Amy Borg

Contributions of weight perceptions to weight loss attempts: differences by body mass index and gender

Previous studies have consistently observed that women are more likely to perceive themselves as overweight compared to men. Similarly, women are more likely than men to report trying to lose weight. Less is known about the impact that self-perceived weight has on weight loss behaviors of adults and whether this association differs by gender. We conducted a cross-sectional analysis among an employee sample (n=899) to determine the association of self-perceived weight on evidence-based weight loss behaviors across genders, accounting for body mass index (BMI) and demographic characteristics. Women were more likely than men to consider themselves to be overweight across each BMI category, and were more likely to report attempting to lose weight. However, perceiving oneself to be overweight was a strong correlate for weight loss attempts across both genders. The effect of targeting accuracy of self-perceived weight status in weight loss interventions deserves research attention.

Randomized Trial of a Literacy-Sensitive, Culturally Tailored Diabetes Self-Management Intervention for Low-Income Latinos: Latinos en Control

OBJECTIVE To test whether a theory-based, literacy, and culturally tailored self-management intervention, Latinos en Control, improves glycemic control among low-income Latinos with type 2 diabetes. RESEARCH DESIGN AND METHODS A total of 252 patients recruited from community health centers were randomized to the Latinos en Control intervention or to usual care. The primarily group-based intervention consisted of 12 weekly and 8 monthly sessions and targeted knowledge, attitudes, and self-management behaviors. The primary outcome was HbA1c. Secondary outcomes included diet, physical activity, blood glucose self-monitoring, diabetes knowledge and self-efficacy, and other physiological factors (e.g., lipids, blood pressure, and weight). Measures were collected at baseline and at 4- and 12-month follow-up. Change in outcomes over time between the groups and the association between HbA1c and possible mediators were estimated using mixed-effects models and an intention-to-treat approach. RESULTS A significant difference in HbA1c change between the groups was observed at 4 months (intervention −0.88 [−1.15 to −0.60] versus control −0.35 [−0.62 to 0.07], P < 0.01), although this difference decreased and lost statistical significance at 12 months (intervention −0.46 [−0.77 to −0.13] versus control −0.20 [−0.53 to 0.13], P = 0.293). The intervention resulted in significant change differences in diabetes knowledge at 12 months (P = 0.001), self-efficacy (P = 0.001), blood glucose self-monitoring (P = 0.02), and diet, including dietary quality (P = 0.01), kilocalories consumed (P < 0.001), percentage of fat (P = 0.003), and percentage of saturated fat (P = 0.04). These changes were in turn significantly associated with HbA1c change at 12 months. CONCLUSIONS Literacy-sensitive, culturally tailored interventions can improve diabetes control among low-income Latinos; however, strategies to sustain improvements are needed.

Step Ahead A Worksite Obesity Prevention Trial Among Hospital Employees

BACKGROUND The worksite represents a promising venue in which to address the issue of obesity. DESIGN Pair-matched, cluster-RCT. Data were collected from 2005 to 2008 and analyzed in 2008. SETTING/PARTICIPANTS A random sample of 806 employees was selected to represent the workforce of six hospitals in central Massachusetts. INTERVENTION The 2-year ecologic intervention sought to prevent weight gain through changes in worksite weight-related norms using strategies targeted at the organization, interpersonal environment, and employees. MAIN OUTCOME MEASURES The primary outcome was change in BMI at the 12- and 24-month follow-ups. Change in perceptions of organizational commitment to employee health and normative coworker behaviors were secondary outcomes. RESULTS There was no impact of the intervention on change in BMI from baseline to 12 (beta=0.272; 95% CI=-0.271, 0.782) or 24 months (beta=0.276; 95% CI=-0.338, 0.890) in intention-to-treat analysis. When intervention exposure (scale=0 to 100) was used as the independent variable, there was a decrease of 0.012 BMI units (95% CI=-0.025, 0.001) for each unit increase in intervention participation at the 24-month follow-up. Employees in intervention sites reported significantly greater improvements in perceptions of organizational commitment to employee health at 12 and 24 months compared to control sites, but there was no impact on perceptions of normative coworker behaviors. CONCLUSIONS The intervention had a dose-response relationship with BMI, with positive effects proportional to extent of participation. Although the intervention was able to change organizational perceptions, successfully improving changes in actual and perceived social norms may be needed to achieve population-level impact in complex worksite organizations.

Translational research at community health centers: challenges and successes in recruiting and retaining low-income Latino patients with type 2 diabetes into a randomized clinical trial.

Purpose To describe methods used to recruit and retain low-income Latinos in a randomized clinical trial (RCT) of a diabetes self-management intervention at 5 community health centers (CHCs) in Massachusetts. Methods Consent from primary care providers (PCPs) was obtained to screen their patients. Trained site research coordinators (SRCs) screened, recruited, and enrolled participants following a multistep process (medical record reviews, PCP approval, a patient eligibility interview) and provided support for retention efforts. Assessment staff were trained in motivational strategies to facilitate retention and received ongoing support from a retention coordinator. Electronic tracking systems facilitated recruitment and retention activities. Results Of an initial pool of 1176 patients, 1034 were active at the time of screening, 592 (57%) were eligible by medical record review, and 487 received PCP approval (92% of reviewed patients). Of these, 293 patients completed the patient screening interview (60% of patients with PCP approval, and 76% of those reached), and 276 were eligible. Sixteen percent of all active patients refused participation, and 8% of contacted patients were unreachable. Two hundred fifty-two patients were randomized after completion of baseline assessments. Clinical, behavioral, and psychosocial assessment completion rates were 92%, 77%, and 86% at 12-month follow-up, respectively, and 93% of patients completed at least one study assessment at 12 months. Conclusions CHCs are a prime setting for translation research aimed to eliminate diabetes health disparities. Successful recruitment and retention efforts must address institutional/organizational, research team, and patient-related challenges. References 1. US Department of Health and Human Services, Centers for Disease Control and Prevention. 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Is the risk of diabetic retinopathy greater in non-Hispanic blacks and Mexican Americans than in non-Hispanic whites with type 2 diabetes? A U.S. population study. Diabetes Care. 1998; 21:1230-1235. 6. Franklin GM, Kahn LB, Baxter J, Marshall JA, Hamman RF. Sensory neuropathy in non-insulin-dependent diabetes mellitus: the San Luis Valley Diabetes Study. Am J Epidemiol . 1990;131:633-643. 7. Agency for Healthcare Research and Quality. National Healthcare Disparities Report, 2006. Rockville, MD: Agency for Healthcare Research and Quality; 2006. Available at: http://www.ahrq.gov/ qual/nhdr06/nhdr06.htm. Accessed January 12, 2010. 8. National Institute of Diabetes and Digestive and Kidney Diseases, National Diabetes Information Clearinghouse (NDIC). National diabetes statistics. Available at: http://diabetes.niddk.nih.gov/dm/ pubs/statistics/index.htm. Accessed January 12, 2010. 9. US Department of Health and Human Services, Office of Minority Research. Diabetes and Hispanic Americans. 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Lorig K, Ritter PL, Villa F, Piette JD. Spanish diabetes self-management with and without automated telephone reinforcement: two randomized trials. Diabetes Care. 2008; 31:408-414. 15. Rosal MC, Olendzki B, Reed GW, Gumieniak O, Scavron J, Ockene IS. Diabetes self-management among low-income Spanish speaking patients: a pilot study. Ann Behav Med. 2005;29:225-235. 16. Mauldon M, Melkus GD, Cagganello M. Tomando Control: a culturally appropriate diabetes education program for Spanish-speaking individuals with type 2 diabetes mellitus. Evaluation of a pilot project. Diabetes Educ. 2006;32:751-760. 17. Centers for Disease Control and Prevention, National Center for Health Statistics. Age-adjusted percentage of civilian, noninstitutionalized population with diagnosed diabetes, Hispanics, United States, 1980-2007. Available at: http://www.ced.gov/diabetes/ statistics/prev/national/figbyhispanic.htm. Accessed March 31, 2010. 18. Flegal KM, Ezzati TM, Harris MI. Prevalence of diabetes in Mexican Americans, Cubans, and Puerto Ricans from the Hispanic health and nutrition examination survey 1982-1984. Diabetes Care. 1991;14(7 Suppl):528-538. 19. Lemon SC, Zapka JG, Estabrook B, Benjamin E. Challenges to research in urban community health centers. Am J Public Health. 2006;96:626-628. 20. Handley MA, Hammer H, Schillinger D. Navigating the terrain between research and practice: a Collaborative Research Network (CRN) case study in diabetes research. J Am Board Fam Med. 2006;19:85-92. 21. Piatt GA, Orchard TJ, Emerson S. Translating the chronic care model into the community: results from a randomized controlled trial of a multifaceted diabetes care intervention. Diabetes Care. 2006;29:811-817. 22. Frayne SM, Burns RB, Hardt EJ, Rosen AK, Moskowitz MA. The exclusion of non-English-speaking persons from research. J Gen Intern Med. 1996;11:39-43. 23. Durant RW, Davis RB, St George M, Williams IC, Blumenthal C, Corbie-Smith GM. Participation in research studies: factors associated with failing to meet minority recruitment goals. Ann Epidemiol. 2007;17:634-642. 24. Centers for Disease Control and Prevention, Department of Health and Human Services. Diabetes data and trends. Available at: http:www.cdc.gov/diabetes/statistics/prev/national/. Accessed March 31, 2010. 25. Surani S, Aguillar R, Komari V, Surani A, Subramanian S. Influence of Hispanic ethnicity in prevalence of diabetes mellitus in sleep apnea and relationship to sleep phase. Postgrad Med. 2009;121:108-112. 26. Link CL, McKinlay JB. Disparities in the prevalence of diabetes: is it race/ethnicity or socioeconomic status? Results from the Boston Area Community Health (BACH) survey. Ethn Dis. 2009;19:288-292. 27. Bryson CL, Ross HJ, Boyko EJ, Young BA. Racial and ethnic variations in albuminuria in the US Third National Health and Nutrition Examination Survey (NHANES III) population: associations with diabetes and level of CKD. Am J Kidney Dis. 2006; 48:720-726. 28. Gross R, Olfson M, Gameroff MJ. Depression and glycemic control in Hispanic primary care patients with diabetes. J Gen Intern Med. 2005;20:460-466. 29. Trief PM, Morin PC, Izquierdo R. Depression and glycemic control in elderly ethnically diverse patients with diabetes: the IDEATel project. Diabetes Care. 2006; 29:830-835. 30. McCarthy CR. Historical background of clinical trials involving women and minorities. Acad Med . 1994;69:695-698. 31. Rosal MC, Benjamin EM, Pekow PS, Lemon SC, von Goeler D. Opportunities and challenges for diabetes prevention at two community health centers. Diabetes Care. 2008; 31:247-254. 32. Blumenthal DS, Sung J, Coates R, Williams J, Liff J. Recruitment and retention of subjects for a longitudinal cancer prevention study in an inner-city black community. Health Serv Res. 1995;30(1 Pt 2):197-205. 33. UyBico SJ, Pavel S, Gross CP. Recruiting vulnerable populations into research: a systematic review of recruitment interventions. J Gen Intern Med. 2007;22:852-863. 34. Corbie-Smith GM. Minority recruitment and participation in health research. N C Med J. 2004; 65:385-387. 35. Bruner DW, Jones M, Buchanan D, Russo J. Reducing cancer disparities for minorities: a multidisciplinary research agenda to improve patient access to health systems, clinical trials, and effective cancer therapy. J Clin Oncol. 2006;24:2209-2215. 36. Blumenthal DS, Lukomnik JE, Hawkins DR, Jr. A proposal to provide care to the uninsured through a network of community health centers. J Health Care Poor Underserved. 1993;4:272-279. 37. Davis SK, Collins KS, Hall A. Community health centers in a changing U.S. health care system. Policy Brief Commonw Fund . 1999;(300):1-13. 38. US Department of Health and Human Services, Health Resources and Services Administration. Bureau of Primary Health Care. America’s health centers: models for quality primary health care. Available at: http://bphc.hrsa.gov/chc/charts/healthcenters.htm. Accessed January 8, 2010. 39. Rosal MC, White MJ, Restrepo A. Design and methods for a randomized clinical trial of a diabetes self-management intervention for low-income Latinos: Latinos en Control. BMC Med Res Methodol. 2009;9:81. 40. Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. 2n

Awareness of diabetes risk factors and prevention strategies among a sample of low-income Latinos with no known diagnosis of diabetes

Purpose This study assessed awareness of type 2 diabetes risk and severity, perceived risk factors, knowledge of diabetes prevention strategies, and challenges of and opportunities for prevention among low-income Latinos in Lawrence, Massachusetts. Methods Qualitative research design. Latinos with no known diagnosis of diabetes participated in 4 focus groups, conducted in Spanish, which were recorded and transcribed for systematic analysis. Results The sample, (N = 41) was largely female (85%) with a wide age range (22-76 years), most (71%) had an educational level of high school or less, and less than half (46%) were employed. Participants had basic knowledge of diabetes, but gaps were apparent. Many perceived family history of diabetes, poor diet, emotional distress, and stress associated with the United States as risk factors for diabetes. There was little or no awareness of risk associated with Latino ethnicity, gestational diabetes, hypertension, lipid abnormalities, or obesity. Few cited physical activity or weight loss as diabetes prevention strategies. More than half the participants perceived themselves at low risk for diabetes. Conclusions This Latino sample had limited knowledge of diabetes risk factors and lifestyle changes that can prevent or delay diabetes onset. Insights for intervening for diabetes prevention are offered.

A randomized clinical trial of a peri-operative behavioral intervention to improve physical activity adherence and functional outcomes following total knee replacement

BackgroundTotal knee replacement (TKR) is a common and effective surgical procedure to relieve advanced knee arthritis that persists despite comprehensive medical treatment. Although TKR has excellent technical outcomes, significant variation in patient-reported functional improvement post-TKR exists. Evidence suggests that consistent post-TKR exercise and physical activity is associated with functional gain, and that this relationship is influenced by emotional health. The increasing use of TKR in the aging US population makes it critical to find strategies that maximize functional outcomes.Methods/DesignThis randomized clinical trial (RCT) will test the efficacy of a theory-based telephone-delivered Patient Self-Management Support intervention that seeks to enhance adherence to independent exercise and activity among post- TKR patients. The intervention consists of 12 sessions, which begin prior to surgery and continue for approximately 9 weeks post-TKR. The intervention condition will be compared to a usual care control condition using a randomized design and a probabilistic sample of men and women. Assessments are conducted at baseline, eight weeks, and six- and twelve- months. The project is being conducted at a large healthcare system in Massachusetts. The study was designed to provide greater than 80% power for detecting a difference of 4 points in physical function (SF36/Physical Component Score) between conditions (standard deviation of 10) at six months with secondary outcomes collected at one year, assuming a loss to follow up rate of no more than 15%.DiscussionAs TKR use expands, it is important to develop methods to identify patients at risk for sub-optimal functional outcome and to effectively intervene with the goal of optimizing functional outcomes. If shown efficacious, this peri-TKR intervention has the potential to change the paradigm for successful post-TKR care. We hypothesize that Patient Self-Management Support to enhance adherence to independent activity and exercise will enhance uniform, optimal improvement in post-TKR function and patient autonomy, the ultimate goals of TKR.Trial RegistrationClinicalTrials.gov: NCT00566826

Navigating to health: Evaluation of a community health center patient navigation program

Patient Navigators are trained, lay health care workers who guide patients in overcoming barriers to health care access and utilization. Little evidence exists regarding reach and impact of Patient Navigators for chronic disease management. This study evaluated a Patient Navigator program aimed at optimizing health care utilization among ethnically diverse patients with diabetes and/or hypertension at a community health center (CHC). Trained Patient Navigators contacted eligible patients who had not seen a primary care provider (PCP) for ≥ 6 months. Outcomes included number of patients reached by Patient Navigators and seen by PCPs after Patient Navigator contact. Distributions and frequencies of outcomes pre- and post-call were compared. A total of 215 patients had ≥ 1 call attempt from Patient Navigators. Of these, 74 were additionally contacted via mailed letters or at the time of a CHC visit. Among the 45 patients reached, 77.8% scheduled an appointment through the Patient Navigator. These patients had higher rates of PCP visits 6 months post-call (90%) than those not reached (42.2%) (p < 0.0001). Findings emphasize the value of direct telephone contact in patient health care re-engagement and may inform the development of future Patient Navigator programs to improve reach and effectiveness.

Development and validation of a Weight Literacy Scale in English and Spanish

Objectives To develop and validate a Weight Literacy Scale in English and Spanish for adults. Methods The two-phase study utilized quantitative and qualitative methods. Phase 1 of the study consisted of developing an initial survey (English and Spanish versions) assessing weight literacy based on a review of the literature; conducting semi-structured interviews with content experts (N = 9) to refine survey items; and conducting in-person cognitive interviews with 20 study participants (N = 10 English-speaking and N = 10 Spanish-speaking adults) for survey pre-testing. Survey items were modified based on Phase 1 findings. Phase 2 consisted of a psychometric study of the Weight Literacy Scale developed in Phase 1. Procedures included administering the Weight Literacy Scale to 200 study participants (N = 100 English-speaking and N = 100 Spanish-speaking adults), a quantitative survey assessing dietary and physical activity behaviors and sociodemographics, measuring participants’ height and weight, and assessing the scale’s validity and internal reliability. A subset of Phase 2 participants (N = 71) completed the weight literacy scale at two-weeks follow-up to assess test-retest reliability. Participant recruitment and study procedures took place in community settings in central Massachusetts for both study phases. Weight literacy scale scores were calculated as the sum of total correct items. Three rounds of factor analysis were performed to identify items for elimination. The Kuder Richardson’s Coefficient of reliability was calculated. Correlations between the Weight Literacy Scale scores and related measures (body mass index and weight status, dietary behaviors, physical activity behaviors, and confidence in filling out medical forms) were examined. Results The final scale included 31 items and demonstrated strong internal consistency (Kuder Richardson Coefficient = 0.90), reasonable construct validity, and acceptable test-retest reliability (ρ = 0.72). Conclusion The Weight Literacy Scale is a reliable and valid research instrument to assess weight literacy among English- and Spanish-speaking adults.

A Web-Based Treatment Decision Support Tool for Patients With Advanced Knee Arthritis: Evaluation of User Interface and Content Design

Background Data-driven surgical decisions will ensure proper use and timing of surgical care. We developed a Web-based patient-centered treatment decision and assessment tool to guide treatment decisions among patients with advanced knee osteoarthritis who are considering total knee replacement surgery. Objective The aim of this study was to examine user experience and acceptance of the Web-based treatment decision support tool among older adults. Methods User-centered formative and summative evaluations were conducted for the tool. A sample of 28 patients who were considering total knee replacement participated in the study. Participants’ responses to the user interface design, the clarity of information, as well as usefulness, satisfaction, and acceptance of the tool were collected through qualitative (ie, individual patient interviews) and quantitative (ie, standardized Computer System Usability Questionnaire) methods. Results Participants were older adults with a mean age of 63 (SD 11) years. Three-quarters of them had no technical questions using the tool. User interface design recommendations included larger fonts, bigger buttons, less colors, simpler navigation without extra “next page” click, less mouse movement, and clearer illustrations with simple graphs. Color-coded bar charts and outcome-specific graphs with positive action were easiest for them to understand the outcomes data. Questionnaire data revealed high satisfaction with the tool usefulness and interface quality, and also showed ease of use of the tool, regardless of age or educational status. Conclusions We evaluated the usability of a patient-centered decision support tool designed for advanced knee arthritis patients to facilitate their knee osteoarthritis treatment decision making. The lessons learned can inform other decision support tools to improve interface and content design for older patients’ use.