Brian M. Shelley

Pilot study: Mindful Eating and Living (MEAL): Weight, eating behavior, and psychological outcomes associated with a mindfulness-based intervention for people with obesity

OBJECTIVES The purpose of this study was to pilot a brief (6-week) group curriculum for providing mindfulness training to obese individuals, called Mindful Eating and Living (MEAL). SETTING AND DESIGN Participants were recruited through a local Young Mens Christian Association (YMCA) in spring 2006. Data was collected at three time points: baseline, completion of intervention (6 weeks), and 3-month follow-up (12 weeks). INTERVENTION Six weekly two-hour group classes (with two monthly follow-up classes). Content included training in mindfulness meditation, mindful eating, and group discussion, with emphasis on awareness of body sensations, emotions, and triggers to overeat. MAIN OUTCOME MEASURES Key variables assessed included changes in weight, body-mass index (BMI), eating behavior, and psychological distress. In addition, physiological markers of cardiovascular risk were evaluated including C-reactive protein (hsCRP), adiponectin, low-density lipoprotein (LDL), and plasminogen activator inhibitor-1 (PAI-1). RESULTS Ten obese patients enrolled with a mean BMI of 36.9 kg/m² [SD±6.2]. The mean weight was 101 kg/m² and the mean age was 44 years (SD=8.7; range=31-62). Compared to baseline data, participants showed statistically significant increases in measures of mindfulness and cognitive restraint around eating, and statistically significant decreases in weight, eating disinhibition, binge eating, depression, perceived stress, physical symptoms, negative affect, and C-reactive protein. CONCLUSIONS This study provides preliminary evidence that a eating focused mindfulness-based intervention can result in significant changes in weight, eating behavior, and psychological distress in obese individuals.

’They Don’t Ask Me So I Don’t Tell Them’: Patient-Clinician Communication About Traditional, Complementary, and Alternative Medicine

PURPOSE Although high rates of traditional medicine and complementary and alternative medicine (TM/CAM) use have been well documented, there has been less attention to the factors influencing communication between patients and their primary care clinicians about TM/CAM. Such communication can be important in anticipating possible drug-herb interactions and in assuring agreement about therapeutic plans. METHODS We used sequential, multistage, qualitative methods, including focus groups, in-depth interviews, and a video vignette, to explore communication about TM/CAM between patients and their primary care clinicians. The study was conducted in RIOS Net (Research Involved in Outpatient Settings Network), a Southwestern US practice-based research network, situated largely in Hispanic and American Indian communities where TM/CAM is an important part of self-care. RESULTS One hundred fourteen patients, 41 clinic staff members, and 19 primary care clinicians in 8 clinic sites participated. The degree and nature of TM/ CAM communication is based on certain conditions in the clinical encounter. We categorized these findings into 3 themes: acceptance/nonjudgment, initiation of communication, and safety/efficacy. Perceived clinician receptivity to and initiation of discussion about TM/CAM strongly influenced patients’ decisions to communicate; perceived clinician expertise in TM/CAM was less important. Clinicians’ comfort with patients’ self-care approaches and their level of concern about lack of scientific evidence of effectiveness and safety of TM/CAM influenced their communication about TM/CAM with patients. CONCLUSIONS Specific communication barriers limit patient-clinician communication about TM/CAM. Clinicians who wish to communicate more effectively with their patients about these topics and better integrate the types of care their patients use can change the communication dynamic with simple strategies designed to overcome these barriers.

A Pilot Study Comparing the Effects of Mindfulness-Based and Cognitive-Behavioral Stress Reduction

OBJECTIVES The objective of this pilot study was to compare the effects of two mind-body interventions: mindfulness-based stress reduction (MBSR) and cognitive-behavioral stress reduction (CBSR). SUBJECTS Fifty (50) subjects were recruited from the community and took part in MBSR (n = 36) and CBSR (n = 14) courses. Participants self-selected into MBSR or CBSR courses taught at different times. There were no initial differences between the MBSR and CBSR subjects on demographics, including age, gender, education, and income. INTERVENTION MBSR was an 8-week course using meditation, gentle yoga, and body scanning exercises to increase mindfulness. CBSR was an 8-week course using cognitive and behavioral techniques to change thinking and reduce distress. DESIGN Perceived stress, depression, psychological well-being, neuroticism, binge eating, energy, pain, and mindfulness were assessed before and after each course. Pre-post scores for each intervention were compared by using paired t tests. Pre-post scores across interventions were compared by using a general linear model with repeated measures. SETTINGS/LOCATIONS: Weekly meetings for both courses were held in a large room on a university medical center campus. RESULTS MBSR subjects improved on all eight outcomes, with all of the differences being significant. CBSR subjects improved on six of eight outcomes, with significant improvements on well-being, perceived stress, and depression. Multivariate analyses showed that the MBSR subjects had better outcomes across all variables, when compared with the CBSR subjects. Univariate analyses showed that MBSR subjects had better outcomes with regard to mindfulness, energy, pain, and a trend for binge eating. CONCLUSIONS While MBSR and CBSR may both be effective in reducing perceived stress and depression, MBSR may be more effective in increasing mindfulness and energy and reducing pain. Future studies should continue to examine the differential effects of cognitive behavioral and mindfulness-based interventions and attempt to explain the reasons for the differences.

A Preliminary Study of the Effects of a Modified Mindfulness Intervention on Binge Eating

The purpose of this study was to explore the feasibility of a modified mindfulness intervention for reducing binge eating. Participants (n = 25) were recruited from the general public for a Mindfulness-Based Stress Reduction (MBSR) course. The standard MBSR format was modified to include brief eating exercises. There was no control group. Participants completed the Binge Eating Scale and other self-report measures before and after the course. There was a decline in binge eating as well as state anxiety and depressive symptoms. Reduced binge eating was related to increased self-acceptance and reduced state anxiety. The results are discussed with regard to laying the foundation for future research on the effects of mindfulness on eating.

Innovative Telementoring for Pain Management: Project ECHO Pain

Introduction: Project ECHO Pain, the innovative telementoring program for health professionals, was developed in 2009 at the University Of New Mexico Health Sciences Center to fill considerable gaps in pain management expertise. Substantive continuing education for clinicians who practice in rural and underserved communities convenes weekly by means of telehealth technology. Case‐based learning, demonstrations, and didactics are incorporated into the interprofessional program that helps to improve pain management in the primary care setting. Method: Three different approaches were used to evaluate the program over a 3‐year period: (1) evaluation of all weekly continuing medical education surveys; (2) aggregation of annual clinic data; and (3) assessment of practice change in clinicians who joined Project ECHO Pain for at least 1 year. Results: Between January 2010 and December 2012, 136 Project ECHO Pain clinics were held, with 3835 total instances of participation, representing 763 unique individuals from 191 different sites. Sixty percent self‐identified as advanced practice or other nonphysician health professional. Statistically significant improvements in participant self‐reported knowledge, skills, and practice were demonstrated. Focus group analyses of 9 subjects detailed specific practice improvements. Discussion: Project ECHO Pain is a successful continuing professional development program. The telementoring model closes the large knowledge gap in pain education seen in primary care and other settings. Expertise is delivered by implementing effective, evidence‐based, and work‐based education for diverse health professionals. Project ECHO Pain serves as a model for interprofessional collaborative practice.

Who Is Willing to Use Complementary and Alternative Medicine

OBJECTIVE The aim of this study was to identify individual differences associated with the willingness to use complementary and alternative medicine (CAM). DESIGN A questionnaire was administered and the relationship between individual differences and the willingness to use CAM was examined using correlation and multiple regression analyses. PARTICIPANTS The sample consisted of 276 undergraduate students (64% female) of diverse ethnicity (43% white, 33% Hispanic, 8% Native American, 16% other) and a wide range of incomes. MEASURES The willingness to use 16 types of CAM was assessed for six categories: whole medical systems, mind-body medicine, biologically based practices, manipulative and body-based practices, energy medicine, and spiritually based practices. The individual differences assessed included age, gender, income, ethnicity, the Big Five personality characteristics, optimism, spirituality, religiosity, and three aspects of emotional intelligence: mood attention, mood clarity, and mood repair. RESULTS The individual differences accounted for approximately one fifth of the variance in overall willingness to use CAM. Openness to experience, spirituality, and mood attention were the strongest predictors of overall willingness to use CAM and were related to the willingness to use most of the individual types of CAM. Older age or female gender was related to greater willingness to use most of the mind-body medicines. Hispanic ethnicity was related to greater willingness to use curanderismo, and Native American ethnicity was related to greater willingness to use Native American medicine and a spiritual/faith healer.

The Marriage of Community-based Participatory Research and Practice-based Research Networks: Can It Work? –A Research Involving Outpatient Settings Network (RIOS Net) Study

Background: Interest in community-based participatory research (CBPR) has surged during the last several years because of its potential to enhance the quality and usefulness of research outcomes. Practice-based research networks (PBRNs) potentially can provide a bridge between the research endeavor and communities; PBRNs have been identified as a promising venue for CBPR. However, this marriage of CBPR and PBRNs faces many challenges, such as locus of project idea generation, time constraints, and funding limitations. Methods: This was a case study of the application of the CBPR model and CBPR principles specific to PBRN research using a recent PBRN study of communication about traditional, complementary, and alternative medicines. Results: Challenges (eg, added cost, time) and benefits (eg, improved research data collection process, enhanced data analysis) resulted from application of the CBPR model and are detailed. Conclusions: For practical and ethical reasons, PBRNs need to adopt the CBPR approach for certain types, if not all, of their research. This might require operational adaptations by the PBRN (eg, a community advisory board, community membership in the network board of directors, and outreach to community groups for input into network priorities) as well as dedicated time and funding.

Expanding Health Care Access Through Education: Dissemination and Implementation of the ECHO Model

Project ECHO (Extension for Community Healthcare Outcomes) is an evidence-based model that provides high-quality medical education for common and complex diseases through telementoring and comanagement of patients with primary care clinicians. In a one to many knowledge network, the ECHO model helps to bridge the gap between primary care clinicians and specialists by enhancing the knowledge, skills, confidence, and practice of primary care clinicians in their local communities. As a result, patients in rural and urban underserved areas are able to receive best practice care without long waits or having to travel long distances. The ECHO model has been replicated in 43 university hubs in the United States and five other countries. A new replication tool was developed by the Project ECHO Pain team and U.S. Army Medical Command to ensure a high-fidelity replication of the model. The adoption of the tool led to successful replication of ECHO in the Army Pain initiative. This replication tool has the potential to improve the fidelity of ECHO replication efforts around the world.

Integrative Medicine Research in New Mexico: Lessons From the Published Literature:

This review provides an in-depth examination of traditional, complementary, and alternative medicine (TCAM) and/or integrative medicine (IM) research in New Mexico, where many unique cultural and traditional healing systems are still commonly used. A comprehensive search for all recent research studies relating to TCAM/IM in New Mexico was carried out by the author. The survey identified 14 research studies, both quantitative and qualitative, published from 1990 to 2004 that included subjects and data on New Mexico. The studies were grouped into the areas of traditional systems and beliefs, mind-body medicine, natural health products, and conventional providers and complementary and alternative medicine, and individual studies were summarized, with the authors commentary. The review confirms that patients in New Mexico from diverse cultures extensively use various forms of TCAM/IM, yet communication about this topic with conventional health care providers is not optimal. The results of this review will inform future education, research, and health care policy in New Mexico.

ECHO Pain Curriculum: Balancing Mandated Continuing Education With the Needs of Rural Health Care Practitioners

Abstract: Chronic pain is a common problem in the United States. Health care professions training at the undergraduate and graduate levels in managing chronic pain is insufficient. The Chronic Pain and Headache Management TeleECHO Clinic (ECHO Pain) is a telehealth approach at Project ECHO (Extension for Community Healthcare Outcomes), which supports clinicians interested in improving their knowledge and confidence in treating patients with chronic pain and safe opioid management. It is a vehicle for educating practicing clinicians (at the “spoke”) based on work-place learning with cases selected by participants from their patient panels combined with short lectures by experts (at the “hub”). ECHO Pain has designed an innovative, interprofessional longitudinal curriculum appropriate for individual and team-based clinicians which includes relevant basic and advanced pain topics. The specific design and delivery of the curriculum enhances its relevance and accessibility to busy clinicians in practice, yet also satisfies statutory requirements for CME in New Mexico. Specific features which balance hub-and-spoke needs are presented in this descriptive article, which is intended to serve as a guide to other clinician educators interested in developing or implementing similar telehealth curricula.