Secondary prevention clinics for coronary heart disease: randomised trial of effect on health Exercise and dietary weight loss in overweight and obese older adults with knee osteoarthritis: the Arthritis, Diet, and Activity Promotion Trial. Participation in health-promoting behaviour: influences on community-dwelling older Chinese people. Use and outcomes of a cholesterol-lowering intervention for rural elderly subjects. Cost and Outcomes of Medicare Reimbursement for HMO Preventive Services An efficacy trial of brief lifestyle intervention delivered by generalist community nurses (CN SNAP trial) Lessons learned from a multidisciplinary heart failure clinic for older women: a randomised controlled trial. Soliciting defined populations to recruit samples of high-risk older adults. Achieving weight and activity goals among diabetes prevention program lifestyle participants. Geographical inequalities in nutrient status and risk of malnutrition among English people aged 65 y and older. Clinical Trial of Tailored Activity and Eating Newsletters With Older Rural Women Exercise and weight loss in obese older adults with knee osteoarthritis: a preliminary study. Attitudes of nursing staff towards nutritional nursing care. Longitudinal effects of preventive services on health behaviors among an elderly cohort. Inflammatory biomarkers and physical function in older, obese adults with knee pain and self-reported osteoarthritis after intensive weight-loss therapy. Intensive weight loss program improves physical function in older obese adults with knee osteoarthritis. How to identify randomized controlled trials in MEDLINE: ten years on. Trial of Nonpharmacologic Intervention in the Elderly (TONE). Design and rationale of a blood pressure control trial. A home-based nutrition intervention to increase consumption of fruits, vegetables, and calcium-rich foods in community dwelling elders. Self-efficacy and health behavior among older adults. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. Revisiting the concept of malnutrition in older people. Secondary prevention clinics for coronary heart disease: four year follow up of a randomised controlled trial in primary care Group office visits change dietary habits of patients with coronary artery disease-the dietary intervention and evaluation trial (D.I.E.T.). Effect of a multidisciplinary intervention on medication compliance in elderly patients with congestive heart failure. Randomized controlled trial of nutritional counseling on body composition and dietary intake in severe CKD. A randomized trial of in-home visits for disability prevention in community-dwelling older people at low and high risk for nursing home admission.
Abstract Objective : To evaluate the effects of secondary prevention clinics run by nurses in general practice on the health of patients with coronary heart disease . Design : R and omised controlled trial of clinics over one year with assessment by self completed postal question naires and audit of medical records at the start and end of the trial . Setting : R and om sample of 19 general practice s in northeast Scotl and . Subjects : 1173 patients ( 685 men and 488 women ) under 80 years with working diagnoses of coronary heart disease who did not have terminal illness or dementia and were not housebound . Intervention : Clinic staff promoted medical and lifestyle aspects of secondary prevention and offered regular follow up . Main outcome measures : Health status measured by the SF-36 question naire , chest pain by the angina type specification , and anxiety and depression by the hospital anxiety and depression scale . Use of health services before and during the study . Results : There were significant improvements in six of eight health status domains ( all functioning scales , pain , and general health ) among patients attending the clinic . Role limitations attributed to physical problems improved most ( adjusted difference 8.52 , 95 % confidence interval 4.16 to 12.9 ) . Fewer patients reported worsening chest pain ( odds ratio 0.59 , 95 % confidence interval 0.37 to 0.94 ) . There were no significant effects on anxiety or depression . Fewer intervention group patients required hospital admissions ( 0.64 , 0.48 to 0.86 ) , but general practitioner consultation rates did not alter . Conclusions : Within their first year secondary prevention clinics improved patients ' health and reduced hospital admissions . Key messages Nurse led clinics in general practice were used to promote secondary prevention to patients with coronary heart disease Within the first year the health of patients invited to the clinics improved Most benefit was in functional status , but chest pain improved too There was no effects on anxiety or depression There were significant reductions in hospital admissions in the first OBJECTIVE The Arthritis , Diet , and Activity Promotion Trial ( ADAPT ) was a r and omized , single-blind clinical trial lasting 18 months that was design ed to determine whether long-term exercise and dietary weight loss are more effective , either separately or in combination , than usual care in improving physical function , pain , and mobility in older overweight and obese adults with knee osteoarthritis ( OA ) . METHODS Three hundred sixteen community-dwelling overweight and obese adults ages 60 years and older , with a body mass index of > or = 28 kg/m(2 ) , knee pain , radiographic evidence of knee OA , and self-reported physical disability , were r and omized into healthy lifestyle ( control ) , diet only , exercise only , and diet plus exercise groups . The primary outcome was self-reported physical function as measured with the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) . Secondary outcomes included weight loss , 6-minute walk distance , stair-climb time , WOMAC pain and stiffness scores , and joint space width . RESULTS Of the 316 r and omized participants , 252 ( 80 % ) completed the study .  Adherence was as follows : for healthy lifestyle , 73 % ; for diet only , 72 % ; for exercise only , 60 % ; and for diet plus exercise , 64 % . In the diet plus exercise group , significant improvements in self-reported physical function ( P < 0.05 ) , 6-minute walk distance ( P < 0.05 ) , stair-climb time ( P < 0.05 ) , and knee pain ( P < 0.05 ) relative to the healthy lifestyle group were observed . In the exercise group , a significant improvement in the 6-minute walk distance ( P < 0.05 ) was observed . The diet-only group was not significantly different from the healthy lifestyle group for any of the functional or mobility measures . The weight-loss groups lost significantly ( P < 0.05 ) more body weight ( for diet , 4.9 % ; for diet plus exercise , 5.7 % ) than did the healthy lifestyle group ( 1.2 % ) . Finally , changes in joint space width were not different between the groups . CONCLUSION The combination of modest weight loss plus moderate exercise provides better overall improvements in self-reported measures of function and pain and in performance measures of mobility in older overweight and obese adults with knee OA compared with either intervention alone AIM This paper reports a study to determine the factors affecting community-dwelling older Chinese people 's  health-promoting behaviour in the domains of physical activity , healthy dietary practice s and stress management , and to identify any barriers to these behaviours . BACKGROUND Previous studies have identified factors affecting different types of health-promoting behaviours , including perceived self-efficacy , perceived benefits and five individual characteristics ( age , sex , marital status , education and perceived health ) of older non-Chinese people . However , few studies have simultaneously taken these factors into account in examining community-dwelling Chinese older people 's health-promoting behaviour . METHOD Individual face-to-face interviews were completed in 2002 - 2003 with a convenience sample of 896 community-dwelling older Chinese people in Hong Kong aged between the ages of 60 and 98 ( years mean 76 ) . Participants had no apparent communication and cognition impairments . A structured interview schedule was used to collect the data . RESULTS Multiple regression analysis showed that perceived self-efficacy , perceived benefits and sex together explained 38.4 % of health-promoting behaviour among community-dwelling older Chinese people in Hong Kong . Fatigue during and after physical activity , enjoyment of unhealthy foods and inadequate family and peer support were the most frequently reported barriers to health-promoting behaviour . CONCLUSION When developing health promotion programmes to motivate community-dwelling older Chinese clients to participate in health-promoting behaviour and to minimize barriers , community nurses should include some activities to increase both the perceived self-efficacy and perceived benefits of health-promoting behaviour . Future studies should include more critical factors based on theories , empirical evidence and knowledge of culture with sample s that are r and om and from more diverse community setting Few studies have evaluated the efficacy of cholesterol-lowering interventions in a community setting and have included a control or comparison group . As part of a preventive health demonstration project in rural Pennsylvania , Medicare beneficiaries underwent cholesterol screening to identify high-risk individuals with serum cholesterol levels > or = 240 mg/dL. These high-risk individuals were r and omized to a  cholesterol-lowering intervention  through either local hospitals or physicians ' offices or to a control group . Baseline and follow-up serum cholesterol levels collected two to three years later were compared according to service location ( hospital versus physician 's office ) , intervention attendance , degree of participation , baseline heart disease history , and cholesterol-lowering medication use at follow-up . Serum cholesterol levels decreased between 5.7 % and 6.6 % in the hospital-based and physician-based groups , as well as in a control group not offered the intervention .  Participation rates did not differ between treatment groups , nor did participation affect serum cholesterol levels . Attendance level and heart disease history were not associated with a greater decrease in serum cholesterol levels . Individuals reporting cholesterol-lowering drug use at follow-up had significantly higher baseline serum cholesterol levels and a significantly greater decrease in total serum cholesterol ( P < .0001 ) than those not on medication . Both nonpharmacological ( diet ) and pharmacological ( drug ) interventions will reduce serum cholesterol levels and heart attack risk . The study results suggest that , at least for older individuals , the impact of nonpharmacological interventions on the community is minimal . We conclude that only very aggressive treatment will significantly loser serum cholesterol levels in older individuals at risk for heart attack Medicare beneficiaries enrolled in a health maintenance organization ( HMO ) were r and omized to a preventive services benefit package for 2 years or to usual care . At 24- and 48-month followups , the treatment group had completed more advance directives , participated in more exercise , and consumed less dietary fat than the control group . Unexpectedly , more deaths occurred in the treatment group . Surviving treatment-group enrollees reported higher satisfaction with health , less decline in self-rated health status , and fewer depressive symptoms than surviving control participants . Despite these changes , the intervention did not yield lower cost per quality -adjusted life year in this historically prevention-oriented HMO Background Lifestyle risk factors , in particular smoking , nutrition , alcohol consumption and physical inactivity ( SNAP ) are the main behavioural risk factors for chronic disease . Primary health care ( PHC ) has been shown to be an effective setting to address lifestyle risk factors at the individual level . However much of the focus of research to date has been in general practice . Relatively little attention has been paid to the role of nurses working in the PHC setting . Community health nurses are well placed to provide lifestyle intervention as they often see clients in their own homes over an extended period of time , providing the opportunity to offer intervention and enhance motivation through repeated contacts . The overall aim of this study is to evaluate the impact of a brief lifestyle intervention delivered by community nurses in routine practice on changes in clients ' SNAP risk factors . Methods / Design The trial uses a quasi-experimental design involving four generalist community nursing services in NSW Australia . Services have been r and omly allocated to an ' early intervention ' group or ' late intervention ' ( comparison ) group . ' Early intervention ' sites are provided with training and support for nurses in identifying and offering brief lifestyle intervention for clients during routine consultations . ' Late intervention site ' provide usual care and will be offered the study intervention following the final data collection point . A total of 720 generalist community nursing clients will be recruited at the time of referral from participating sites . Data collection consists of 1 ) telephone surveys with clients at baseline , three months and six months to examine change in SNAP risk factors and readiness to change 2 ) nurse survey at baseline , six and 12 months to examine changes in nurse confidence , attitudes and practice s in the assessment and management of SNAP risk factors 3 ) semi-structured interviews/focus with nurses , managers and clients in ' early intervention ' sites to explore the feasibility , acceptability and sustainability of the intervention . Discussion The study will provide evidence about the effectiveness and feasibility of brief lifestyle interventions delivered by generalist community nurses as part of routine practice . This will inform future community nursing practice and PHC policy . Trial Registration BACKGROUND many heart failure disease management programs are primarily conducted in the male population . An approach incorporating disciplines such as physiotherapy , occupational therapy , social work , dietary and pharmacy in a st and ardized clinical pathway merits further investigation in older women with HF . METHODS in this r and omized controlled trial , female patients in the intervention group received the multidisciplinary clinical pathway consisting of a series of 12 visits over a 6-week period in an outpatient clinic . RESULTS ninety-one community dwelling female patients aged 63 to 89 were r and omized . Comparison of change between the two groups from baseline in the Minnesota Living with Heart Failure Question naire score did not show a difference ( P<0.470 ) . There was also no difference between the two groups in functional outcome as measured by change from baseline by the Physical Self-Maintenance Scale ( P<0.321 ) . The treatment group had significantly more hospitalizations , and cardiologist visits during the study period ( P < 0.0001 ) . CONCLUSION It is feasible to conduct a r and omized study in a frail community-based older female population and to test a complex multidisciplinary pathway . Future studies should provide insight into the optimal intensity and duration of heart failure management programs with optimal targeting BACKGROUND Generalizable research on high-risk older persons requires sample s that are both large enough for adequate statistical power and similar enough to community population s that its results can be generalized to them . We tested the effectiveness and efficiency of mixed-mode ( mail-telephone ) solicitation of a defined population as a method for recruiting a large , representative sample for a r and omized trial of outpatient geriatric evaluation and management ( GEM ) . METHODS Fee-for-service , community-dwelling older Medicare beneficiaries were mailed a short self-administered screening question naire . Eligible respondents were called to assess eligibility and willingness to give consent ; consenters were called again for baseline data . Information about nonrespondents , ineligibles , and refusers was obtained from the Health Care Financing Administration . RESULTS The response rate to the screening question naire was 61.1 % . Of the respondents , 13.2 % were eligible for the study and , of those , 34.4 % agreed to participate . Response rates appeared to be influenced by small financial incentives and by subjects ' age , race , sex , location of residence , and use of hospitals in the previous year . Consent rates were influenced by age and sex . The final sample ( N = 522 ) was representative of community high-risk respondents in racial composition , previous use of hospitals , and probability of repeated admission ( Pre ) in the future , but it was slightly younger and contained a higher percentage of men .  Recruitment costs averaged $ 286.92 per consenting person . CONCLUSIONS Mixed-mode solicitation of defined population s can produce , at reasonable cost , large sample s whose representativeness of community high-risk population s can be determined . Procedures that may enhance the success of this approach include : advance communication with members of the target population and their families and physicians ; provision of medical and small financial incentives ; continuous monitoring of recruitment results ; and attention to subjects ' needs for convenience , time , transportation , and reassurance OBJECTIVE The Diabetes Prevention Program ( DPP ) showed that intensive lifestyle intervention reduced the risk of diabetes by 58 % . This paper examines demographic , psychosocial , and behavioral factors related to achieving weight loss and physical activity goals in the DPP lifestyle participants . RESEARCH METHODS AND PROCEDURES Lifestyle participants ( n = 1079 ; mean age = 50.6 , BMI = 33.9 , 68 % female , and 46 % from minority groups ) had goals of 7 % weight loss and 150 min/wk of physical activity . Goal achievement was assessed at the end of the 16-session core curriculum ( approximately week 24 ) and the final intervention visit ( mean = 3.2 years ) as a function of demographic , psychosocial , and behavioral variables . RESULTS Forty-nine percent met the weight loss goal and 74 % met the activity goal initially , while 37 % and 67 % , respectively , met these goals long-term . Men and those with lower initial BMI were more likely to meet activity but not weight loss goals .  Hispanic , Asian , and Native Americans were more likely to meet the long-term activity goals , and whites were more likely to meet the initial weight loss goal . In multivariate analyses , meeting the long-term weight loss goal and both activity goals increased with age , while psychosocial and depression measures were unrelated to goal achievement .  Dietary self-monitoring  was positively related to meeting both weight loss and activity goals , and meeting the activity goal was positively related to meeting the weight loss goal . Participants who met initial goals were 1.5 to 3.0 times more likely to meet these goals long-term . DISCUSSION Success at meeting the weight loss and activity goals increased with age . Initial success predicted long-term success . Self-monitoring and meeting activity goals were related to achieving and sustaining weight loss OBJECTIVE Geographical inequalities in health continue to be a problem within developed countries . This study investigated whether there were north-south geographical inequalities among older people living in Engl and with respect to risk of protein-energy malnutrition and status of nutrients , particularly those derived from fruit and vegetables . METHODS A secondary analysis of data collected prospect ively by the National Diet and Nutrition Survey of people aged 65 y and older was undertaken to assess geographical prevalence of risk of protein-energy malnutrition ( 1155 subjects ) and nutrient status ( 881 to 1046 subjects ) . RESULTS A north-south gradient was found in risk of protein-energy malnutrition ( 19.4 % , 12.3 % , and 11.2 % in the northern , central , and southern regions , respectively ; P = 0.013 , P for trend = 0.002 ) . This was accompanied by a north-south gradient in the status of vitamin C ( 30 , 38 , and 46 micromol/L in the respective regions , P < 0.001 ) , which was associated with deficiency ( < 11 micromol/L ) in a third of subjects in the northern region , a range of carotenoids ( P = 0.023 to < 0.001 ) , vitamin D ( P < 0.001 ) , and selenium ( P < 0.001 ) . These inequalities were accompanied by gradients in indices of health status and socioeconomic status , which could account only partly for the " geographical " inequalities . Circulating vitamin C and carotenoid concentrations were related to the intake of fruit and vegetables . CONCLUSIONS This study suggests there is a north-south divide in the risk of protein-energy malnutrition and a range of nutrients , which have been implicated in the development of common chronic diseases Background : Unhealthy diet and lack of physical activity increase rural midlife and older women 's risk of chronic diseases and premature death , and they are behind urban residents in meeting Healthy People 2010 objectives . Objectives : The objective of this study was to compare a tailored intervention based on the Health Promotion Model with a generic intervention to increase physical activity  and  healthy eating  among rural women . Methods : In a r and omized-by-site , community-based , controlled , clinical trial , Wellness for Women , 225 women aged 50 to 69 years were recruited in two similar rural areas . Over 12 months , women received by mail either 18 generic newsletters or 18 newsletters computer tailored on Health Promotion Model behavior-specific cognitions ( benefits , barriers , self-efficacy , and interpersonal support ) , activity , and eating . Outcomes at 6 and 12 months included behavioral markers and biomarkers of physical activity and eating . Data were analyzed by repeated- measures analysis of variance and chi-square tests ( & agr ; < .05 ) . Results : Both groups significantly increased stretching and strengthening exercise and fruit and vegetable servings and decreased percentage of calories from fat , whereas only the tailored group increased moderate or greater intensity activity and decreased percentage of calories from saturated fat from baseline to 6 months . Both groups increased stretching and strengthening exercise , whereas only the tailored group increased moderate or greater intensity activity and fruit and vegetable servings and decreased percentage of calories from fat from baseline to 12 months . Both groups had several changes in biomarkers over the study . A higher proportion of women receiving tailored newsletters met Healthy People 2010 criteria for moderate or greater intensity activity , fruit and vegetable servings , and percentage of calories from fat at 12 months . Discussion : Mailed computer-tailored and generic print newsletters facilitated the adoption of change in both activity and eating over 6 months . Tailored newsletters were more efficacious in facilitating change over 12 months OBJECTIVE The purpose s of this pilot study were to determine if a combined dietary and exercise intervention would result in significant weight loss in older obese adults with knee osteoarthritis , and to compare the effects of exercise plus dietary therapy with exercise alone on gait , strength , knee pain , biomarkers of cartilage degradation , and physical function . DESIGN Single-blind , two-arm , r and omized clinical trial conducted for 24 weeks . SETTING A university health and exercise science center . PARTICIPANTS Twenty-four community-dwelling obese older adults aged > or = 60 years , body mass index > or = 28 , knee pain , radiographic evidence of knee osteoarthritis , and self-reported physical disability . INTERVENTION R and omization into two groups : exercise and diet ( E&D ) and exercise alone ( E ) . Exercise consisted of a combined weight training and walking program for 1 hour three times per week . The dietary intervention included weekly sessions with a nutritionist utilizing cognitive-behavior modification to change dietary habits to reach a group goal of an average weight loss of 15 lb ( 6.8 kg ) over 6 months . MEASUREMENTS All measurements were conducted at baseline and 3 and 6 months , except for synovial fluid analysis , which was obtained only at baseline and 6 months . In addition , weight was measured weekly in the E&D group . Physical disability and knee pain were measured by self-report and physical performance was measured using the 6-minute walk and stair climb tasks . Biomechanical testing included kinetic and kinematic analysis of gait and isokinetic strength testing . Synovial fluid was analyzed for levels of total proteoglycan , keratan sulfate , and interleukin-1 beta . RESULTS Twenty-one of the 24 participants completed the study , with one dropout in the E&D group and two in the E group . The E&D group lost a mean of 18.8 lb ( 8.5 kg ) at 6 months compared with 4.0 lb ( 1.8 kg ) in the E group ( P = .01 ) . Significant improvements were noted in both groups in self-reported disability and knee pain intensity and frequency as well as in physical performance measures . However , no statistical differences were found between the two groups at 6 months in knee pain scores or self-reported performance measures of physical function . There was no difference in knee strength between the groups , with both groups showing modest improvements from baseline to 6 months . At 6 months , the E&D group had a significantly greater loading rate ( P = .03 ) and maximum braking force ( P = .01 ) during gait . There were no significant between-group differences in the other biomechanical measures . Synovial fluid sample s were obtainable at both baseline and 6 months in eight participants ( four per group ) . The level of keratan sulfate decreased similarly in both groups from an average baseline of 96.8 + /- 37.1 to 71.5 + /- 23 ng/microg total proteoglycan . The level of IL-1 decreased from 25.3 + /- 9.8 at baseline to 8.3 + /- 6.1 pg/mL. The decrease in IL-1 correlated with the change in pain frequency ( r = -0.77 , P = .043 ) . CONCLUSIONS Weight loss can be achieved and sustained over a 6-month period in a cohort of older obese persons with osteoarthritis of the knee through a dietary and exercise intervention . Both exercise and combined weight loss and exercise regimens lead to improvements in pain , disability , and performance . Moreover , the trends in the biomechanical data suggest that exercise combined with diet may have an additional benefit in improved gait compared with exercise alone . A larger study is indicated to determine if weight loss provides additional benefits to exercise alone in this patient population Fulfilling nutritional requirements in residents with eating problems can be a challenge for both the person in need of help and for the caregiver . In helping and supporting these residents , a positive attitude is assumed to be as important as practical skill . The aim of this study was to test the hypothesis that nutritional education and implementation of a nutritional programme would change the attitudes towards nutritional nursing care among nursing staff with daily experience of serving food and helping residents in municipal care . The study was carried out as a before and after experimental design . An attitude scale , staff attitudes to nutritional nursing care ( SANN scale ) , was developed and used . The response on the scale gives a total SANN-score and scores in five underlying dimensions : self ability , individualization , importance of food , assessment and secured food intake .  Nursing staff at eight different residential units ( n = 176 ) responded to the attitude scale and , of these , staff at three of the units entered the study as the experimental group . After responding to the attitude scale , nutritional education was introduced and a nutritional programme was implemented in the experimental units . One year later , attitudes were measured a second time ( n = 192 ) . Of these , 151 had also responded on the first occasion . Education and implementation of a nutritional programme did not significantly change attitudes . Overall , nursing staff responded with positive attitudes towards nutritional nursing care . Most of the positive attitudes concerned items within the dimension importance of food . In contrast , items within self ability showed the lowest number of staff with positive attitudes This study examines the longitudinal ( 48 months ) effects of a preventive services intervention trial with Medicare beneficiaries . The health promotion intervention incorporated a series of workshops and targeted individualized counseling dealing primarily with nutrition and exercise . All subjects completed a health risk appraisal ( HRA ) question naire , which served as a dependent measure . Results show significant , positive changes in intervention subjects in two activity outcomes ,  aerobic activity and stretching exercises .  Although previous research on this cohort found significant positive changes in nutrition behaviors at 12-month follow-up , these differences were not sustained over the three-year follow-up period . The results offer encouragement that continued research on health promotion will eventually produce protocol s for select activities that will improve the status of seniors ' health OBJECTIVES To describe the relationships between proinflammatory biomarkers and self-reported and performance-based physical function and to examine the effect of weight loss on these markers of inflammation . DESIGN R and omized , longitudinal , clinical study comparing subjects eating an energy-restricted diet and participating in exercise training with a control group . SETTING Community-base participants for the Physical Activity , Inflammation and Body Composition Trial . PARTICIPANTS Eighty-seven obese ( body mass index ( BMI ) > 30.0 kg/m(2 ) ) adults aged 60 and older with knee pain and self-report of osteoarthritis . MEASUREMENTS Inflammatory biomarkers ( interleukin 6 ( IL-6 ) , tumor necrosis factor alpha ( TNFalpha ) , C-reactive protein , and soluble receptors for TNFalpha ( sTNFR1 and sTNFR2 ) ) and self-reported ( Western Ontario and McMaster University Osteoarthritis Index question naire ) and performance-based ( 6-minute walk distance and stair climb time ) measures of physical function at baseline and 6 months . RESULTS Mean ( st and ard error of the mean ) weight loss was 8.7 % ( 0.8 % ) in the intervention group , compared with 0.0 % ( 0.7 % ) in the control group . sTNFR1 was significantly less in the intervention group than in the control group at 6 months . sTNFR1 and sTNFR2 predicted stair climb time at baseline . Change across the 6-month intervention for sTNFR2 was an independent predictor for change in 6-minute walk distance . CONCLUSION These results indicate that an intensive weight-loss intervention in older obese adults with knee pain can help improve inflammatory biomarkers and that changes in these concentrations showed associations with physical function OBJECTIVE Physical function and body composition in older obese adults with knee osteoarthritis ( OA ) were examined after intensive weight loss . RESEARCH METHODS AND PROCEDURES Older obese adults ( n = 87 ; > or = 60 years ; BMI > or = 30.0 kg/m2 ) with symptomatic knee OA and difficulty with daily activities were recruited for a 6-month trial . Participants were r and omized into either a weight stable ( WS ) or weight loss ( WL ) program . Participants in WL ( 10 % weight loss goal ) were prescribed a 1000 kcal/d energy deficit diet with exercise 3 d/wk . WS participants attended health information sessions . Body composition and physical function ( Western Ontario and McMaster University Osteoarthritis Index , 6-minute walking distance , and stair climb time ) were assessed at baseline and 6 months . Statistical analysis included univariate analysis of covariance on 6-month measurements using baseline values as covariates . Associations between physical function and body composition were performed . RESULTS Body weight decreased 8.7 + /- 0.8 % in WL and 0.0 + /- 0.7 % in WS . Body fat and fat-free mass were lower for WL than WS at 6 months ( estimated means : fat = 38.1 + /- 0.4 % vs. 40.9 + /- 0.4 % , respectively ; fat-free mass = 56.7 + /- 0.4 vs. 58.8 + /- 0.4 kg , respectively ) . WL had better function than WS , with lower Western Ontario and McMaster University Osteoarthritis Index scores , greater 6-minute walk distance , and faster stair climb time ( p < 0.05 ) . Changes in function were associated with weight loss in the entire cohort . DISCUSSION An intensive weight loss intervention incorporating energy deficit diet and exercise training improves physical function in older obese adults with knee OA . Greater improvements in function were observed in those with the most weight loss OBJECTIVE The research ers sought to assess whether the widely used 1994 Cochrane Highly Sensitive Search Strategy ( HSSS ) for r and omized controlled trials ( RCTs ) in MEDLINE could be improved in terms of sensitivity , precision , or parsimony . METHODS A gold st and ard of 1,347 RCT records and a comparison group of 2,400 non-trials were r and omly selected from MEDLINE .  Terms occurring in at least 1 % of RCT records were identified . Fifty percent of the RCT and comparison group records were r and omly selected , and the ability of the terms to discriminate RCTs from non-trial records was determined using logistic regression . The best performing combinations of terms were tested on the remaining records and in MEDLINE . RESULTS The best discriminating term was " Clinical Trial " ( Publication Type ) . In years where the Cochrane assessment of MEDLINE records had taken place , the strategies identified few additional unindexed records of trials . In years where Cochrane assessment has yet to take place , " R and omized Controlled Trial " ( Publication Type ) proved highly sensitive and precise . Adding six more search terms identified further , unindexed trials at reasonable levels of precision and with sensitivity almost equal to the Cochrane HSSS . CONCLUSIONS Most reports of RCTs in MEDLINE can now be identified easily using " R and omized Controlled Trial " ( Publication Type ) . More sensitive search es can be achieved by a brief strategy , the Centre for Review s and Dissemination/Cochrane Highly Sensitive Search Strategy ( 2005 revision ) National and international policy-making organizations advocate nonpharmacologic therapies to reduce blood pressure ( BP ) . However , data to support such recommendations in older persons are virtually nonexistent . The Trials of Nonpharmacologic Intervention in the Elderly ( TONE ) is a r and omized , controlled trial that will test whether weight loss or a reduced sodium ( Na ) intake or both can maintain satisfactory BP control , without unacceptable side effects , after withdrawal of antihypertensive drug therapy . Medication-treated hypertensives ( aged 60 to 80 years ) with a systolic BP less than 145 mm Hg and a diastolic BP less than 85 mm Hg who are taking one antihypertensive medication are r and omly assigned to one of four groups : ( 1 ) weight loss alone , ( 2 ) reduced Na intake alone , ( 3 ) combined weight loss and reduced Na intake , or ( 4 ) usual life-style ( control group ) .  Overweight participants are r and omized to one of these four groups , while nonoverweight individuals are assigned to either the reduced Na intake or the usual life-style group . The interventions , tailored to the needs of older persons , use behavioral approaches to accomplish intervention-specific goals ( weight loss > or = 10 lb , daily Na intake < or = 80 mEqa ) . Three months after the start of intervention , antihypertensive drug therapy is withdrawn . The primary trial end point is a BP of 150/90 mm Hg or higher , resumption of antihypertensive drug therapy , or the occurrence of a BP-related clinical complication during 2 to 3 years of follow-up . It is anticipated that TONE findings may identify an effective and acceptable nonpharmacologic approach to control hypertension in the increasingly large number of older persons treated with antihypertensive drug therapy OBJECTIVE To increase fruit , vegetable , and calcium-rich food consumption in community-dwelling , functionally impaired elderly . DESIGN Six-month , home-based nutrition intervention study . SUBJECTS Seventy men and women older than age 69 years were r and omized to either a nutrition education intervention ( n = 38 ) or a control group that received an exercise intervention ( n = 32 ) . INTERVENTION Nutrition education was design ed to increase fruit , vegetable , and calcium-rich food consumption .  MAIN OUTCOME MEASURES Food intake was assessed by a food frequency question naire . Fasting blood measures of nutrients and carotenoids were performed . Statistical Analysis Two-group r and omized controlled trial with pre-test and post-test design and intention-to-treat analysis . Analysis of covariance to was used to assess differences between the two groups . Baseline and change partial correlation coefficients were performed between intake and blood nutrient levels . Paired t tests were conducted to test within-group changes . RESULTS Compared with the exercise group , subjects in nutrition group increased their self-reported intake of fruits by 1.1 + /- 0.2 ( mean + /- SEM ) servings per day ( 2.8 to 3.9 , P = .01 ) , vegetables 1.1 + /- 0.2 servings per day ( 2.3 to 3.4 , P = .001 ) , and milk/dairy 0.9 + /- 0.2 servings per day ( 3.0 to 3.9 , P = .001 ) . There was an increase in the dietary intake of alpha-carotene and beta-carotene in the nutrition group and this correlated with the increase in blood concentrations of alpha-carotene and beta-carotene ( P < or = .02 ; r = 0.33 and r = 0.33 , respectively ) . CONCLUSION The results of this study suggest that it is possible to improve the dietary intake of community dwelling elders to include more fruits , vegetables , and calcium-rich foods . Recommendations for increasing consumption of fruits , vegetables , and calcium-rich foods should be specific and individualized to meet the dietary pattern and lifestyle of the individual . Compliance should be encouraged with record keeping as well as through continuous monitoring and positive reinforcement Self-efficacy has a well-established , beneficial effect on health behavior and health status in young and middle-aged adults , but little is known about these relationships in older population s. We examined this issue as part of a r and omized trial to determine the cost savings and changes in health-related quality of life associated with the provision and reimbursement of a preventive services package to 2,524 Medicare beneficiaries enrolled in Group Health Cooperative of Puget Sound .  Baseline self-efficacy data  were collected for all participants in five behavioral areas : exercise , dietary fat intake , weight control , alcohol intake , and smoking . Results reveal that efficacy and outcome expectations for these health behaviors are not independent . Correlational and factor analyses indicate two dimensions of efficacy expectations , one consisting of exercise , dietary fat , and weight control , and another consisting of smoking and alcohol consumption . Outcome expectations of the five behaviors form a single dimension . Older adults with high self-efficacy had lower health risk in all behaviors and better health . Regression analyses detected a positive association between socioeconomic status and health-related quality of life ( p < .02 ) , but the strength of the association declined ( p < .11 ) after the self-efficacy measures entered the model , indicating that self-efficacy explains part of the association between socioeconomic status and health status . Interventions aim ed at improving self-efficacy also may improve health status BACKGROUND Congestive heart failure is the most common indication for admission to the hospital among older adults . Behavioral factors , such as poor compliance with treatment , frequently contribute to exacerbations of heart failure , a fact suggesting that many admissions could be prevented . METHODS We conducted a prospect i ve , r and omized trial of the effect of a nurse-directed , multidisciplinary intervention on rates of readmission within 90 days of hospital discharge , quality of life , and costs of care for high-risk patients 70 years of age or older who were hospitalized with congestive heart failure . The intervention consisted of comprehensive education of the patient and family , a prescribed diet , social-service consultation and planning for an early discharge , a review of medications , and intensive follow-up . RESULTS Survival for 90 days without readmission , the primary outcome measure , was achieved in 91 of the 142 patients in the treatment group , as compared with 75 of the 140 patients in the control group , who received conventional care ( P = 0.09 ) . There were 94 readmissions in the control group and 53 in the treatment group ( risk ratio , 0.56 ; P = 0.02 ) . The number of readmissions for heart failure was reduced by 56.2 percent in the treatment group ( 54 vs. 24 , P = 0.04 ) , whereas the number of readmissions for other causes was reduced by 28.5 percent ( 40 vs. 29 , P not significant ) . In the control group , 23 patients ( 16.4 percent ) had more than one readmission , as compared with 9 patients ( 6.3 percent ) in the treatment group ( risk ratio , 0.39 ; P = 0.01 ) . In a subgroup of 126 patients , quality -of-life scores at 90 days improved more from base line for patients in the treatment group ( P = 0.001 ) . Because of the reduction in hospital admissions , the overall cost of care was $ 460 less per patient in the treatment group . CONCLUSIONS A nurse-directed , multidisciplinary intervention can improve quality of life and reduce hospital use and medical costs for elderly patients with congestive heart failure AIM The aim of this study is to revisit the concept of malnutrition in older people , trace the new development and test the use of refined framework with empirical data . BACKGROUND Malnutrition in older people is a common and significant problem worldwide . Continuing Chen 's earlier work in 2001 , a refinement was conducted and a prospect i ve study was design ed to test the use of this refined framework . DESIGN A cohort study of 114 hospitalized older patients in Northern Taiwan . METHODS The sample consists of 114 older patients aged 65 years and older , who were admitted for the cardiac and orthopaedic services at a tertiary 2300-bed hospital . From March to August 2004 , assessed by one trained nurse , participants completed a structured face-to-face interview evaluating their age , visual/hearing impairments , oral health , cognitive status , comorbidities , medication use , social economic status , functional status , social support , depressive symptoms and nutritional status within 48 hours of admission . Participants who stayed > 5 days were reassessed before discharge ( n = 70 ) . The data from admission were the main focus of this report . RESULTS Regression analysis revealed that that more medication taken , female gender , lower functional status ( beta = 0.34 , P < 0.001 ) and higher depressive symptoms were independent predictors of poor nutritional status , with the full model accounting for 48.2 % of the variance . The result is in-line with the original theoretical underpinnings and it suggests that this refined framework detailing sub-concepts and measurable indices appears to fit the empirical data and suitable for clinical use . CONCLUSION The findings lend support to the use of this framework in managing malnutrition in older people . RELEVANCE TO CLINICAL PRACTICE Nurses have an essential role in providing care for older people a framework like this would provide a road map guiding the intervention efforts Abstract Objectives : To evaluate the effects of nurse led clinics in primary care on secondary prevention , total mortality , and coronary event rates after four years . Design : Follow up of a r and omised controlled trial by postal question naires and review of case notes and national data sets . Setting : Stratified , r and om sample of 19 general practice s in north east Scotl and . Participants : 1343 patients ( 673 intervention and 670 control ) under 80 years with a working diagnosis of coronary heart disease but without terminal illness or dementia and not housebound . Intervention : Nurse led secondary prevention clinics promoted medical and lifestyle components of secondary prevention and offered regular follow up for one year . Main outcome measures : Components of secondary prevention ( aspirin , blood pressure management , lipid management , healthy diet , exercise , non-smoking ) , total mortality , and coronary events ( non-fatal myocardial infa rct ions and coronary deaths ) . Results : Mean follow up was at 4.7 years . Significant improvements were shown in the intervention group in all components of secondary prevention except smoking at one year , and these were sustained after four years except for exercise . The control group , most of whom attended clinics after the initial year , caught up before final follow up , and differences between groups were no longer significant . At 4.7 years , 100 patients in the intervention group and 128 in the control group had died : cumulative death rates were 14.5 % and 18.9 % , respectively ( P=0.038 ) . 100 coronary events occurred in the intervention group and 125 in the control group : cumulative event rates were 14.2 % and 18.2 % , respectively ( P=0.052 ) . Adjusting for age , sex , general practice , and baseline secondary prevention , proportional hazard ratios were 0.75 for all deaths ( 95 % confidence intervals 0.58 to 0.98 ; P=0.036 ) and 0.76 for coronary events ( 0.58 to 1.00 ; P=0.049 ) Conclusions : Nurse led secondary prevention improved medical and lifestyle components of secondary prevention and this seemed to lead to significantly fewer total deaths and probably fewer coronary events .  Secondary prevention clinics should be started sooner rather than later . What is already known on this topic Several effective interventions exist for the secondary prevention of coronary heart disease , but implementing them in practice has proved difficult Secondary prevention programmes for coronary heart disease have improved short term outcomes such as processes of care and quality of life What this study adds Short term improvements in uptake of secondary prevention produced by nurse led clinics are maintained in the longer term Improved medical and lifestyle components of secondary prevention produced by nurse led clinics seem to lead to fewer total deaths and coronary BACKGROUND We evaluated the effectiveness of a low-cost group visit intervention for changing the dietary intake and lipid levels of patients with known coronary artery disease ( CAD ) . METHODS We performed a controlled r and om group assignment trial in 4 community outpatient clinics . The Dietary Intervention and Evaluation Trial r and omized 97 patients with CAD to either a control group that followed the National Cholesterol Education Program 's Step II-III diet plan ( n=48 ) or an experimental group that received meal plans , recipes , and nutritional information during monthly group office sessions ( n=49 ) . Both groups received lipid-lowering medications and were followed-up over 12 months . We assessed dietary intake , fasting lipid profiles , hemoglobin A1C levels , and per member per month ( PMPM ) expense data . RESULTS Food frequency data showed that eating fruits and vegetables and cooking with monounsaturated fat increased significantly in the experimental group compared with the control group at 1 year ( P=.0072 ; P=.0001 ; P=.0004 ) . The total PMPM expenses decreased for both groups ( 38 % for the experimental group and 10 % for the control group ) , but the cost difference was statistically nonsignificant ( P=.2975 ) . Both groups noted low-density lipoprotein reductions , significant only in the experimental group ( P=.0035 ) . CONCLUSIONS Our study suggests that using group office visits for patients with CAD was an effective method for helping subjects make dietary changes and for improving lipid levels .  Patients with known CAD and elevated lipid levels were willing to make significant lifestyle changes when offered a program that emphasizes healthy foods in a group visit format PURPOSE The objectives of this investigation were to prospect ively assess medication compliance rates in elderly patients with congestive heart failure , to identify factors associated with reduced compliance , and to evaluate the effect of a multidisciplinary treatment approach on medication adherence . PATIENTS AND METHODS A total of 156 patients > or = 70 years of age ( mean , 79.4 + /- 6.0 ; 67 % female , 65 % nonwhite ) hospitalized with congestive heart failure were evaluated prospect ively . Prior to discharge , patients were r and omized to the study intervention ( n = 80 ) or conventional care ( n = 76 ) . The intervention consisted of comprehensive patient education , dietary and social service consultations , medication review , and intensive postdischarge follow-up . Detailed data were collected on all prescribed medications at the time of discharge , and compliance was assessed by pill counts 30 + /- 2 days later . RESULTS The overall compliance rate during the first 30 days after discharge was 84.6 + /- 15.1 % ( range , 23.1 - 100 % ) . Compliance was 87.9 + /- 12.0 % in patients r and omized to the study intervention , compared with 81.1 + /- 17.2 % in the control group ( P = 0.003 ) . A compliance rate of > or = 80 % was achieved by 85.0 % of the treatment group versus 69.7 % of the control group ( P = 0.036 ) . By multivariate analysis , assignment to the treatment group was the strongest independent predictor of compliance ( P = 0.008 ) . Other variables included in the model were Caucasian race ( P = 0.044 ) and not living alone ( P = 0.09 ) . CONCLUSIONS A multidisciplinary treatment strategy is associated with improved medication compliance during the first 30 days following hospital discharge in elderly patients with congestive heart failure . Improved compliance may contribute to improved outcomes in these patients BACKGROUND Progressive loss of kidney function results in an increased risk of malnutrition . Despite this , there is little evidence informing the impact of nutrition intervention on predialysis patients with chronic kidney disease ( CKD ; stages 4 and 5 ) . STUDY DESIGN R and omized controlled trial . SETTING & PARTICIPANTS 56 out patients ( men , 62 % ; mean age , 70.7 + /- 14.0 [ SD ] years ) with CKD were r and omly allocated to intervention ( n = 29 ) or control ( n = 27 ) by using a concealed computer-generated sequence . INTERVENTION The intervention group , provided with individualized dietary counseling with regular follow-up aim ed at achieving an intake of 0.8 to 1.0 g/kg of protein and greater than 125 kJ/kg of energy , or control , receiving written material only . OUTCOMES & MEASURES Change in body composition ( body cell mass , measured by means of total-body potassium , in 40 of 56 participants ) , nutritional status ( Subjective Global Assessment ) , and energy and protein intake ( 3-day food record ) . RESULTS During the 12 weeks , the intervention group had 3.5 % ( 95 % confidence interval , -2.1 to 9.1 ) less decrease in body cell mass , 17.7-kJ/kg/d ( 95 % confidence interval , 8.2 to 27.2 ) greater increase in energy intake , greater improvement in Subjective Global Assessment ( P < 0.01 ) , and no significant difference in protein intake compared with the control group ( -0.04 g/kg/d ; 95 % confidence interval , -0.73 to 0.16 ) . The intervention was associated with greater increases in energy and protein intake in women than men ( interaction P < 0.001 for both ) . LIMITATIONS Power to detect change in body cell mass , potential bias in ascertainment of Subjective Global Assessment . CONCLUSIONS In predialysis patients with CKD , structured nutrition intervention had a greater effect on energy and protein intake in women than men . Additional investigations are warranted to determine the impact on body composition BACKGROUND In-home preventive visits with multidimensional geriatric assessment s can delay the onset of disabilities in older people . METHODS This was a stratified r and omized trial . There were 791 participants , community-dwelling people in Bern , Switzerl and , older than 75 years . The participants ' risk status was based on 6 baseline predictors of functional deterioration . The intervention consisted of annual multidimensional assessment s and quarterly follow-up in-home visits by 3 public health nurses ( nurses A , B , and C ) , who , in collaboration with geriatricians , evaluated problems , gave recommendations , facilitated adherence with recommendations , and provided health education . Each nurse was responsible for conducting the home visits in 1 ZIP code area . RESULTS After 3 years , surviving participants at low baseline risk in the intervention group were less dependent in instrumental activities of daily living ( ADL ) compared with controls ( odds ratio , 0.6 ; 95 % confidence interval , 0.3 - 1.0 ; P = .04 ) . Among subjects at high baseline risk , there were no favorable intervention effects on ADL and an unfavorable increase in nursing home admissions ( P= .02 ) . Despite the similar health status of subjects , nurse C identified fewer problems in the subjects who were visited compared with those assessed by nurses A and B. Subgroup analysis revealed that among low-risk subjects visited by nurses A and B , the intervention had favorable effects on instrumental ADL ( P = .005 ) and basic ADL ( P = .009 ) , reduced nursing home admissions ( P = .004 ) , and result ed in net cost savings in the third year ( US $ 1403 per person per year ) . Among low-risk subjects visited by nurse C , the intervention had no favorable effects . CONCLUSIONS These data suggest that this intervention can reduce disabilities among elderly people at low risk but not among those at high risk for functional impairment , and that these effects are likely related to the home visitor 's performance in conducting the visits
OBJECTIVES To evaluate the effectiveness of nutritional education or advice on physical function , emotional health , quality of life , nutritional indices , anthropometric indicators , mortality , service use and costs of care in people over 65 years of age living at home .