There are no randomized clinical trials on the topics addressed in this review. All studies reviewed were prospective observational studies, so all conclusions are based on Evidence Category, C. The conclusions for the three questions addressed in the review are: 1) regular physical activity clearly attenuates many of the health risks associated with overweight or obesity; 2) physical activity appears to not only attenuate the health risks of overweight and obesity, but active obese individuals actually have lower morbidity and mortality than normal weight individuals who are sedentary, and 3) inactivity and low cardiorespiratory fitness are as important as overweight and obesity as mortality predictors. Research needs include extending current observations to more diverse populations, including more studies in women, the elderly, and minority groups, assessment methods need to be improved, and randomized clinical trials addressing the questions discussed in this review should be undertaken. Owing to size, complexity, and cost, these trials will need to be designed with valid noninvasive measures of subclinical disease processes as outcomes.

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Background Decades of effectiveness research has established the benefits of using patient decision aids (PtDAs), yet broad clinical implementation has not yet occurred. Evidence to date is mainly derived from highly controlled settings; if clinicians and health care organizations are expected to embed PtDAs as a means to support person-centered care, we need to better understand what this might look like outside of a research setting. Aim This review was conducted in response to the IPDAS Collaboration’s evidence update process, which informs their published standards for PtDA quality and effectiveness. The aim was to develop context-specific program theories that explain why and how PtDAs are successfully implemented in routine healthcare settings. Methods Rapid realist review methodology was used to identify articles that could contribute to theory development. We engaged key experts and stakeholders to identify key sources; this was supplemented by electronic database (Medline and CINAHL), gray literature, and forward/backward search strategies. Initial theories were refined to develop realist context-mechanism-outcome configurations, and these were mapped to the Consolidated Framework for Implementation Research. Results We developed 8 refined theories, using data from 23 implementation studies (29 articles), to describe the mechanisms by which PtDAs become successfully implemented into routine clinical settings. Recommended implementation strategies derived from the program theory include 1) co-production of PtDA content and processes (or local adaptation), 2) training the entire team, 3) preparing and prompting patients to engage, 4) senior-level buy-in, and 5) measuring to improve. Conclusions We recommend key strategies that organizations and individuals intending to embed PtDAs routinely can use as a practical guide. Further work is needed to understand the importance of context in the success of different implementation studies.

Men and women with higher fitness levels consumed diets that more closely approached national dietary recommendations than their lower fit peers.

Background The Shared Decision Making (SDM) Process scale is a short patient-reported measure of the amount of SDM that occurs around a medical decision. SDM Process items have been used previously in studies of surgical decision making and exhibited discriminant and construct validity. Method Secondary data analysis was conducted across 8 studies of 11 surgical conditions with 3965 responses. Each study contained SDM Process items that assessed the discussion of options, pros and cons, and preferences. Item wording, content, and number of items varied, as did inclusion of measures assessing decision quality, decisional conflict (SURE scale), and regret. Several approaches for scoring, weighting, and the number of items were compared to identify an optimal approach. Optimal SDM Process scores were compared with measures of decision quality, conflict, and regret to examine construct validity; meta-analysis generated summary results. Results Although all versions of the scale were highly correlated, a short, partial credit, equally weighted version of the scale showed favorable properties. Overall, higher SDM Process scores were related to higher decision quality ( d = 0.18, P = 0.029), higher SURE scale scores ( d = 0.57, P < 0.001), and lower decision regret ( d = −0.34, P < 0.001). Significant heterogeneity was present in all validity analyses. Limitations Included studies all focused on surgical decisions, several had small sample sizes, and many were retrospective. Conclusion SDM Process scores showed resilience to coding changes, and a scheme using the short, partial credit, with equal weights was adopted. The SDM Process scores demonstrated a small, positive relationship with decision quality and were consistently related to lower decision conflict and less regret, providing evidence of validity across several surgical decisions.

Background This article evaluates the evidence for the inclusion of patient narratives in patient decision aids (PtDAs). We define patient narratives as stories, testimonials, or anecdotes that provide illustrative examples of the experiences of others that are relevant to the decision at hand. Method To evaluate the evidence for the effectiveness of narratives in PtDAs, we conducted a narrative scoping review of the literature from January 2013 through June 2019 to identify relevant literature published since the last International Patient Decision Aid Standards (IPDAS) update in 2013. We considered research articles that examined the impact of narratives on relevant outcomes or described relevant theoretical mechanisms. Results The majority of the empirical work on narratives did not measure concepts that are typically found in the PtDA literature (e.g., decisional conflict). Yet, a few themes emerged from our review that can be applied to the PtDA context, including the impact of narratives on relevant outcomes (knowledge, behavior change, and psychological constructs), as well as several theoretical mechanisms about how and why narratives work that can be applied to the PtDA context. Conclusion Based on this evidence update, we suggest that there may be situations when narratives could enhance the effectiveness of PtDAs. The recent theoretical work on narratives has underscored the fact that narratives are a multifaceted construct and should no longer be considered a binary option (include narratives or not). However, the bottom line is that the evidence does not support a recommendation for narratives to be a necessary component of PtDAs.

Objective. If shared decision making (SDM) is to be part of quality assessment, it is necessary to have good measures of SDM. The purpose of this study is to compare the psychometric performance of 3 short patient-reported measures of SDM. Methods. Patients who met with a specialist to discuss possible surgery for hip or knee osteoarthritis (hips/knees), lumbar herniated disc, or lumbar spinal stenosis (backs) were surveyed shortly after the visit and again 6 months later. Some of the patients saw a patient decision aid (PDA) prior to the meeting. The 3 SDM measures were the SDM Process_4 (SDMP) survey, CollaboRATE, and SURE scale. The follow-up survey included measures of decision regret, satisfaction, and decision quality. Results. Patients in the sample ( N = 649) had a mean age of 63.3 years, 51% were female, 60% were college educated, and there were more hip/knee patients than back patients (69% v. 31%). Forty-nine percent had surgery. For hips/knees, the SDMP and SURE scores were significantly associated with viewing all of the PDA compared with those who did not ( P < 0.001), but not for CollaboRATE ( P = 0.35). For backs, none of the scores were significantly associated with viewing all the PDA. All 3 scores were significantly associated with less regret and higher satisfaction ( P < 0.001) for hips/knees. For backs, only SURE and CollaboRATE were significantly associated with less regret, and only SDMP was significantly associated with higher satisfaction. For hips/knees and backs, the SDMP and SURE scales were significantly associated with an informed patient-centered decision ( P < 0.001), but this relationship was not significant for CollaboRATE (hips/knees: P = 0.24; backs: P = 0.25). Discussion. Each measure has some evidence of validity. SURE and SDMP better discriminate the use of PDAs and have higher decision quality.

Objective: Because the percentage of missing portion sizes was large in the Aerobics Center Longitudinal Study (ACLS), careful consideration of the accuracy of standard portion sizes was necessary. The purpose of the present study was to investigate the consequences of using standard portion sizes instead of reported portion sizes on subjects' nutrient intake. Methods: In 2307 men and 411 women, nutrient intake calculated from a 3-day dietary record using reported portion sizes was compared with nutrient intake calculated from the same record in which standard portion sizes were substituted for reported portion sizes. Results: The standard portion sizes provided signi®cantly lower estimates (> 20%) of energy and nutrient intakes than the reported portion sizes. Spearman correlation coef®cients obtained by the two methods were high, ranging from 0.67 to 0.93. Furthermore, the agreement between both methods was fairly good. Thus, in the ACLS the use of standard portion sizes rather than reported portion sizes did not appear to be suitable to assess the absolute intake at the group level, but appeared to lead to a good ranking of individuals according to nutrient intake. These results were con®rmed by the Continuing Survey of Food Intake by Individuals (CSFII), in which the assessment of the portion size was optimal. When the standard portion sizes were adjusted using the correction factor, the ability of the standard portion sizes to assess the absolute nutrient intake at the group level was considerably improved. Conclusions: This study suggests that the adjusted standard portion sizes may be able to replace missing portion sizes in the ACLS database. Keywords Dietary record Epidemiological methodsFood Nutrient intake Portion sizeIn nutritional epidemiology studies, minimizing measurement error is a key element in the successful elucidation of diet±disease relationships. One of the main errors in the assessment of nutrient intake occurs during the determination of portion size. Where information about portion size is missing, standard portion sizes have traditionally been used. This assumes that standard portion sizes accurately re¯ect the amount typically consumed. However, ®ndings on the accuracy of standard portions are con¯icting 1±8 . As part of the large-scale observational ACLS, dietary intake was assessed using the dietary record method. Information about portion size was obtained by estimating the amount for each food consumed. However, for many food items information on portion size was not available. Since the percentage of missing portion sizes was large (22%), this prompted the need to determine whether standard portion sizes were able to replace missing portion sizes in the ACLS data set.The aim of the present study is to investigate in the ACLS database the consequences of using standard portion sizes instead of reported portion sizes on subjects' nutrient intakes. Furthermore, we evaluated the effect of substituting standard portion sizes for reported portion sizes on nutrient intake in th...