Worcester Area Trial for Counseling in Hyperlipidemia (WATCH).

OBJECTIVE: To assess the effectiveness of a dietitian-based nutrition counseling and education program for patients with hyperlipidemia. DESIGN: A 4-session program implemented as a complement to a randomized physician-delivered intervention. SUBJECTS/SETTING: From 12 practice sites of the Fallon Clinic, 1,162 subjects with hyperlipidemia were recruited, 645 of whom had data sufficient for our primary analyses. INTERVENTION: Two individual and 2 group sessions conducted over 6 weeks. MAIN OUTCOME MEASURES: Total and saturated fat levels; serum low-density lipoprotein cholesterol levels; and body weight, measured at baseline and after 1 year. STATISTICAL ANALYSES: Multiple linear regression was used to evaluate changes in outcome measures. RESULTS: After 1 year, there were significant reductions in outcome measures for subjects attending 3 or 4 nutrition sessions vs subjects attending fewer than 3 sessions or those never referred to a nutrition session. Reductions (mean +/- standard error) in saturated fat (measured as percent of energy) were 2.7 +/- 0.5%, 2.1 +/- 0.5%, and 0.3 +/- 0.1%, respectively. These reductions correspond to roughly a 22% relative change from baseline in those attending 3 or 4 sessions. Corollary reductions were observed for total fat (measured as percent of energy): 8.2 +/- 1.4%, 5.0 +/- 1.4%, and 0.7 +/- 0.4%; low-density lipoprotein cholesterol: 0.48 +/- 0.11 mmol/L, 0.13 +/- 0.11 mmol/L, and 0.02 +/- 0.03 mmol/L; and body weight: 4.5 +/- 0.9 kg, 2.1 +/- 0.8 kg, and 1.1 +/- 0.2 kg. The specified changes were additive to those of the physician-delivered intervention. APPLICATIONS/CONCLUSIONS: This investigation provides empirical data demonstrating the effectiveness of a dietitian-delivered intervention in the care of patients with hyperlipidemia.

Effect of physician-delivered nutrition counseling training and an office-support program on saturated fat intake, weight, and serum lipid measurements in a hyperlipidemic population: Worcester Area Trial for Counseling in Hyperlipidemia (WATCH).

OBJECTIVE: To evaluate the effectiveness of a training program for physician-delivered nutrition counseling, alone and in combination with an office-support program, on dietary fat intake, weight, and blood low-density lipoprotein cholesterol levels in patients with hyperlipidemia. PARTICIPANTS AND METHODS: Forty-five primary care internists at the Fallon Community Health Plan, a central Massachusetts health maintenance organization, were randomized by site into 3 groups: (1) usual care; (2) physician nutrition counseling training; and (3) physician nutrition counseling training plus an office-support program. Eleven hundred sixty-two of their patients with blood total cholesterol levels in the highest 25th percentile, having previously scheduled physician visits, were recruited. Physicians in groups 2 and 3 attended a 3-hour training program on the use of brief patient-centered interactive counseling and the use of an office-support program that included in-office prompts, algorithms, and simple dietary assessment tools. Primary outcome measures included change at 1-year of follow-up in percentage of energy intake from saturated fat; weight; and blood low-density lipoprotein cholesterol levels. RESULTS: Improvement was seen in all 3 primary outcome measures, but was limited to patients in group 3. Compared with group 1, patients in group 3 had average reductions of 1.1 percentage points in percent of energy from saturated fat (a 10.3% decrease) (P = .01); a reduction in weight of 2.3 kg (P<.001); and a decrease of 0.10 mmol/L (3.8 mg/dL) in low-density lipoprotein cholesterol level (P = .10). Average time for the initial counseling intervention in group 3 was 8.2 minutes, 5.5 minutes more than in the control group. CONCLUSION: Brief supported physician nutrition counseling can produce beneficial changes in diet, weight, and blood lipids.

Relationship between leisure-time physical activity and selected dietary variables in the Worcester Area Trial for Counseling in Hyperlipidemia.

We evaluated the relationship between Leisure-time Physical Activity (LTPA) and selected dietary variables in the Worcester Area Trial for Counseling in Hyperlipidemia. Subjects were males (N = 425) and females (N = 494) of mean age 49.8 and 48.4 yr, respectively. Dietary data were collected using a 7-d (7DDR) and a 24-h dietary recall (24HR), and LTPA information was obtained along with the 7DDR. Subjects were categorized into four levels of LTPA (0-29 (N = 548), 30-60 (N = 98), 61-120 (N = 137), and > or = 121 min.wk-1 (N = 136)). Results from ANOVA revealed that active subjects (LTPA > or = 30 min.wk-1) consumed fewer servings per week of meats, fried foods, sweets, and 2-4% milk and more servings of fruits, vegetables, low fat dairy products, and 0-1% milk than did inactive subjects (LTPA = 0-29 min.wk-1). Comparison of selected 7DDR-derived macro- and micronutrients revealed that active individuals consumed a lower fat and a more micronutrient dense diet than their more inactive counterparts. These findings were not materially altered by adjustment for age, gender, education, and smoking. Finally, the 7DDR results were confirmed in analyses of the 24HR data in a slightly smaller group of subjects (N = 756). The present findings have implications for etiologic investigations on outcomes that have both LTPA and diet as risk factors, and for targeting public health interventions.

A lipid trial tracking system.

A computerized tracking system was developed for the monitoring of recruitment and participant follow-up in the Worcester Area Trial for Counseling in Hyperlipidemia (WATCH). In this study, over 8,000 subjects were screened, from which 1,278 were recruited over a two-year period. Subjects were randomized into three conditions (one is control, the other two with interventions) and followed for one year. Patient lipid profiles, dietary intakes, and psychosocial data were collected at baseline and after one year. The tracking system developed proved essential to the efficient management of WATCH and can be adapted for other research and nonresearch purposes.

Gender differences in social desirability and social approval bias in dietary self-report.

Social desirability (the tendency to respond in such a way as to avoid criticism) and social approval (the tendency to seek praise) are two prominent response set biases evident in answers on structured questionnaires. These biases were tested by comparing nutrient intakes as estimated from a single 24-hour diet recall interview (24 HR) and a 7-day dietary recall (7DDR). Data were collected as part of the Worcester Area Trial for Counseling in Hyperlipidemia, a randomized, physician-delivered nutrition intervention trial for hypercholesterolemic patients conducted in Worcester, Massachusetts, from 1991 to 1995. Of the 1,278 total study subjects, 759 had complete data for analysis. Men overestimated their fat and energy intakes on the 7DDR as compared with the 24HR according to social approval: One unit increase in the social approval score was associated with an overestimate of 21.5 kcal/day in total energy intake and 1.2 g/day in total fat intake. Women, however, underestimated their dietary intakes on the 7DDR relative to the 24HR according to social desirability: One unit increase in the social desirability score was associated with an underestimate of 19.2 kcal/day in energy intake and 0.8 g/day in total fat. The results from the present study indicate that social desirability and social approval biases appear to vary by gender. Such biases may lead to misclassification of dietary exposure estimates resulting in a distortion in the perceived relation between health-related outcomes and exposure to specific foods or nutrients. Because these biases may vary according to the perceived demands of research subjects, it is important that they be assessed in a variety of potential research study populations.

Effect of training and a structured office practice on physician-delivered nutrition counseling: the Worcester-Area Trial for Counseling in Hyperlipidemia (WATCH).

We examined the effectiveness of a training program for physician-delivered nutrition counseling, alone and in combination with a structured office practice environment for nutrition management, on physicians' counseling practices. Forty-five primary care internists and 1,278 of their patients in the top quarter of the cholesterol distribution at a central Massachusetts health maintenance organization (the Fallon Clinic) were enrolled into a randomized controlled trial. Physicians were randomized by site into three conditions: (1) usual care, (2) physician nutrition counseling training, and (3) physician nutrition counseling training plus a structured office practice environment for nutrition management (prompts and the provision of lipid results and counseling algorithms). A randomly selected 325 patients were given a 10-item patient exit interview (PEI) assessing whether the physician provided advice; assessed past changes, barriers, and resources; negotiated specific plans and goals; provided patient materials; referred the patient to a dietitian; and developed plans for follow-up. Condition 3 physicians demonstrated significantly greater implementation of the nutrition counseling sequence than did physicians in either of the other two conditions (P < .0001). Referrals to nutrition services were markedly reduced in condition 2, despite PEI scores no different than those in condition 1. Higher PEI scores for patients seen by physicians in condition 3 were stable for as long as two years beyond training. Primary care internists, when provided with both training in counseling techniques and a supportive office environment, will carry out patient counseling appropriately. Training alone, however, is not sufficient and may be counterproductive. Medical Subject Headings (MeSH): hypercholesterolemia, diet therapy, coronary disease, health behavior, primary health care, medical education, managed care programs.

Physician training for patient-centered nutrition counseling in a lipid intervention trial.

BACKGROUND: We examined the effect of a 3-hr training program on physicians' lipid intervention knowledge, attitudes, and skills. The program teaches physicians skills to conduct a brief dietary risk assessment and provide patient-centered counseling to enable patients with elevated lipids to change their dietary patterns. METHOD: The training is part of a randomized trial of lipid-lowering interventions, the Worcester Area Trial for Counseling in Hyperlipidemia. Primary care internists practicing in a health maintenance organization (HMO) were assessed, before and after training using questionnaires and audiotapes to document changes in knowledge about diet, attitudes about intervention, reported nutrition intervention practices, and counseling and assessment skills. Physicians also rated the value that they thought the training program had to them. RESULTS: After completion of the program the physicians' use of dietary counseling steps, as assessed by blinded evaluation of audiotaped physician-patient interactions, significantly increased (mean pre = 5.4, mean post = 9.2; t = 9.9; P < or = 0.001). In this regard, there were instances in the use of 7 of the 14 specific counseling steps. Physicians also demonstrated increases in self-perceived preparedness as measured by a 5-point scale (mean pre = 3.2, mean post = 4.0; t = 4.25; P < 0.001), confidence in having an effect (mean pre = 3.3, mean post = 3.9; t = 3.16; P < 0.01), perception that materials were available to aid intervention (mean pre = 2.7, mean post = 4.0; t = 5.29; P < 0.001), and perception that they have access to a nutritionist (mean pre = 3.5, mean post = 4.0; t = 2.63; P < 0.01). They rated the value of the program between very good and excellent. CONCLUSION: Results of this 3-hr educational program indicate that physicians in an HMO are responsive to the teaching of specialized skills deemed important for promoting health behavior change in their patients.

Smoking intervention for cardiac patients: in search of more effective strategies.

Smoking cessation greatly reduces morbidity and mortality associated with coronary artery disease (CAD). This paper presents details of an individually delivered smoking intervention program for patients with CAD that had been shown to be effective in a previously reported randomized clinical trial. Treatment components include inpatient counseling, followed by a single outpatient visit and follow-up by telephone. This approach compared to traditional outpatient group intervention engenders much higher levels of patient participation and is suitable to the special needs of cardiac patients.