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Correspondence avoid surgery in rapidly progressive or chemo-insensitive disease. 4 Genotyping of pancreatic tumours via fine needle aspiration could influence the clinical management of pancreatic cancer. Fine-needle aspiration sequencing was used to identify subgroups of patients with specific actionable mutations related to resectable or locally advanced tumours. 5 In patients with radiologically resectable or borderline resectable tumours, preoperative fine-needle aspiration sequencing could distinguish between patients with a genetic pattern associated with micrometastatic tumours, who should undergo neoadjuvant therapy, and those with a truly localised disease that would be amenable to a surgery-first strategy. Michele Reni has served as a consultant for or on the advisory boards of Celgene, Boehringer-Ingelheim, Lilly, Genentech, Baxalta, Novocure, Astra-Zeneca, Pfizer, and Merck-Serono, and has received honoraria from Celgene. Massimo Falconi has received honoraria from Celgene, Ipsen and Novartis. The other authors declare no competing interests. *Stefano Crippa, Michele Reni, Gianpaolo Balzano, Claudio Doglioni, Massimo Falconi crippa1.stefano@hsr.it Division of Pancreatic Surgery, IRCCS San Raffaele Hospital, Milan, Italy (SC, GB, MF); Medical Oncology Department, IRCCS San Raffaele Hospital , Milan, Italy (MR); Department of Pathology, IRCCS San Raffaele Hospital , Milan, Italy (CD); Clinical and Translational Research Program on Pancreatic Cancer, IRCCS San Raffaele Hospital, Milan, Italy (SC, MR, GB, CD, MF) e178 Barreto SG, Windsor JA. Justifying vein resection with pancreatoduodenectomy. Lancet Oncol 2016; 17: e118–24 Giovinazzo F, Turri G, Katz MH, Heaton N, Ahmed I. Meta-analysis of benefit of portal-superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma. Br J Surg 2016; 103: 179–91. Bapat AA, Hostetter G, Von Hoff DD, Han H. Perineural invasion and associated pain in pancreatic cancer. Nat Rev Cancer 2011; Sohal DP, Walsh RM, Ramanathan RK, Khorana AA. Pancreatic adenocarcinoma: treating a systemic disease with systemic therapy. J Natl Cancer Inst 2014; 106: dju011 Valero V, Saunders TJ, He J, et al. Reliable detection of somatic mutations in fine needle aspirates of pancreatic cancer with next-generation sequencing: implications for surgical management. Ann Surg 2016; Author’s reply Stefano Crippa and colleagues, in responding to our manuscript, 1 agree that increasing the radicality of surgery for pancreatic ductal adenocarcinoma, including synchronous vein resection, is suspect. Indeed, a recent meta-analysis 2 indicates that synchronous vein resection, as reported, increases mortality and decreases survival. Crippa and colleagues put forward two interesting ideas that warrant further discussion. The first is that the surgery-first approach for pancreatic ductal adenocarcinoma might ultimately be retired, given that pancreatic ductal adenocarcinoma is usually systemic at presentation, local treatments have little effect, and neoadjuvant therapy has possible benefits. For now, the absence of high-level evidence for neoadjuvant therapy leaves largely theoretical benefits; namely that neoadjuvant therapy will reveal the biology (ie, those patients that can progress on neoadjuvant therapy will avoid futile surgery), or alter the biology (ie, those patients that are downstaged will become resectable). The preliminary results of the ALLIANCE trial 3 damages the lustre of these purported benefits with no improvement in the number of resections (10 [50%] of 20 patients who completed all preoperative therapy), and no rescue of aggressive tumour biology. This leads to the second idea, in which Crippa and colleagues suggest a biological (rather than radiological) basis for selecting patients for neoadjuvant therapy with a view to reduce the number of synchronous vein resections. Endoscopic ultrasonography- guided genotyping is a possible way to select subgroups of patients with heterogenous pancreatic ductal adenocarcinoma 4 who will benefit from neoadjuvant therapy. In support of this method, Hruban and colleagues 5 suggested that an intact SMAD4/DPC4 gene might be used to select surgery because there is lesser risk of distant metastases for this genotype. 6 In the future, we hope to more accurately select a subgroup of patients in whom a surgery-first approach, and even synchronous vein resection, is justified, but it is much more likely that precision neoadjuvant therapy will ultimately result in less radical surgery and the introduction of non-surgical techniques to support the response to neoadjuvant therapy. We declare no competing interests. Savio G Barreto, *John A Windsor j.windsor@auckland.ac.nz Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India (SGB); Hepatobiliary Pancreatic and Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand (JAW) Barreto S, Windsor J. Justifying vein resection with pancreatoduodenectomy. Lancet Oncol 2016; 17: e118–24. Giovinazzo F, Turri G, Katz MH, Heaton N, Ahmed I. Meta-analysis of benefits of portal-superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma. Br J Surg 2016; Varadhachary G, Fleming J, Crane C, et al. Phase II study of preoperation mFOLFIRINOX and chemoradiation for high-risk resectable and borderline resectable pancreatic adenocarcinoma. Proc Am Soc Clin Oncol 2015; 33 (suppl 3): abstr 362. Killock D. Pancreatic cancer: a problem quartered—new subtypes, new solutions? Nat Rev Clin Oncol 2016; 13: 201. Hruban RH, Adsay NV. Molecular classification of neoplasms of the pancreas. Hum Pathol Iacobuzio-Donahue CA, Fu B, Yachida S, et al. DPC4 gene status of the primary carcinoma correlates with patterns of failure in patients with pancreatic cancer. J Clin Oncol 2009; The US Cancer Moonshot initiative We recently sent the following letter to Vice President of the USA, Joe Biden, to state that we, as Deans and Directors of Public Health schools and programmes around the USA, strongly support the goals of the Cancer Moonshot initiative to www.thelancet.com/oncology Vol 17 May 2016

BACKGROUND: Epidemic increases in childhood obesity and associated health risks are resulting in efforts to implement school policies related to nutrition and physical activity (NPA). With multicomponent policy efforts, challenges exist in characterizing the extent of policy change across the breadth of NPA policies. METHODS: Aggregated policy indices were created to characterize NPA policy implementation in Arkansas public schools from 2004 through 2009. Index scores are presented by year, domain, and school level. RESULTS: Both mean and median index scores increased over time, with greater changes seen in nutrition than in physical activity policy scores. The composite index score was heavily dependent on the nutrition index score and, thus, is relatively less useful for the purposes of our evaluation. Policy index scores varied by school level, rurality, enrollment size, and percentage of students eligible for federal meal programs. CONCLUSIONS: The policy index approach facilitates the consideration of the effect of school policy change in a holistic, aggregated way. School characteristics influence policy adoption, and thus, should be taken into consideration in the promotion of policy change.

The Association of Schools of Public Health (ASPH) released the Doctor of Public Health (DrPH) Core Competency Model in 2009. Between 2007 and 2009, a national expert panel with members of the academic and practice communities guided by the ASPH Education Committee developed its 7 performance domains, including 54 competencies. We provide an overview and analysis of the challenges and issues associated with the variability in DrPH degree offerings, reflect on the model development process and related outcomes, and discuss the significance of the model, future applications, and challenges for integration across educational settings. With the model, ASPH aims to stimulate national discussion on the competencies needed by DrPH graduates with the new challenges of 21st-century public health practice and to better define the DrPH degree.

Objective: Examine the accuracy of parental weight perceptions of overweight children before and after the implementation of childhood obesity legislation that included BMI screening and feedback. Methods and Procedures: Statewide telephone surveys of parents of overweight (BMI ≥ 85th percentile) Arkansas public school children before (n = 1,551; 15% African American) and after (n = 2,508; 15% African American) policy implementation were examined for correspondence between parental perception of child's weight and objective classification. Results: Most (60%) parents of overweight children underestimated weight at baseline. Parents of younger children were significantly more likely to underestimate (65%) than parents of adolescents (51%). Overweight parents were not more likely to underestimate, nor was inaccuracy associated with parental education or socioeconomic status. African-American parents were twice as likely to underestimate as whites. One year after BMI screening and feedback was implemented, the accuracy of classification of overweight children improved (53% underestimation). African-American parents had significantly greater improvements than white parents (P < 0.0001). Discussion: Parental recognition of childhood overweight may be improved with BMI screening and feedback, and African-American parents may specifically benefit. Nonetheless, underestimation of overweight is common and may have implications for public health interventions.

African American women have significantly higher mortality rates from heart disease and stroke than White women despite advances in treatment and the management of risk factors. Community health workers (CHWs) serve important roles in culturally relevant programs to prevent disease and promote health. This article describes the Pine Apple Heart and Stroke Project's activities to (1) revise the Women's Wellness Sourcebook Module III: Heart and Stroke to be consistent with national guidelines on heart disease and stroke and to meet the needs of African American women living in rural southern communities; (2) train CHWs using the revised curriculum; and (3) evaluate the training program. Revisions of the curriculum were based on recommendations by an expert advisory panel, the staff of a rural health clinic, and feedback from CHWs during training. Questionnaires after training revealed positive changes in CHWs' knowledge, attitudes, self-efficacy, and self-reported risk reduction behaviors related to heart disease, stroke, cancer, and patient-provider communication. This study provides a CHW training curriculum that may be useful to others in establishing heart disease and stroke programs in rural underserved communities.

OBJECTIVE Intervening in depression and/or low perceived social support within 28 days after myocardial infarction (MI) in the Enhancing Recovery in Coronary Heart Disease (ENRICHD) clinical trial did not increase event-free survival. The purpose of the present investigation was to conduct post hoc analyses on sex and ethnic minority subgroups to assess whether any treatment subgroup is at reduced or increased risk of greater morbidity/mortality. METHODS The 2481 patients with MI (973 white men, 424 minority men, 674 white women, 410 minority women) who had major or minor depression and/or low perceived social support were randomly allocated to usual medical care or cognitive behavior therapy. Total mortality or recurrent nonfatal MI (ENRICHD primary endpoint) and cardiac mortality or recurrent nonfatal MI (secondary endpoint) were analyzed as composite endpoints by group for time to first event using Cox proportional hazards regression. RESULTS There was a trend in the direction of treatment efficacy for white men for the primary endpoint (hazard ratio [HR], 0.80; 95% confidence interval, 0.61-1.05; p =.10) and a significant (p

OBJECTIVE To compile lessons learned from the Uniontown Community Health Project. METHODS Lessons-learned information was gathered from project staff and community volunteers. RESULTS Analysis led to the identification of 6 lessons: (a) Establish personal working relationships in communities; (b) find a local community coordinator to lead efforts; (c) be patient in implementing a community health advisor (CHA) model; (d) be flexible and emphasize simplicity when implementing community activities; (e) recognize that meeting research goals requires compromise; and (f) plan transfer of project activities to the community from the beginning. CONCLUSION These lessons may benefit others implementing CHA programs.

Sex differences in the pathophysiologic course of coronary artery disease (CAD) are widely recognized, yet accurate diagnosis of coronary artery disease in women remains challenging.To determine sex differences in the clinical manifestation of CAD, we studied chest pain reported during daily activities, exercise, and mental stress in 170 men and 26 women. All patients had documented CAD (50% narrowing in at least 1 major coronary artery or prior myocardial infarction) and all had 1-mm ST-segment depression on treadmill exercise. We collected psychologic test results, serum samples (potassium, epinephrine, norepinephrine, cortisol, b-endorphin, and glucose), and cardiac function, sensory threshold, and autonomic function data at specified times before, during, or after exercise and mental stress tests to assess measures of depression, anxiety, and neurohormonal and thermal pain perception.Women reported chest pain more often than men during daily activities (P =.04) and during laboratory mental stressors (P =.01) but not during exercise. Men had lower scores than women on measures of depression, trait anxiety, harm avoidance, and reward dependence (P.05 for all). Women had significantly lower plasma b-endorphin levels at rest (4.2 +/- 3.9 vs 5.0 +/- 2.5 pmol/L for men, P =.005) and at maximal mental stress (6.4 +/- 5.1 vs 7.4 +/- 3.5 pmol/L for men, P.01). A higher proportion of women than men had marked pain sensitivity to graded heat stimuli applied to skin (hot pain threshold41 degrees C, 33% vs 10%, P =.001).Our results reflect sex differences in the affective and discriminative aspects of pain perception and may help explain sex-related differences in clinical presentations.

PURPOSE: Stress Management Intervention (SMI) was one of seven nonpharmacologic approaches evaluated in Phase I Trials of Hypertension Prevention (TOHP-I) for efficacy in lowering diastolic blood pressure (BP) in healthy men and women aged 30 to 54 years with diastolic BP 80–89 mm Hg. METHODS: A total of 242 and 320 participants were randomized to SMI or an “assessment only” SMI Control, respectively, at four clinical centers. The SMI consisted of 37 contact hours in 21 group and two individual meetings over 18 months and included: training in four relaxation methods, techniques to reduce stress reactions, cognitive approaches, communication skills, time management, and anger management within a general problem-solving format. Standardized protocols detailed methods and timing for collecting BP, psychosocial measures, and urinary samples from both SMI and SMI Control participants. RESULTS: In intention-to-treat analyses, although significant baseline to termination BP reductions were observed in both groups, net differences between the SMI and SMI Control groups' BP changes (mean (95% CI)) were not significant: −0.82 (−1.86, 0.22) for diastolic BP, and −0.47 (−1.96, 1.01) for systolic BP. Extensive adherence sub-group analyses found one effect: a significant 1.36 mm Hg ( p = 0.01) reduction in diastolic BP relative to SMI Controls at the end of the trial for SMI participants who completed 61% or more of intervention sessions. CONCLUSIONS: While the TOHP-I SMI was acceptable to participants as evident from high levels of session completion, the absence of demonstrated BP lowering efficacy in intention-to-treat analyses suggests that the TOHP-I SMI is an unlikely candidate for primary prevention of hypertension in a general population sample similar to study participants. The isolated finding of significant diastolic BP lowering in SMI participants with higher adherence provides very weak evidence of SMI BP lowering efficacy and may be a chance finding. Whether similar or other stress management interventions can produce significant BP lowering in populations selected for higher levels of BP, stress, or intervention adherence remains to be demonstrated.

Despite the proven benefits of many cardiac procedures, some are used less frequently for African Americans than for white patients with known or suspected coronary disease. This study explored differences between ethnic groups that may affect patient recall of physician recommendations of cardiac procedures. Also examined were patients' responses when asked about adhering to those recommendations. The data examined were collected from interviews with 1,333 African American and white hospital inpatients with known coronary disease admitted to the Birmingham-Black Health Seeking for Coronary Heart Disease Project (1989-1990) in Alabama. Respondents were asked to recall previous health care encounters, physician recommendations of cardiac procedures, and adherence to those recommendations. Compared with whites, fewer African American patients recalled physicians recommending some cardiac procedures. If procedure recommendations were recalled, no ethnic differences were found in patient recall of adhering to those recommendations. Predictors of recall of the recommended procedures were identified by multivariate logistic regression. Patients' knowledge of having coronary disease was the common factor that predicted their recall of all cardiac procedures. Other predictor variables included some cardiac risk factors and symptoms, socioeconomic status, and ethnicity. Although health care practice is influenced by many factors, it is important to examine variables that may lead to a reduction in ethnic disparities in coronary disease morbidity and mortality.

OBJECTIVE This study was undertaken to determine the relationship between heightened reactivity of blood pressure (BP) during stress and 5-year changes in blood pressure and hypertensive status, using the CARDIA study. METHOD A total of 3364 participants (910 white men, 909 white women, 678 black men, and 867 black women), initially 20 to 32 years old and normotensive, were included. Cardiovascular reactivity to psychological stressors (video game and star-tracing tasks for 3 minutes, cold pressor test for 1 minute) was measured in 1987-1988. We then examined reactivity as a predictor of significant BP change (> or = 8 mm Hg, thought to represent a clinically significant increase) over the next 5 years. Logistic regression models were used to control for potential covariates. Significant BP change and the development of hypertension (BP greater than 140/90 or taking medication for hypertension) over the 5-year follow-up were examined in separate analyses. RESULTS Increased systolic blood pressure (SBP) reactivity to the video game was associated with a significant 5-year SBP increase among the entire cohort, independent of resting SBP (p < .0001). Subsequent analyses showed that this relationship held for men but not for women. Reactivity to the star-tracing task or the cold pressor test did not predict significant BP change. Among black men only, new hypertensives (N = 36) had greater diastolic blood pressure (DBP) reactivity to the video game (p = .01). CONCLUSIONS Although BP reactivity to all physical and mental stressors used in this study did not consistently predict 5-year change in BP in this young cohort, the results indicate that reactivity to a video game stressor predicts 5-year change in BP and early hypertension among young adult men. These findings are consistent with other studies showing the usefulness of stressors producing a primarily beta-adrenergic response in predicting BP change and hypertension. The results may be limited by the shortened initial rest and recovery periods used in the CARDIA protocol.

Treatment efficacy for homeless substance abusers (primarily crack cocaine) was studied in a randomized control design with subjects (n = 176) assigned to usual care (UC) or an enhanced day treatment program plus abstinent contingent work therapy and housing (EC). Subjects met DSM-III-R criteria for Substance Use Disorder and McKinny Act criteria for homelessness. UC involved weekly individual and group counseling. EC involved a day treatment program consisting of daily attendance, transportation, lunch, manualized psychoeducational groups, and individual counseling. A total of 131 (74.4%) subjects (62 UC and 69 EC) were treated and followed. UC subjects attended 28.5% and EC attended 48.4% of expected treatment during the first 2 months. After 2 months, EC subjects experienced up to 4 months of abstinent contingent work therapy (44.9% of EC subjects) and housing (37.7% of EC subjects), with day treatment available two afternoons per week. Longitudinal Wei-Lachin analyses of medians (reported alcohol use, days homeless and employed) and proportions (cocaine toxicologies) were conducted across 2-, 6-, and 12-month follow-up points. EC had 36% fewer positive cocaine toxicologies at 2-months and 18% fewer at 6-months than UC with regression toward baseline at 12-months. EC had 8 days fewer days of reported alcohol use in the past 30 days, 52 fewer days homeless in the past 60 days, and 10 more days employed in the past 30 days from baseline to the 12-months. UC showed no changes except a temporary increase in employment at 6-months. This is one of the first demonstrations that homeless cocaine abusers can be retained and effectively treated.

The Women's Health Trial: Feasibility Study in Minority Populations (WHT:FSMP), a randomized trial of 2208 women, was conducted to investigate three questions. First, can women from minority and low-socioeconomic-status populations be recruited in numbers sufficient to evaluate a dietary intervention designed to lower fat intake. Second, the efficacy of a low fat, increased fruit/vegetable/ grain product intervention for reducing fat consumption. Third, will participation in the intervention lower plasma cholesterol and estradiol levels relative to the controls. The baseline results showed that an adequate number of minority and low SES women could be recruited to test the study hypotheses. A diverse study population of postmenopausal women consuming a high fat diet was recruited: 28% of participants were Black, 16% were Hispanic, 11% had less than a high school level of education, and 15.5% had household incomes of < $15,000.

The objective of this study was to determine whether exaggerated blood pressure (BP) reactivity to stress and psychosocial characteristics are related to left ventricular mass (LVM) in a large cohort of young adults. Analyses were conducted with 3,742 participants of the CARDIA study (945 white men, 1,024 white women, 781 black men, and 992 black women), evaluated in 1990 to 1091 with echocardiographic measurement of LVM. Analyses were stratified by gender and race. The relationships of LVM/height2.7 and cardiovascular reactivity to physical and psychological stressors (treadmill exercise, cold pressor, video game, and star-tracing tasks), were examined in both univariate and multivariate analyses adjusting for baseline BP, weight, and other relevant biobehavioral variables. The relationships between LVM and several psychosocial characteristics (hostility, anger suppression, anxiety, depressive symptoms, and education) were also assessed. Systolic blood pressure (SBP) reactivity to exercise was significantly related to LVM in black and white men; LVM was 10% greater among white men with exaggerated (upper quintile) peak exercise SBP than among other white men. SBP reactivity to the cold pressor test was related to LVM in all race/gender groups, although the relationship remained significant only among white men and women in the multivariate analysis. Diastolic blood pressure (DBP) reactivity to the video game was related to LVM only among black men in adjusted analyses. After adjusting for resting BP, weight, and other covariates in linear multiple regression models, SBP reactivity to exercise explained only 3% of the variance in LVM among white men. Otherwise, reactivity to other stressors or psychosocial variables accounted for no more than 1% of the variance in LVM. It was concluded that among a cohort of young adults, blood pressure reactivity to physical and mental stressors did not add substantially to the prediction of LVM when resting BP, weight, and other covariates were taken into account.

These analyses examined the relationship between fasting plasma lipids and several psychosocial factors in a healthy cohort of 5115 black and white men and women between the ages of 18 and 30. Primary analyses were performed within race/gender subgroups and were supplemented with analyses examining consistency of associations across these groups. After controlling for age, high density lipoprotein (HDL) decreased, triglycerides increased, low density lipoprotein (LDL) increased, and the total cholesterol/HDL cholesterol ratio increased with increasing level of education in black men. This pattern is, in general, opposite to that found in other groups, particularly white women, whose lipid profile was found to be less atherogenic the higher the education. These associations were strongly confounded with health behaviors. There was also a positive association between hostility and triglycerides in women but not in men. No significant association with any plasma lipid for either race or gender was found for Type A behavior, social support, or life events. Despite a narrow plasma lipid range in these young adults, these data support the conclusion that increasing education is associated with a less atherogenic plasma lipid profile, except in black men, for whom education is associated with a less favorable plasma lipid profile. Among other psychosocial factors, the only consistent finding was an inverse association between hostility and triglycerides in women.

The validity of self-reported crack cocaine use among 131 homeless persons participating in an outpatient substance abuse treatment research demonstration project was assessed by comparing the concordance of self-report and urinalysis results. The subjects were participants in either a Usual Care outpatient program or an Enhanced Care day treatment program that included drug free contingent work therapy and housing. For all subjects across four evaluation points, the false negative classification by self-report (i.e., denied verified use) rate for crack cocaine use was 32.0%. Denied verified use was greater in Usual Care (34.9%) than in Enhanced Care clients (23.7%) and greater at follow-up as compared to treatment entry for all clients. The findings are explained in terms of social desirability and the influence of treatment contingencies and greater accountability specific to the Enhanced Care program. The need for validation of self-reported cocaine use data among homeless persons in settings where contingencies are present and in other drug treatment or research settings is recommended.

This article describes the evaluation of the Arkansas Act 1220 of 2003, a comprehensive legislative proposal to address the growing epidemic of childhood obesity through changes in the school environment. In addition, the article discusses specific components of the evaluation that may be applicable to other childhood obesity policy evaluation efforts. The conceptual framework for the evaluation, research questions, and evaluation design are described, along with data collection methods and analysis strategies. A mixed methods approach, including both quantitative (surveys, telephone interviews) and qualitative (key informant interviews, records reviews) approaches, was utilized to collect data from a range of informant groups including parents, adolescents, school principals, school district superintendents, and other stakeholders. Challenges encountered with the evaluation are discussed, as are strategies to overcome those challenges. Now in its 9th year, this evaluation has documented substantial changes to school policies and environments but fewer changes to student and family behaviors. The evaluation may inform the methods of other evaluations of childhood obesity prevention policies, as well as inform policymakers about how quickly they might expect implementation of such policies in their own states and localities and anticipate both positive and adverse outcomes.

OBJECTIVES. This study examined health care-seeking behaviors to elucidate factors that contribute to differences in patterns of coronary heart disease between African Americans and Whites. The prevalence of diagnosed coronary heart disease, patients' perceptions of symptoms and attribution of symptoms, and predictors of painful symptoms and attribution of cardiac symptoms were examined. METHODS. The study involved 2416 patients admitted with diagnoses of coronary artery disease, ischemic heart disease, or myocardial infarction or to rule out myocardial infarction. Structured interview questions were used to obtain demographic information, symptoms precipitating admission, and patients' attribution of their symptoms. Discharge diagnoses were obtained from hospital records. RESULTS. Acute myocardial infarction, unstable angina, nonacute ischemic heart disease, and atherosclerosis were more frequent in White patients. For Blacks, the odds of reporting painful symptoms were only 64% of the odds found for Whites when other factors were controlled, and the odds of attributing symptoms to cardiac origins were almost 50% lower for Blacks than for Whites. CONCLUSIONS. The tendency of Blacks to report fewer painful symptoms and to attribute their symptoms to noncardiac origins may contribute to differences in care-seeking and in medical management of heart disease in Blacks.

Changes in school nutrition and physical activity policies and environments are important to combat childhood obesity. Arkansas Act 1220 of 2003 was among the first and most comprehensive statewide legislative initiatives to combat childhood obesity through school-based change. Annual surveys of principals and superintendents have been analyzed to document substantial and important changes in school environments, policies, and practices. For example, results indicate that schools are more likely to require that healthy options be provided for student parties (4.5% in 2004, 36.9% in 2008; Por= 0.0001) and concession stands (1.6% in 2004, 19.6% in 2008; Por= 0.0001), ban commercial advertising by food or beverage companies (31.7% in 2005, 42.6% in 2008; Por= 0.0001), and offer skim milk options for students in cafeterias (white milk: 26.1% in 2004, 41.0% in 2008, Por= 0.0001; chocolate milk: 9.0% in 2004, 24.0% in 2008, Por= 0.0001). They are less likely to have vending machines available during the lunch period (72.3% in 2004, 37.2% in 2008; Por= 0.0001) and to include sodas in vending machines (83.8% in 2004, 73.5% in 2008; Por= 0.0001). Other changes were noted in foods and beverages offered in the cafeteria, in classrooms, and at school events, as well as in fund-raising and physical activity practices. A significant number of school districts have modified physical education requirements for elementary schools and developed policies prohibiting the use of physical activity as a punishment. We conclude that Arkansas Act 1220 of 2003 is associated with a number of changes in school environments and policies, resulting from both statewide and local initiatives spawned by the Act.

School performance of overweight children has been found to be inferior to normal weight children; however, the reason(s) for this link between overweight and academic performance remain unclear. Psychosocial factors, such as weight-based teasing, have been proposed as having a possible mediating role, although they remain largely unexplored.Random parental telephone survey data (N=1 071) of public school students collected as part of the statewide evaluation of Arkansas Act 1220, a law to reduce childhood obesity, were used. Overweight status (body mass index85th percentile for gender and age) and weight-based teasing were examined as predictors of poorer school performance.Overweight status was a significant predictor of poorer school performance (OR=1.51; 95% CI=1.01, 2.25), after adjustment for gender, school level, free and reduced lunch participation, and race. However, the addition of weight-based teasing to the model (with weight category and covariates) reduced the weight category parameter estimate by 24%, becoming non-significant (OR=1.40; 95% CI=0.93, 2.10) and indicating a possible mediating effect of weight-based teasing on the relationship between weight category and school performance. Weight-based teasing was significantly associated with school performance, with lower odds of strong school performance among weight-based teased children (OR=0.44; 95% CI=0.27, 0.74).Psychosocial variables, such as weight-based teasing, should be considered in future research examining the impact of childhood obesity on school performance and in future intervention studies.

Arkansas was among the first states to pass comprehensive legislation to combat childhood obesity, with Arkansas Act 1220 of 2003. Two distinct but complementary evaluations of the process, impact, and outcomes of Act 1220 are being conducted: first, surveillance of the weight status of Arkansas children and adolescents, using the statewide data amassed from the required measurements of students' body mass indexes (BMIs); and second, an independent evaluation of the process, impact, and outcomes associated with Act 1220. Various stakeholder groups initially expressed concerns about the Act, specifically concerns related to negative social and emotional consequences for students and an excessive demand on health care. Evaluation data, however, suggest that few adverse effects have occurred either in these areas of concern or in other concerns which have emerged over time. Schools are changing environments and implementing policies and programs to promote healthy behaviors and BMI levels have not increased since the implementation of Act 1220 in 2004. The Arkansas experience to date may serve to inform the efforts of other states to adopt policies to address the epidemic of childhood obesity.

The Uniontown, Alabama Community Health Project trained and facilitated Community Health Advisors (CHAs) in conducting a theory-based intervention designed to reduce the risk for cardiovascular disease (CVD) among rural African-American women. The multiphased project included formative evaluation and community organization, CHA recruitment and training, community intervention and maintenance. Formative data collected to develop the training, intervention and evaluation methods and materials indicated the need for programs to increase knowledge, skills and resources for changing behaviors that increase the risk of CVD. CHAs worked in partnership with staff to develop, implement, evaluate and maintain strategies to reduce risk for CVD in women and to influence city officials, business owners and community coalitions to facilitate project activities. Process data documented sustained increases in social capital and community capacity to address health-related issues, as well as improvements in the community's physical infrastructure. This project is unique in that it documents that a comprehensive CHA-based intervention for CVD can facilitate wide-reaching changes in capacity to address health issues in a rural community that include improvements in community infrastructure and are sustained beyond the scope of the originally funded intervention.

Previous studies have been inconclusive as to whether peak flow meter use teaches asthma patients to better perceive their own pulmonary functioning. This investigation utilized a delayed baseline design to determine if pulmonary awareness could be improved among a sample of 24 adult patients who compared daily peak expiratory flow rates (PEFR) with asthma symptom ratings. Results indicated that among this sample of adult patients: (i) perception of pulmonary functioning was poor, (ii) adherence to peak flow meter use was poor, and (iii) among patients who use peak flow meters daily, self-perception of pulmonary functioning did not improve significantly. Summary tables and descriptive statistics for pulmonary functioning are provided, and treatment implications are discussed.

Background The relationship of changes in weight to outcomes in patients after myocardial infarction (MI) is controversial. Methods From the ENRICHD trial data, we assessed weight change, and the associations of baseline weight and change at follow-up with outcomes and interactions between psychosocial factors. Results At baseline, 73.6% of patients (n = 1706) were overweight or obese; 134 patients had body mass index of ≥40. Underweight patients were more likely to die or have nonfatal recurrent MI. After controlling for covariates, overweight and obese patients had similar outcomes to normal-weight patients. Eighteen percent of patients gained >5%, 27% lost >5%, and 55% had ≤5% change in weight. Compared with weight loss of ≤5%, the risk of death (adjusted hazard ratio 1.74, P = .01) and cardiovascular death (hazard ratio 1.79, P = .04) increased with weight loss of >5%. After propensity matching, weight loss of >5% remained as a significant risk factor for death and cardiovascular death. There was no interaction between weight change and depression and/or social support at baseline or follow-up. Weight change was not associated with recurrent MI or cardiovascular hospitalizations. Conclusions A large proportion of patients lose or gain >5% of body weight after an MI. The association between obesity and lower mortality is modulated by comorbidities. Weight loss after MI is associated with worse outcomes and is not related to depression or social support.

Sodium reduction is efficacious for primary prevention of hypertension, but the feasibility of achieving this effect is unclear. The objective of the paper is detailed analyses of adherence to and effects of the sodium reduction intervention among overweight adults in the Trials of Hypertension Prevention, Phase II. Sodium reduction (comprehensive education and counselling about how to reduce sodium intake) was tested vs no dietary intervention (usual care) for 36-48 months. A total of 956 white and 203 black adults, ages 30-54 years, with diastolic blood pressure 83-89 mmHg, systolic blood pressure (SBP)

Background. Effective treatment for patients with acute myocardial infarction is limited by patient delay in seeking care. Inadequate knowledge of heart attack symptoms may prolong delay. An intervention designed to reduce delay was tested in the Rapid Early Action for Coronary Treatment (REACT) Community Trial. In this report, the impact on knowledge of heart attack symptoms is presented. Methods. Twenty communities were randomized to intervention or comparison status in a matched-pair design. Intervention strategies included community organization, public education, professional education, and patient education. The main outcome measures were based on information regarding knowledge of symptoms collected in a series of four random-digit-dialed telephone surveys. Results. Knowledge of REACT-targeted symptoms increased in intervention communities. No change was observed in comparison communities. The net effect was an increase of 0.44 REACT-targeted symptoms per individual (P < 0.001). The intervention effect was greater in ethnic minorities, persons with lower household incomes, and those with family or spouse history of heart attack (P < 0.05). Conclusions. The REACT intervention was modestly successful in increasing the general public's knowledge of the complex constellation of heart attack symptoms. The intervention program was somewhat more effective in reaching disadvantaged subgroups, including ethnic minorities and persons with lower income. Despite these successes, the post-intervention level of knowledge was suboptimal.

Bonnie K. Sanderson, Department of Medi-cine; Carol E. Cornell, Department of Medicine;Vera Bittner, Department of Medicine; LeaVonnePulley, Department of Health Behavior; KathyKirk, Department of Biostatistics; Mary AnnLittleton, Department of Health Behavior; JamesM. Raczynski, Department of Medicine, Centerfor Health Promotion, all in the Center of HealthPromotion, University of Alabama at Birmingham.Ye Yang, Department of Psychiatry, University ofMaryland at Baltimore, Baltimore, MD. NellBrownstein and Dyann Matson-Koffman, Cen-ters for Disease Control and Prevention, Atlanta,GA.Address correspondence to Dr. Sanderson, De-partment of Medicine, Division of CardiovascularDisease, University of Alabama at Birmingham,307 Lyons Harrison Research Building, Birming-ham, AL 35294. E-mail: bsanderson@uabmc.edu

OBJECTIVE: The Depression Interview and Structured Hamilton (DISH) is a semistructured interview developed for the Enhancing Recovery in Coronary Heart Disease (ENRICHD) study, a multicenter clinical trial of treatment for depression and low perceived social support after acute myocardial infarction. The DISH is designed to diagnose depression in medically ill patients and to assess its severity on an embedded version of Williams' Structured Interview Guide for the Hamilton Depression scale (SIGH-D). This article describes the development and characteristics of the DISH and presents a validity study and data on its use in ENRICHD. METHODS: In the validity study, the DISH and the Structured Clinical Interview for DSM-IV (SCID) were administered in randomized order to 57 patients. Trained interviewers administered the DISH, and clinicians administered the SCID. In ENRICHD, trained research nurses administered the DISH and recorded a diagnosis. Clinicians reviewed 42% of the interviews and recorded their own diagnosis. The Beck Depression Inventory (BDI) was administered in both studies. RESULTS: In the validity study, the SCID diagnosis agreed with the DISH on 88% of the interviews (weighted kappa = 0.86). In ENRICHD, the clinicians agreed with 93% of the research nurses' diagnoses. The BDI and the Hamilton depression scores derived from the DISH in the two studies correlated 0.76 (p < .0001) in the validity study and 0.64 (p < .0001) in ENRICHD. CONCLUSIONS: These findings support the validity of the DISH as a semistructured interview to assess depression in medically ill patients. The DISH is efficient in yielding both a DSM-IV depression diagnosis and a 17-item Hamilton depression score.

Community characteristics are being recognized as important determinants for effective community-based programs. Community capacity to collaboratively identify issues, establish collective goals, and mobilize resources is built on experience with such interactions and trust among collaborators. Conceptual approaches and methods to develop community capacity rarely have been a focus of research programs, at least in part due to categorical funding, which often limits the scope and duration of interventions, thereby limiting capacity development. This approach uses multiple categorical funding sources to create sustained community programs involving multiple systems to increase capacity. Quasi-experimental evidence of increases in community capacity within two Alabama communities is presented.

Barriers to the use of emergency medical services (EMS) and patient delay in seeking care can limit the receipt or effectiveness of reperfusion therapies and the availability of prehospital emergency cardiac care. The Rapid Early Action for Coronary Treatment (REACT) trial was designed to determine the impact of a community intervention on use of EMS among demographic and clinical subgroups of patients with suspected acute cardiac ischemia.A randomized controlled community trial was conducted in 20 pair-matched communities in the United States. One community from each pair received an 18-month, multicomponent community education program. Data were collected at 44 participating hospitals during a four-month baseline period and throughout the 18-month trial, using medical record abstracts to collect information on mode of transport to the hospital and other sociodemographic and clinical variables. Eligible patients were persons agedor = 30 years presenting with chest pain or discomfort to emergency departments (EDs) who were admitted and discharged with a cardiac-related diagnoses (ICD 410-414, 427-429, 440, 786.9).The net change in the odds of EMS use was an increase of 34% in intervention compared with control communities [adjusted odds ratio (OR) 1.34, 95% CI 1.07-1.67]. We observed greater increases in the odds of EMS use among patients who had chronic or other cardiac diagnoses (adjusted OR 1.53, 95% CI 1.18-1.99, and adjusted OR 1.52, 95% CI 1.17-1.97, respectively) than in those diagnosed as having acute ischemia (adjusted OR 1.14, 95% CI 0.91-1.44). We observed greater increases in odds of EMS ulse in those who were retired (adjusted OR 1.62, 95% CI 1.29-2.04) or had systolic blood pressure (SBP) at or below 160 mm Hg upon presentation to the ED (adjusted OR 1.55, 95% CI 1.26-1.91 for SBP 100-160 mm Hg; 1.61, 95% CI 0.88-2.97 for SBP100 mm Hg).The REACT trial demonstrated a significant impact on the use of EMS among patients admitted to the hospital for suspected acute myocardial infarction, with greater increases among patients with chronic or other cardiac ICD-9 discharge diagnoses, those presenting with lower SBP, and retired persons.

Background. Patient delay in seeking health care for heart attack symptoms is a continuuing problem in the United States. Methods. Investigators conducted focus groups (N = 34; 207 participants) in major U.S. regions (NE, NW, SE, SW, MW) as formative evaluation to develop a multi-center randomized community trial (the REACT Project). Target groups included adults with previous heart attacks, those at higher risk for heart attack, and bystanders to heart attacks. There were also subgroups reflecting gender and ethnicity (African-American, Hispanic-American, White). Findings. Patients, bystanders, and those at higher risk expected heart attack symptoms to present as often portrayed in the movies, that is, as sharp, crushing chest pain rather than the more common onset of initially ambiguous but gradually increasing discomfort. Patients and those at higher risk also unrealistically judge their personal risk as low, understand little about the benefits of rapid action, are generally unaware of the benefits of using EMS/9-1-1 over alternative transport, and appear to need the “permission” of health care providers or family to act. Moreover, participants reported rarely discussing heart attack symptoms and appropriate responses in advance with health care providers, spouses, or family members. Women often described heart attack as a “male problem,” an important aspect of their underestimation of personal risk. African-American participants were more likely to describe negative feelings about EMS/9-1-1, particularly whether they would be transported to their hospital of choice. Conclusions. Interventions to reduce patient delay need to address expectations about heart attack symptoms, educate about benefits and appropriate actions, and provide legitimacy for taking specific health care-seeking actions. In addition, strategy development must emphasize the role of health care providers in legitimizing the need and importance of taking rapid action in the first place.

This study presents findings on the effect of an office-based obstetrics training program (given the acronym OBIWOM) on substance use assessment, management, and referral self-efficacy among obstetricians and staff of private, community-based obstetric practices.Participants were obstetricians and staff from 10 of 27 available community-based, private obstetric practices in the target areas, for a practice participation rate of 37%. This study used a delayed treatment design to compare self-efficacy between practice staff randomly assigned to an immediate or delayed intervention group.Self-efficacy increased significantly after intervention from baseline to first follow-up for the immediate group, while no change was shown for the delayed (control) group. The impact of the intervention on self-efficacy was replicated in the assessment construct only after the intervention for the delayed group.This research shows that education and training can effectively improve self-efficacy in obstetricians and their staff in the management of substance use and pregnancy.

Background. This study evaluated the effects of a school-based dietary intervention program to increase fruit and vegetable consumption among fourth-graders. Methods. Twenty-eight elementary schools were randomized to an immediate intervention condition or to a delayed intervention control condition. Measures of diet and psychosocial variables were collected at base line and 1 and 2 years post-baseline. The intervention included classroom, parent, and cafeteria components. Results. Mean daily consumption of fruit and vegetables was higher for the intervention children compared with controls at Follow-up 1 (X0t = 3.96, Xc = 2.28) and at Follow-up 2 (Xt = 3.20, Xc = 2.21). Macro- and micronutrient changes favoring the intervention children were also observed at both Follow-up 1 and Follow-up 2. Mean daily consumption of fruit and vegetables was higher for intervention parents compared with controls at Follow-up 1 (Xt = 4.23, Xc = 3.94) but not at Follow-up 2. Conclusions. Strong effects were found for the High 5 intervention on fruit and vegetable consumption, on macro- and micro-nutrients, and on psychosocial variables. Future work is needed to enhance the intervention effects on parents' consumption and to test the effectiveness of the intervention when delivered by classroom teachers.

ContextAntenatal corticosteroids for fetal maturation have been underused, despite evidence for their benefits in cases of preterm birth.ObjectiveTo evaluate dissemination strategies aimed at increasing appropriate use of this therapy.Design and SettingTwenty-seven tertiary care institutions were randomly assigned to either usual dissemination of practice recommendations (n=14) or usual dissemination plus an active, focused dissemination effort (n=13).SubjectsObstetricians and their preterm delivery cases at participating hospitals.InterventionRecommendations by a National Institutes of Health (NIH) Consensus Conference held in late February–early March 1994 were disseminated in early May 1994. Usual dissemination was publication of the recommendations and endorsement by the American College of Obstetricians and Gynecologists. Active dissemination was a year-long educational effort led by an influential physician and a nurse coordinator at each facility, consisting of grand rounds, a chart reminder system, group discussion of case scenarios, monitoring, and feedback.Main Outcome MeasureUse or nonuse of antenatal corticosteroids was abstracted from medical records of eligible women delivering at the participating hospitals in the 12 months immediately prior to release of the NIH recommendations (average number of records abstracted, 130) and in the 12 months following their release (average number of records abstracted, 122).ResultsActive dissemination significantly increased the odds of corticosteroid use after the conference. Use increased from 33.0% of eligible patients receiving corticosteroids to 57.6%, or by 75% over baseline, in usual dissemination hospitals. Use increased from 32.9% to 68.3%, or an 108% increase, in active dissemination hospitals. Gestational age and maternal diagnosis affected use of the therapy in complex ways.ConclusionAn active, focused dissemination effort increased the effectiveness of usual dissemination methods when combined with key principles to change physician practices.

School-based research requires a multi-level recruitment process to ensure an adequate sample. This article describes the High 5 Alabama recruitment experience at four levels; district, school, classroom and individual. One hundred percent of 28 schools across three districts and 108 classroom teachers contacted agreed to participate. Moderate success (69%) at the individual level, which required active parental consent for the student and parent to participate, resulted in 1,698 student/parent participants. An examination of differences between participants and nonparticipants revealed under-representation of a subsample of the population in the project sample. Suggestions obtained from project staff and teachers intended to enhance future school-based recruitment strategies include enlistment of a district advocate; meeting with teachers to solicit support; using incentives with students and teachers; direct contact with parents; having teachers keep rosters of students returning consent forms; and tailoring recruitment strategies for specific subpopulations.

Objective Many patients with coronary artery disease (CAD) develop myocardial ischemia in response to mental stress. This has been documented both in the natural environment and in the laboratory. However, the reproducibility of laboratory mental stress-induced ischemia has not been investigated. Method Sixty patients with documented CAD and a positive exercise stress test discontinued cardiac medications and underwent two standardized mental stress tests (a timed Stroop Color-Word test and a public speaking task) in a nuclear cardiology laboratory (Visit 1), and repeated this procedure between 2 and 8 weeks later (Visit 2). Measurements of cardiovascular function and neurohormonal responses were obtained throughout testing, and mood state was assessed before and after testing. Results Sixty-eight percent of the 56 patients with detailed radionuclide data from both visits had consistent responses (ie, ischemia either present during both sessions or absent during both) to the Stroop task (kappa = .29, p = .03), 61% had consistent responses to the speech task (kappa = .20, p = .12), and 60% had consistent responses when ischemia was considered present if it occurred during either the Stroop test, the speech task, or both, and absent if it did not occur during either task (kappa = .22, p = .07). Hemodynamic and neuroendocrine responses to the tests were moderately reproducible. Conclusions We conclude that two popular laboratory tests for mental stress-induced myocardial ischemia are modestly reproducible. The relatively low reproducibility is probably influenced by uncertainties in detecting relatively small changes in wall motion, habituation of the patient to repeated exposure to psychological stressors, and physiological differences in threshold for ischemia on different days of testing.

Objective This study evaluated physiological, neuroendocrine, and psychological status and functioning of patients with coronary artery disease in order to clarify their role in the expression of symptoms during myocardial ischemia (MI), and to establish repeatability of responses to mental stress. Design and methods of the study are presented. Methods One hundred ninety-six coronary artery disease patients were examined during physical and mental stress tests in four hospitals. Eligibility criteria included narrowing of at least 50% in the diameter of at least one major coronary artery or verified history of myocardial infarction, and evidence of ischemia on an exercise treadmill test. Psychological, biochemical, and autonomic function data were obtained before, during, and after exposure to mental and exercise stressors during 2 or 3 half-days of testing. Ventricular function was assessed by radionuclide ventriculography, and daily ischemia by ambulatory electrocardiography. Sixty patients returned for a short-term mental stress repeatability study. Twenty-nine individuals presumed to be free of coronary disease were also examined to establish reference values for cardiac responses to mental stress. Results Study participants were 41 to 80 years of age; 83 (42%) had a history of MI, 6 (3%) of congestive heart failure, and 163 (83%) of chest pain; 170 (87%) were men; and 90 (46%) had ischemia accompanied by angina during exercise treadmill testing. Ischemia during ambulatory monitoring was found in 35 of 90 (39%) patients with and 48 of 106 (45%) patients without angina during exercise-provoked ischemia. Intraobserver variability of ejection fraction changes during bicycle exercise and two mental stress tests (Speech and Stroop) was good (kappa = 1.0, .90, and .76, respectively; percent agreement = 100, 97.5, and 93.8%, respectively). Variability of assessed wall motion abnormalities during bicycle exercise was better (kappa, agreement = 85%) than during Speech or Stroop kappa and .57, percent agreement = 70% and 82.5%, respectively). Conclusions Study design, quality control data, and baseline characteristics of patients enrolled for a clinical study of symptomatic and asymptomatic myocardial ischemia are described. Lower repeatability of reading wall motion abnormalities during mental stress than during exercise may be due to smaller effects on wall motion and lack of an indicator for peak mental stress.

In the Training Levels Comparison Trial, 197 male coronary heart disease patients were randomized to low or high intensity training with target heart rates, which corresponded to 50% and 85% of the VO2max achieved on the previous exercise test, respectively. Patients were to exercise at their assigned intensity level at three 1-h long supervised sessions per week for 2 yr. This paper reports on two components of adherence: attendance at exercise sessions and achievement of heart rates in the target range. During the first year of training, the average percent of exercise sessions attended (mean +/- SE) for the low intensity group (64.0 +/- 2.5%) was significantly higher than for the high intensity group (55.5% +/- 2.7%). At the end of 1 yr of training, 54% and 37% of the low and high intensity patients, respectively, achieved heart rates within 5 beats.min-1 of their target heart rates. Although the low intensity program was preferable to achieve maximum attendance, attenders on the high intensity program achieved higher heart rates. These results suggest that to maximize the achieved heart rate, it would be optimal to motivate a cardiac rehabilitation patient to train at the high intensity level for a prolonged period of time.

This research examines the influence of treatment attendance at two substance abuse outpatient treatment programs of the Birmingham Substance Abuse Homeless Project on substance abuse, homelessness, and unemployment outcomes with homeless persons abusing primarily crack cocaine. Results revealed that significant reductions across a one year period in alcohol use, cocaine use, and homelessness were more likely to occur in clients who attended an average of 4.1 treatment days per week (High attendance or Enhanced Care group) than clients who attended less than one day a week on the average (Low attendance or Usual Care and Medium attendance groups). These results are consistent with the literature suggesting that more intensive contact early in treatment results in better long-term outcome with cocaine abusers, but has now been demonstrated with homeless cocaine abusers who have additional problems associated with housing and employment.

The Training Levels Comparison (TLC) trial was a grant-supported, multicenter, randomized, controlled clinical trial designed to determine whether cardiac rehabilitation patients would benefit from supervised exercise for a prolonged period (2 years) and whether subjecting patients to a more vigorous exercise program than currently recommended would provide additional cardiac benefit. If high-intensity exercise does not enhance the cardiac benefit, then physical activity should be limited to low-intensity levels that are safer, easier to implement and more adaptable to a greater number of patients. Patients were randomly assigned to either a low-intensity or high-intensity training program. All patients were to attend three 1-hour supervised exercise sessions per week for a period of 2 years. Attendance at exercise sessions and adherence to assigned treatments were monitored throughout the study. Patients were evaluated for outcome measures at 3, 6, 12, and 24 months. This paper reports the study design and methodology for the TLC trial, and should be useful in providing methodologies to facilitate comparison of data from other studies with different levels of exercise as an intervention.

OBJECTIVES. Because few data are available concerning physical activity among minority and low-income persons, we characterized physical activity patterns among public housing residents. METHODS. Two separate cross-sectional surveys were conducted 1 year apart of randomly selected residents of eight rental communities administered by the housing authority of Birmingham, Ala. Indigenous interviewers completed 687 interviews in survey 1 and 599 in survey 2. RESULTS. In both surveys, respondents were most frequently young adult African-American women, reflecting the predominance of women in these communities. Participants were generally poorly educated and either unemployed or working in service occupations. Thirty percent of the respondents in both surveys reported no participation in any of 13 physical activities in the previous year; approximately half reported activity levels equivalent to or less than walking 4 hours per week for 8 months of the year. Respondents who were younger and male were significantly more likely to have higher activity levels. CONCLUSIONS. A sedentary life-style is common among this low-income minority group, and, thus, interventions to promote exercise in these communities are needed.

Multiple psychophysiological measures and personality assessment techniques were combined to facilitate the diagnosis of headache type and improve upon existing methodology. Twenty-four migraine, 24 chronic tension headache patients, and 24 normal age- and gender-matched controls were assessed with bilateral measures of frontalis and occipitalis EMG and blood volume pulse. All subjects completed the MMPI. Results suggest that headache subjects could be differentiated on baseline heart rates and MMPI scales 1,2,3, and 7. Only one physiological measure served as an index of psychological distress, suggesting issues of an interaction between psychophysiological and personality variables, as well as the chronicity of the headache.

To test the short-term feasibility and efficacy of seven nonpharmacologic interventions in persons with high normal diastolic blood pressure.Randomized control multicenter trials.Volunteers recruited from the community, treated and followed up at special clinics.Of 16,821 screenees, 2182 men and women, aged 30 through 54 years, with diastolic blood pressure from 80 through 89 mm Hg were selected. Of these, 50 did not return for follow-up blood pressure measurements.Three life-style change groups (weight reduction, sodium reduction, and stress management) were each compared with unmasked nonintervention controls over 18 months. Four nutritional supplement groups (calcium, magnesium, potassium, and fish oil) were each compared singly, in double-blind fashion, with placebo controls over 6 months.Primary: change in diastolic blood pressure from baseline to final follow-up, measured by blinded observers. Secondary: changes in systolic blood pressure and intervention compliance measures.Weight reduction intervention produced weight loss of 3.9 kg (P less than .01), diastolic blood pressure change of -2.3 mm Hg (P less than .01), and systolic blood pressure change of -2.9 mm Hg (P less than .01). Sodium reduction interventions lowered urinary sodium excretion by 44 mmol/24 h (P less than .01), diastolic blood pressure by 0.9 mm Hg (P less than .05), and systolic blood pressure by 1.7 mm Hg (P less than .01). Despite good compliance, neither stress management nor nutritional supplements reduced diastolic blood pressure or systolic blood pressure significantly (P greater than .05).Weight reduction is the most effective of the strategies tested for reducing blood pressure in normotensive persons. Sodium reduction is also effective. The long-term effects of weight reduction and sodium reduction, alone and in combination, require further evaluation.

Objectives To examine rates of weight-based teasing before initiation of school-based childhood obesity prevention policies (Arkansas Act 1220 of 2003) and during the 2 years following policy implementation, as well as demographic factors related to weight-based teasing. Design Analysis of consecutive random cross-sectional statewide telephone surveys conducted annually across 3 years. Setting Sample representative of Arkansas public school students with stratification by geographic region, school level (elementary, middle, and high school), and school size (small, medium, and large). Participants Parents of children enrolled in Arkansas public schools and index adolescents 14 years or older. Intervention Statewide school-based obesity policies, including body mass index screening. Main Outcome Measures Survey items about weight-based teasing, other teasing, body weight and height, and sociodemographic factors, as well as school characteristics obtained from the Common Core of Data of the National Center for Education Statistics. Results At baseline, 14% of children experienced weight-based teasing by parental report. The prevalence of weight-based teasing did not change significantly from baseline in the 2 years following school-based policy changes. Children and adolescents most likely to be teased because of weight were those who were overweight, obese, white, female, and 14 years or older, as well as those teased for other reasons. Adolescent report of weight-based teasing yielded similar patterns. Conclusion Although the effectiveness of school-based obesity prevention policies remains unclear, policy changes did not lead to increased weight-based teasing among children and adolescents.

Elevated blood pressure is a risk factor for cardiovascular disease, and weight reduction is currently advocated as a nonpharmacologic approach for the management of hypertension. Results of clinical trials indicate weight reduction is effective in preventing and treating hypertension. Knowledge of the results of clinical trials is extremely important for health educators since: 1) these findings provide a scientific basis for educating other health professionals about the beneficial effects of dietary approaches to the management of hypertension; 2) discussion of these results with patients may provide a means for altering patients' expectations and achieving im-. proved treatment compliance; and 3) the processes by which clinical trials have achieved their dietary goals can provide health educators with extensive clinical experience upon which to draw in working with nonstudy patients. The content and general results of clinical trial programs are reviewed as well as features associated with health promotion in clinical trial and behavioral weight loss research.

Associations between self-reported average daily alcohol intake and blood pressure were assessed in 5031 black and white men and women ages 18-30 from the Coronary Artery Risk Development in Young Adults Study (CARDIA). In general, intake was positively but weakly related to both systolic and diastolic blood pressure. Associations with systolic pressure were generally stronger than those with diastolic pressure. With average daily alcohol intake categorized as none, 0.1-9.9 ml, 10.0-19.9 ml, 20.0-29.9 ml, and 30.0+ ml, mean systolic pressure, adjusted for age, body mass index, education, smoking, and physical activity, increased progressively with increasing intake in black and white men and in white women. Mean diastolic pressure increased progressively with increasing intake only in white men and women, but was highest for those averaging 30.0+ ml per day in black women as well as white men and women. Mean pressures were also compared for those averaging 75.0+ ml per day (men) or 50.0+ ml per day (women) vs those reporting no intake. Differences in adjusted mean pressures for white men were 3.2 mmHg (95% confidence limits (CL) -0.3, 6.8) for systolic pressure and 1.7 mmHg (-1.6, 5.0) for diastolic pressure. In black men differences were 4.4 mmHg (1.4, 7.4) and 3.4 mmHg (0.6, 6.3), respectively. Differences in white women were 1.4 mmHg (-2.5, 5.3) for systolic pressure and 0.9 mmHg (-2.7, 4.5) for diastolic pressure and for black women, -0.2 mmHg (-4.3, 3.8) and 1.9 mmHg (-1.9, 5.8). Separate analyses in smokers and nonsmokers of the associations between alcohol intake and blood pressure suggested that associations may differ by smoking status in some sex-race groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Weight loss appears to be an effective method for primary prevention of hypertension. However, the long-term effects of weight loss on blood pressure have not been extensively studied.To present detailed results from the weight loss arm of Trials of Hypertension Prevention (TOHP) II.Multicenter, randomized dinical trial testing the efficacy of lifestyle interventions for reducing blood pressure over 3 to 4 years. Participants in TOHP II were randomly assigned to one of four groups. This report focuses only on participants assigned to the weight loss (n = 595) and usual care control (n = 596) groups.Men and women 30 to 54 years of age who had nonmedicated diastolic blood pressure of 83 to 89 mm Hg and systolic blood pressure less than 140 mm Hg and were 110% to 165% of their ideal body weight at baseline.The weight loss intervention included a 3-year program of group meetings and individual counseling focused on dietary change, physical activity, and social supportWeight and blood pressure data were collected every 6 months by staff who were blinded to treatment assignmentMean weight change from baseline in the intervention group was -4.4 kg at 6 months, -2.0 kg at 18 months, and -0.2 kg at 36 months. Mean weight change in the control group at the same time points was 0.1, 0.7, and 1.8 kg. Blood pressure was significantly lower in the intervention group than in the control group at 6, 18, and 36 months. The risk ratio for hypertension in the intervention group was 0.58 (95% CI, 0.36 to 0.94) at 6 months, 0.78 (CI, 0.62 to 1.00) at 18 months, and 0.81 (CI, 0.70 to 0.95) at 36 months. In subgroup analyses, intervention participants who lost at least 4.5 kg at 6 months and maintained this weight reduction for the next 30 months had the greatest reduction in blood pressure and a relative risk for hypertension of 0.35 (CI, 0.20 to 0.59).Clinically significant long-term reductions in blood pressure and reduced risk for hypertension can be achieved with even modest weight loss.

ContextDelayed access to medical care in patients with acute myocardial infarction (AMI) is common and increases myocardial damage and mortality.ObjectiveTo evaluate a community intervention to reduce patient delay from symptom onset to hospital presentation and increase emergency medical service (EMS) use.Design and SettingThe Rapid Early Action for Coronary Treatment Trial, a randomized trial conducted from 1995 to 1997 in 20 US cities (10 matched pairs; population range, 55,777-238,912) in 10 states.ParticipantsA total of 59,944 adults aged 30 years or older presenting to hospital emergency departments (EDs) with chest pain, of whom 20,364 met the primary population criteria of suspected acute coronary heart disease on admission and were discharged with a coronary heart disease–related diagnosis.InterventionOne city in each pair was randomly assigned to an 18-month intervention that targeted mass media, community organizations, and professional, public, and patient education to increase appropriate patient actions for AMI symptoms (primary population, n=10,563). The other city in each pair was randomly assigned to reference status (primary population, n=9801).Main Outcome MeasuresTime from symptom onset to ED arrival and EMS use, compared between intervention and reference city pairs.ResultsGeneral population surveys provided evidence of increased public awareness and knowledge of program messages. Patient delay from symptom onset to hospital arrival at baseline (median, 140 minutes) was identical in the intervention and reference communities. Delay time decreased in intervention communities by −4.7% per year (95% confidence interval [CI], −8.6% to −0.6%), but the change did not differ significantly from that observed in reference communities (−6.8% per year; 95% CI, −14.5% to 1.6%; P=.54). EMS use by the primary study population increased significantly in intervention communities compared with reference communities, with a net effect of 20% (95% CI, 7%-34%; P

The relation between personality characteristics and the psychological functioning of headache patients has long been a topic of interest. Early investigations focused on clinical and anecdotal reports while recent research has moved toward a more objective evaluation of headache groups by using the MMPI. However, the findings from diverse studies have not been integrated, nor has a rationale for the use of these data in the clinical management of headache been formally presented. The focus of this review is to present a concise, integrated analysis of previous group MMPI headache studies and apply these findings to differential diagnosis, prediction of treatment outcome, and client-treatment matching. Five selected clinical case studies indicating various degrees of psychopathology in migraine headache patients are presented to highlight treatment issues in support of an idiographic utilization of the MMPI for the clinical treatment of headache patients.

The present paper introduces the Tension Mannequin, a self-report questionnaire on which tension levels of various muscle groups are rated. In Experiment 1 this instrument was administered to 44 normal adults preceding and following relaxation training. Questionnaire results revealed that subjects used three tension level ratings across muscles. Only 14% of the sample rated all muscle groups identically. Pre-training correlations between the individual muscle ratings and a general rating of tension suggested that the general rating was made by averaging tension in various muscle sites. The questionnaire appeared to be sensitive to the effects of relaxation training since pre- and post-comparisons of all muscle groups were significantly different. Experiment 2 investigated whether the questionnaire would differentiate subjects suffering at least three tension headaches per week from those reporting less than three. Results revealed that the frequent headache group had greater subjective tension in the forehead and neck. A case example illustrates how the Tension Mannequin revealed the importance of back discomfort to a patient's experience of tension headaches and general tension.