A randomized controlled trial of a physician-directed treatment program for low-income patients with high blood cholesterol: the Southeast Cholesterol Project

OBJECTIVE: To assess the effectiveness of a cholesterol-lowering intervention designed to facilitate the management of hypercholesterolemia by primary care clinicians. DESIGN: Randomized controlled trial, with randomization of clinician-patient groups. SETTING: Twenty-one community and rural health centers in North Carolina and Virginia. PARTICIPANTS: Primary care clinicians (n = 42, 71% physicians) and the patients they enrolled with high cholesterol (n = 372). Twenty-two clinicians were randomized to give the special intervention (184 patients) and 20 to give usual care (188 patients). Two thirds of participating patients were women, 40% were African American, and 11% were Native American. INTERVENTION: A 90-minute tutorial to train clinicians how to use a structured assessment and treatment program (Food for Heart Program) consisting of a brief dietary assessment and three 5- to 10-minute dietary counseling sessions given by the primary care clinician, referral to a local dietitian if the low-density lipoprotein cholesterol (LDL-C) remained elevated at 4-month follow-up, and a prompt for the clinician to consider lipid-lowering medication based on the LDL-C at 7-month follow-up. MAIN OUTCOME MEASURES: Changes in total and LDL cholesterol at 4-month follow-up and averaged over a 1-year follow-up period (4-, 7-, and 12-month follow-up). RESULTS: At 4-month follow-up, total cholesterol decreased 0.33 mmol/L (12.6 mg/dL) in the intervention group and 0.21 mmol/L (8.3 mg/dL) in the control group: the difference was 0.11 mmol/L (4.2 mg/dL) (90% confidence interval [CI], -0.02 to 0.24 mmol/L [-0.7 to 9.1 mg/dL]). The average reduction during the 1-year follow-up period was 0.09 mmol/L (3.6 mg/dL) greater in the intervention group (90% CI, -0.01 to 0.19 mmol/L [-0.3 to 7.5 mg/dL]). Eight percent of intervention patients were taking lipid-lowering medication at follow-up visits compared with 15% of control patients. In a subgroup analysis restricted to the 89% of returnees who were not taking lipid-lowering medication, the reduction in total cholesterol at 4-month follow-up was 0.14 mmol/L (5.5 mg/dL) greater in the intervention group (95% CI, 0.01 to 0.28 mmol/L [0.3 to 10.7 mg/dL]); averaged over 1 year, it was 0.14 mmol/L (5.3 mg/dL) greater (95% CI, 0.03 to 0.24 mmol/L [1.2 to 9.4 mg/dL]). Changes in LDL-C were similar. CONCLUSIONS: Total cholesterol and LDL-C decreased more in the intervention group than in the control group. Overall, the difference in lipid reduction between groups was modest and of borderline statistical significance; among participants who did not take lipid-lowering medication during follow-up, the difference in lipid reduction between groups was larger. We conclude that primary care clinicians can be trained to give a cholesterol-lowering intervention to low-income patients that results in modest, short-term reductions in total cholesterol and LDL-C

Conducting Community Audits to Evaluate Community Resources for Healthful Lifestyle Behaviors: An Illustration From Rural Eastern North Carolina

A community audit is a qualitative and quantitative research technique in which researchers drive through a community to observe its physical and social attributes, primarily through windshield tours and "ground truthing." Ground truthing is a verification process that uses data gathered by direct observation to corroborate data gathered from secondary sources. Community audits have been used for epidemiologic studies and in program planning for health-promotion interventions. Few studies have detailed the methodology for conducting community audits in rural areas or the extent to which community audits can contribute to an accurate assessment of community characteristics (eg, presence of sidewalks) and nutrition and physical activity resources (eg, produce stands, parks) that may promote healthful lifestyle behaviors. The objective of this article is to describe our approach to conducting a community audit (consisting of windshield tours and ground truthing) to enumerate resources, to assess community characteristics, and to inform revisions to a community guide on nutrition and physical activity resources. We conducted an audit in 10 communities in a rural eastern North Carolina county in 2010. We also collected data from secondary sources to make comparisons with community audit data. The initial resource guide included 42 resources; the community audits identified 38 additional resources. There was moderate to high agreement between windshield tour observations and secondary data sources for several community characteristics, such as number of fast-food restaurants (67% agreement) and existence of sidewalks (100% agreement). Community audits improved the description of health-promoting community resources and the context in which people make lifestyle choices

Rural African American Women With Severe Obesity: A Cross-Sectional Analysis of Lifestyle Behaviors and Psychosocial Characteristics

PurposeTo examine differences in lifestyle behavioral and psychosocial factors between rural African American women with Class 3 obesity and those with overweight, and Class 1-2 obesity.DesignCross-sectional study.SettingRural Southeastern United States.SubjectsParticipants included 289 African American women with a mean age of 56 years, 66% with a high school education or less, and a mean body mass index (BMI) of 38.6 kg/m2; 35% (n = 102) were classified with Class 3 obesity.MeasuresWe objectively measured height, weight, and physical activity steps/day. Self-reported dietary and physical activity behaviors, general health-related quality of life, mental health, and social support were measured with validated surveys.AnalysisChi-Square analysis for categorical variables and analysis of variance (ANOVA) – via multiple linear regression – for continuous variables.ResultsThere were no significant demographic differences between BMI groups, except for age, where women with Class 3 obesity were on average younger (51 vs 58 y, P < .001). Although dietary behaviors did not differ significantly between groups, we observed significant group differences in self-reported and objective measures of physical activity. The age-adjusted difference in means for self-reported total physical activity minutes/wk. was 91 minutes, with women categorized with Class 3 obesity reporting significantly fewer weekly minutes than those with overweight/Class 1-2 obesity (64.3 vs 156.4 min/wk. respectively, P < .01). Among psychosocial variables, only in the physical component scores of health-related quality of life did we find significant group differences – lower physical well-being among women with Class 3 obesity compared to those with overweight/Class 1-2 obesity (P = .02).ConclusionFor African American women with Class 3 obesity living in rural setting, these findings suggest behavioral weight loss interventions may need to target physical activity strategies that address physical, psychosocial, and environmental barriers

Analysis of the third national health and nutrition examination survey (NHANES III) using expert ratings of job categories

Background Few epidemiologic studies have addressed the exposure–response relationships between work activities and symptomatic knee osteoarthritis (OA). This analysis used data from a national survey and ergonomists' ratings to address this issue. Methods Interview and knee X-ray data were obtained from the Third National Health and Nutrition Examination Survey. Occupational ratings were obtained using ergonomists. A weighted logistic regression was used. Results Among men, a significant exposure–response relationship was found between symptomatic knee OA and kneeling. In both genders, there was a significant trend in heavy lifting and severe symptomatic knee OA. Approximately 20.7% of knee OA can be attributed to kneeling >14% of the workday among men. Conclusions The significant exposure–response relationships suggest that modest reductions in certain occupational activities can reduce the burden of knee OA. The study was limited by unvalidated expert ratings. Research is needed to identify hazardous characteristics of work activities and to clarify exposure–response relationships. Am. J. Ind. Med. 51:37–46, 2008. © 2007 Wiley-Liss, Inc.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/57516/1/20512_ftp.pd

Community-engagement to support cardiovascular disease prevention in disparities populations: three case studies

Cardiovascular diseases remain the leading cause of death in the United States, and are characterized by socioeconomic, geographic, ethnic, and gender disparities in risk, morbidity and mortality. In response, public health efforts have moved beyond approaches focusing on individual-level behavior change toward culturally appropriate community-focused efforts. In specific, engagement of community partners is now recognized as essential to facilitate changes at multiple levels to improve cardiovascular disease outcomes. This paper shares lessons learned to deepen appreciation for the unique challenges community-engagement in health disparities research entails, including variations in practice, time commitment, and complexity. This paper presents three case studies documenting community-engagement in the planning, implementation and evaluation processes. All projects collaborated with community partners in contexts with disproportionately high rates of cardiovascular disease but with distinct programmatic foci: the East Los Angeles, California project focused on improving access to fresh fruit and vegetables through corner store makeovers; the Boston, Massachusetts project reached out to and engaged Puerto Rican community members in a lifestyle intervention study; and the Lenoir County, North Carolina project engaged local restaurant owners and a range of community agencies in healthy lifestyle promotion activities. These cases provide examples of the unique solutions and approaches to issues common in doing community-engagement work

A Church-based Diabetes Self-management Education Program for African Americans With Type 2 Diabetes

INTRODUCTION: Diabetes self-management education interventions in community gathering places have been moderately effective, but very few studies of intervention effectiveness have been conducted among African Americans with type 2 diabetes. This paper describes a church-based diabetes self-management education intervention for African Americans, a randomized controlled trial to evaluate the intervention, and baseline characteristics of study participants. METHODS: A New DAWN: Diabetes Awareness & Wellness Network was conducted among 24 churches of varying size in North Carolina. Each church recruited congregants with type 2 diabetes and designated a diabetes advisor, or peer counselor, to be part of the intervention team. Participants were enrolled at each church and randomized as a unit to either the special intervention or the minimal intervention. The special intervention included one individual counseling visit, twelve group sessions, three postcard messages from the participant's diabetes care provider, and twelve monthly telephone calls from a diabetes advisor. Baseline data included measures of weight, hemoglobin A1c, blood pressure, physical activity, dietary and diabetes self-care practices, and psychosocial factors. The study to evaluate the intervention (from enrollment visit to last follow-up) began in February 2001 and ended in August 2003. RESULTS: Twenty-four churches (with 201 total participants) were randomized. Sixty-four percent of the participants were women. On average, the participants were aged 59 years and sedentary. They had an average of 12 years of education, had been diagnosed with diabetes for 9 years, had a body mass index of 35, had a hemoglobin A1c level of 7.8%, and had a reported dietary intake of 39% of calories from fat. CONCLUSION: A New DAWN is a culturally sensitive, church-based diabetes self-management education program for African Americans with type 2 diabetes that is being evaluated for effectiveness in a randomized controlled trial. The outcomes of A New DAWN will contribute to the literature on community-based interventions for minority populations and help to inform the selection of approaches to improve diabetes care in this population

Conceptualizing and comparing neighborhood and activity space measures for food environment research

Greater accessibility to geospatial technologies has led to a surge of spatialized public health research, much of which has focused on food environments. The purpose of this study was to analyze differing spatial measures of exposure to supermarkets and farmers’ markets among women of reproductive age in eastern North Carolina. Exposure measures were derived using participant-defined neighborhoods, investigator-defined road network neighborhoods, and activity spaces incorporating participants’ time space behaviors. Results showed that mean area for participant-defined neighborhoods (0.04 sq. miles) was much smaller than 2.0 mile road network neighborhoods (3.11 sq. miles) and activity spaces (26.36 sq. miles), and that activity spaces provided the greatest market exposure. The traditional residential neighborhood concept may not be particularly relevant for all places. Time-space approaches capturing activity space may be more relevant, particularly if integrated with mixed methods strategies

Farmers\u27 market use is associated with fruit and vegetable consumption in diverse southern rural communities

Background While farmers’ markets are a potential strategy to increase access to fruits and vegetables in rural areas, more information is needed regarding use of farmers’ markets among rural residents. Thus, this study’s purpose was to examine (1) socio-demographic characteristics of participants; (2) barriers and facilitators to farmers’ market shopping in southern rural communities; and (3) associations between farmers’ market use with fruit and vegetable consumption and body mass index (BMI). Methods Cross-sectional surveys were conducted with a purposive sample of farmers’ market customers and a representative sample of primary household food shoppers in eastern North Carolina (NC) and the Appalachian region of Kentucky (KY). Customers were interviewed using an intercept survey instrument at farmers’ markets. Representative samples of primary food shoppers were identified via random digit dial (RDD) cellular phone and landline methods in counties that had at least one farmers’ market. All questionnaires assessed socio-demographic characteristics, food shopping patterns, barriers to and facilitators of farmers’ market shopping, fruit and vegetable consumption and self-reported height and weight. The main outcome measures were fruit and vegetable consumption and BMI. Descriptive statistics were used to examine socio-demographic characteristics, food shopping patterns, and barriers and facilitators to farmers’ market shopping. Linear regression analyses were used to examine associations between farmers’ market use with fruit and vegetable consumption and BMI, controlling for age, race, education, and gender. Results Among farmers’ market customers, 44% and 55% (NC and KY customers, respectively) reported shopping at a farmers’ market at least weekly, compared to 16% and 18% of NC and KY RDD respondents. Frequently reported barriers to farmers’ market shopping were market days and hours, “only come when I need something”, extreme weather, and market location. Among the KY farmers’ market customers and NC and KY RDD respondents, fruit and vegetable consumption was positively associated with use of farmers’ markets. There were no associations between use of farmers’ markets and BMI. Conclusions Fruit and vegetable consumption was associated with farmers’ market shopping. Thus, farmers’ markets may be a viable method to increase population-level produce consumption

Examining the Influence of Price and Accessibility on Willingness to Shop at Farmers' Markets Among Low-income Eastern North Carolina Women

To examine the influence of farmers’ market pricing and accessibility on willingness to shop at farmers’ markets, among low-income women