The Inter-Relation of the Cardio-Autonomic Nervous System and HPA-Axis and its Association with Cardiovascular Precursors in Children

Stress, via the activation of the stress response system, has been linked to the emergence of cardiovascular precursors. The majority of studies relating the autonomic nervous system and the hypothalamic pituitary adrenal (HPA) axis, the two main branches of the stress response system, to stress and cardiovascular precursors have focused on examining each branch of the stress response system in isolation. However, considering only these singular associations disregards the structural and functional inter-connection between the stress response systems. Examining the inter-relation between the stress systems among children and adolescents is particular opportune given the emergence of cardiovascular precursors early in the life course. The objective of the current research program was to examine the patterning of the cardio-autonomic nervous system and HPA axis, and whether the inter-relation between these stress systems was associated with cardiovascular precursors among children. Three studies were conducted. Study 1 demonstrated the patterning of the stress response system, and found that the inter-relation between stress systems better accounted for the relation between stress and the stress response system than either system alone. Extending these results, Study 2 demonstrated that the inter-relation between stress systems was associated with cardiovascular precursors in a population-based sample of children. Exposure to stress moderated the association between inter-relation of stress systems and cardiovascular precursors, which was more robust among children with greater stressful life events. Study 3 replicated these results in a sample of children at-risk for obesity, and demonstrated that the inter-relation between stress systems was related to cardiovascular precursors among at-risk children with greater stress exposure. Overall, this research program found that the inter-relation between the stress systems was related to cardiovascular precursors, and children’s environmental exposure to stressful events influenced these associations. Future studies should consider using an inter-relation approach, which may provide greater insight into the association between stress and cardiovascular health than considering the stress systems independently. The patterning of the stress response system has implications for future studies examining how stress “gets under the skin” to promote the development of disease

Psychometric properties of the diurnal cortisol profile in youth

Cortisol is the end product of the hypothalamic pituitary adrenal axis (HPA). It is released in a diurnal profile with a noticeable morning rise (cortisol awakening response) and decline throughout the day (diurnal slope). Cortisol is of interest to many researchers due to its association with negative physical and mental health consequences. For the diurnal cortisol profile to be considered a stable individual difference, it must be reliable to measure. Current knowledge of the reliability of the diurnal cortisol profile is almost entirely based on adults. The reliability in youth may differ due developmental factors, such as puberty, among other possible covariates. The present study evaluated the reliability of calculated indices and individual measures of the diurnal cortisol profile in youth aged 9 to 18 years. Three groups of youth collected five to six saliva samples per day over two to three days. Cortisol assays and calculated indices were conducted using standardized methods. Results indicated maximum peak cortisol level, the total cortisol concentration over a day (AUC TG ), and the cortisol awakening response relative to ground (AUCAG ) can be moderately reliably assessed in children and adolescents when sampled over two to three days. At least seven days are needed to obtain reliable measures of the change in cortisol concentration (AUCI , diurnal slope). Important covariates to consider include sleep duration, day of week, pubertal stage, time of awakening, and perceived stress. These findings suggest the diurnal cortisol profile in children and adolescents can be reliably assessed and reflects a stable individual difference. Methodological considerations and suggestions for future research are discussed

Barriers and facilitators in implementing a pilot, pragmatic, telemedicine-delivered healthy lifestyle program for obesity management in a rural, academic obesity clinic

Few evidence-based strategies are specifically tailored for disparity populations such as rural adults. Two-way video-conferencing using telemedicine can potentially surmount geographic barriers that impede participation in high-intensity treatment programs offering frequent visits to clinic facilities. We aimed to understand barriers and facilitators of implementing a telemedicine-delivered tertiary-care, rural academic weight-loss program for the management of obesity

Feasibility and acceptability of a rural, pragmatic, telemedicine‐ delivered healthy lifestyle programme

Background: The public health crisis of obesity leads to increasing morbidity that are even more profound in certain populations such as rural adults. Live, two‐way video‐conferencing is a modality that can potentially surmount geographic barriers and staffing shortages. Methods: Patients from the Dartmouth‐Hitchcock Weight and Wellness Center were recruited into a pragmatic, single‐arm, nonrandomized study of a remotely delivered 16‐week evidence‐based healthy lifestyle programme. Patients were provided hardware and appropriate software allowing for remote participation in all sessions, outside of the clinic setting. Our primary outcomes were feasibility and acceptability of the telemedicine intervention, as well as potential effectiveness on anthropometric and functional measures. Results: Of 62 participants approached, we enrolled 37, of which 27 completed at least 75% of the 16‐week programme sessions (27% attrition). Mean age was 46.9 ± 11.6 years (88.9% female), with a mean body mass index of 41.3 ± 7.1 kg/m2 and mean waist circumference of 120.7 ± 16.8 cm. Mean patient participant satisfaction regarding the telemedicine approach was favourable (4.48 ± 0.58 on 1‐5 Likert scale—low to high) and 67.6/75 on standardized questionnaire. Mean weight loss at 16 weeks was 2.22 ± 3.18 kg representing a 2.1% change (P \u3c .001), with a loss in waist circumference of 3.4% (P = .001). Fat mass and visceral fat were significantly lower at 16 weeks (2.9% and 12.5%; both P \u3c .05), with marginal improvement in appendicular skeletal muscle mass (1.7%). In the 30‐second sit‐to‐stand test, a mean improvement of 2.46 stands (P = .005) was observed. Conclusion: A telemedicine‐delivered, intensive weight loss intervention is feasible, acceptable, and potentially effective in rural adults seeking weight loss

“The Last Thing You Have to Worry About”: A Thematic Analysis of Employment Challenges Faced by Cancer Survivors

The evidence base for interventions that support the employment goals of cancer survivors is growing but inconclusive. As the first step in initiating a community-engaged program of research aimed at developing and testing interventions to support the employment goals of cancer survivors, 23 cancer survivors, 17 healthcare providers, and 5 employers participated in individual interviews to elicit perceptions regarding local challenges and resources related to work maintenance and optimization within the context of cancer treatment. Interviews were recorded and transcribed verbatim. A thematic analysis was conducted to identify cross-cutting experiences that were voiced by all three types of participants. Three themes were found in the data: (1) the onus for identifying and articulating work-related issues is upon the cancer survivor; (2) the main support offered to cancer survivors involved time away from work and flexibility with scheduling work and treatment activities; and (3) participants voiced a lack of information regarding one or more aspects related to supporting employment goals of cancer survivors. Supportive resources designed for cancer survivors, employers, and/or healthcare providers are needed to help cancer survivors optimize their employment situations

Feasibility and acceptability of a rural, pragmatic, telemedicine‐delivered healthy lifestyle programme

Background: The public health crisis of obesity leads to increasing morbidity that are even more profound in certain populations such as rural adults. Live, two‐way video‐conferencing is a modality that can potentially surmount geographic barriers and staffing shortages. Methods: Patients from the Dartmouth‐Hitchcock Weight and Wellness Center were recruited into a pragmatic, single‐arm, nonrandomized study of a remotely delivered 16‐week evidence‐based healthy lifestyle programme. Patients were provided hardware and appropriate software allowing for remote participation in all sessions, outside of the clinic setting. Our primary outcomes were feasibility and acceptability of the telemedicine intervention, as well as potential effectiveness on anthropometric and functional measures. Results: Of 62 participants approached, we enrolled 37, of which 27 completed at least 75% of the 16‐week programme sessions (27% attrition). Mean age was 46.9 ± 11.6 years (88.9% female), with a mean body mass index of 41.3 ± 7.1 kg/m2 and mean waist circumference of 120.7 ± 16.8 cm. Mean patient participant satisfaction regarding the telemedicine approach was favourable (4.48 ± 0.58 on 1‐5 Likert scale—low to high) and 67.6/75 on standardized questionnaire. Mean weight loss at 16 weeks was 2.22 ± 3.18 kg representing a 2.1% change (P \u3c .001), with a loss in waist circumference of 3.4% (P = .001). Fat mass and visceral fat were significantly lower at 16 weeks (2.9% and 12.5%; both P \u3c .05), with marginal improvement in appendicular skeletal muscle mass (1.7%). In the 30‐second sit‐to‐stand test, a mean improvement of 2.46 stands (P = .005) was observed. Conclusion: A telemedicine‐delivered, intensive weight loss intervention is feasible, acceptable, and potentially effective in rural adults seeking weight loss