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Randomized Controlled Trials - Protocols/Proposals (eHealth)
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Original Paper
South Asian Heart Risk Assessment (SAHARA): Randomized Controlled Trial Design and Pilot Study
Zainab Samaan1,2,3,4, MBChB, MSc, PhD, MRCPsych; Karleen M Schulze4, MMath; Catherine Middleton5, PhD; Jane Irvine6, DPhil, CPsych; Phillip Joseph4, MD; Andrew Mente2,3,4, PhD; Baiju R Shah7, MD, PhD; Guillaume Pare2,4,8, MD, MSc; Dipika Desai2,4, MSc; Sonia S Anand2,3,4,9, MD, PhD, FRCPc; SAHARA Investigators2
1Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, ON, Canada
2Population Genomics Program, Chanchlani Research Centre, McMaster University, Hamilton, ON, Canada
3Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
4Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
5Ryerson University, Toronto, ON, Canada
6York University, Toronto, ON, Canada
7Evaluative Clinical Sciences, Schulich Heart Research Program, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada
8McMaster University, Pathology and Molecular Medicine, Hamilton, ON, Canada
9Department of Medicine, McMaster University, Hamilton, ON, Canada
Department of Medicine
McMaster University
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ABSTRACTBackground: People of South Asian origin suffer a high burden of premature myocardial infarction (MI). South Asians form a growing proportion of the Canadian population and preventive strategies to mitigate the risk of MI in this group are needed. Prior studies have shown that multimedia interventions are effective and feasible in inducing health behavior changes among the obese, smokers, and among those who are sedentary.
Objective: Among at-risk South Asians living in Canada, our objectives are to determine: (1) the feasibility of a culturally tailored multimedia intervention to induce positive behavioral changes associated with reduced MI risk factors, and (2) the effectiveness and acceptability of information communicated by individualized MI and genetic risk score (GRS) reports.
Methods: The South Asian HeArt Risk Assessment (SAHARA) pilot study enrolled 367 individuals of South Asian origin recruited from places of worship and community centers in Ontario, Canada. MI risk factors including the 9p21 genetic variant status were provided to all participants after the baseline visit. Participants were randomly allocated to receive a multimedia intervention or control. The intervention group selected health goals and received personalized health messages to promote adherence to their selected goals. After 6 months, all participants had their MI risk factors repeated. The methods and results of this study are reported based on the CONSORT-EHEALTH guidelines.
Results: The mean age of participants was 53.8 years (SD 11.4), 52.0% (191/367) were women, and 97.5% (358/367) were immigrants to Canada. The mean INTERHEART risk score was 13.0 (SD 5.8) and 73.3% (269/367) had one or two copies of the risk allele for the 9p21 genetic variant. Both the intervention and control groups made some progress in health behavior changes related to diet and physical activity over 6 months. Participants reported that their risk score reports motivated behavioral changes, although half of the participants could not recall their risk scores at the end of study evaluation. Some components of the multimedia intervention were not widely used such as logging onto the website to set new health goals, and participants requested having more personal interactions with the study team.
Conclusions: Some, but not all, components of the multimedia intervention are feasible and have the potential to induce positive health behavior changes. MI and GRS reports are desired by participants although their impact on inducing sustained health behavior change requires further evaluation. Information generated from this pilot study has directly informed the design of another randomized trial designed to reduce MI risk among South Asians.
Trial Registration: ClinicalTrials.gov NCT01577719; http://clinicaltrials.gov/ct2/show/NCT01577719 (Archived by WebCite at http://www.webcitation.org/6J11uYXgJ).
(JMIR Res Protoc 2013;2(2):e33)
multimedia; South Asians; health; risk; assessment; randomized; trial
Myocardial infarction (MI) due to coronary artery disease (CAD) remains a major cause of death globally [1]. The rising prevalence of overweight, obesity, and type 2 diabetes is predicted to potentiate the CAD epidemic in developing countries [2]. South Asians, people who originate from the Indian subcontinent, suffer a high burden of premature MI [3,4], and are projected to account for 40% of the global CAD burden by 2020 [5]. More than 1.2 million South Asians live in Canada and are the fastest growing group of non-white Canadians [6]. Our previous study has shown that, compared to white Caucasians in Canada, South Asians suffer a 2.5 times excess prevalence of elevated glucose (dysglycemia), and CAD [7], and develop cardiometabolic risk factors (ie, abnormal glucose and lipids) at significantly lower body mass index (BMI) values [8].
Despite several previous studies showing excess cardiometabolic risk [4,9,10] and increased premature MI among South Asians [11], there is no routine screening process of South Asians for CAD despite the Canadian Cardiovascular Society recommendations to screen "high-risk" groups including South Asians [12]. Therefore, there is a need for routine screening of CAD risk factors in South Asian adults and to develop and test interventions to improve risk factors among South Asians. This is critical because collectively common risk factors (abnormal lipids, elevated glucose, elevated blood pressure, and abdominal obesity) account for over two-thirds of the population attributable risk of MI [4].
Several studies have shown that multimedia interventions to manage risk factors of common disorders and to modify health behaviors are effective [13-19]. Multimedia interventions include use of email messaging, text messaging, video- or computer-based education, and electronic personalized health records, which are attractive because they involve components of goal setting and feedback—key components of health behavior modification, are relatively cost efficient, and have the potential to be scalable to large numbers of individuals [20-25].
The use of MI risk tools to guide risk factor modification in cardiovascular prevention is increasing [26]. More recently the addition of genetic information into these risk tools has been evaluated. This has been made possible by the recent large-scale genetic studies that have identified common genetic variants associated with MI risk. The most robust genetic variant associated with increased risk for MI is a common polymorphism located on the short arm of chromosome 9 (9p21) [27,28]. This genetic variant is common in the general population, with 50% of people carrying one copy of the risk allele, which increases MI by 15-20%, and 25% of the population carrying two copies of the risk allele, which increases MI risk by 30-40% [29]. Further there is evidence to suggest that the MI risk associated with 9p21 may be modified by healthy dietary patterns [30]. While some recent studies have evaluated whether knowledge of genetic risk of a condition influences individuals' behavior change [31,32], the results remain inconclusive. To our knowledge there have been no multimedia health behavior modification interventions, which have incorporated genetic risk information among South Asians at risk for MI.
To address this gap we conducted a pilot study, the South Asian HeArt Risk Assessment (SAHARA) among at-risk South Asians living in Canada, to determine: (1) the feasibility of a culturally tailored multimedia intervention to induce positive behavioral changes associated with reduced MI risk factors, and (2) the effectiveness and acceptability of information communicated by individualized MI and genetic risk score (GRS) reports. Information generated from the SAHARA pilot study will directly inform the design of another randomized trial designed to test the effectiveness of this intervention to reduce MI risk among South Asians.
Study Design and Recruitment
The study is a randomized controlled pilot trial that was approved by the McMaster/Hamilton Health Sciences Research Ethics Board on June 3, 2009 (09-225).
Individuals were recruited from places of worship and community centers in Southwestern Ontario, Canada, during the period from January 16, 2011 to January 29, 2012. Recruitment clinics were setup in these "high-yield" locations at high yield times (following weekly ceremonies and scheduled activities) to maximize enrollment. The study team contacted community leaders in the recruitment locations to obtain permission to inform the congregation about the study, and this was done 1-2 weeks prior to the screening event.
Men and women ≥30 years of age of South Asian ancestry, defined as people whose ancestors originate from the Indian subcontinent (India, Pakistan, Bangladesh, and Sri Lanka), were eligible for inclusion in the SAHARA pilot study. All participants were required to have access to email, cell phone with text messaging capability, or a smart phone (ie, a handheld device capable of sending and receiving text messages and searching the Internet such as an iPhone or Blackberry).
Exclusion Criteria
Individuals who had suffered a previous MI, had coronary artery bypass graft (CABG) surgery, coronary angioplasty, or stroke, who were not permanent residents of Ontario, and who did not have an Ontario health card were excluded.
Consent and Baseline Data Collection
Written informed consent, including consent to use of the health card number to facilitate future record linkage with health services databases, and to analyze DNA for genetic variants, was obtained from each participant. Information on risk factors including cholesterol status, diabetes, hypertension, current, former, and second-hand exposure to tobacco smoke, diet, physical activity, sedentary behaviors, and psychosocial stress questions was collected. Stages of change information based on Prochaska's model of change [33] were also obtained for diet, physical activity, sedentary behavior, and smoking. Blood pressure (two measures 3 minutes apart using an automated OMRON device), body weight and height (to calculate BMI), waist and hip circumference, and body fat percentage using a digital bioelectrical impedance scale were measured. A 30-mL nonfasting blood sample was collected from all participants, and was processed onsite within 2 hours of collection. The blood samples were analyzed for apolipoprotein A1 and B, HbA1C, and the 9p21 single nucleotide polymorphism (SNP) (rs1333049) genotype using Taqman. All genotypes were in Hardy-Weinberg equilibrium (HWE) for the total sample (P>.05). Previous studies have reported a minimal difference in apolipoproteins' levels when comparing fasting to nonfasting levels [34]. The remaining serum and plasma aliquots were placed in long-term storage for future study-related analysis.
Risk Profile
Using the information collected at the baseline visit, a MI risk report was generated for each participant using the INTERHEART risk score (IHRS; Multimedia Appendix 1, which is a simple and valid risk factor scoring system developed and validated from the INTERHEART case-control study to assess MI risk in adult men and women [35]. This risk model included the following factors: apolipoprotein B-to-A1 ratio, smoking, second-hand smoke exposure, hypertension, HbA1c, abdominal obesity, physical inactivity, diet, and psychosocial factors. As part of the SAHARA pilot study the risk score report was pretested and modified in an easy to understand format that classifies individuals as low (0-9), moderate (10-15), or high (16-48) risk using a color visual display (Figure 1) (also see website [36]). In addition to IHRS, a GRS based on 9p21 genotype information was generated. The GRS was developed, pretested, and modified in an easy to understand format and classifies individuals who have 0, 1, or 2 risk alleles using a color visual display (Figure 2). The contents of the report were pretested in 2 focus groups conducted at a South Asian temple, and modified to the grade 5 reading level.
Approximately 4-6 weeks after the screening visit was completed, participants were sent an email asking them to log onto the secured MyOSCAR-SAHARA website [37], to access their risk score results. If they were eligible for randomization (based on study inclusion criteria), they were prompted to click on a button that took them to a Web portal to be randomized to intervention or control (usual advice) groups using a computer-generated algorithm in OSCAR (Open Source Clinical Applications and Resources)—an open source software project launched by the Department of Family Medicine at McMaster University in Hamilton, ON, Canada, in 2002, designed for the delivery of evidence-based resources and decision support at the point of care for both patients and providers [37]. We used a specially constructed MyOSCAR-SAHARA personalized website to enable study participants' to retrieve their results, and to set goals which triggered a series of goal-tailored health messages they received by email or text message (for screenshots, see Figures 3-7).
Intervention and control groups received the same baseline assessment and usual care while only the intervention group received the study intervention.
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|Figure 1. IHRS risk report example.
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|Figure 2. Genetic risk score. Through your blood work, we looked for a specific SNP in your DNA which has been shown to be a marker for heart attack risk. This SNP is located on chromosome 9, and is known as 9p21. The SNP is not within a gene itself, but is likely closely related to a gene which causes coronary artery disease. The 9p21 SNP has been shown to increase heart attack risk in several different ethnic groups, including South Asians. Based on your blood work, we determined if you did not have this SNP, only had it on one chromosome (inherited from one parent), or had it on two chromosomes (inherited from both parents). Having either one or two copies of this marker increases your genetic risk of having a heart attack.
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|Figure 3. SAHARA home page.
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|Figure 4. Welcome email.
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|Figure 5. Second welcome email.
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|Figure 6. MyOSCAR Web login.
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|Figure 7. SAHARA Web consent and personal health record page.
Participants randomized to the intervention were prompted to choose a health goal on the website in the areas of (1) healthy diet, (2) physical activity, (3) reducing sedentary behaviors, and (4) smoking cessation, and were prompted to update their goals weekly on the website. Participants then received health messages via email or text, tailored to their chosen health goal on a daily basis. The messages were based on self-efficacy and social support concepts [38-41] to motivate subjects to make health behavior changes including providing advice and support regarding reduction of energy-dense, nutrient-poor foods (ie, fried, fast foods, sugary beverages, and desserts), advocating increased consumption of fruits and vegetables, encouraging sedentary individuals to minimize sedentary behaviors and increase regular physical activity, and encouraging smokers to quit smoking. Participants were given a choice of methods to receive the health messages by: (1) email sent to an account using a personal computer or a handheld device (eg, BlackBerry, iPhone, or other smartphones), or (2) text message (short message service, SMS) to a handheld device (any cell phone).
In addition to the health messages, a weekly health tip was sent to all intervention participants by email outlining a particular health topic related to healthy lifestyle or an analysis of a recent medical study reported in the press. All of these health messages were then posted on our public website (Figure 3). The components of the intervention are listed in Textbox 1
Participants randomized to the control group were provided with advice on how to interpret their risk report, and if any significantly abnormal results were identified, they were encouraged to discuss them with their family doctor. All participants had access to the SAHARA website that contained health information regarding cardiovascular risk factors from a South Asian perspective [42]. This website includes information on culturally relevant healthy dietary habits, and the health benefits of regular physical activity. The site also includes a frequently asked questions section, and a mechanism for participants to ask our study team study-related questions and receive feedback.
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|Textbox 1. Multimedia intervention components of the SAHARA pilot study.
Website Usage and Adherence to Intervention "Fidelity"
Participants usage of the goal setting website was monitored centrally, and for those participants who did not log on to access their risk score reports or for intervention participants who had not set goals 2 weeks from the time they were prompted by email, a study team member attempted to reach them by telephone to encourage them to access their results and set goals. After 4 weeks if results had not been accessed from the website, a printed MI and genetic risk score report was mailed to participants' home.
Pilot Study Outcome Measures
The two outcome measures of the pilot study included: First, feasibility of the intervention, defined by: (1) success at transmitting risk score information and health messages via electronic media (website, email, and cell phone), (2) success at participants returning to use the website and set health goals, as this reflects the uptake of the intervention and helps to assess the effect of intervention on health behaviors, and (3) trend in the risk score change to indicate if the intervention leads to progressive health behavior change. Second, effectiveness and acceptability of risk score information was measured by: (1) participants' knowledge of their risk score over time, (2) if this information induced positive behavior change, and (3) participants' satisfaction with the information received.
All participants were followed up for a minimum of 6 months after randomization and repeat risk factor assessment was collected at the end of the study. End of study data were collected via face-to-face reassessment at the recruitment sites (238/324, 73.5%) and by telephone or mail (86/324, 26.5%). Repeat HbA1C and apolipoproteins A1 and B were also collected from participants who attended the face-to-face reassessment visit.
The reporting of this study follows the CONSORT-EHEALTH [43] guidelines Multimedia Appendix 2.
Participants (n=412) were screened from 11 centers between January 2011 and January 2012. Among them, 41 were ineligible (5 had cardiovascular disease—CVD, 23 had no email accounts, 13 were missing information required for the risk score, and 4 were eligible but not randomized due to a clerical error), leaving 367 participants randomized into the pilot study. Follow-up data collection occurred between October 28, 2011 and November 11, 2012. The median time of follow-up is 280 days with the interquartile range (IQR) of 252-319 days follow-up. As shown in Figure 8, there were 43 participants (21/167, 12.6% and 22/204, 10.8% of the intervention and control group, respectively) who did not complete the follow-up (21 were not contactable and 22 participants withdrew from the study).
Demographic and Social Characteristics
Participants' characteristics are shown in Table 1. Briefly the mean age is 53.8 years (minimum age=30.0 years, maximum age=82.0 years, and median age=53.0 years), approximately half are women, and the majority of participants are immigrants to Canada. More than half reported speaking English at home, 88.7% (323/364) received more than secondary school education and 69.2% (254/367) are actively employed. More than 52.0% (191/367) are vegetarian; few (4/367, 1.1%) use or are exposed to tobacco, and approximately one-quarter (27.5%, 101/367) engage in regular physical activity. Further, more than 32.0% (117/367) are exposed to more than 2 hours of screen time per day. The mean BMI at baseline is 26.4 (SD 3.5) for men and 26.5 (SD 4.1) for women. Three quarters of participants have one or two risk alleles for the 9p21 genetic variant.
Risk Factor Information at Baseline and End of Study
Table 2 shows participants' risk factors at baseline and follow-up. Over a quarter of all participants had hypertension and elevated cholesterol at baseline, and 13.8% (44/319) reported having type 2 diabetes. Over two thirds of participants are inactive at leisure time, the mean servings of fruits and vegetables consumed daily are 2 and 3, respectively, and more than 27.1% (86/317) of participants reported having stress and depressive symptoms. Objective study measures including HbA1c (mean 5.9, SD 0.8; apolipoprotein B-to-A1 ratio: mean 0.68, SD 0.18) and waist-to-hip ratio (WHR, men: mean 0.95, SD 0.05; women: mean 0.88, SD 0.07) indicate that the cohort has a moderate risk for MI, with the mean IHRS being 13.0 (SD 5.8).
Feasibility: Success at Transmitting Messages Via Electronic Media
All participants were required to have an email access (including shared family email if they choose to use this email account) to be eligible for this study. The majority of participants (352/367, 96%) had personal email access (Table 3). Most participants had no difficulty logging into website or viewing their results, although 23% (74/324) reported having some technical problems with the website, which inhibited the risk score report and health messages delivery.
Success at Participants Returning to Use the Website and Set Health Goals
Participants use of the MyOSCAR-SAHARA website was monitored to determine how many participants logged on to the website to view their risk score reports and in the case of intervention participants, to set health goals. The login to the study MyOSCAR-SAHARA website was low for both groups (82/182, 45.1% of intervention and 115/185, 62.7% of control groups did not logon or used the website only once). The mean number of login attempts of the intervention group mean was 2.64 (SD 3.17, median 2.0) and the control group was 1.63 (SD 2.14, median 1.0). The difference between intervention and control groups login was statistically significant as expected since the intervention group was asked to set goals (Wilcoxon two-sample test, P=.0003). Figure 9 shows the frequency of login by intervention and control groups. On average the intervention group selected 1.12 goals (SD 1.67, median 1.0).
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|Figure 8. Participants' flow diagram.
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|Table 1. Demographic characteristics.
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|Table 2. Baseline and follow-up risk factors in intervention and control groups.
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|Table 3. Electronic access and reported technical difficulties.
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|Figure 9. Summary of login attempts to website over the course of the pilot study.
Signal That Intervention Leads to Behavioral Changes
Both the intervention and control group showed a reduction at follow-up in blood pressure, and reported less stress and depression compared to baseline. There was also an improvement in physical activity and reduction in fried food and snacks consumption in both groups at follow-up. Comparing follow-up to baseline score change, the intervention group had a significant reduction in their IHRS score at follow-up (intervention group baseline IHRS: mean 13.4, SD 5.8; follow-up IHRS: mean 12.1, SD 5.9, P=.002), and a trend was seen in the control group (baseline IHRS: mean 12.6, SD 5.8; follow-up IHRS: mean 11.7, SD 5.9, P=.05) (see Table 2), though these results were not statistically significant.
Risk Score
Risk Report Feedback
Participants were asked to acquire their risk score reports (IHRS and GRS) following the baseline assessment by logging onto the MyOSCAR-SAHARA website. If they did not retrieve it, it was mailed to their homes. At the end of the study, participants were asked about their knowledge and recall of their risk scores (Tables 4 and 5). Overall while participants reported appreciating receiving their risk information, the recall between baseline and end of study of risk status was low. For example, of 68 participants who were told they were high-risk at baseline, only 11 recalled this correctly (11/68, 16.2%), 17 recalled being moderate risk (17/68, 25.0%), 3 recalled it being low risk (4/68, 4.4%), and 37 could not recall their risk score (37/38, 54.4%) at all. Similarly only 7.3% (5/68) of participants recalled their increased genetic risk score accurately at follow-up (Table 5).
Risk Scores and Motivation to Change
Figure 10 shows individuals reporting that knowledge of their risk for MI could be a motivator to change health behaviors including diet and physical activity. There was a trend (P=.06) showing the intervention group as compared to the control group was more likely to agree that the risk score was a motivator for increasing health behaviors especially for physical activity, though these results were not statistically significant (Figure 10).
Stages of Change
We assessed the stages of change for three main domains: diet, physical activity, and weight loss. Although we also included smoking, only three individuals are current smokers in this sample. Overall, more than 13.9% (51/367) of participants progressed from inactive (precontemplation, contemplation, and preparation) to the active (action, maintenance) stage in diet and physical activity, and 12.5% (46/367) progressed to the active stage in weight loss plans; however, no significant differences were observed between intervention and control groups (Table 6).
Exit Survey
At the end of the pilot study, feedback from the study participants was obtained by asking all participants about their experiences of participating in the pilot study. The main feedback included: (1) daily messages were too frequent which could potentially lead them to ignore the messages; (2) phone calls to remind participants to login to the study website were too frequent, while others reported that there was not enough in-person contact and would have liked to have a mid-program visit that with more face-to-face contact with the study team; and (3) IHRS and GRS reports should be sent via email and remove the website login component. Most of the participants reported that participation in the SAHARA study was worthwhile for them. Table 7 shows summary of the exit survey.
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|Table 4. Agreement between MI risk score results and participants recall of risk score at follow-up.
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|Table 5. Agreement between genetic risk score results and participants recall of risk score at follow-up.
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|Figure 10. Motivation to change behavior based on risk score reports.
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|Table 6. Stages of changea: moving from inactive to active stage by intervention at follow-up.
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|Table 7. Exit survey (n=317).
Principal Findings
We observed that a multimedia health behavior intervention is feasible in a South Asian population at risk for MI. While participants reported being motivated by receiving the risk score information, a number of features of the SAHARA intervention require optimization prior to assessing its effectiveness in MI risk factor reduction.
Most participants had access to email, Internet, and text messages and had no difficulty receiving email or text messages. However, our requirement of participants to proactively logon to the website to receive their risk reports, and to set goals was problematic with 23.9% (88/367) of the study participants reporting technical difficulties. It is likely that this contributed to the low number of goals chosen over the course of the follow-up, and reduced the interventions potential impact on changing health behaviors. In addition, participants received the study messages either by email/text checked on a mobile device or emails checked on a fixed device. These different methods of receiving messages may have also impacted the uptake of the study intervention. The anticipated difference would be based on the fact that the mobile device message would likely be received in real time or close to it, whereas the fixed device message might not be received immediately, although it may reach people when they're more ready to act on the information (ie, they have specifically chosen to sit down at the computer, as compared to a mobile device when the email/text may arrive when the person is doing something else). In this study it is not known the impact of receiving messages via mobile or a fixed device on the intervention uptake and outcome. Despite these technical challenges, the intervention group showed a significant reduction in the IHRS score at follow-up, and were more likely than control subjects to report that their personalized risk scores motivated them to increase their healthy dietary choices, physical activity, and reduce sedentary behaviors. The greater engagement of the intervention group in the study, their receipt of regular messages and reminders to change their health behaviors, may explain this difference.
Based on the participants' feedback from the exit survey, the use of a website health behavior intervention, which requires participants to logon to a website, reduces the chances that participants will be engaged in the study. In our study, 54.9% (100/182) of the intervention group logged onto the website at least twice, which is in keeping with previous studies using Internet-based intervention to aid smoking cessation [44]. A systematic review and meta-analysis of Web-based intervention studies to induce behavioral changes reported that the average logon to website/person/study duration in weeks varies from 2.6 logons/person/32 weeks in a study of depression to 1008 logons/person/36 weeks in a study of HIV. In addition the average time spent on website in minutes per person varied from 4.5 to 45 minutes/person [45]. Furthermore, even when information is sent directly to participants by email, the rate of opening the email is variable. For example in a study of 345 men and women where daily email messages were sent to improve employees' diet and physical activity behaviors in the workplace, only 68.9% (238/345) of the emails were opened by study participants [23], even though all study participants worked in the same office and had a computer at their desk. This is consistent with other studies using Web-based interventions where an uptake of only 62% was reported [46]. To optimize the uptake of the intervention for the main SAHARA trial we will ask participants to set their goals at the baseline interview, we will remove the logon to website requirement to access risk score reports, and we will deliver the reports directly to participants by emails. These components will be followed by telephone calls and one face-to-face visit mid-way through the study, to ensure receipt and knowledge of risk scores, and to maintain participant interest in the study.
Individuals who participated in this pilot study were at moderate risk of MI based on their baseline IHRS compared to risk score values reported in the validation study [35]. Both the intervention and control groups made some progress in changing their health behaviors and in general participants reported the information they received was useful. Despite participants claiming that their risk reports motivated behavioral changes, half of the participants could not recall their risk report at 6 months. The poor risk score recall may reflect low health literacy (ie, the degree to which individuals can obtain, process, and understand the basic health information) and numeracy (how individuals interpret medical risk information) [47]. However, our sample was of high socioeconomic status, well educated, and we pretested our risk score information in focus groups and presented the information (Figure 2) at the grade 5 reading level. Thus, we attempted to minimize low health literacy and numeracy as possible barriers to understanding risk score information. It is also possible that the active phenomenon of resistance to retain negative information about one's health to maintain an optimistic view of future health was at play. Such views have been described as psychological defense mechanisms [48]; however, it is difficult to confirm if such views hold in the current study. In addition, the low risk score recall may also represent the phenomenon of "unrealistic optimism" whereby individuals display an optimism bias when evaluating own susceptibility to risk [49]. However, this view does not explain the poor recall of low-risk reports.
The low recall rate of health information received, including in face-to-face counseling, is not uncommon. In a large study investigating the recall of health advice given face-to-face to patients (n=3261) who participated in the EuroHeart Failure Survey 12 weeks following discharge, only 57.8% (1885/3261) of patients recalled advice on exercise, 54.9% (1793/3261) recalled advice on diet, 41.9% (1369/3261) recalled advice on smoking, and only 38.9% (1271/3261) recalled advice on alcohol [50]. Nonetheless in our study, participants reported that knowledge of their risk factor and genetic risk score were motivators to improve their health behaviors even if they could not recall their exact risk category. It is possible that recall may vary by the type of information provided to participants, and recall may decrease over time. For example, patients with type 2 diabetes are more likely to recall health recommendations regarding medications than regarding health behaviors [51], and provision of genetic risk information to smokers regarding their risk of lung cancer showed early high recall of risk status yet lower recall with increasing duration of follow-up [52]. We hypothesized that genetic information may motivate behavior change differently than nongenetic health information because of the highly personalized nature of the information [47]. In a recent study among patients with type 2 diabetes who participated in a lifestyle modification trial in which genetic information was provided in a gene score, almost all participants (98%) reported that high-risk genetic results would increase their motivation for lifestyle modification. On the other hand their response to receiving low-risk genetic results varied, with some reporting that low-risk genetic status would decrease their motivation to take on lifestyle changes. However, their reported response has not yet been correlated to their actual change in risk factors as this study is on-going [53]. Future studies, including the main SAHARA trial must assess if provision of genetic risk information is strongly correlated with changes in risk factors and clinical outcomes.
We assessed the stage of change transition over the course of the follow-up. It is known now that the stages of change are not linear and individuals do not progress from one stage to the next as originally proposed [33]. Rather, these stages follow a spiral model with relapses that resets the process back to the precontemplation stage [54]. Despite these challenges, the stages of change model is widely used and accepted as a useful measure to assess motivation to change and the impact of this motivation on achieving the desired behavioral modification [55]. We observed that 25.8% (94/367) of the participants progressed forward in stages of change relating to physical activity, while 18.2% (67/367) regressed in their stages of change. Overall however more than 12.5% (46/367) progressed from the inactive to an active stage at the end of study in all three domains (physical activity, diet, and weight loss). No difference between intervention and control subjects in stages of change transitions was observed.
Our pilot study had a number of strengths, which include recruitment of an apparently healthy population sample of reasonable size, and prospective measurement of health behaviors that included objective measurements (ie, lipid, blood pressure, and anthropometric measurements). Some limitations of our intervention occurred including the technical challenges of logging onto the website, the low rate of logons to set health goals, and relatively poor recall of personal risk at follow-up. Despite these, a significant reduction in the MI risk score was observed in follow-up. In addition the SAHARA study population may not be representative of all South Asians in Canada; however, the socioeconomic characteristics of SAHARA participants are similar to findings from previous health surveys in Ontario [56].
Modifications to the SAHARA Trial Intervention
We have taken a number of steps to optimize the SAHARA intervention prior to testing its effectiveness in MI risk reduction in a future trial. These changes include: (1) risk reports and randomization status will be emailed directly to participants, (2) the number of health goals participants can focus on has been reduced from 4 to 2, with only one being chosen at one time for a 6-month duration, (3) the duration of follow-up will be extended to 12 months with baseline, 6 months and 12 months face-to-face visits occurring, (4) increasing the frequency of in-person contacts to improve adherence to the intervention and interest in the program, (5) health tips will be tailored to each participant based on the goal selected and their readiness to change, and (6) the frequency of messages will be reduced from daily to weekly and sent at a time of day chosen by participants.
A multimedia intervention is feasible and has the potential to induce positive health behavior changes aimed at reducing MI risk. Information generated from the SAHARA pilot has directly informed the design of the main randomized trial designed to test the effectiveness of a multimedia behavioral intervention to reduce MI risk among South Asians.
This study was funded by a grant from the Heart and Stroke Foundation of Ontario, HSFO Grant # NA 6865. We would like to thank the coordinating center members Andre Oliveria, Zahra Sohani, Fahd Naufal, Chetna Mistry, Sindoora Iyer, Hasheel Lodhia, Manpreet Kooner, Farah Khan, Sadia Wasty, Shruti Javali, Sujane Kandasamy, Monisha Nundy, Debi Sloane, Sarah McGarrity, Rani Sethi, Chander Khanna, Thiagarajan, Rita Verma, Yashoda Valliere, Taran Ohson, Anisha Dubey, Stacey Nezic, Enrico Rullo, Arjun Kumar, and Sherry Zafar. We would like to also thank the MyOSCAR-SAHARA Development team members Tracey Carr and Jay Gallagher, who are also collaborators of our work.
Conflicts of Interest
The funding sponsor has no role in the conduct or reporting of the study. MyOSCAR-SAHARA was developed by the Department of Family Medicine, McMaster University. Dr Anand holds a Canada Research Chair in Ethnicity and Cardiovascular Disease, Michael G DeGroote Chair Heart and Stroke Foundation Chair in Population Health, and May Cohen Eli Lilly Chair in Womens Health at McMaster University.
Multimedia Appendix 1
The INTERHEART Risk Score.[PDF File (Adobe PDF File), 11KB]
Multimedia Appendix 2
CONSORT-EHEALTH checklist V1.6.2 [43].[PDF File (Adobe PDF File), 997KB]
- Sanderson JE, Mayosi B, Yusuf S, Reddy S, Hu S, Chen Z, et al. Global burden of cardiovascular disease. Heart 2007 Oct;93(10):1175 [FREE Full text] [CrossRef] [Medline]
- Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet 2006 May 27;367(9524):1747-1757. [CrossRef] [Medline]
- Bedi US, Singh S, Syed A, Aryafar H, Arora R. Coronary artery disease in South Asians: an emerging risk group. Cardiol Rev 2006;14(2):74-80. [CrossRef] [Medline]
- Joshi P, Islam S, Pais P, Reddy S, Dorairaj P, Kazmi K, et al. Risk factors for early myocardial infarction in South Asians compared with individuals in other countries. JAMA 2007 Jan 17;297(3):286-294. [CrossRef] [Medline]
- Murray C, Lopez AD. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. Cambridge, MA: The Harvard School of Public Health on behalf of the World Health Organization and the World Bank; 1996.
- Canada S. Ethnocultural Portrait of Canada Highlight Tables, 2006 Census, Statistics Canada, 2006. 2006 Apr 29. URL: http://www12.statcan.ca/census-recensement/2006/dp-pd/hlt/97-562/index.cfm?Lang=E [accessed 2013-08-13] [WebCite Cache]
- Anand SS, Yusuf S, Vuksan V, Devanesen S, Teo KK, Montague PA, et al. Differences in risk factors, atherosclerosis, and cardiovascular disease between ethnic groups in Canada: the Study of Health Assessment and Risk in Ethnic groups (SHARE). Lancet 2000 Jul 22;356(9226):279-284. [Medline]
- Razak F, Anand SS, Shannon H, Vuksan V, Davis B, Jacobs R, et al. Defining obesity cut points in a multiethnic population. Circulation 2007 Apr 24;115(16):2111-2118 [FREE Full text] [CrossRef] [Medline]
- Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases: Part II: variations in cardiovascular disease by specific ethnic groups and geographic regions and prevention strategies. Circulation 2001 Dec 4;104(23):2855-2864 [FREE Full text] [Medline]
- Tillin T, Forouhi N, Johnston DG, McKeigue PM, Chaturvedi N, Godsland IF. Metabolic syndrome and coronary heart disease in South Asians, African-Caribbeans and white Europeans: a UK population-based cross-sectional study. Diabetologia 2005 Apr;48(4):649-656. [CrossRef] [Medline]
- Forouhi NG, Sattar N, Tillin T, McKeigue PM, Chaturvedi N. Do known risk factors explain the higher coronary heart disease mortality in South Asian compared with European men? Prospective follow-up of the Southall and Brent studies, UK. Diabetologia 2006;49(11):2580-2588. [Medline]
- Anderson TJ, Grégoire J, Hegele RA, Couture P, Mancini GB, McPherson R, et al. 2012 update of the Canadian Cardiovascular Society guidelines for the diagnosis and treatment of dyslipidemia for the prevention of cardiovascular disease in the adult. Can J Cardiol 2013 Feb;29(2):151-167. [CrossRef] [Medline]
- Kodama S, Saito K, Tanaka S, Horikawa C, Fujiwara K, Hirasawa R, et al. Effect of Web-based lifestyle modification on weight control: a meta-analysis. Int J Obes (Lond) 2012 May;36(5):675-685. [CrossRef] [Medline]
- Whittaker R, Maddison R, McRobbie H, Bullen C, Denny S, Dorey E, et al. A multimedia mobile phone-based youth smoking cessation intervention: findings from content development and piloting studies. J Med Internet Res 2008;10(5):e49 [FREE Full text] [CrossRef] [Medline]
- Jay M, Adams J, Herring SJ, Gillespie C, Ark T, Feldman H, et al. A randomized trial of a brief multimedia intervention to improve comprehension of food labels. Prev Med 2009 Jan;48(1):25-31. [CrossRef] [Medline]
- Barak A, Hen L, Boniel-Nissim M, Shapira N. A comprehensive review and a meta-analysis of the effectiveness of Internet-based psychotherapeutic interventions. J Technol Human Serv 2008 Jul 03;26(2-4):109-160. [CrossRef]
- Cuijpers P, van Straten A, Andersson G. Internet-administered cognitive behavior therapy for health problems: a systematic review. J Behav Med 2008 Apr;31(2):169-177 [FREE Full text] [CrossRef] [Medline]
- Spek V, Cuijpers P, Nyklícek I, Riper H, Keyzer J, Pop V. Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis. Psychol Med 2007 Mar;37(3):319-328. [CrossRef] [Medline]
- Webb TL, Joseph J, Yardley L, Michie S. Using the internet to promote health behavior change: a systematic review and meta-analysis of the impact of theoretical basis, use of behavior change techniques, and mode of delivery on efficacy. J Med Internet Res 2010;12(1):e4 [FREE Full text] [CrossRef] [Medline]
- Jeste DV, Dunn LB, Folsom DP, Zisook D. Multimedia educational aids for improving consumer knowledge about illness management and treatment decisions: a review of randomized controlled trials. J Psychiatr Res 2008 Jan;42(1):1-21. [CrossRef] [Medline]
- Pop-Eleches C, Thirumurthy H, Habyarimana JP, Zivin JG, Goldstein MP, de Walque D, et al. Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders. AIDS 2011 Mar 27;25(6):825-834. [CrossRef] [Medline]
- Cole-Lewis H, Kershaw T. Text messaging as a tool for behavior change in disease prevention and management. Epidemiol Rev 2010 Apr;32(1):56-69 [FREE Full text] [CrossRef] [Medline]
- Franklin PD, Rosenbaum PF, Carey MP, Roizen MF. Using sequential e-mail messages to promote health behaviors: evidence of feasibility and reach in a worksite sample. J Med Internet Res 2006;8(1):e3 [FREE Full text] [CrossRef] [Medline]
- Car J, Sheikh A. Email consultations in health care: 2--acceptability and safe application. BMJ 2004 Aug 21;329(7463):439-442 [FREE Full text] [CrossRef] [Medline]
- Car J, Sheikh A. Email consultations in health care: 1--scope and effectiveness. BMJ 2004 Aug 21;329(7463):435-438 [FREE Full text] [CrossRef] [Medline]
- Persell SD, Lloyd-Jones DM, Friesema EM, Cooper AJ, Baker DW. Electronic health record-based patient identification and individualized mailed outreach for primary cardiovascular disease prevention: a cluster randomized trial. J Gen Intern Med 2013 Apr;28(4):554-560. [CrossRef] [Medline]
- Helgadottir A, Thorleifsson G, Manolescu A, Gretarsdottir S, Blondal T, Jonasdottir A, et al. A common variant on chromosome 9p21 affects the risk of myocardial infarction. Science 2007 Jun 8;316(5830):1491-1493 [FREE Full text] [CrossRef] [Medline]
- Schunkert H, Götz A, Braund P, McGinnis R, Tregouet DA, Mangino M, Cardiogenics Consortium. Repeated replication and a prospective meta-analysis of the association between chromosome 9p21.3 and coronary artery disease. Circulation 2008 Apr 1;117(13):1675-1684 [FREE Full text] [CrossRef] [Medline]
- McPherson R, Pertsemlidis A, Kavaslar N, Stewart A, Roberts R, Cox DR, et al. A common allele on chromosome 9 associated with coronary heart disease. Science 2007 Jun 8;316(5830):1488-1491 [FREE Full text] [CrossRef] [Medline]
- Do R, Xie C, Zhang X, Männistö S, Harald K, Islam S, INTERHEART investigators. The effect of chromosome 9p21 variants on cardiovascular disease may be modified by dietary intake: evidence from a case/control and a prospective study. PLoS Med 2011 Oct;8(10):e1001106 [FREE Full text] [CrossRef] [Medline]
- Marteau TM, French DP, Griffin SJ, Prevost AT, Sutton S, Watkinson C, et al. Effects of communicating DNA-based disease risk estimates on risk-reducing behaviours. Cochrane Database Syst Rev 2010(10):CD007275. [CrossRef] [Medline]
- Bloss CS, Schork NJ, Topol EJ. Effect of direct-to-consumer genomewide profiling to assess disease risk. N Engl J Med 2011 Feb 10;364(6):524-534. [CrossRef] [Medline]
- Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: toward an integrative model of change. J Consult Clin Psychol 1983 Jun;51(3):390-395. [Medline]
- Mora S, Rifai N, Buring JE, Ridker PM. Fasting compared with nonfasting lipids and apolipoproteins for predicting incident cardiovascular events. Circulation 2008 Sep 2;118(10):993-1001 [FREE Full text] [CrossRef] [Medline]
- McGorrian C, Yusuf S, Islam S, Jung H, Rangarajan S, Avezum A, INTERHEART Investigators. Estimating modifiable coronary heart disease risk in multiple regions of the world: the INTERHEART Modifiable Risk Score. Eur Heart J 2011 Mar;32(5):581-589 [FREE Full text] [CrossRef] [Medline]
- PHRI. URL: https://rome.phri.ca/interheartriskscore [accessed 2013-08-13] [WebCite Cache]
- OSCAR. URL: http://myoscar.org/ [accessed 2013-08-13] [WebCite Cache]
- Fishbein M, Ajzen I. Belief, Attitude, Intention, and Behavior: An Introduction to Theory and Research. Reading, MA: Addison-Wesley Pub. Co; 1975.
- Migneault JP, Dedier JJ, Wright JA, Heeren T, Campbell MK, Morisky DE, et al. A culturally adapted telecommunication system to improve physical activity, diet quality, and medication adherence among hypertensive African-Americans: a randomized controlled trial. Ann Behav Med 2012 Feb;43(1):62-73. [CrossRef] [Medline]
- Miller WR, Rollnick S, Conforti K. Motivational Interviewing, Second Edition: Preparing People for Change. NY: Guilford Publications, Inc; 2002.
- Locke EA, Latham GP. Building a practically useful theory of goal setting and task motivation. A 35-year odyssey. Am Psychol 2002 Sep;57(9):705-717. [Medline]
- SAHARA. URL: http://www.saharaproject.ca/ [accessed 2013-08-13] [WebCite Cache]
- Eysenbach G, CONSORT-EHEALTH Group. CONSORT-EHEALTH: improving and standardizing evaluation reports of Web-based and mobile health interventions. J Med Internet Res 2011;13(4):e126 [FREE Full text] [CrossRef] [Medline]
- Swartz LH, Noell JW, Schroeder SW, Ary DV. A randomised control study of a fully automated internet based smoking cessation programme. Tob Control 2006 Feb;15(1):7-12 [FREE Full text] [CrossRef] [Medline]
- Wantland DJ, Portillo CJ, Holzemer WL, Slaughter R, McGhee EM. The effectiveness of Web-based vs. non-Web-based interventions: a meta-analysis of behavioral change outcomes. J Med Internet Res 2004 Nov 10;6(4):e40 [FREE Full text] [CrossRef] [Medline]
- Cunningham JA, Wild TC, Cordingley J, van Mierlo T, Humphreys K. A randomized controlled trial of an internet-based intervention for alcohol abusers. Addiction 2009 Dec;104(12):2023-2032 [FREE Full text] [CrossRef] [Medline]
- McBride CM, Koehly LM, Sanderson SC, Kaphingst KA. The behavioral response to personalized genetic information: will genetic risk profiles motivate individuals and families to choose more healthful behaviors? Annu Rev Public Health 2010;31:89-103. [CrossRef] [Medline]
- Taylor SE, Collins RL, Skokan LA, Aspinwall LG. Maintaining positive illusions in the face of negative information: getting the facts without letting them get to you. J Soc Clin Psychol 1989 Jun;8(2):114-129. [CrossRef]
- Weinstein ND. Unrealistic optimism about susceptibility to health problems: conclusions from a community-wide sample. J Behav Med 1987 Oct;10(5):481-500. [Medline]
- Lainscak M, Cleland JG, Lenzen MJ, Nabb S, Keber I, Follath F, et al. Recall of lifestyle advice in patients recently hospitalised with heart failure: a EuroHeart Failure Survey analysis. Eur J Heart Fail 2007 Nov;9(11):1095-1103. [CrossRef] [Medline]
- Kravitz RL, Hays RD, Sherbourne CD, DiMatteo MR, Rogers WH, Ordway L, et al. Recall of recommendations and adherence to advice among patients with chronic medical conditions. Arch Intern Med 1993 Aug 23;153(16):1869-1878. [Medline]
- Sanderson SC, Humphries SE, Hubbart C, Hughes E, Jarvis MJ, Wardle J. Psychological and behavioural impact of genetic testing smokers for lung cancer risk: a phase II exploratory trial. J Health Psychol 2008 May;13(4):481-494. [CrossRef] [Medline]
- Vassy JL, O'Brien KE, Waxler JL, Park ER, Delahanty LM, Florez JC, et al. Impact of literacy and numeracy on motivation for behavior change after diabetes genetic risk testing. Med Decis Making 2012;32(4):606-615. [CrossRef] [Medline]
- Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Applications to addictive behaviors. Am Psychol 1992 Sep;47(9):1102-1114. [Medline]
- DiClemente CC, Schlundt D, Gemmell L. Readiness and stages of change in addiction treatment. Am J Addict 2004;13(2):103-119. [CrossRef] [Medline]
- Chiu M, Austin PC, Manuel DG, Tu JV. Comparison of cardiovascular risk profiles among ethnic groups using population health surveys between 1996 and 2007. CMAJ 2010 May 18;182(8):E301-E310 [FREE Full text] [CrossRef] [Medline]
|BMI: body mass index
|CABG: coronary artery bypass graft
|CAD: coronary artery disease
|GRS: genetic risk score
|HWE: Hardy-Weinberg equilibrium
|IHRS: INTERHEART risk score
|IQR: interquartile range
|MI: myocardial infarction MI
|OSCAR: Open Source Clinical Applications and Resources
|SAHARA: South Asian HeArt Risk Assessment
|SMS: short message service
|SNP: single nucleotide polymorphism
|WHR: waist-to-hip ratio
|Edited by G Eysenbach; submitted 16.03.13; peer-reviewed by CJ( Wu, L Quintana, G Ramesh Prasad; comments to author 11.06.13; revised version received 01.07.13; accepted 29.07.13; published 20.08.13
Please cite as:
Samaan Z, Schulze KM, Middleton C, Irvine J, Joseph P, Mente A, Shah BR, Pare G, Desai D, Anand SS, SAHARA Investigators
South Asian Heart Risk Assessment (SAHARA): Randomized Controlled Trial Design and Pilot Study
JMIR Res Protoc 2013;2(2):e33
URL: http://www.researchprotocols.org/2013/2/e33/
doi: 10.2196/resprot.2621
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Copyright©Zainab Samaan, Karleen M Schulze, Catherine Middleton, Jane Irvine, Phillip Joseph, Andrew Mente, Baiju R Shah, Guillaume Pare, Dipika Desai, Sonia S Anand, SAHARA Investigators. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 20.08.2013.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on http://www.researchprotocols.org, as well as this copyright and license information must be included.


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Three strikes law an expensive travesty of justice
With the dubious distinction of being the country that locks up more citizens than any other country, it takes many, many tax dollars to accomplish this.
The latest stated figure was over $32,000 each person per year.
As an advocate of reform to our mandatory sentencing law, "3-Strikes," I wonder how many are aware that those serving life sentences without parole are deteriorating physically as they age and cost about three times as much to incarcerate than their younger counterparts.
They are no longer a threat to society but are far more expensive to the taxpayer.
An ironic twist to this expensive situation is the fact that the majority of those presently serving life under this law have been convicted of relatively minor offenses.
Although criminal acts, when compared with the heinous crimes that do deserve such punishment, it is ridiculous that they should be sharing that same fate.
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text:
The Trouble With Templeton
by Cam Johns for yirmag.com
Ok, I am now sold. After listening and living with The Trouble With Templeton's Rookie for a while now I think I finally got it. This realisation did not come easy however, with countless stop start listens, the record on the whole felt adequate but it was just not resonating with me as much I would have liked. You could say I was having "trouble"… You could also say that quote unquote "jokes" are something I should never attempt.
It may have been the amount of love I had seen for this record that in some way scared me off, so when the chance came to make a trip to the Northcote Social Club to see them live, I needed to attend. As I have mentioned before hearing a band perform their songs live often brings another dimension to their work, allowing a different perspective to the songs and the band in general. After subjecting my body, mind and soul (but really, mostly my ears) to this record the week leading up to the 16th of August, I do believe I was more than prepared and ready for this experience.
After picking up my now regular partner on my musical journeys, my girlfriend Courtney, we started our trek towards Northcote. On a very blustery and miserable Melbourne night and not wanting to listen to the game of football that was already over, a final go around of 'Rookie' was decided upon. I was very excited because Courtney had never been to this particular venue. A venue that is one of my favourites for live music, with many of my most memorable live music moments happening right at the Northcote Social Club. From being one of 10 or so people in a very empty Magic Kids gig that's saw the front man roam the very empty floor space, to a Tiny Ruins gig that saw every attendee sit cross legged on the floor as soon as she appeared on stage, to the 3 straight nights I attended last year, I just love the intimacy and feel of the whole room. I think it would be safe to say my love for the venue had me in high spirits already.
After telling Courtney all about these stories multiple times while gushing about my love for NSC, we had arrived and walking in I was surprised at the turn out. And it then occurred to me that I had in fact missed most of the supporting acts. Missing Willow Darling completely and much to my dismay half of Ali Barter's set. Which I was really gutted about because Ali has the type of vocal style I really fall head over heels for, where she is singing over her breath which really adds weight to all her songs. I really recommend heading over to her pozible page and helping fund her new album, I know I already have.
Check out her E.P here:
Trip - EP by Ali Barter
And check out her pozible page here and help in anyway you can: http://www.pozible.com/project/27173/157415
When Ali left the stage and the crowd moved slightly, we pounced at the opportunity and firmly entrenched ourselves right at the front of the stage. After all the instruments and everything was set up the Brisbane 5 piece came out on stage. What really struck me was how young they really were which really contrasted with how mature they sound on Rookie, youthful but very mature. With Hugh Middleton on electric guitar, Betty Yeowart on keys, Sam Pankhurst on bass, Ritchie Daniell on drums and of course frontman and guitarist Thomas Calder filling up the stage nicely. Anticipation had hit me and from the first track I was all in. To be honest with you I don't quite remember what song it was, with my focus and undivided attention locked on the three closest members facial expressions. When I get this close at a gig I am always interested in musicians "Music Face". Sam had his eyes closed, lips pinched together and head swaying along to his bass line. Ritchie was mouth beat boxing along to his drum work perfectly and Thomas was doing the thing I really love to see from a lead singer, and that is close his eyes while singing. In my opinion it shows feeling and a real connection to his music. Unfortunately because I was so close to the right of the stage I did not get to observe Betty or Hugh's music face and I do apologise for that.
Creepy face watching aside, the tightness that TTWT exude is a real testament to them all as performers considering they have only been together over a year. From the very OK Computer inspired 'Whimpering Child' to the acoustic lead and keyboard laden 'Six Months In A Cast' every track sounding even better in a live setting… then came the only track on 'Rookie' I was hesitant on hearing. 'Like A Kid' was a track that from first listen just rubbed me the wrong way. The main reason being, in my brain anyway, its insane similarity to the 2003/2004 hit 'In The Shadows' by The Rasmus. And thankfully hearing it live improved it ten fold. Possibly seeing others enjoy it around me helped or perhaps the slight echo on the vocals benefited from the space in the room, it just felt less confined and allowed to breathe. Around this time Thomas admitted to having a cold and apologised for anything that sounded shit and the evidence was shown on his understandably sweaty brow but vocally you could not even tell.
Then something strange happened. Some sections of the crowd started to intermittently chat to each other and the inescapable incoherent chatter was rather drowning. Bad timing had it that the loudest of the talk started during 'Secret Pastures', a beautiful acoustic guitar and soft vocal track that I felt didn't get the right amount of respect from the crowd. A few of the more vocal respectful patrons tried to get them to, for lack of a better phrase, "shut the fuck up". This did not seem deter Thomas at all though and despite the distractions he didn't let them in. I was in awe of his vocal ability, which could have been underpar considering the illness he was battling, and I seriously think he has one of the strongest voices in all of indie rock/pop right now. I implore people to absolutely catch them live.
Every one of the tracks on Rookie plays to this bands strengths, Thomas' vocal capabilities and the extremely catchy choruses on every single one of these songs. Their ear for melody makes them so easy to like, which is evident from the popularity with the general public and critics alike. With a record as polished as this and a live show that should surely only improve, I have no doubt that this is only the start of a long fruitful career.
Tracks to get behind: Whimpering Child, Six Months In A Cast, I Recorded You, Secret Pastures, Glue, You Are New
Rookie is out now via their website here: http://thetroublewithtempleton.com/buy/
Watch the music videos for 'Six Months In A Cast', 'You Are New' and 'Like A Kid' here:
(via lackingempathy)
(via bestyaneverhad)
(via breeelise)
OUTTAKE#1 http://wp.me/s2fN2L-outtake1
(via powerfulsilencemaker)
Rooney Mara as Lisbeth Salander in The Girl with the Dragon Tattoo
how is she even this perfect
(via crazygurl259)
puke on all celebrities in their sunroofs
<3 Samuel Shanahoy now on www.yirmag.com <3
(via youarethesource)
(via permissiontoexist)
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"Misha Grace is my human name and boy dog is my ghost name. I paint lots of pictures and I make lots of videos. I project live visuals with Friendships at shows but sometime it's hard because of the epilepszz in my brain. I like to make things that make your brain work and which sometimes hurts your brain because it doesn't make sense. I like to breed art… no wait, I try to make art breed like they do with pandas. Music is beautiful and paintings are too. I'm confused a lot of the time because I have a learning disorder but I think that's kind of funny. Come hang with me because I like company."
The visual fuckery of Misha Grace is an explosion of colour, sound and imagery, driven by a passion to push viewer's imaginations to the next level. It's hard to encapsulate the emotive strength of Misha's work without selling it short. Misha's ability to create completely unique reactions from viewer to viewer perhaps offers a better explanation of the seemingly effortless complexity of her work. Our Creative director Diarmaid Murray describes her work as "The right kind of weird." –Something we too at Youth in Revolt strive to embody. This is why we have chosen Misha Grace as our pick for our first film post. Get comfortable and enjoy the other-worldly visual fuckery of Misha Grace by following this link: http://yirmag.com/2013/05/07/misha-grace-artist/
To simply say Mell Hall is a writer would be selling her short. Although words are her first love this extremely talented and versatile writer has also made a name for herself as a stylist, brand consultant, publicist and more recently a DJ. With an ever growing list of accomplishments under her belt, perhaps a more appropriate description would be a young successful entrepreneur who has attained that ever so elusive and sought after goal of making a living from doing what she loves.
When I sat down to have coffee with Mell at my local coffee shop I presented her with my ideas for this piece "You're too kind." She laughs modestly about being referred to as a 'young successful entrepreneur', but credit should be giving where credit is due, and Mell Hall has more than earned the title. Rarely ever caught without a pen in hand, laptop present or more recently headphones on, Mell Hall is constantly working on some type of creative project. Heavily inspired by the people she surrounds herself with whom she admires greatly, she speaks fondly of the creative's she shares residency with at her beloved Villa. "The Villa is my home, my bane. It's filled with a range of creatives doing their thing." When I ask her about what it's like to live a double life as a writer by day and the other half of all female DJ act Kolors by night Mell explains it involves a lot of Red Bull, all nighters, bronzer and lipstick "it's a girl's best friend when trying to look awake." She also speaks warmly about her partner in crime behind the decks, Jess Hatzis', and what it's like working together to provide party-goers with the perfect disco. "We know exactly what the other is thinking, and therefore our sets are compatible. She never seises to amaze me."
As discussion moves back to her writing we find ourselves swapping stories about the first time we both felt the written word's relentless gravitational pull."I knew I wanted to be a writer when my year ten English teacher was bought to tears by my modern portrayal of Shakespeare's Romeo and Juliet with a little help from Nick Cave." She tells me "That night I went straight home and told my Mum I wanted to be a writer." If didn't show at the time, I was impressed. As she politely listens to me waffle on about why I decided to become a writer we find that we both originally planned to enter the work force as nurses, It's then, that it becomes apparent to me that Mell is one of those rare people that you can both find common ground with but also look up to and aspire to be like one day.
We speak for what seems like a short amount of time more, but is in actual fact is another hour about her various projects, goals, dreams and boys (an unavoidable subject when two females sit down over coffee it seems) and I can't help but wonder where does it stop? Well not here apparently, as Mell gears up to take on her newest creative venture a long side long time friend James Fava. Fall Street Records , a word play on the duos combined names is a fresh new music label that they've both dreamed of starting together for years, and is now finally becoming a reality. With DJ Yasumo and infectious indie rock band I Know the Chief already signed up, things are looking extremely promising.


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- Museum Day Live – The Bechtler Museum of Modern Art is offering free admission September 27 to visitors presenting a Museum Day Live! ticket. The free day is part of Smithsonian magazine's nationwide Museum Day Live! event which gives museums the opportunity to emulate the free admission policy of all the Smithsonian museums in Washington D.C. Museum Day Live! tickets are available for download here and must be presented at the Bechtler admissions desk. Each ticket provides free entrance for two people on September 27.
Get directions and parking information.
Art-related gifts are available at the museum store, open during standard hours.
Opens one hour after the museum opens and closes two hours prior to the museum closing. Service not available on Tuesday, Saturday or Sunday.


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Hagit Cohen of the Anxiety and Stress Research Unit at Ben-Gurion University of the Negev's Faculty of Health Sciences found the level of cortisol -- a hormone secreted in times of stress to help the body cope with threats -- was nearly three times higher just before voting than the cortisol level of the control group and nearly twice their level 21 months later.
It is known that when a person is in a state of stress, threat or emotional distress, the body releases a series of hormones such as cortisol, known as the "stress hormone," Cohen said.
The study, published in the journal European Neuropsychopharmacology, found the level of cortisol was nearly three times higher just before voting than the cortisol level of the control group, and nearly twice their level 21 months later.
The researchers conducted the study on Israel's Election Day in 2009 on 113 people who were on their way to vote. They were asked to give a saliva sample for cortisol testing and to complete a questionnaire examining their emotional arousal at a stand that was placed about 10 yards from the ballot box.
2014: NFL Cheerleaders [PHOTOS]


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the blog
Friday, August 16, 2013
Jacob Morton for W Magazine "Come As You Are"
Mert Alas and Marcus Piggott - Photographer
Edward Enninful - Fashion Editor/Stylist
Jack Borkett - Fashion Editor/Stylist
Lena Ott - Hair Stylist
Malcolm Edwards - Hair Stylist
Yadim - Makeup Artist
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View the full story on Models.com!
This entry was posted in VISION Men and tagged fashion, Jacob Morton, Los Angeles, male, Men, Model, Models.com, vision los angeles. Bookmark the permalink.


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Planned Parenthood Action president Cecile Richards, is featured in the latest Obama campaign video, praising the President for insuring free birth control and warning voters about Mitt Romney.
"We worked very hard with this administration to ensure that regardless of their employer to get access to birth control with no expensive co-pay or deductible," Richards says, as a photo in the video features Obama bumping fists with a nurse.
In a video which features several young children and babies, Richard praises president Obama for his record of support for the largest abortion provider in the country, but she is careful not to mention the word 'abortion.'
"Most of the women who come to Planned Parenthood come because they need preventive care access," she insists. "They need access to affordable birth control, life saving cancer screenings, and the kind of care we provide."
Richards added that Romney, "literally wants to take women back to the 1950s."
We're not sure about that, but maybe she has inside information about a time-traveling Delorean in his garage.


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Monthly Archives: November 2012
Boesak Discusses Justice, Peace: Wilson Lecture Hosts Anti-Apartheid Leader
By Devin Corbitt Chair of the Western Cape region of the African National Conference; President of the World Alliance of Reformed Churches; founder of the United Democratic Front; and leader of South Africa's anti-apartheid movement: these are just a few … Continue reading
Posted in Features Tagged Boesak, Justice, peace, Wilson Lecture Leave a comment
National Hazing Prevention Week Comes to Close
By Colin Malone National Hazing Prevention Week (NHPW) ties up today after five days and two events focused around spreading knowledge about hazing and preventing it. Jason Chapman, Assistant Director of Student Activities, organized the events. "When people talk about … Continue reading
Posted in News Tagged Greek, hazing, hazing prevention week Leave a comment
Friends, Fans, Families Show Support: Power Up Pirates Weekend Celebrate Athletics
By Marin Bramblett Family, fans, and prospective students donned their yellow and black in school spirit for the Power Up Pirates, Family Weekend, and Prospective Student-Athlete events last Saturday.With all of the events taking place and the extra people on … Continue reading
Posted in Sports Tagged alumni, Power Up Pirates, Sports, Student Life Leave a comment
Men's Soccer Makes Comeback
By John Stickels The men's soccer team will face Austin College on Friday, followed by a trip to Centenary College in Louisiana on Sunday. This will be the first time the Pirates play these teams this season. Last weekend the … Continue reading
Posted in Sports Tagged athletics, Futbol, Men's Soccer, Soccer, Sports Leave a comment
UPC Showcases FNL Events: Students Perform in the Friday Lineup
By Olivia Stephenson Sophomore Sarah Cook performed with her guitar and ukulele in front of a cheering crowd of supporters. Cook's performance was one of many student talent showcases that the University Planning Council (UPC) will feature throughout the semester … Continue reading
Posted in Culture Tagged Friday Night Live, student performers, Univeristy Programming Council Leave a comment
New Pirate Bike Repair Station Complete
By Nikko Gianino SUPD installed a bike repair station between the bike racks and recycling center west of the Ruter dormitory over the summer. Recent graduate Ben Parafina was responsible for the station's installation. Parafina got the idea while working … Continue reading
Reducing Employment: Degrees Add Advantage
By Jeffrey McKenzie In August, the unemployment rate fell from 8.3 to 8.1 percent. Unemployment among the 20-24 age group stands at 14.6 percent. Furthermore, there are an increasing number of graduates that are unable to find full-time jobs in … Continue reading
Posted in Opinions Tagged Degrees & Unemployment, Level fo Education, Unemployment Leave a comment
Cullen Building Still in Progress
By Hannah Steen Part of the ongoing renovation process both inside and outside the Cullen building was completed in August. Now that the second and attic floors of the building are finished, the professionals who work there have moved back … Continue reading
Posted in News Tagged Cullen Building, Cullen Building Renovations, Roy and Lillie Cullen Leave a comment


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Posts Tagged 'dog collars'
Garmin's Dog Collars Promise to Reduce Barking, Train Your Dog For the Canine Olympics
Aside from a dog that bites, a dog that barks incessantly is the worst kind of dog. They annoy neighbors, wake up sleeping babies, and all but make you want to pull your hair out. Beagles might be among the worst offenders, b...


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The barcc clothesline hangs today until 4pm in the campus center. Be sure to see this powerful display! http://t.co/Lo9JBcRDan
RT @OfficeStudLife: want to participate with the Wheelock community in the BARCC walk? check it out:
Reminder: Meet employers at the Career Fair Weds Apr 3, 2:30PM in Campus Center. Not just for seniors!
The @brave_ma team is in the campus center collecting signatures to fight #teendatingviolence #endtdv…
So proud of the Wheelock team in the barcc #walk4change! #worldofgood
See what's Trending Now for @WheelockCollege
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While Americans are still forking out big bucks for Internet plans under 100Mbps, Romanian ISP RCS & RDS plans to offer 1Gbps connections from November at just US$18 per month.
Digi Net 500 customers can expect to pay close to US$15 for a 500Mbps connection (down speeds 62.5 MB per second) while Digi Net 1000 customers will have access to 1Gbps speeds, which means you can download 125MB per second. Over in the US, an Google's equivalent Gigabit plan costs US$70.
For now, only customers in urban areas will have access to the fast service. They do plan to expand into the more rural countryside later on. They've also advised customers who plan to use the 1Gbps service to upgrade their home wireless routers to support the blazing fast down speeds.


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Ive lost 4stone 5lb but seem to be really struggling to have motivation now
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Ive lost 4stone 5lb but seem to be really struggling to have motivation now
Hi, Kcpjdrcmummy!
I have also hit a brick wall i lost 3 stone 3.5lb and now i have around 3.5lb left to loose and i just cant do it! i seem to want to be naughty all the time! i think i need a boost of some sort?
Hi all, I know i don't have much too lose ( about 1 stone) but i'm really struggling. loose 2 or 3 pounds n then nothing.. I've cut out the sweet stuff but crave it badly at night. Any ideas?
Only thing that seemed to help me was a black coffee or a black tea xx
Sent from my HTC One using MiniMins.com mobile app
But no I'm in exactly the same position! Need motivation. I think this forum and looking at success stories could help x
Sent from my HTC One using MiniMins.com mobile app
Hi I was in the same position as u! I only hav stone an half to loose it took me from march to June to loose 7lb on ww an for 3 wks lost nothin even tho I stuck to it an excerise I got so fed up decided to change to sw an hav lost 4lb in the first wk! I think mayb I wasn't eatin enough on ww cause I was hungry a lot of the time but wit sw ur always eatin :)
It is hard when you have lost a significant amount. I got my 2.5 stone award in march and I'm still yoyoing between that and my 3 stone. I got as close as 1/2lb away and all the way back to 6.5lb away. Really hit that wall and not even half way to target. I'm doing sw and just seem to have run out of ideas, things I used to eat and do to keep me away from the syns just don't work anymore! Its hard! Xx


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"Posted for brother in law
"Boat motor will not idle without hitting the electric choke every few seconds. Runs fine from one quarter throttle to full throttle but I have to take my time getting it up to or it will stop (I used to be able to hammer the throttle from idle with no problems). I checked fuel filter, replaced spark plugs and added a can of Sea Foam to gas tank. Im thinking it has something to do with the fuel pump. "
if you guys have any ideas or suggestions please share


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- Fonterra posts revenue jump; cuts forecast payout
- US, California release roadmap for solar projects
- Citizens Financial sets IPO at $21.50 a share
- Things to know about $8B wind energy proposal
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Quebec hoping for mining windfall: budget
Quebec Premier Jean Charest, right, applauds Finance Minister Raymond Bachand, centre, during the budget speech Tuesday, March 20, 2012 at the legislature in Quebec City. THE CANADIAN PRESS/Jacques Boissinot
QUEBEC - The Quebec government is banking on a royalty bonanza from its natural-resources sector to help Canada's most indebted province begin its long climb out of the red.
In releasing its 2012-13 budget Tuesday, Quebec revealed that its path to prosperity hinges on whether it can cash in on its abundance of minerals, forests and hydroelectricity.
The document calls for a $1.5-billion deficit in 2012-13, but says the government remains on track to fulfil its long-held pledge to balance the budget by 2013-14.
The budget, possibly the last for an unpopular Premier Jean Charest before the next election, also tries to strike a positive populist tone for voters: no new tax hikes or user fees.
In the next election — which must be called before the end of 2013 — Charest will likely portray himself as a sound economic manager, while at the same time hammering away at the uncertainty of sovereignty.
While this budget attempts to highlight economic improvements in Quebec under his watch, it also acknowledges the province remains Canada's most heavily indebted. A year ago, Quebec had a gross debt of $173 billion, which represented 54.3 per cent of gross domestic product.
But Charest's Liberals predict things are turning around.
The party is counting on the promise it sees in the province's natural resources sector and, in particular, the expansion of the province's mining industry under Quebec's sweeping northern development plan.
"We're building the future and taking all the opportunities that lie before us," Finance Minister Raymond Bachand said in Quebec City before tabling the budget in the legislature.
The government expects the mining sector alone to grow nearly 10-fold over a half-dozen years — from an average of $42 million in royalties per year between 2006-07 and 2009-10 to $415 million in 2016-17.
Bachand estimates that existing mining operations — and those currently being built — will funnel $4 billion in royalties into public coffers over the next 10 years.
Even though some mines are still being constructed, he's confident his forecast is a reliable one.
"In finance, we usually don't count our eggs before they're hatched," Bachand said.
"Of course, if the hen is there, the eggs are going to be laid tomorrow."
He said cash from the province's natural-resources sectors has already started to flow. Bachand predicted total royalties in 2011-12 to hit nearly $1.2 billion, and climb to $1.5 billion by 2016-17.
The province even wants to get in on some of the anticipated action.
Bachand's budget announced the creation of a new government branch that will invest public money in mining, oil and gas initiatives. He said it will eventually manage an equity portfolio of up to $1.2 billion.
He added that a team of financial experts will ensure the government makes only the soundest investments.
"We want also to have a share, and invest in some cases where the risk is not too high, in the mining and oil companies," said Bachand.
Other budget highlights include:
— A deduction of 10 per cent in payroll tax for workers 65 and over, as of 2013.
— $1.3 billion in new capital for Quebec companies.
— A new voluntary retirement savings initiative aimed at providing two million Quebecers with access to private pension plans.
— More assistance to allow senior citizens to stay at home.
— And a projected surplus of $2.5 billion 2016-17.
The Opposition Parti Quebecois said the provincial royalties from natural resources aren't high enough.
"The government is very timid," said PQ finance critic Nicolas Marceau, adding the stay-the-course budget makes it clear the Liberals are preparing for an election.
Francois Legault, head of the Coalition for Quebec's Future, slammed the Liberals for not doing enough to reduce spending and attacked their record on the debt.
''We really are using the credit card of our children,'' said Legault, a former PQ minister who founded the right-leaning party a few months ago.
One controversial government strategy to increase revenue, which has dogged the Liberals for months, was not altered in their budget despite mounting pressure.
The government stood firm on its intention to hike tuition fees for university, a plan that has angered students across Quebec and triggered tens of thousands of the province's youth to take to the streets in protest.
Instead, the major focus of the budget — the northern development plan, or Plan Nord — is aimed in part at helping establish Charest's political legacy.
Over the last year, Charest has travelled to different corners of the world to promote the sweeping, multibillion-dollar initiative.
His government expects the Plan Nord to pump $14 billion back to the province over 25 years and create some 20,000 jobs.
Charest, who will travel to Brazil next month, has courted potential investors by portraying Quebec as a stable place to invest.
MSN.ca Money's editorial goal is to provide a forum for personal finance and investment ideas. Our articles, columns, message board posts and other features should not be construed as investment advice, nor does their appearance imply an endorsement by Microsoft of any specific security or trading strategy. An investor's best course of action must be based on individual circumstances.
How long does it take you to completely unpack after moving in?
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It's a rainy April Day, so thought I would try this chili. My husband and I thought it was pretty good, and I will make again. Changes I made: Used 1 lb of ground turkey, didn't use the beef broth; added red pepper flakes; used masa harina as the thickener and used black beans & Great White Northern beans. Also, made the quesadillas.
Beef and Beer Chili
nansmi Posted: 04/22/10
lksmithnj Posted: 01/18/09
Very easy and very good! Don't add all the beef broth unless you really need it, which I didn't. I also let it cook down longer than the recipe called for. I added a small can of niblets corn, more cumin and more chili powder. Definitely a keeper in our household!
ajknightfan Posted: 02/07/10
I, like some of you, did not use the beef broth. I also used canned dices tomatoes in place of some of the tomato sauce. This was fantastic. I can't wait to try it with turkey meat and see if I can lower the fat even more. This will be made regularly in the winter months in my house.
JasonM Posted: 10/05/09
I made only a few changes to this recipe. 1) I didn't have quite enough chili powder, so I added a bit of chipotle chili powder and paprika to round out the taste. 2) I added about 1/2 tsp of ground coriander and about 1/4 cup of chopped fresh cilantro. 3) I used a 12oz Guinness Draught instead of the suggested beer. 4) I added an extra tablespoon and a half of cornmeal because I wasn't satisfied with the consistency after just one tablespoon. With those changes, anyway, this was a flavorful and pleasant chili. Having used the chipotle powder, it had just enough heat going for it and the cilantro added a nice touch to go with the lime juice. We'll make this again.
corinneja Posted: 11/20/08
I make this recipe regularly, but I add a pinch of cayenne pepper and double the amount of cornmeal, to thicken it a bit more. It makes a great weeknight meal with cornbread.
AdrienneandDave Posted: 09/20/09
I made this last night to serve for tonight...but I tasted it last night. It tasted good BUT I made a few changes. I hadn't even read the reviews, but it seemed really watery so I halfed the beer and broth amounts, and doubled the corn meal and salt amount. It had a good flavor, but not much heat, which is fine for my 3 year old and great uncle, LOL. If you decrease the broth and beer-- I think its a flavorfull chili, but isn't very spicy.
ca1allicat Posted: 02/09/09
Was an ok recipe but there are many more great chili recipes that I would rather make.
Chinna Posted: 12/15/08
Yummy! This is a great dish for those cold winter nights.
BakingLibrarian Posted: 12/24/08
I took some of the advice here about upping the spices and the meat and using two kinds of beans; I also did not use the beer and instead used more broth. It was AWESOME. I made an additional batch to freeze after the first one ran out because my husband and I were both nuts about it. Fabulous!
kel00007 Posted: 01/11/09
I came online and read the reviews before I made this last night. My boyfriend, his father and sister LOVED it and gobbled it all up!! I doubled up on the meat, added extra garlic, red pepper flakes; I used a packet of beef broth mix instead of a cup of broth. I also took one reviewers advice and had a few sips of my Sam Adams before I added it to the recipe. I also drained the tomatoes before adding, and used 2 tsp of cornmeal. It made the chili hearty and robust (not watery at all.) I served with shredded cheddar on top, and I made quesadillas as a side dish. Yum, Yum, Yum.
windmill Posted: 01/23/09
I thought this tasted pretty gross, I won't make it again. O.K. for family night...no guests
SMStauffer Posted: 09/02/10
Much too thin and watery. Next time I won't use the beef broth; it's not usual in chili anyway. We don't care for the "cornmeal as thickener." I used a minced jalapeno rather than chili powder, and added fresh cilantro. Might try chipotle next time. It's a good beginning, but needs a lot of additions to make it great.
Cavldr Posted: 08/26/09
I like soupy chili but, like most of the reviewers, made a number of changes;therefore it seems most reviewers rated the recipe based on their changes, not the original recipe. I'd say the original recipe is poor at best. The number of stars should be based on the recipe as printed lest the original author may think they did well.
raquel46 Posted: 02/22/10
LOVE THIS! both my 2 year olds love it and so does my 8 year old
lfirebrand Posted: 10/10/09
This was really good, easy to make, and went together fast. I doubled the ground beef and omitted the beans. I added 1 (14 ounce) can of white hominy, 3 Tbl of tomato paste and 1 chipotle pepper. I also simmered longer that the recipe called for, until the chili was nice and thick. This was delicious served with corn muffins.
CV91915 Posted: 01/13/10
This is a solid chili recipe and has found its way into my rotation of regular recipes. Like others, I made a couple of minor changes, which I do to every recipe. 50% more beef and some chili/garlic sauce for more heat. It works well on my low-calorie diet too.
flambe99 Posted: 11/17/10
I tweaked this after reading the reviews and was happy with the results. I doubled the meat, cumin, chili powder, garlic, and red pepper flakes. I forgot to buy cornmeal, so I just crumbled some tortilla chips into the pot. Served over rice and topped with cheese and sour cream with corn mini-muffins on the side.
dreamc76 Posted: 01/18/11
very favorful and easy to make. i used lamb instead of beef, fresh tomatoes, and added corn and allowed to simmer for 45 min to thicken. will deffinately be making again since hard to please chef/boyfriend said best chili he ever had!
wilso132 Posted: 02/04/11
We really liked this recipe..especially because it didn't take that long to make it. We added a lot more of the spices and added tobasco and others to make it a little more spicy.
nwilker Posted: 09/19/11
Used 2 amber beers (skipped the beef broth), added a jalapeno, added chopped green chili, upped to 1 pound of meet, simmered for a lot longer, and added a cup of water. I definitely should have used beer i liked vs, beer that was in the cooler. The lime smoothed out the taste very well. It was tasty but i don't know if it's do it again.
Cbyrdie Posted: 10/11/11
Definitely needs quite a few additions - up the beef and spices and added in a little cayenne for a kick. We also used corn and black beans and finished with light sour cream and cheese. Shiner Bock complemented the taste nicely! Good base recipe and its quick for a weeknight.
Susan1947 Posted: 10/10/11
After reading other reviews, I omitted the beef broth, added extra garlic, and used Rotel original tomatoes instead of plain. Cilantro would have been nice but didn't have any so next time. Otherwise followed the recipe pretty much. We both enjoy with shredded cheese garnish.
hawrmc Posted: 10/29/11
I'm tired of people changing the whole recipe then rating it three stars.. If you change the recipe, you shouldn't rate this one!!
Kellykel Posted: 04/03/13
This is my go-to chili recipe. I sort of agree with Hawrmc, you can't change everything about a recipe and then say you don't like it. I don't technically change it. The can of tomatoes it calls for just happens to be a variety from Kroger with Jalapenos mixed in (I'm from the SW, what do you expect) and where it calls for beer, I add a beer with some flavor, KIllian's Irish Red. (I don't consider Budweiser to be actual beer) The Killians gives this a really great depth of flavor. I have tried other beers such as noble pils and October fest but neither of them had the same flavor. I have made this recipe at home and also over the campfire at Yellowstone it is super easy, always tastes good and never goes to waste.


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Are you like me? Were you having a tough time finding a decisive KO of the year front runner for 2012? Enter the man with the iron fist.
40 year old kickboxing legend, movie star, and former MMA champion Cung Le came into his main event role opposite Rich Franklin as a sizeable underdog. Franklin used his reach advantage in anticipation of the dangerous spinning attacks that Le possesses early on. When you are pitted up against a fighter like Le and are expecting something flashy the danger is that he may just catch with with a good old fashioned punch to the jaw. That's exactly what Le did, and it was a beauty.
Just over two minutes into the contest Le landed a picture perfect overhand right that face planted the former UFC middleweight champion right into the canvas. While Le celebrated what easily goes down as the biggest win of his career, Franklin remained down and out from what could go down as the most memorable KO inside of the Octagon this year when it's all said and done.
Check out the fight highlight below.
Video: UFC on FUEL TV: Le/Franklin Recap
Franklin living a UFC dream
Hyun Gyu Lim Ruled 'Medically Unfit,' Pulled From 'UFC on FUEL TV: Franklin vs. Le'
UFC on FUEL TV 6 – Rich Franklin vs. Cung Le Highlights
'UFC on FUEL TV: Franklin vs. Le' Live Weigh-In Results
UFC On Fuel TV 6 Franklin vs. Le predictions and analysis
UFC on FUEL TV 6 Weigh-in Video and Results
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