Nutritional pyramid for post-gastric bypass patients.

BACKGROUND: Life-long nutrition education and diet evaluation are key to the long-term success of surgical treatment of obesity. Diet guidelines provided for bariatric surgery patients generally focus on a progression through dietary stages, from the immediate post-surgical period to 6 months after surgery. However, long-term dietary guidelines for those surgically treated for obesity are not readily available. Therefore, there is a need for dietary recommendations for meal planning and nutritional supplementation for bariatric surgery patients beyond the short-term, post-operative period. The purpose of this paper is to construct an educational tool to provide long-term nutritional and behavioral advice for the post-bariatric patient. METHODS: The manuscript summarizes the current knowledge on dietary strategies and behaviors associated with beneficial nutritional outcomes in the long term of post-bariatric surgery patients. RESULTS: Dietary and nutritional recommendations are presented in the form of a "bariatric food pyramid" designed to be easily disseminated to patients. CONCLUSIONS: The development of educational tools that are easy to understand and follow is essential for effective patient management during the surgery follow-up period. The pyramid can be used as a tool to help both therapists and patients to understand nutrition recommendations and thus promote a healthy long-term post-op dietary pattern based on high-quality protein, balanced with nutrient-dense complex carbohydrates and healthy sources of essential fatty acids.

Clinical utility of a fingerstick technology to identify individuals with abnormal blood lipids and high-sensitivity C-reactive protein levels.

PURPOSE: The purpose of this study was to determine the ability of a commonly used fingerstick technology to identify individuals with abnormal blood levels of total cholesterol (TC), calculated low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides (TG), and high-sensitivity C-reactive protein (hsCRP) compared with a standardized laboratory. METHODS: Participants (n = 250; mean age, 48.0 +/- 13.5 years; 66% female; 36% nonwhite) were eligible for primary prevention of cardiovascular disease (CVD). Blood lipids and hsCRP were measured simultaneously by (1) fingerstick analyzed by Cholestech LDX analyzers and (2) fresh venous blood that was analyzed by Columbia University General Clinical Research Center (GCRC) Core Laboratory. Pearson correlation coefficients, kappa, sensitivity, and specificity were calculated for fingerstick versus GCRC laboratory values for lipids and hsCRP. RESULTS: The correlations betweenfingerstick and core laboratory for TC, LDL-C, HDL-C, TG, and hsCRP were .91, .88, .77, .93, and .81, respectively (all p< .01). Sensitivity and specificity of the fingerstick to identify those with abnormal lipids and hsCRP > or = 1 mg/L were all > or = 75%. CONCLUSION: Fingerstick screening is accurate and has good clinical utility to identify persons with abnormal blood lipids and hsCRP at the point of care in a diverse population that is eligible for primary prevention of CVD. These results may not be generalizable to patients at high risk for CVD or who have known hyperlipidemia.

Waist circumference, body mass index, and their association with cardiometabolic and global risk.

Total body fat and adipose tissue distribution are associated with cardiometabolic risk, yet there are conflicting data as to whether waist circumference (WC) or body mass index (BMI) is a better predictor of cardiovascular risk. To determine whether WC or BMI was more strongly associated with cardiometabolic risk, family members of patients with cardiac disease were studied (N=501; mean age, 48 years; 66% female; 36% nonwhite). Height, weight, WC, BMI, blood pressure, high-density lipoprotein cholesterol, triglycerides, glucose, high-sensitivity C-reactive protein, and lipoprotein-associated phospholipase A(2) were systematically measured. Global risk was calculated using the Framingham function. Increased WC and BMI were equally strong predictors of cardiometabolic and global risk. The prevalence of cardiometabolic risk factors and their correlation with WC and BMI varied by race/ethnicity. Our data support inclusion of WC and BMI in screening guidelines for diverse populations to identify individuals at increased cardiometabolic risk.

Usefulness of self-reported periodontal disease to identify individuals with elevated inflammatory markers at risk of cardiovascular disease.

Periodontal disease has been associated with cardiovascular disease (CVD), and inflammation may represent a common pathophysiology. Oral health screening in the context of CVD risk assessment represents a potential opportunity to identify individuals at risk for CVD. The purposes of this study were to determine if self-reported oral health status is independently associated with inflammatory markers and if oral health assessment as part of CVD risk screening can identify at-risk individuals without traditional CVD risk factors. A baseline analysis was conducted among participants in the National Heart, Lung, and Blood Institute's Family Intervention Trial for Heart Health (FIT Heart; n = 421, mean age 48 +/- 13.5 years, 36% nonwhite) without CVD or diabetes who underwent standardized assessment of oral health, lifestyle, CVD risk factors, and the inflammatory markers high-sensitivity C-reactive protein and lipoprotein-associated phospholipase A(2). Statistical associations between oral health, risk factors, and inflammatory markers were assessed, and logistic regression was used to adjust for effects of lifestyle and potential confounders. Periodontal disease was independently associated with being in the top quartile of lipoprotein-associated phospholipase A(2) compared with the lower 3 quartiles (odds ratio 1.9, 95% confidence interval 1.1 to 3.2) after adjustment for lifestyle and risk factors. Histories of periodontal disease were reported by 24% of non-overweight, non-hypertensive, non-hypercholesterolemic participants, and of these participants, 37% had elevated high-sensitivity C-reactive protein (> or =3 mg/L) or lipoprotein-associated phospholipase A(2) (> or =215 ng/ml) levels. In conclusion, self-reported periodontal disease is independently associated with inflammation and common in individuals without traditional CVD risk factors.

Validation of the MEDFICTS dietary assessment questionnaire in a diverse population.

BACKGROUND: The National Cholesterol Education Program (NCEP) recommends MEDFICTS, a rapid screening instrument for dietary fat, to assess adherence to the Adult Treatment Panel (ATP) III Therapeutic Lifestyle Changes (TLC) diet (score <40 points indicates intake of <7% of energy from saturated fat, <30% of energy from total fat, and <200 mg dietary cholesterol/day). MEDFICTS has only been validated in small, select populations and its utility in diverse clinical settings is unknown. OBJECTIVE: To evaluate the ability of MEDFICTS to identify individuals who are nonadherent to a TLC diet in an ethnically diverse population that includes both English- and Spanish-speakers. DESIGN: MEDFICTS was administered concurrently with the Gladys Block Food Frequency Questionnaire to participants (n=501; mean age 48+/-13.5 years; 36% nonwhite; 66% female) in the National Heart, Lung, and Blood Institute Family Intervention Trial for Heart Health (FIT Heart) at the baseline screening visit. Reliability and validity analyses were conducted overall and by sex, age, and race/ethnicity. RESULTS: MEDFICTS score correlated significantly with percentage of energy from saturated fat (r=0.52, P<0.0001), percentage of energy from total fat (r=0.31, P<0.0001), and milligrams per day of dietary cholesterol (r=0.54, P<0.0001). Sensitivity of MEDFICTS to correctly identify TLC diet adherence was 85.7% and did not differ significantly by sex, age, or race/ethnicity. Specificity of MEDFICTS to correctly identify nonadherence to the TLC diet was low (56.9%) and significantly worse for women than men (48.4% vs 72.9%; P<0.0001), but did not differ significantly in older vs younger participants or among white, black, or Hispanic participants. CONCLUSION: Our data suggest that sex-specific recalibration of MEDFICTS may improve specificity and clinical utility.

A novel family-based intervention trial to improve heart health: FIT Heart: results of a randomized controlled trial.

BACKGROUND: Family members of patients with cardiovascular disease (CVD) may be at increased risk due to shared genes and lifestyle. Hospitalization of a family member with CVD may represent a "motivational moment" to take preventive action. METHODS AND RESULTS: A randomized, controlled clinical trial was conducted in healthy adult family members (N=501; 66% female; 36% nonwhite; mean age, 48 years) of patients hospitalized with CVD to evaluate a special intervention (SI) with personalized risk factor screening, therapeutic lifestyle-change counseling, and progress reports to physicians versus a control intervention (CIN) on the primary outcome, mean percent change in low-density lipoprotein cholesterol (LDL-C), and other risk factors. Validated dietary assessments and standardized risk factors were obtained at baseline and 1 year (94% follow-up). At baseline, for 93% of subjects, saturated fat comprised > or = 7% of total caloric intake, and 79% had nonoptimal LDL-C levels (of which 50% were unaware). There was no difference in the SI versus the CIN with respect to the mean percent change in LDL-C (-1% versus -2%, respectively; P=0.64), owing to a similar significant reduction in LDL-C in both groups (-4.4 mg/dL and -4.5 mg/dL, respectively). Diet score significantly improved in the SI versus the CIN (P=0.04). High-density lipoprotein cholesterol declined significantly in the CIN but not in the SI (-3.2% [95% CI, -5.1 to -1.3] versus +0.3% [95% CI, -1.7 to +2.4]; P=0.01). At 1 year, SI subjects were more likely than controls to exercise >3 days per week (P=0.04). CONCLUSIONS: The SI was not more effective than the CIN in reducing the primary end point, LDL-C. The screening process identified many family members of hospitalized patients with CVD who were unaware of their risk factors, and further work is needed to develop and test interventions to reduce their CVD risk.

Cardiovascular disease knowledge, medication adherence, and barriers to preventive action in a minority population.

Lack of knowledge and awareness of cardiovascular disease may contribute to disproportionately higher risk in minorities. The authors studied minorities in Harlem, New York (N=214), to evaluate knowledge and preventive behaviors. More than half of the participants did not know optimal blood pressure (BP) (52%) and cholesterol (60%) goals. Lack of health insurance (odds ratio, 2.1; 95% confidence interval, 1.0-4.5) and less than a high school education (odds ratio, 2.0;95% confidence interval, 1.02-3.87) were associated with not knowing optimal BP. Among those with BP >/=140/90 mm Hg, 34% were unaware that they had high BP, and age younger than 55 years was predictive of lack of awareness that they had high BP (odds ratio, 8.5; 95% confidence interval, 2.6-28.1). Predictors of medication nonadherence included age younger than 45 years vs age 45 years or older (P=.004) and no health insurance vs health insurance (P=.01). Younger, less educated, uninsured patients should be targeted for educational interventions regarding cardiovascular disease prevention goals, personal risk, and the importance of medication adherence.

National study of women's awareness, preventive action, and barriers to cardiovascular health.

BACKGROUND: There is growing awareness of cardiovascular disease (CVD) as the leading cause of death in women, but whether this greater awareness is associated with increased action by women to lower their personal or family's risk is unknown. METHODS AND RESULTS: A nationally representative sample of 1008 women selected through random-digit dialing were given a standardized questionnaire about history of CVD/risk factors, awareness of leading cause of death, knowledge of healthy and personal levels of CVD risk factors, self-reported actions taken to reduce risk, and barriers to heart health. The rate of awareness of CVD as the leading cause of death has nearly doubled since 1997 (55% versus 30%) was significantly greater for whites compared with blacks and Hispanics (62% versus 38% and 34%, respectively) and was independently correlated with increased physical activity (odds ratio, 1.35; 95% CI, 1.00 to 1.83) and weight loss (odds ratio, 1.47; 95% CI, 1.14 to 2.02) in the previous year in logistic regression models. Fewer than half of the respondents were aware of healthy levels of risk factors. Awareness that personal level was not healthy was positively associated with action. Most women took steps to lower risk in family members and themselves. The most frequently cited barriers for heart health were confusion in the media (49%), the belief that health is determined by a higher power (44%), and caretaking responsibilities (36%). CONCLUSIONS: General awareness of CVD risk among women is associated with preventive action. Educational interventions need to be targeted at racial/ethnic minority women.

Ethnic differences in barriers and referral to cardiac rehabilitation among women hospitalized with coronary heart disease.

Important gender differences in cardiac rehabilitation utilization are well established, yet few studies have documented whether reported barriers and referrals vary by ethnicity. This is a cross-sectional study to determine whether barriers and referrals to participation in cardiac rehabilitation differed by race/ethnicity in 304 women (52% ethnic minorities) hospitalized with coronary heart disease. Nearly all subjects (92%) strongly agreed that physician referral was important to participation in rehab, but only 22% of subjects reported physician instruction to attend. Whites were more likely than minorities to report instruction to attend cardiac rehabilitation, and minorities were more likely to report financial barriers when compared with whites. These disparities need to be addressed because minority women have a worse prognosis following hospitalization for coronary heart disease, and cardiac rehabilitation has been shown to improve survival.

Waist circumference predicts cardiometabolic and global Framingham risk among women screened during National Woman's Heart Day.

PURPOSE: To evaluate the cardiometabolic risk profiles of 6938 women (mean age 49.2 +/- 14.6 years) attending the 2005 Sister to Sister: Everyone Has a Heart Foundation free public health standardized cardiovascular disease (CVD) risk factor screening events in 12 cities across the United States by race/ethnicity and waist circumference. MAIN FINDINGS: Among women without a history of CVD or diabetes (n = 6327), 90% were found to have at least one major modifiable CVD risk factor, with one-third of women having three or more major risk factors. Nearly half of all women with elevated total cholesterol (> or = 200 mg/dL) or low high-density lipoprotein (HDL)-cholesterol (< 50 mg/dL) did not report a known history of abnormal cholesterol. Among women with no history of hypertension, 16% had a blood pressure > or = 140/90 mm Hg. Unrecognized diabetes and glucose intolerance were striking among fasting women (n = 1218; 9% had a blood glucose > or = 126 mg/dL and 43% had a blood glucose > or = 100 mg/dL). In adjusted logistic regression models, women with a waist circumference > or = 35 inches were more likely to have blood pressure > or = 140/90 (OR = 1.9, p < 0.0001), total cholesterol > or = 200 mg/dL (OR = 1.2, p = 0.006), HDL-cholesterol < 50 mg/dL (OR = 2.5, p < 0.0001), fasting glucose > or = 100 mg/dL (OR = 2.0, p < 0.0001), and Framingham global risk score > or = 10%, CVD or diabetes (OR = 2.0, p < 0.0001). Waist circumference was significantly correlated with Framingham global risk (r = 0.24, p < 0.001) and number of risk factors (r = 0.24, p < 0.0001). Increased clustering of risk factors was predictive of waist size > or = 35 inches vs. < 35 inches in logistic models (p for trend > 0.0001). Among a subsample of women who underwent standardized screening for stress and depression, 62% had stress levels associated with increased cardiac risk, and 27% met criteria for clinical depression. CONCLUSIONS: Hypertension, dyslipidemia, and/or impaired fasting glucose were newly identified in approximately half the women screened. Waist size significantly correlated with clustering of risk factors, global Framingham risk score, CVD and diabetes, suggesting it may be an easily measured surrogate for women at increased risk of future cardiovascular clinical events who may benefit from further assessment and intervention.

Coronary heart disease in ethnically diverse women: risk perception and communication.

OBJECTIVES: To assess perceived vs calculated risk of coronary heart disease (CHD), preferred methods of communicating risk, and the effect of brief educational intervention to improve accurate perceptions of personal risk. SUBJECTS AND METHODS: Of 1858 women who underwent screening mammography between April and September 2003 at the Columbia University Medical Center in New York, NY, we assessed 125 women with no history of cardiovascular disease who participated in a risk factor screening and education program. Demographic variables were evaluated by interviewer-assisted standardized questionnaires. Absolute 10-year CHD risk was calculated using the Framingham global risk assessment. Perceived 10-year risk and preferred method of communicating risk were evaluated systematically. RESULTS: Among 110 research participants who were eligible for risk estimation, 59% had a 10-year risk of less than 10%. However, only half of those women accurately perceived their risk as low. After a brief educational intervention, the women's ability to correctly categorize their personal CHD risk improved significantly. Preferred methods to communicate risk varied by level of education and age. Older women (> or = 65 years) and those with a high school education or less were more likely to prefer simple methods of having CHD risk communicated compared with their counterparts. CONCLUSIONS: These data underscore the need to determine preferences for providing risk information and to test various formats for communicating CHD risk to improve awareness and management of CHD risk factors, especially among women of different age groups and education levels.