MCQs Key PApers Flashcards
With regards to Nurses HEalth Study, all statements below are true EXCEPT:
A) was a large (>80,000 women), retrospective cohort study that looked at modifiable lifestyle risk factors at first diagnosis of fatal or non fatal MI
B) studied a number of risk factors for chronic disease, including assessment of nutritional quality of subject’s diet, which was ranked and stratified into quintiles
C) concluded that “Among women, adherence to lifestyle guidelines involving diet, exercise, and abstinence from smoking is associated with a very low risk of coronary heart disease.”
D) nutrients used to assess the nutritional quality of subject’s diet included: high fiber, high marine omega 3s and folate; this data was used to calculate diet score, based on this score the top 40% of women were found to have the lowest risk of CVD
E) Results showed that there was incremental risk of CV events for each low-risk factor added
answer: A, F
A) FALSE: it was a PROSPECTIVE study - at baseline subjects had to be free of CVD, DM, cancer; 14 years follow up;
b) TRUE: other modifiable risk factors studied were: smoking, normal BMI (<25), moderate alcohol consumption (5-30g or 1/5to 1oz/day), other nutrients considered: high polyunsat. to ssaturated fats ratio, lower glycemic load
c) TRUE (Stampfer 200)
E) TRUE: more risk factors = higher risk; 3 risk factors =51% PAR, 4 RF = 50% PAR, 5 RF= 74%PAR (PAR = population attributable risk= incidence of a dis in the poppn. that would be eliminated if exposure were eliminated):
With regards to Nurse’s HEalth Study 1 and 2 AND Health Professionals Follow-up Study, all statements below are true, EXCEPT:
A) very large sets of longitudinal data were analyzed and resulted in many papers, including several nested-in studies, such as the one by Pan et al 2011 on association of red meat and t2dm
B) Results showed that the amount of fruit and vegetables consumed did not make statistically significant difference to CVD risk
C) found that all red meat but particularly processed red meat increased the risk of t2d: every 100g of unprocessed red meat had increased risk of t2d 1.2 times every 50g of processed red meat increased risk of t2d 1.5 times
D) substituting nuts and seeds for red meat showed greater risk reduction than substituting wholegrain cereal
answer: B, D
A) true (37,083 men in the Health Professionals Follow-Up Study (1986–2006), 79,570 women in the Nurses’ Health Study I (1980–2008), and 87,504 women in the Nurses’ Health Study II (1991–2005); more than 4 million person-years of follow-up
B)FALSE: EACH DAILY SERVING OF FRUIT AND VEG DECR THE CVD RISK BY 4% (RR 0.96, p<0.01 FOR TREND)
C) TRUE After adjustment for age, BMI, and other lifestyle and dietary risk factors, both unprocessed and processed red meat intakes were positively associated with T2D risk in each cohort (all P-trend <0.001). The pooled HRs (95% CIs) for a one serving/d increase in unprocessed, processed, and total red meat consumption were 1.12 (1.08, 1.16), 1.32 (1.25, 1.40), and 1.14 (1.10, 1.18), respectively. The results were confirmed by a meta-analysis: 442,101 participants and 28,228 diabetes cases): the RRs (95% CIs) were 1.19 (1.04, 1.37) and 1.51 (1.25, 1.83) for 100 g unprocessed red meat/d and for 50 g processed red meat/d, respectively.
D) FALSE (processed meat substitution w/ nuts = appx 30% reduction, wholegrain appx 35% reduction)
With regards to Nurse’s HEalth Study 1 and 2 AND Health Professionals Follow-up Study, all statements below are true, EXCEPT:
A) substitution of meat for non-meat alternatives, such as nuts, legumes, whole grain, low fat dairy, poultry and fish, resulted in reduced risk of mortality for all substitution groups
B) unsaturated fats, especially PUFAs, and/or high-quality carbohydrates can be used to replace saturated fats to reduce CHD risk
C) isocaloric substitution of saturated fats with refined starches/ added sugars had no effect on reduction of risk in cvd, with very strong statistical significance
D) replacing (isocaloric) SFA’s with PUFAs, MUFAs and wholegrain cereal all showed risk reduction of CHD and were all statistically significant
E) quality of carbohydrates has no effect on CHD risk
F) transfats raised the risk, comp to SFAs
Answer: C, E
A) TRUE (Pan et al. AnIntMed2012)
B) TRUE (Li et al. JACC 2015): 20% risk reduction in CVD was observed when the highest quintile of PUFAS intake was compared with lowest quintile quintile ; NB high quality carbs = provident from wholefood
C) False: p <0.1
D) TRUE (PUFAS 25% reduction, p<0.001, MUFAs 15% reduction p<0.02, wholegrain 9% reduction p<0.01)
E) FALSE: highest quintile wholegrain vs lowest quintile 10% risk reduction (0.003), refined startches and sugars no effect on risk (see answer C)
F) TRUE
With regards to Ornish Heart Study (Ornish 1990, 1998), choose the CORRECT statement(s):
A) major weakness of the study is that there was no control group and no blinding
B) it was a cross sectional study
C) the intervention was Intensive Lifestyle Intervention Program, consisting of: low fat (10% Kcal), vegetarian diet, aerobic exercise, smoking cessation, stress management, group psychosocial support and statin
D) outcome measures included: angiography, lipids and other biomarkers, medication dosing, self-reported adherence
E) 1 year results were published in JAMA in 1990 and 5year results were published in the same journal in 1998
answer: D
A) FALSE: 48 subjects (on waiting list for surgical intervention w/ moderate coronary stenosis); randomised into INTERVVENTION (28): Intensive Lisfestyle Intervention; CONTROL(40): usual AHA counselling re diet and exercise; BLINDING: blinded quantitative angiography
B) FALSE: quantitative angio at baseline, at 1 year and at 5 years
C) FALSE: NO LIPID LOWERING MEDS used in intervention gp.
D) TRUE
E) TRUE
With regards to Ornish Heart Study , choose the CORRECT statement(s):
A) 5-year results showed: almost 8% mean reduction in stenoses in the intervention group and almost 30% mean reduction in the control group overall
B) subset of control group patients that were not on any lipid lowering medications serves as a better comparison to the intervention group, where no medications were used. This subset showed an impressive 46% relative increase in stenoses at 5 years
C) control group had almost 30% increase in extent of stenoses and appx 2.5x increased risk of fatal and non-fatal cardiac events compared to intervention group
D) dose-response association between adherence to program and regression of stenoses was observed, (82% of experimental gr. showing regression)
E) Most change happened in the first year of intervention, as it was hard for the experimental group to adhere to the program long-term, at five years the gap between the intervention group and control group closed in
A) FALSE - reduction in the intervention gp vs increase in stenoses in the control group
B) TRUE
C) TRUE
D) TRUE
E) FALSE: more regression of CAD occured after 5 years compared to after 1 year => intervention continued effect; control gp continued progression of stenoses
Below are examples of key studies demonstrating benefits of LS interventions compared to conventional approaches. Match studies with their results (e.g. A-2):
A) National Diabetes Prevention Program (NDPP) showed 58% effective vs medication 31%
B) ) Exercise vs PTCA (percutaneous coronary angioplasty): exercise = 26% better survival
C) Safer control of biomarkers (e.g. cholesterol) PORTFOLIO diet () equivalent cholesterol control to low dose SEs without side effects
D) appx 8% reduction of coronary stenosis with ITLC (intensive LS change) program vs increase in stenosis with standard AHA approach & 2.5% increase of risk for fatal and non-fatal cardiac events with standard AHA approach compared to ITLC at 5 y follow up
1) Jenkins, JAMA 2002
2) Knowler, NEMJ 2002
3) Hambrecht, Circulation 2004
4) Ornish, JAMA 1998
answer: A-2 B-3 C-1 D-4
With regards to Jenkin’s 2003 PORTFOLIO diet study, choose all CORRECT statements:
A) its small size and short duration of follow up are some of its main shortfalls
B) it is the first study to demonstrate that diet is better than statins in lowering cholesterol
C) statins and diet had very similar effects in terms of latency and size of effect (lowering cholesterol)
D) PORTFOLIO diet was high in: plants high in sterols, omega-3-rich, oily fish, wholegrains
ANSWER: A, C
A) TRUE: only 46 subjects, randomised into 3 groups, 1 month follow up , N=16 on PORTFOLIO DIET
B) FALSE: very similar effect (see answ C)
C) TRUE; appx 2 weeks from initiation to drop in levels, 30% drop in LDL in diet gp, 28% drop in statin gp (8% drop in control)
D) FALSE: high sterol plants, soy protein, viscous fibers, almonds
Below are examples of key studies demonstrating benefits of LS interventions compared to conventional approaches. Match studies with their results (e.g. A-2):
A) Showed that dietary energy restriction can reverse the abnormalities underlying T2D (normalisation of beta-cell function and hepatic insulin sensitivity, as well as lowered hepatic and pancreatic fat infiltration)
B) Was one of the first studies that concluded that ITLC may modulate gene expression in the prostate, the 5-y follow up study showed that ITLC resulted in sustained increased telomere length
C) Compared ILI (Intensive Lifestyle Intervention) with a Diabetes Support and Education (DSE) intervention and showed that intensive lifestyle intervention achieved better rates of T2D remission compared to conventional education program. Improved remission rates were sustained up to 4 years after the intervention. However, the absolute number of t2d remissions was modest.
D) Compared 4 of the most popular approaches to weight loss and concluded that adherence to a program is more important than the diet consumed
1) “LOOK AHEAD” Study, Gregg et al, Jama 2012
2) “GEMINAL” study, Ornish et al, Proc Natl Acad Sci, 2008
3) Dansinger, JAMA 2005
4) “COUTNERPOINT” STUDY: Lim et al, Diabetologica 2011
answer: A- 4 B-2 C-1 D-3
All of the studies below are examples of delivering ITLCs, EXCEPT:
A) CHIP program (Aldana, JOEM 2005)
B) DASH diet (Appel, NEJM 1997)
C) Lifestyle Heart Trial (ORnish, Lancet 1990, JAMA 1998)
D) PORTFOLIO diet (Jenkins, JAMA 2003)
E) COUNTERPOINT Study (Lim Diabetologia 2011)
F) GEMINAL study (Ornish et al, Proc Natl Sci USA 2008)
G) DIETFITS rct (gaRDNER JAMA 2018)
answer: D, G, E (both diet only)
With regards to the Diabetes Prevention Program (DPP) (Knowler NEJM 2002), all below is true EXCEPT:
A) it was a large prospective study, where healthy subjects were followed for 14 years to identify risk factors for T2D
B) the study ended early because of its dramatic results; it showed that
C) the effects of metformin on prevention of diabetes in pre-diabetic subjects were similar to the lifestyle intervention
D) ITLC was found more beneficial than metformin to slow down T2D in subjects with IGT
E) clearly showed that ITLC is superior to medication in slowing the progress of IGT to T2D, however long term benefits require further evaluation
answer: A, C
A) FALSE: large (3234 prediabetic subjects); randomised, multicentre study: 3 randomised groups: 1. metformin, 2. placebo, 3. ITLC; goals 1: 7% or > wt loss, 2. >150min/week or more physical activity;
1ry outcome = incidence of T2D at the end of follow up period; follow up period = 2.8 years
B) TRUE: study was planned to go for 4 years, however both intervention arms (Met, ITLC) showed dramatic improvement in IGT => it was considered unethical for the study to continue; MET reduced incidence by 31%, ITLC by 58% compared to placebo
C) FALSE: ITLC was appx twice as effective as metformin: NNT over 3 years for ITLC was 6.9 (7), NNT for metformin over 3 years was 13.9(14) => to prevent one case of diabetes over 3 years, 6.9 people would need to participate in ITLC, or 13.9 would need to take metformin
D) TRUE (see above- half NNT vs metformin, half incidence at 3 years, lower incidence at 4y)
E) TRUE, NB: further analysis at 4 y. (planned end point) showed that effects continued at 4 years (cumulative incidence Plac 37%, MET 29%, ITLC 20%)
With regards to Hambrecht 2004 study: Percutaneous coronary angioplasty PCI) vs exercise in patients with stable coronary artery disease, all below is true EXCEPT:
A) compared the effects of exercise vs stenting in people with known, stable coronary artery disease on a battery of measures, including clinical, functional, physiological and economic measures
B) Subjects were randomised into 2 intervention gp’s: 1. daily exercise at moderate intensity or 2. PCI with stent
C) healthy subjects were recruited at random and represented a good cross-section of population
D) exercise was shown to be equally effective as PCI but was better tolerated (less side effects)
E) the long term effects need further evaluation/ analysis
answer: C, D
A) TRUE: assessed measures: 1. clinical symptoms, 2. exercise capacity (functional) 3. coronary perfusion (physiological), 4. cost-effectiveness analysis (economic); Clinical end points: fatal or non-fatal cardiovascular and cerbrovascular events
B) TRUE: (n=43) cycling for 20min or more @ 70% of symptom free HR (i.e. 70% of subject’s maximal HR) ; PCI n=33)
C) FALSE: subjects were recruited after a “routine angioplasty”, hence were symptomatic at the time (ZW’s assumption), MALE <70yo only (n=101), (ZW unsure about ethnicity, etc. - see the orig. article if interested)
D) FALSE: exercise: SUPERIOR event-free survival (88% vs 70%,; p=0.023) and improved exercise capacity (+16%, p<0.001), at LOWER COST (1/2 the cost: almost 7k to improve 1 class of Canadian Cardiovasc. Soc. (CCS) w/ stent, almost 3.5k to improve 1 class of CCS w/ exercise, p=0.001), & reduced re-hospitalisations and revascularisations
E) TRUE; study duration was 12 months
With regards to Dansinger et al. study, JAMA 2005; choose all CORRECT statements from below:
A) Compared 4 of the most common weight loss programs and concluded that ITLC, such as Ornish’s SPECTRUM program, is the best approach for most
B) it was an RCT
Answer:
A) FALSE: Atkins, Ornish, WEight Watchers and Zone Diets were assessed for weight loss and heart disease risk reduction
B) FALSE: there was NO CONTROL group: 4 x n=40 for Atkins (low carb), Zone (macronutrient balance), Weight watchers (calorie restriction) Ornish (low fat, plant based)
Below are examples of key studies demonstrating benefits of LS interventions compared to conventional approaches. Match studies with their results (e.g. A-2):
A) Compared two common weight loss approaches (low-fat and low-carbohydrate diets), delivering intensive diet-focused intervention over 1 year. Similar weight loss was achieved by both groups at 12mo.
It also tested specific genotypes known to be assoc w/ insulin dynamic and macronutrient diet composition to see if these could influence wt loss. It showed absence of interaction between weight loss and genotype and between weight loss and baseline insulin.
B) This study demonstrated that short term FMD provokes epigenetic changes that modulate beta cell numbers and promote insulin secretion and glucose homeostasis with implications for both type 1 and type 2 diabetes.
C) Compared significant calorie-restriction (800kcal) + structured support (intervention) with best-practice care, as per UK guidelines (control) in OW/Obese subjects with T2D. Found that T2D remission was strongly assoc w/ wt loss and WT loss was better achieved by the intervention gp.
1) DiRECT RCT, Lean et al. Lancet 2018
2) DIETFITS RCT, Gardner
3) Cheng et al. Cell 2017
Answer:
A-2
B-3
C-1
Van Ommen et al.’s article “From Diabetes Care to Diabetes Cure” (Front Endocrinology 2018) reviews cure-focused interventions for type 2 diabetes and discusses the scientific technological advancements. All of the statements below are true, EXCEPT:
A) From a biological view, most of the processes involved in insulin resistance are reversible. This theoretically makes the disease reversible and curable by changing dietary habits and physical activity, particularly when adopted early in the disease process. Yet, this is not fully implemented and exploited
in health care due to numerous obstacles.
B) Authors argue that the implementation of lifestyle
as cure necessitates personalized and sustained lifestyle adaptations, which can only be
established by a systems approach.
C) The solution provided for type 2 diabetes is unique to T2D but it is such a prevalent condition that it justifies the change in system
D) The economic benefits have been clearly demonstrated by a 10-year study in T2D, yet the systems have failed to adapt
answer: C A) TRUE B) TRUE C) FALSE : this approach is translatable to other life-style related diseases. D) TRUE
With regards to GEMINAL STUDY (Ornish et Al. Proc Natl Acad Sci USA. 2008) choose CORRECT answer(s):
A) was a pivotal study demonstrating the effect of lifestyle modification at genetic level in men with early stage prostate cancer
B) only 30% of studied tissue had tumour cells, which renders the results questionable
C) one of the major limitations of GEMINAL Study is that it had no comparison group
D) The intervention was a low-fat, whole food, plant-based diet, participants were provided all of their food during the intervention period
E) one of the strengths was that supplementation with fish oil, and vitamins E and C, amongst other supplements, were given as part of intervention
F) genetic microarray clearly demonstrated down-regulation of a number of genes known to be associated with tumorigenesis (p < 0.05)
G) significant improvements in weight, abdominal obesity, blood pressure and lipid profile were observed (p < 0.05)
answer: A, C, F, G
A) TRUE
B) FALSE: this means that gene expression profiles are largely based on normal tissue, hence indicate that impact of lifestyle changes is not restricted to prostate cancer cells, however it is still considered a limitation of this study
C) TRUE
D) FALSE: multifaceted intervention: 1. low-fat (10% of calories from fat), whole food, plant-based diet, 2. Stress management, 60 minutes per day (gentle yoga-based stretching, breathing, meditation, imagery or progressive relaxation) 3. Moderate aerobic exercise (walking 30 minutes per day for six days per week) and A one hour group support session per week.
Participants were provided with all of their food during the intervention period.
E) FALSE: The diet was supplemented with soy (a daily serving of tofu plus 58 grams (2.04 ounces) of a fortified soy protein powdered beverage), fish oil (3 grams (0.1 ounces) daily), vitamin E (100 units daily), selenium (200 mg daily), and vitamin C (2 grams (0.07) daily). This can be seen as multiple interventions and makes it difficult to attribute effect size to any particular intervention.
F) TRUE: 453 genes downreg., 48 genes upreg: assoc w/ protein metabolisism and modification, intracell. protein traffic and protein phosphorylation
