Christopher N. Sciamanna

Evaluation of an internet-based physical activity intervention: A preliminary investigation

The Internet has the potential for delivering innovative, interactive physical activity (PA) interventions to large numbers of people. This study was designed to test the efficacy of an Internet intervention that consisted of a Web site plus 12 weekly e-mail tip sheets, compared with a waiting list control group. The Internet intervention was theory based and emphasized clear, graphical presentation of PA information. Sixty-five (30 intervention and 35 control) sedentary adult employees of several large hospitals (9 men and 56 women) were randomly assigned to 1 of the 2 study arms. Of the 65 participants, 57 completed the 1-month follow-up, and 52 completed the 3-month follow-up. At both 1 and 3 months, those in the intervention group were significantly more likely to have progressed in stage of motivational readiness for PA than participants in the control group: 1 month, χ2(1, N=52) = 4.05, p > .05; 3 months, χ2(1, N = 52) = 6.45, p > .01. We hypothesized that at 1 and 3 months, the intervention group would exhibit significant increases relative to the control group on the number of minutes of moderate activity. At the 1-month assessment, the intervention group did exhibit significant increases, relative to the control group in moderate minutes, F(1, 54) = 5.79, p > .05; however, at the 3-month assessment this difference was no longer significant. In addition, secondary analyses were conducted to examine total number of minutes of walking reported. At 1 month, the intervention group did exhibit significant increases, relative to the control group, in walking minutes, F(1, 54) = 12.1, p > .001. At the 3-month assessment, amount of time spent in walking activity continued to be significantly higher for the intervention group compared with the control group, F(1, 48) = 5.2, p > .05. These findings show that a theoretically based PA Web site and weekly e-mail tip sheets can have a short-term impact on PA motivation and behavior both at 1 and 3 months. As Internet access increases, and as bandwith and other technical attributes of this medium improve, Web site delivered health behavior interventions will become increasingly useful in public health promotion.

Long-term weight loss maintenance in the United States

Context:Although the rise in overweight and obesity in the United States is well documented, long-term weight loss maintenance (LTWLM) has been minimally explored.Objective:The aim of this study is to estimate the prevalence and correlates of LTWLM among US adults.Design, setting and participants:We examined weight data from 14 306 participants (age 20–84 years) in the 1999–2006 National Health and Nutrition Examination Survey (NHANES). We defined LTWLM as weight loss maintained for at least 1 year. We excluded individuals who were not overweight or obese at their maximum weight.Results:Among US adults who had ever been overweight or obese, 36.6, 17.3, 8.5 and 4.4% reported LTWLM of at least 5, 10, 15 and 20%, respectively. Among the 17.3% of individuals who reported an LTWLM of at least 10%, the average and median weight loss maintained was 19.1 kg (42.1 pounds) and 15.5 kg (34.1 pounds), respectively. LTWLM of at least 10% was higher among adults of ages 75–84 years (vs ages 20–34, adjusted odds ratio (OR): 1.5; 95% confidence interval (CI): 1.2, 1.8), among those who were non-Hispanic white (vs Hispanic, adjusted OR: 1.6; 95% CI: 1.3, 2.0) and among those who were female (vs male, adjusted OR: 1.2; 95% CI: 1.1, 1.3).Conclusions:More than one out of every six US adults who has ever been overweight or obese has accomplished LTWLM of at least 10%. This rate is significantly higher than those reported in clinical trials and many other observational studies, suggesting that US adults may be more successful at sustaining weight loss than previously thought.

Telephone Versus Print Delivery of an Individualized Motivationally Tailored Physical Activity Intervention: Project STRIDE

OBJECTIVE Given that only 25% of Americans meet physical activity recommendations, there is a need to develop and disseminate effective, evidence-based interventions to promote physical activity. The authors tested 2 delivery channels, telephone and print, to determine whether one was more effective in promoting physical activity. DESIGN The authors randomly assigned 239 healthy, sedentary adults to (a) telephone-based individualized feedback, (b) print-based individualized feedback, or (c) contact control. Both intervention arms were guided by a motivationally tailored, theoretically driven computer expert system. MAIN OUTCOME MEASURES Physical activity as measured by the 7-day Physical Activity Recall interview. RESULTS At 6 months, both telephone and print arms significantly increased in minutes of moderate intensity physical activity compared with control, with no differences between the intervention arms. At 12 months, print participants reported a significantly greater number of moderate intensity minutes than both telephone and control participants, who did not differ. CONCLUSION Results suggest that both telephone and print enhance the adoption of physical activity among sedentary adults; however, print interventions may be particularly effective in maintaining physical activity in the longer term.

Smoking cessation treatment on the Internet: Content, quality, and usability

The explosive growth in access to the Internet suggests that the Internet may be a viable channel through which we can reach and treat the large population of smokers who are unlikely to use other modes of intervention. We applied national guidelines from the U.S. Public Health Service to assess the quality of interventions for smoking cessation that are available on the Internet. The Public Health Service guidelines were codified into two instruments to record and to rate quality of the intervention contents. Usability guidelines established by the National Cancer Institute were used to develop an instrument to assess Web site usability. Of the 202 Web sites identified in searches, 77% did not provide direct intervention over the Internet and were excluded from analyses. A total of 46 Web sites were included in our review. Usability assessments showed mixed results. Web sites were visually well organized and used consistent graphical design; however, reading difficulty averaged above the 8th-grade level. Over 80% of Web sites provided no coverage of one or more of the key components of tobacco treatment recommended in the guidelines. Ironically, areas receiving the least coverage were those most amenable to the interactive capabilities of the Internet, such as providing tailored, personalized advice to quit and arranging follow-up contact. Smokers seeking quality tobacco dependence treatment on the Internet may have difficulty distinguishing among the numerous Web sites available. Web sites that provide direct treatment often fail to fully implement treatment guidelines and do not take full advantage of the interactive and tailoring capabilities of the Internet.

A Silent Response to the Obesity Epidemic Decline in US Physician Weight Counseling

Background:Guidelines recommend that physicians screen all adults for obesity and offer an intensive counseling and behavioral interventions for weight loss for obese adults. Current trends of weight-related counseling are unknown in the setting of the US obesity epidemic. Objectives:To describe primary care physician (PCP) weight-related counseling, comparing counseling rates in 1995–1996 and 2007–2008. Research Design:Data analysis of outpatient PCP visits in 1995–1996 and 2007–2008, as reported in the National Ambulatory Medical Care Survey. Subjects:A total of 32,519 adult primary care visits with PCPs. Measures:Rates of counseling for weight, diet, exercise, and a composite variable, weight-related counseling (defined as counseling for weight, diet, or exercise) between survey years. Adjusted analyses controlled for patient and visit characteristics. Results:Weight counseling declined from 7.8% of visits in 1995–1996 to 6.2% of visits in 2007–2008 [adjusted odds ratios, 0.64; 95% confidence intervals, 0.53, 0.79]. Rates of receipt of diet, exercise, and weight-related counseling similarly declined. Greater declines in odds of weight-counseling receipt were observed among those with hypertension (47%), diabetes (59%), and obesity (41%), patients who stand the most to gain from losing weight. Conclusions:Rates of weight counseling in primary care have significantly declined despite increased rates of overweight and obesity in the United States. Further, these declines are even more marked in patients with obesity and weight-related comorbidities, despite expectations to provide such care by both patients and policymakers. These findings have implications for determining deliverable, novel ways to engage PCPs in addressing the obesity epidemic.

Comparative effectiveness of diagnostic testing strategies in emergency department patients with chest pain: an analysis of downstream testing, interventions, and outcomes.

IMPORTANCE Patients presenting to the emergency department (ED) with chest pain whose evaluation for ischemia demonstrates no abnormalities receive further functional or anatomical studies for coronary artery disease; however, comparative evidence for the various strategies is lacking and multiple testing options exist. OBJECTIVE To compare chest pain evaluation pathways based on their association with downstream testing, interventions, and outcomes for patients in EDs. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of health insurance claims data for a national sample of privately insured patients from January 1 to December 31, 2011. Individuals with a primary or secondary diagnosis of chest pain in the ED were selected and classified into 1 of 5 testing strategies: no noninvasive testing, exercise electrocardiography, stress echocardiography, myocardial perfusion scintigraphy, or coronary computed tomography angiography. MAIN OUTCOMES AND MEASURES The proportion of patients in each group who received a cardiac catheterization, coronary revascularization procedure, or future noninvasive test as well as those who were hospitalized for an acute myocardial infarction (MI) during 7 and 190 days of follow-up. RESULTS In 2011, there were 693 212 ED visits with a primary or secondary diagnosis of chest pain, accounting for 9.2% of all ED encounters. After application of the inclusion and exclusion criteria, 421 774 patients were included in the final analysis; 293 788 individuals did not receive an initial noninvasive test and 127 986 did, representing 1.7% of all ED encounters. Overall, the percentage of patients hospitalized with an MI was very low during both 7 and 190 days of follow-up (0.11% and 0.33%, respectively). Patients who did not undergo initial noninvasive testing were no more likely to experience an MI than were those who did receive testing. Compared with no testing, exercise electrocardiography, myocardial perfusion scintigraphy, and coronary computed tomography angiography were associated with significantly higher odds of cardiac catheterization and revascularization procedures without a concomitant improvement in the odds of experiencing an MI. CONCLUSIONS AND RELEVANCE Patients with chest pain evaluated in the ED who do not have an MI are at very low risk of experiencing an MI during short- and longer-term follow-up in a cohort of privately insured patients. This low risk does not appear to be affected by the initial testing strategy. Deferral of early noninvasive testing appears to be reasonable.

Using electronic/computer interventions to promote physical activity

The internet has been used as a method to deliver various health interventions (eg, weight management, smoking cessation, increasing physical activity). An electronic search (ie, PubMed, PsycInfo, Web of Science) for internet-based physical activity interventions among adults yields fewer than 25 studies. Although many have considered physical activity as one element of a multifactorial behavioural intervention, few have focused exclusively on changing sedentary behaviour. Overall, current results are encouraging and it appears that response to an internet-based physical activity intervention is similar to response to other more established, effective interventions. Given that primary care referrals for physical activity are successful in changing sedentary behaviour to some extent, there is an urgent need for investigations into the effect of using an internet-based physical activity programme within the context of primary care. Although no studies that have combined an established internet-based physical activity programme with primary care were found, there is evidence that significant progress would probably be made by providing clinicians with information on internet-based physical activity programmes.

Ethnic/racial disparities in hospital procedure volume for lung resection for lung cancer.

Background:Ethnic/racial minorities experience poorer outcomes from lung cancer than non-Hispanic whites. Higher hospital procedure volume is associated with better survival from lung resection for lung cancer. Objectives:We examined whether (1) ethnic/racial minorities are more likely to obtain lung resections at lower volume hospitals, (2) ethnicity/race is associated with inpatient mortality, (3) hospital volume mediates this association, and (4) hospital selection is mediated by racial/ethnic segregation, differences in insurance coverage, or limited hospital choice. Methods:Six years of data from the Nationwide Inpatient Sample (NIS 1998–2003, unweighted n = 50,245, weighted n = 129,506) were used in multivariate models controlling for sociodemographic factors, case complexity, and hospital characteristics. Additional analyses were conducted using the Area Resource File, which provided data on ethnic density and number of surgical hospitals in the hospital region. Results:Blacks/African Americans (odds ratio [OR] = 0.45; 0.34–0.58) and Latinos (OR = 0.44; 0.32–0.63) had lower odds of obtaining lung resection at a high-volume hospital than non-Hispanic whites. Blacks/African Americans (OR = 1.30; 1.01–1.67), Latinos (OR = 1.41; 1.02–1.94), and other racial/ethnic minorities (OR = 1.46; 1.04–2.06) also had higher odds of dying in hospital, but this association was statistically nonsignificant after controlling for hospital volume. Hospital location was not associated with lung resection procedure volume, nor did location mediate the association between ethnicity/race and hospital volume. Conclusions:Ethnic/racial minorities are obtaining lung resection in lower volume hospitals and are more likely to die in hospital. Hospital volume is associated with higher mortality, but health insurance, segregation, and number of surgical hospitals within a county do not account for observed disparities.

Comparison of five measures of motivation to quit smoking among a sample of hospitalized smokers

AbstractOBJECTIVE: To compare the predictive validity of several measures of motivation to quit smoking among inpatients enrolled in a smoking cessation program. METHODS: Data collected during face-to-face counseling sessions included a standard measure of motivation to quit (stage of readiness [Stage]: precontemplation, contemplation, or preparation) and four items with responses grouped in three categories: “How much do you want to quit smoking” (Want), “How likely is it that you will stay off cigarettes after you leave the hospital” (Likely), “Rate your confidence on a scale from 0 to 100 about successfully quitting in the next month” (Confidence), and a counselor assessment in response to the question, “How motivated is this patient to quit?” (Motivation). Patients were classified as nonsmokers if they reported not smoking at both the 6-month and 12-month interviews. All patients lost to follow-up were considered smokers. MAIN RESULTS: At 1 year, the smoking cessation rate was 22.5%. Each measure of motivation to quit was independently associated with cessation (p<.001) when added individually to an adjusted model. Likely was most closely associated with cessation and Stage was least. Likely had a sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio of 70.2%, 68.1%, 39.3%, 88.6%, and 2.2, respectively. CONCLUSIONS: The motivation of inpatient smokers to quit may be as easily and as accurately predicted with a single question as with the series of questions that are typically used.

Practices Associated with Weight Loss Versus Weight-Loss Maintenance Results of a National Survey

BACKGROUND Few studies have examined the weight-control practices that promote weight loss and weight-loss maintenance in the same sample. PURPOSE To examine whether the weight control practices associated with weight loss differ from those associated with weight-loss maintenance. METHODS Cross-sectional survey of a random sample of 1165 U.S. adults. The adjusted associations of the use of 36 weight-control practices in the past week with success in weight loss (≥10% lost in the past year) and success in weight-loss maintenance (≥10% lost and maintained for ≥1 year) were examined. RESULTS Of the 36 practices, only 8 (22%) were associated with both weight loss and weight-loss maintenance. Overall, there was poor agreement (kappa=0.22) between the practices associated with weight loss and/or weight-loss maintenance. For example, those who reported more often following a consistent exercise routine or eating plenty of low-fat sources of protein were 1.97 (95% CI=1.33, 2.94) and 1.76 (95% CI=1.25, 2.50) times more likely, respectively, to report weight-loss maintenance but not weight loss. Alternatively, those who reported more often doing different kinds of exercises or planning meals ahead of time were 2.56 (95% CI=1.44, 4.55) and 1.68 (95% CI=1.03, 2.74) times more likely, respectively, to report weight loss but not weight-loss maintenance. CONCLUSIONS Successful weight loss and weight-loss maintenance may require two different sets of practices. Designing interventions with this premise may inform the design of more effective weight-loss maintenance interventions.