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Development and initial evaluation of a culturally sensitive cholesterol-lowering diet program for Mexican and African American patients with systemic lupus erythematosus
Abstract
To develop and evaluate acceptability of an intensive and ethnic-specific cholesterol-lowering diet program with a strong behavioral component in patients with systemic lupus erythematosus (SLE).
A comprehensive program with a behavioral component and culturally sensitive menus was developed in an effort to alter dietary behavior in patients with SLE. Four SLE patients, 2 African American and 2 Mexican American, enrolled in this program. Data on food intake (3-day food record), acceptability of the program (subjective response), and physiologic variables were collected at baseline, 6 weeks, and 12 weeks.
The program was highly rated by all patients and found to be informative, easy to understand, ethnically sensitive, and to contain useful behavioral maintenance strategies. All 4 patients surpassed or were close to their diet goals at both 6 and 12 weeks. In this small group of patients, there was a statistically significant reduction in low-density lipoprotein cholesterol (P = 0.04) and body weight (P = 0.001), as assessed by repeated measures analysis of variance.
The culturally specific cholesterol-reducing diet program was highly rated and appeared to be effective in changing the diet of this small group of SLE patients, as determined by their food records and body weight. The impact of this program, including the individual components on cardiovascular disease risk factors, needs to be evaluated in a larger multiple-arm study with a lengthier intervention.
... Several studies were specifically designed for participants with chronic conditions, 24,27 such as diabetes, 17,20,21,23,29 obesity, 7,8,22,25,33,35 and systemic lupus erythematosus. 15 But regardless of recruitment efforts, many study samples comprised mostly overweight/ obese participants. † Socioeconomic status varied greatly. ...
... 8,14,16 Single-group pre-post test designs were used in only 8 studies. 15,21,[25][26][27][28]30,31 Most studies measured outcomes at the completion of the intervention. Delays between intervention completion and outcome measurement ranged from approximately 1 week to 12 months. ...
... Several studies used combinations of individually delivered and group-based interventions, 21,29,32 and others incorporated home-based components. 6,15,19,24,28 Only 2 studies involved completely home-based interventions. 9,10 Chen et al 9 delivered their program via mail and telephone, whereas Buller and colleagues 10 used a Web site. ...
This article provides a review of health promotion research conducted among Latinos. The authors examined 31 intervention studies promoting physical activity and/or healthy diet in Latino samples. Overall, findings suggested that Latinos are responsive to interventions promoting physical activity and healthy diet, despite facing numerous barriers to health promotion. In fact, 12 of the 21 studies that measured physical activity and 19 of the 26 studies that measured dietary behavior reported that the intervention produced significant improvements in those health behaviors. Design strengths of these studies included the high rates of retention and large number of randomized controlled trials. However, there were concerns regarding the lack of diversity in the samples (mostly Mexican American women), limiting the generalizability of the findings and the underutilization of objective measures of physical activity and diet behavior in intervention studies.
... In addition, the hyperlipid diet (rich in cholesterol and saturated fat) is one of the major factors for maintaining dyslipidemia in SLE, perpetuating and aggravating lipid profi le changes. 8,13,14 On the other hand, antioxidant nutrients, such as β-carotene, α-tocopherol, ascorbic acid, and selenium are known to protect against tissue damages by both activating macrophages, monocytes and granulocytes, and suppressing the activity of cytokines and TNF-α. 15 Diet therapy is a promising way to approach SLE, with the indication of vitamin-and mineral-rich foods (mainly the antioxidant ones) and mono/polyunsaturated fatty acids, and moderate energy consumption, aiming at reducing infl ammatory markers and helping in the treatment of those comorbidities and of the adverse reactions to drugs. ...
... 15 Diet therapy is a promising way to approach SLE, with the indication of vitamin-and mineral-rich foods (mainly the antioxidant ones) and mono/polyunsaturated fatty acids, and moderate energy consumption, aiming at reducing infl ammatory markers and helping in the treatment of those comorbidities and of the adverse reactions to drugs. 11,13,16,17 ...
The authors reviewed the influence of nutritional factors on systemic lupus erythematosus (SLE) and discussed an alternative treatment option. The autoimmunity and inflammatory process of SLE are related to the presence of dyslipidemia, obesity, systemic arterial hypertension, and metabolic syndrome, which should be properly considered to decrease cardiovascular risk. A diet with moderate protein and energy content, but rich in vitamins, minerals (especially antioxidants), and mono/polyunsaturated fatty acids can promote a beneficial protective effect against tissue damage and suppression of inflammatory activity, in addition to helping the treatment of those comorbidities. Diet therapy is a promising approach and some recommendations may offer a better quality of life to patients with SLE.
... These findings included: ▸ discussions of specific predisease states that may predispose to adverse outcomes; 77 ▸ factors that impact motivation to participate in intervention programmes; 82 ▸ the interplay of disease-coping mechanisms with cultural factors unique to African-Americans. 76 78 Findings of improved health outcomes following racetailored interventions 81 83 84 87 were similar to the reported acceptability and effectiveness of other culturally specific intervention programmes 108 and consistent with studies that have suggested ways to neutralise, at least partially, the disadvantages of lower socioeconomic status associated with the excess morbidity and mortality in African-Americans with SLE. 45 109 110 These include: ▸ improving access to quality healthcare; ▸ targeting educational programmes to promote recognition and understanding of the disease and the comorbid conditions that affect outcome; ▸ implementing programmes to improve selfmonitoring and adherence to medical regimens; ▸ developing opportunities to facilitate homemaking, childrearing and working outside the home; ▸ applying psychosocial interventions to enhance selfconfidence and social support. Self-management programmes in particular have demonstrated significant improvements in health distress, self-reported global health and activity limitation, with trends towards improvement in self-efficacy and mental stress management around the world [111][112][113][114][115][116][117] and in solely African-American populations with lupus 81 83 84 87 and may be one of the most promising areas of quality-of-life intervention. ...
Systemic lupus erythematosus (SLE) is a multi-organ autoimmune disorder that can cause significant morbidity and mortality. A large body of evidence has shown that African-Americans experience the disease more severely than other racial-ethnic groups. Relevant literature for the years 2000 to August 2015 were obtained from systematic searches of PubMed, Scopus, and the EBSCOHost platform that includes MEDLINE, CINAHL, etc. to evaluate research focused on SLE in African-Americans. Thirty-six of the 1502 articles were classified according to their level of evidence. The systematic review of the literature reported a wide range of adverse outcomes in African-American SLE patients and risk factors observed in other mono and multi-ethnic investigations. Studies limited to African-Americans with SLE identified novel methods for more precise ascertainment of risk and observed novel findings that hadn't been previously reported in African-Americans with SLE. Both environmental and genetic studies included in this review have highlighted unique African-American populations in an attempt to isolate risk attributable to African ancestry and observed increased genetic influence on overall disease in this cohort. The review also revealed emerging research in areas of quality of life, race-tailored interventions, and self-management. This review reemphasizes the importance of additional studies to better elucidate the natural history of SLE in African-Americans and optimize therapeutic strategies for those who are identified as being at high risk.
... Alternatively, there were patient-centered weight loss interventions that incorporated multiple behavior change techniques or were developed with the input of stakeholders (e.g., patients and caregivers) to reduce accessibility barriers (43,73,75,78,81). Research participants received guidelines to reduce caloric intake that took into account individual circumstances, such as food and physical activity preferences and functional status. ...
Obesity is a common comorbidity in adults with mobility-impairing neurological and musculoskeletal conditions, such as stroke and arthritis. The interaction between mobility impairments and environmental factors often compromises motivation and ability to engage in healthy behaviours. Such difficulties to engage in healthy behaviours can result in energy imbalance, weight gain and a cycle of functional declines; i.e. obesity can exacerbate mobility impairments and symptoms and increase the likelihood of other comorbid conditions, all of which make it more difficult to engage in healthy behaviours. To help disrupt this cycle, there is a need to identify strategies to optimize energy balance. Thus, this review summarizes clinical trials of nutrition and weight loss interventions in adults with mobility-impairing conditions. Although adults with osteoarthritis were represented in large rigorous clinical trials, adults with neurological conditions were typically represented in studies characterized by a small number of participants, a short-term follow-up and high attrition rates. Studies varied greatly in outcome measures, description and implementation of the interventions, and the strategies used to promote behaviour change. Nutrition and weight loss research in adults with mobility-impairing conditions is still in its formative stages, and there is a substantial need to conduct randomized controlled trials.
... In addition, culturally sensitive adaptations of CB programs have improved outcomes. For example, in one study of Mexican and African American patients with systemic lupus erythematous, ethnic-specific diets combined with cognitive-behavioral modification techniques resulted in lowered low-density lipoprotein, total cholesterol, and weight (Shah, Coyle, Kavanaugh, Adams-Huet, & Lipsky, 2000). ...
Obesity and type 2 diabetes are increasing significantly in the Hispanic population and in the Hispanic population with schizophrenia. In the Diabetes Prevention Project (DPP), cognitive-behavioral (CB) interventions were more effective in reducing weight and preventing diabetes.
To test a CB group intervention based on the DPP model among Hispanic individuals with schizophrenia on weight, body mass index (BMI), and waist-hip circumference (WH).
Pilot study using a pre-post quasi-experimental design and convenience sample of 8 subjects from a public mental health clinic who met for 8 weekly group meetings.
No significant differences in BMI, weight, or WH scores based on t-test results; the subjects' weight remained stable, there was a trend toward weight loss, and no one gained weight during the trial.
No further weight gain is a finding that merits further research using a larger sample size and a randomized controlled design. J Am Psychiatr Nurses Assoc, 2008; 13(6), 353-359.
Lupus is a chronic disease that requires an interdisciplinary treatment management approach to facilitate optimal outcomes. One key component believed critical to overall treatment management is the inclusion of educational programs to improve patient knowledge. It is unclear which educational programs are most effective in improving patient knowledge of lupus and, ultimately, long-term outcomes. The purpose of this review is to examine the current literature related to educational programs for patients with lupus.
The authors reviewed the influence of nutritional factors on systemic lupus erythematosus (SLE) and discussed an alternative treatment option. The autoimmunity and inflammatory process of SLE are related to the presence of dyslipidemia, obesity, systemic arterial hypertension, and metabolic syndrome, which should be properly considered to decrease cardiovascular risk. A diet with moderate protein and energy content, but rich in vitamins, minerals (especially antioxidants), and mono/polyunsaturated fatty acids can promote a beneficial protective effect against tissue damage and suppression of inflammatory activity, in addition to helping the treatment of those comorbidities. Diet therapy is a promising approach and some recommendations may offer a better quality of life to patients with SLE.
Many health conditions are treated, at least in part, by therapeutic diets. Although the success of any intervention depends on its acceptability to the patient, the acceptability of therapeutic diets and factors that influence it have been largely neglected in nutrition research. A working definition of acceptability is proposed and an examination and summary are provided of available data on the acceptability of common diet regimens used for medical conditions. The goal is to suggest ways to improve the success of therapeutic diets. The proposed working definition of "acceptability" refers to the user's judgment of the advantages and disadvantages of a therapeutic diet-in relation to palatability, costs, and effects on eating behaviour and health-that influence the likelihood of adherence. Very low-calorie, reduced-fat omnivorous, vegetarian and vegan, and low-carbohydrate diets all achieve acceptability among the majority of users in studies of up to one year, in terms of attrition and adherence rates and results of questionnaires assessing eating behaviours. Longer studies are fewer, but they suggest that vegetarian, vegan, and reduced-fat diets are acceptable, as indicated by sustained changes in nutrient intake. Few studies of this length have been published for very low-calorie or low-carbohydrate diets. Long-term studies of adherence and acceptability of these and other therapeutic diets are warranted.
To examine serving size knowledge in African Americans and how it is related to body mass index (BMI).
Serving size knowledge of food commonly consumed by African Americans was assessed by asking the subjects to select the amount of food considered to be a single serving size by the United States Department of Agriculture and the Food and Drug Administration. Seventeen food items were tested, and the amounts selected were weighed. Body mass index was estimated from measured height and weight.
Churches. PARTICPANTS: Ninety-five African American women.
Amount of food selected and BMI.
The amount of food selected was compared with the respective standard serving using the 1-sample Wilcoxon signed rank test. The association between BMI and the amount selected was assessed by logistic regression.
The subjects significantly overestimated (P = .001 to .02) serving sizes for cornflakes, apple, watermelon, butter, whole milk, chips, and regular soda. Body mass index was significantly associated with overestimation of cornflakes, butter, cookies, and macaroni and cheese (P = .01 to .03), and the odds ratio for overestimating these food items was 1.46-1.65 times greater per 5-unit increase in BMI.
African American women overestimated the serving sizes for 7 of the food items tested, and 4 of the estimates were correlated with BMI. Education regarding serving size is recommended for certain food items.
To evaluate the effect of a culturally sensitive cholesterol lowering diet program on lipid and lipoproteins, body weight, nutrient intakes, and quality of life (QOL) in patients with systemic lupus erythematosus (SLE).
Seventeen patients with SLE were randomized to a Step 2 diet intervention group or a control group for 12 weeks. The diet intervention was made up of weekly group sessions during the first 6 weeks followed by telephone counseling every 2 weeks for the last 6 weeks. Data on fasting lipid and lipoproteins, body weight, food intake (3 day food record), and QOL were collected at baseline, 6 weeks, and 12 weeks. Program acceptability was assessed in the diet group at 6 weeks.
The intervention was found to be highly acceptable and culturally sensitive. The changes in nutrient intakes at 6 and 12 weeks in the diet group were -49% and -33%, respectively, for cholesterol, -44% and -32%, respectively, for percentage calories from fat, and -46% and -32%, respectively, for percentage calories from saturated fat. The corresponding figures in the control group were +22% and -8% for cholesterol, +9% and +6% for percentage calories from fat, and +5% and +7% for percentage calories from saturated fat. The treatment by time interaction was significant for all the dietary variables (p = 0.0003 to 0.02). QOL was reported to improve by 15-17% in the diet group and decrease by 4-6% in the control group, and the treatment by time interaction was significant (p = 0.05). The changes in the physiological variables at 6 and 12 weeks in the diet group were -10% and -6%, respectively, for total cholesterol, -10% and -2%, respectively, for low density lipoprotein (LDL) cholesterol, -11% and -4%, respectively, for high density lipoprotein (HDL) cholesterol, -25% and -34%, respectively, for very low density lipoprotein (VLDL) cholesterol, -8% and -24%, respectively, for triglycerides, and -2% and -5%, respectively, for body weight. The corresponding figures in the control group were -5% and -3% for total cholesterol, -6% and -5% for LDL cholesterol, 0% and +12% for HDL cholesterol, +4% and -8% for VLDL cholesterol, -6% and -15% for triglycerides, and -5% and -6% for body weight. The treatment by time interaction was significant for HDL cholesterol (p = 0.04). A significant reduction was seen in the diet group for total cholesterol at 6 and 12 weeks, LDL and HDL cholesterol at 6 weeks, and body weight at 12 weeks (p = 0.0002 to 0.01).
This culturally sensitive cholesterol reducing diet program was highly accepted and effective in changing the diet and QOL of patients with SLE. The effect on serum lipids, lipoproteins, and body weight, however, was modest. A larger randomized study with a longer intervention period is necessary to test the effectiveness of a cholesterol-lowering diet on lipids and lipoproteins in patients with SLE.
To evaluate the effect of a culturally sensitive cholesterol lowering dietary program on energy, protein, fiber, vitamin and mineral intake, diet quality, and hemoglobin levels in patients with systemic lupus erythematosus (SLE).
Seventeen patients with SLE were randomized to a Step II diet intervention group or a control group for 12 weeks. The diet intervention was made up of weekly group sessions during the first 6 weeks followed by telephone counseling every 2 weeks for the last 6 weeks. Food intake was assessed by 3-day food record at baseline, 6, and 12 weeks. Diet quality was assessed by expressing the nutrients as a percentage of the Dietary Reference Intakes of the US National Academy of Sciences, or as a percentage of the nutrient guidelines by the National Cholesterol Education Program, Adult Treatment Panel III. Between- and within-group changes in nutrient intakes were assessed by repeated measures ANOVA.
The changes in nutrient intakes were not significantly different between the groups for any of the nonfat nutrients except vitamin B12 (p = 0.05), which decreased in the diet group and increased in the control group. Within-group analysis showed a significant reduction (p = 0.0003 to 0.02) in the diet group in energy and sodium intake at 6 and 12 weeks and B12 intake at 12 weeks compared to the respective baseline values (28-32%, 37-41%, and 43%, respectively). Sodium intake decreased to 66-71% of the total sodium allowance (< 2400 mg per day) in the diet group. The intervention was successful in maintaining adequate intakes or even increasing intakes of most nutrients except B12, dietary fiber, folate, calcium, and iron, which were slightly higher or below 67% of the Dietary Reference Intakes or other dietary guidelines. Anemia, as assessed by hemoglobin levels, was present throughout the study and did not correlate with iron intake.
This culturally sensitive cholesterol reducing diet program was successful in decreasing sodium intake and maintaining adequate intakes of most nutrients except B12, dietary fiber, iron, calcium, and folate. Future intervention studies in patients with SLE need to pay special attention to these nutrients and the presence of anemia.
Patients with mechanical heart valves must follow lifelong warfarin therapy. Warfarin, however, is a difficult drug to manage because it has a narrow therapeutic window and potentially serious side effects. Successful anticoagulation treatment is dependent upon the patient's knowledge of this drug; however, little is known regarding the determinants of such knowledge. Therefore, the purpose of this study was to determine the influence of both in-hospital teaching practices as well as socioeconomic status and demographic variables on patients' knowledge of warfarin therapy.
A telephone survey was conducted among 100 patients 3 to 6 months after mechanical heart valve replacement. A previously validated 20-item questionnaire was used to measure the patient's knowledge of warfarin, its side effects, and vitamin K food sources. Demographic information, socioeconomic status data, and medical education information were also collected. Knowledge scores were compared using the Student t test or one-way analysis of variance. Variables with P < or = .2 on univariate analysis were entered in multiple stepwise regression analysis.
Sixty-one percent of participants had scores indicative of insufficient knowledge of warfarin therapy (score < or = 80%). Age was negatively related to warfarin knowledge scores (r = 0.27, P = .007). Patients with family incomes greater than $25,000, who had greater than a grade 8 education, and who were employed or self-employed had significantly higher warfarin knowledge scores (P = .007, P = .002, and P = .001, respectively). Gender, ethnicity, and warfarin therapy before surgery were not related to warfarin knowledge scores. Furthermore, none of the in-hospital teaching practices significantly influenced knowledge scores, whereas receiving postdischarge community counseling significantly improved knowledge scores (P = .001). Multivariate regression analysis revealed that understanding the concept of International Normalized Ratio, knowing the acronym, age, and receiving community counseling after discharge were the strongest predictors of warfarin knowledge. Accessing postdischarge counseling resulted in significantly improved warfarin knowledge scores. Because improved knowledge has been associated with improved compliance and control, our findings support the need to develop a comprehensive postdischarge education program or at least to ensure that patients have access to a community counselor to compliment the in-hospital education program.
To conduct a review of published studies that have addressed the effectiveness of weight-loss interventions for Hispanic individuals in the United States, identify key components of effective interventions for this population, and provide a set of recommendations for the development of effective treatment programs.
Online bibliographic databases were searched from 1980 to September 2006. STUDY INCLUSION/EXCLUSION CRITERIA: Two key search dimensions ("Latino" or "Mexican-American" or "Hispanic" or "Spanish-speaker"; and "weight-loss" or "weight-reduction" or "obesity treatment" or "diet intervention") were used to search for articles.
The methods and findings of all retrieved articles were evaluated, and summary outcome data were taken from published results.
The limited number of published articles found, and the lack of identifying information on key variables (eg, manner in which subjects were determined to be "Hispanic," level of acculturation, socioeconomic status [SES], number of years living in the United States, country of origin, etc) precluded conducting a formal meta-analysis on the available outcome data.
The review identified only three controlled intervention studies specifically targeting Hispanic populations for weight-loss; most of the available studies were not randomized and did not assess key variables, such as acculturation, type of community of origin, level of education, etc. Most available "culturally sensitive" health-related interventions targeting Hispanic populations do not specify what made the interventions "culturally sensitive" beyond the translation of the materials into Spanish.
Traditional weight-loss interventions developed for use on Anglo-American subjects do not appear to have been effective for Hispanic individuals. There is an urgent need to both develop effective interventions and to improve the methodologic thoroughness in the design, implementation, and reporting of such interventions for this population.
Assessment of habitual physical activity in epidemiologic and health education studies has been difficult. A seven-day physical activity recall interview was developed and administered in a community health survey, a randomized clinical trial, and two worksite health promotion programs during 1979-1982. These studies were conducted in several populations in California, Texas, Pennsylvania, and New Jersey. Energy expenditure estimates from the physical activity recall conformed to expected age- and sex-specific values in the cross-sectional community survey. Estimates of energy expenditure were also congruent with other questions on physical activity and job classification. In a randomized, one-year exercise trial, the physical activity recall detected increases in energy expenditure in the treated group and was positively associated with miles run during training (p less than 0.05). Changes in energy expenditure were associated with changes in maximal oxygen uptake (VO2max (r = 0.33, p less than 0.05) and body fatness (r = -0.50, p less than 0.01) at six months, and in high density lipoprotein-cholesterol (r = 0.31, p less than 0.05) and triglyceride (r = -0.41, p less than 0.01) at one year. The physical activity recall detected significant (p less than 0.01) increases in energy expenditure in treatment groups in two worksite health promotion projects. These data suggest that the physical activity recall provides useful estimates of habitual physical activity for research in epidemiologic and health education studies.
Selectively reviewed problem-solving theory and research for possible applications in behavior modification. Problem solving was defined as a behavioral process which (a) makes available a variety of response alternatives for dealing with a problematic situation, and (b) increases the probability of selecting the most effective response from among these alternatives. 5 stages of problem solving were identified: (a) general orientation or "set," (b) problem definition and formulation, (c) generation of alternatives, (d) decision making, and (e) verification. Training in problem solving was conceptualized as a form of self-control training, I.e., the individual "learns how to solve problems" and thus discovers for himself the most effective way of responding. General guidelines are presented for clinical application with cases characterized by a deficit in effective behavior and its emotional consequences. (2 P. Ref.)
To investigate risk factors of systemic lupus erythematosus (SLE) in relation to diet and reproduction, a population-based case-control study was conducted during the period from October 1988 to October 1989 in Miyagi Prefecture in northeastern Japan. Included in the study were 52 female patients with the recent SLE onset. Two sex- and birth year-matched (+/- 2 years) controls for each patient were selected from the general population. The analysis on diet showed that the frequent intake of meat was associated with an increased risk (frequent vs. rare, relative risk (RR) 3.36; 95% confidence interval (CI) 1.10-10.24) and that the patients preferred fatty meat such as beef or pork. The analysis on menstrual history revealed that menstrual irregularity was also associated with an increased risk (RR 3.79; 95% CI 1.43-10.01). These results suggest that dietary and reproductive factors may be responsible for the onset and the progression of SLE.
The incidence, prevalence, and outcome of systemic lupus erythematosus (SLE) were examined in a large, well-defined population for which extensive records of complete medical care are available. The prevalence was 1:1,969; in women aged 15 to 64 years, approximately 1:700; in black women 15 to 64, 1:245. Mortality was low: only five deaths among 70 patients in whom SLE was freshly diagnosed occurred during an eightyear period. The projected ten-year survival rate exceeds 90%. The prevalence of clinically important renal disease was only 11%. Previous estimates of the prevalence of renal disease in SLE have been based on skewed series. Several clinical patterns of SLE were discerned: least common was the violent, rapidly fatal one; most patients experienced a benign, chronic course or intermittently stuttering illness; some had only one or a few brief episodes of the disease.
The degrees of cross-sectional area luminal narrowing by atherosclerotic plaques of each 5 mm long segment of each of the four major (right, left main, left anterior descending and left circumflex) epicardial coronary arteries in 22 necropsy patients (age 16 to 37 years, 21 women) with systemic lupus erythematosus (SLE) was determined, and the findings were compared to those in 13 control subjects. Of 623 coronary segments (5 mm long) in the patients with SLE, 80 (13 percent) were narrowed 76 to 100 percent (controls = 0 of 431 segments); 125 (20 percent), 51 to 75 percent (controls = 6 percent); 273 (44 percent), 26 to 50 percent (controls = 63 percent) and 145 (23 percent), 0 to 25 percent (controls = 31 percent). Of the 22 patients with SLE, 10 had one or more of the four major coronary arteries narrowed 76 to 100 percent in cross-sectional area, and 12 patients had lesser degrees of narrowing similar to that in the 13 control subjects. The 10 patients with SLE and severe coronary narrowing compared to the 12 patients with SLE and no severe (> 75 percent) coronary narrowing had significantly higher (1) mean values of total serum cholesterol (382 versus 290 mg/dl), (2) mean systolic/diastolic systemic arterial pressures (175/119 versus 151/93 mm Hg), (3) frequencies of mitral valvular disease (seven of 10 patients versus none of 12 patients) and (4) frequencies of pericardial adhesions (seven of 10 patients versus three of 12 patients).
THE SECOND report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II, or ATP II) presents the National Cholesterol Education Program's updated recommendations for cholesterol management. It is similar to the first in general outline, and the fundamental approach to treatment of high blood cholesterol is comparable. This report continues to identify low-density lipoproteins (LDL) as the primary target of cholesterol-lowering therapy. As in the first report, the second report emphasizes the role of the clinical approach in primary prevention of coronary heart disease (CHD). Dietary therapy remains the first line of treatment of high blood cholesterol, and drug therapy is reserved for patients who are considered to be at high risk for CHD. However, the second report contains new features that distinguish it from the first. These include the following:
Increased emphasis on
See also pp 3002 and 3009.
"Facilitating Treatment Adherence" provides practical clinical guidelines and describes adherence enhancement techniques for health care professionals dealing with noncompliant patients. Meichenbaum and Turk synthesize the vast amount of literature on the subject and formulate specific procedures for improving patient participation, such as anticipating nonadherence, considering the prescribed self-care curative measures from the patient's perspective, improving the patient-doctor relationship, customizing treatment, enlisting family support, and making use of other health care providers. . . . Numerous summary tables and examples of assessment instruments and interviews are included. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Objective. To examine racial differences in the incidence of systemic lupus erythematosus (SLE).
Methods. A population-based registry of SLE patients in Allegheny County, Pennsylvania, was used to identify incident cases of SLE diagnosed between January 1, 1985 and December 31, 1990, from 3 sources, by medical record review (University of Pittsburgh Lupus Databank, rheumatologists, and hospitals). Capture-recapture methods using log-linear models were used to estimate the level of case-finding and to calculate 95% confidence intervals (CI). Incidence rates were calculated per 100,000 population.
Results. A total of 191 definite and 78 probable incident cases of SLE were identified, and the overall annual incidence rates were 2.4 (95% CI 2.1–2.8) and 1.0 (95% CI 0.8–1.3), respectively. The crude incidence rates of definite SLE were 0.4 for white males, 3.5 for white females, 0.7 for African-American males, and 9.2 for African-American females. The annual incidence rates of definite SLE remained fairly constant over the study interval. African-American females with definite SLE had a younger mean age at diagnosis compared with white females (P < 0.05). Since the overall ascertainment rate was high (85%; 95% CI 78–92%), the ascertainment-corrected incidence rate for definite SLE, 2.8 (95% CI 2.6–3.2), was similar to the crude rate.
Conclusion. Our rates clearly confirm previous reports of an excess incidence of SLE among females compared with males and among African-Americans compared with whites. We have used capture–recapture methods to improve the accuracy of SLE incidence rates, and we advocate their use to facilitate comparisons across studies.
LR: 20061115; JID: 7501160; 0 (Antilipemic Agents); 0 (Cholesterol, HDL); 0 (Cholesterol, LDL); 57-88-5 (Cholesterol); CIN: JAMA. 2001 Nov 21;286(19):2401; author reply 2401-2. PMID: 11712930; CIN: JAMA. 2001 Nov 21;286(19):2400-1; author reply 2401-2. PMID: 11712929; CIN: JAMA. 2001 Nov 21;286(19):2400; author reply 2401-2. PMID: 11712928; CIN: JAMA. 2001 Nov 21;286(19):2400; author reply 2401-2. PMID: 11712927; CIN: JAMA. 2001 May 16;285(19):2508-9. PMID: 11368705; CIN: JAMA. 2003 Apr 16;289(15):1928; author reply 1929. PMID: 12697793; CIN: JAMA. 2001 Aug 1;286(5):533-5. PMID: 11476650; CIN: JAMA. 2001 Nov 21;286(19):2401-2. PMID: 11712931; ppublish
This text sharply focuses on the cutting edge issues in health psychology today. Its renowned author team offers a broad range of knowledge and expertise in the behavioral sciences. Together they present a balanced treatment of basic research and applied issues, theory, assessment, treatment and biopsychosocial and clinical approaches. The case studies feature real people dealing with illness and illuminate text material.
To estimate the frequency of and examine risk factors for coronary artery disease (CAD) in patients with systemic lupus erythematosus (SLE) in a prospective longitudinal study.
Patients were SLE are enrolled in The Johns Hopkins Lupus Cohort, a prospective study of outcomes in 229 subjects with SLE. CAD was defined as angina, myocardial infarction, or sudden death. Data on CAD risk factors were obtained prospectively every 3 months and were analyzed using univariate and multiple logistic regression.
CAD occurred in 19 (8.3%) of 229 patients with SLE and accounted for 3 (30%) of 10 deaths as of December 31, 1990. Compared to subjects without CAD, those with CAD were more likely to have been older at both diagnosis of SLE (37.1 years versus 28.9 years, p = 0.004) and at entry into the cohort (47.1 years versus 34.7 years, p < 0.0001), to have a longer mean duration of SLE (12.3 years versus 8.1 years, p = 0.013) and a longer mean duration of prednisone use (14.3 years versus 7.2 years, p < 0.0001), to have a higher mean serum cholesterol (271.2 mg/dL versus 214.9 mg/dL, p < 0.0001) or a cholesterol level greater than 200 mg/dL (odds ratio [OR] 14.5, 95% confidence intervals [CI] 1.9, 112.1), and to have both a history of hypertension (OR 3.5, 95% CI 1.3, 9.6) and a history of use of antihypertensive medications (OR 5.5, 95% CI 1.8, 17.2). There were no significant associations with other known CAD risk factors such as smoking, diabetes, family history of CAD, race, or sex, or variables related to steroid therapy including the presence of cushingoid features or ever use of corticosteroids. The best multiple logistic regression model for CAD included age at diagnosis, duration of prednisone use, requirement for antihypertensive treatment, maximum cholesterol level, and obesity (using NHANES-II [National Health and Nutrition Examination Survey] definitions).
Primary and secondary prevention strategies directed at hypertension, hypercholesterolemia, and obesity, as well as other known CAD risk factors, should be routinely employed in the management of patients with SLE.
The Hypertension Prevention Trial (HPT) was a randomized unmasked multicenter trial designed to address questions concerning the feasibility and efficacy of dietary intervention in the primary prevention of hypertension. Participants in the diet treatments were given counseling to achieve and sustain changes in calorie, sodium, and/or potassium intake. Diet composition, sodium and potassium excretion, and body weight were assessed for all participants at 6-mo intervals over 3 y. This paper provides information about extent and possible sources of bias in the dietary assessment methodology used in the HPT. Estimates of nutrient intake were derived from food records, urinalysis, and measurement of body weight. Reported potassium intake increased and sodium intake declined to a greater degree during the study than did potassium and sodium excretion. Our results indicate that repeated assessments of diet, which depend upon participant recording, may not accurately represent usual diet in a dietary trial.
However, current knowledge of outcome in SLE is based mainly on findings in studies of selected patients from racially mixed populations, and there have been few prospective longitudinal studies. The importance of clinical and serologic subsets for outcome in SLE has therefore never been properly addressed with epidemiological methodology. In the present investigation, outcome of the disease was studied prospectively in relation to clinical manifestations during a 6-year follow-up of a complete Caucasian SLE cohort, comprising all adult SLE patients from a defined Caucasian population in southern Sweden.
A major international study, properly designed and executed, could establish whether the population differences that seem to exist in prevalences of SLE are real and whether these differences, eg, in black and Chinese groups residing in different parts of the world, depend upon varied genetic constitution or whether they reflect environmental influences. The noninfectious environmental influences that should be considered are toxic and dietary ones.
The increased incidence of atherosclerotic coronary artery disease in patients with systemic lupus erythematosus (SLE) may be due to a dyslipoproteinemia caused by corticosteroid administration. To determine whether lipoprotein lipid levels are abnormal in SLE and the relation of lipoprotein levels to corticosteroid use, lipid and apolipoprotein levels were measured in 46 female patients with SLE and 30 matched control subjects. The patients with SLE had higher levels of plasma triglyceride (134 versus 73 mg/dl; p <0.001), cholesterol (201 versus 168 mg/dl; p <0.001), and low-density lipoprotein cholesterol (121 versus 94 mg/dl; p <0.001) than control subjects. The levels of high-density lipoprotein cholesterol, high-density lipoprotein subfraction 3 cholesterol, and apolipoprotein Al were similar in the two groups, but high-density lipoprotein subfraction 2 cholesterol was lower in the patients with SLE (10.2 versus 18.2 mg/dl; p <0.001). When patients with SLE treated with prednisone (n = 32) were compared to patients with SLE not treated with prednisone (n = 14), the former had higher triglyceride (158 versus 87 mg/dl; p <0.001), cholesterol (214 versus 170 mg/dl; p <0.001), and low-density lipoprotein cholesterol (130 versus 103 mg/dl; p <0.001) levels. The patients with SLE not treated with prednisone had lipid levels similar to those in control subjects except that high-density lipoprotein cholesterol was lower (49.7 versus 59.0 mg/dl; p <0.05). The daily prednisone dosage in the treated patients with SLE correlated with levels of cholesterol (r = 0.38, p <0.02), high-density lipoprotein cholesterol (r = 0.40, p <0.02), and high-density lipoprotein subfraction 3 cholesterol (r = 0.47, p <0.01). Thus, female patients with SLE have a dyslipoproteinemia of the type that would place them at an increased risk for coronary artery disease. Corticosteroids, used in the treatment of SLE, seem to play a role in the pathogenesis of the observed lipoprotein abnormalities.
To study the causes of death in patients with SLE, followed prospectively in a single center.
The study population comprised 665 patients with systemic lupus erythematosus (SLE). Causes of death were determined by review of hospital files, autopsy reports, and death certificates. Nonparametric lifetable models were used to calculate Kaplan-Meier estimates of survival probabilities.
One hundred and twenty-four patients (18.6%) had died. The primary causes of death were active SLE in 20 (16%), infection in 40 (32%), acute vascular event in 19 (15.4%), sudden death in 10 (8.1%), organ failure in 6 (4.8%), malignancy in 8 (6.5%), others in 8 (6.5%), and unknown in 13 (10.5%). Death as a result of active SLE was more common in patients who died within 5 years of diagnosis compared to those dying after 5 years (p = 0.021), and deaths due to vascular events and end organ failure not related to active lupus were more frequent in the late death group (p = 0.028). The overall 5, 10, 15, and 20 year survival rates were 93, 85, 79, and 68%, respectively. Patients with SLE had a 4.92 fold increased risk for death compared with the general population.
Survival rates continue to improve in SLE but causes of mortality vary at different stages.
To review advances and controversies in the diagnosis and management of systemic lupus erythematosus with visceral involvement (renal, neuropsychiatric, cardiopulmonary, and hematologic disease).
Review of the English-language medical literature with emphasis on articles published in the last 5 years. More than 400 articles were reviewed.
Recent debates pertaining to lupus nephritis have focused on the value of kidney biopsy data and the role of cytotoxic drug therapies. Many studies have shown that estimates of prognosis are enhanced by consideration of clinical, demographic, and histologic features. For patients with severe lupus nephritis, an extended course of pulse cyclophosphamide therapy is more effective than a 6-month course of pulse methylprednisolone therapy in preserving renal function. Adding a quarterly maintenance regimen to monthly pulse cyclophosphamide therapy reduces the rate of exacerbations. Plasmapheresis appears not to enhance the effectiveness of prednisone and daily oral cyclophosphamide. Small case series have shown pulses of cyclophosphamide to be beneficial in patients with lupus and neuropsychiatric disease refractory to glucocorticoid therapy, acute pulmonary disease (pneumonitis or hemorrhage), and thrombocytopenia. Patients with systemic lupus erythematosus have an increased prevalence of valvular and atherosclerotic heart disease, apparently because of factors related to the disease itself and to drug therapy.
Cytotoxic agents are superior to glucocorticoid therapy for the treatment of proliferative lupus nephritis, but the optimal duration and intensity of cytotoxic therapy remain undefined. Definitive studies of the treatment of autoimmune thrombocytopenia and acute pulmonary disease and of the diagnosis and treatment of neuropsychiatric disease are not available.
To evaluate dietary therapy in the treatment of hyperlipidemia in patients with systemic lupus erythematosus (SLE).
Using the National Cholesterol Education Program (NCEP) guidelines, we screened 89 patients with SLE for hyperlipidemia. Step 1 dietary therapy was instituted in 28 patients as recommended by the NCEP. Twenty-six patients failed Step 1 intervention and received Step 2 dietary therapy for an additional 3 months. Twenty-nine control patients with SLE were tested for hyperlipidemia.
The 89 patients with SLE (94% women, 77% black) had a mean age of 37.2 years. Fasting values were total cholesterol (TC) 6.22 +/- 0.16 mmol/l (240.9 +/- 6.0 mg/dl), low density lipoprotein cholesterol (LDL-C) 4.08 +/- 0.14 mmol/l, (157.6 +/- 5.3 mg/dl), high density lipoprotein (HDL-C) 1.37 +/- 0.08 mmol/l (53.0 +/- 3.1 mg/dl), and triglyceride (TG) 1.71 +/- 0.12 mmol/l, (151.9 +/- 10.6 mg/dl). The mean dose of prednisone was 14.2 +/- 1.6 mg/day. Prednisone dose correlated with levels of TC (p < 0.01) by linear regression. The 28 patients receiving Step 1 dietary intervention had TC 6.11 +/- 0.19 mmol/l (236.4 +/- 7.3 mg/dl), LDL-C 4.05 +/- 0.19 mmol/l (156.6 +/- 7.5 mg/dl), HDL-C 1.31 +/- 0.08 mmol/l (50.7 +/- 3.0 mg/dl), and TG 1.64 +/- 0.12 mmol/l (145.4 +/- 10.3 mg/dl). The 26 patients receiving Step 2 dietary intervention had TC 5.84 +/- 0.17 mmol/l (226.0 +/- 6.6 mg/dl), LDL-C 3.83 +/- 0.19 mmol/l (148.0 +/- 7.2 mg/dl), HDL-C 1.25 +/- 0.08 mmol/l (48.5 +/- 3.2 mg/dl), and TG 1.66 +/- 0.15 mmol/l (147.1 +/- 13.4 mg/dl). The mean prednisone dose was 14.8 +/- 3.0 mg/day for both study groups. There was no significance between prednisone doses in all groups studied (p = 0.08). After 6 months of dietary therapy, there was a significant decrease in only the TC (p = 0.158).
TC correlated directly with the prednisone dose. Six months of dietary intervention was required to significantly decrease the TC. Further management of hyperlipidemia will probably require drug intervention.
This study was conducted to validate a shortened version of the Rapid Estimate of Adult Literacy in Medicine (REALM). This screening instrument is designed to be used in public health and primary care settings to identify patients with low reading levels. It provides reading grade estimates for patients who read below a ninth-grade level. The REALM can be administered in one to two minutes by personnel with minimal training.
Two hundred and three patients in four university hospital clinics (internal medicine, family practice, ambulatory care, and obstetrics/gynecology) were given the REALM and three other standardized reading tests: the reading recognition section of the Peabody Individual Achievement Test-Revised (PIAT-R), the Wide Range Achievement Test-Revised (WRAT-R), and the Slosson Oral Reading Test-Revised (SORT-R). One hundred inmates at a state prison were also given the REALM twice, one week apart, to determine test-retest reliability.
The REALM correlated well with the three other tests. (Correlation coefficients were 0.97 [PIAT-R], 0.96 [SORT-R], and 0.88 [WRAT-R].) All correlations were significant at P < .0001. Test-retest reliability was 0.99 (P < .001).
The REALM provides an estimate of patient reading ability, displays excellent concurrent validity with standardized reading tests, and is a practical instrument for busy primary care settings.
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Dysliproteinemia in systemic lupus erythematosus: effect of corticosteroids
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