David L. Mount

One-year changes in symptoms of depression and weight in overweight/obese individuals with type 2 diabetes in the Look AHEAD study.

Depressed individuals are frequently excluded from weight loss trials because of fears that weight reduction may precipitate mood disorders, as well as concerns that depressed participants will not lose weight satisfactorily. The present study examined participants in the Look AHEAD study to determine whether moderate weight loss would be associated with incident symptoms of depression and suicidal ideation, and whether symptoms of depression at baseline would limit weight loss at 1 year. Overweight/obese adults with type 2 diabetes (n = 5,145) were randomly assigned to an Intensive Lifestyle Intervention (ILI) or a usual care group, Diabetes Support and Education (DSE). Of these, 5,129 participants completed the Beck Depression Inventory (BDI) and had their weight measured at baseline and 1 year. Potentially significant symptoms of depression were defined by a BDI score ≥10. Participants in ILI lost 8.6 ± 6.9% of initial weight at 1 year, compared to 0.7 ± 4.8% for DSE (P < 0.001, effect size = 1.33), and had a reduction of 1.4 ± 4.7 points on the BDI, compared to 0.4 ± 4.5 for DSE (P < 0.001, effect size = 0.23). At 1 year, the incidence of potentially significant symptoms of depression was significantly lower in the ILI than DSE group (6.3% vs. 9.6%) (relative risk (RR) = 0.66, 95% confidence interval (CI) = 0.5, 0.8; P < 0.001). In the ILI group, participants with and without symptoms of depression lost 7.8 ± 6.7% and 8.7 ± 6.9%, respectively, a difference not considered clinically meaningful. Intentional weight loss was not associated with the precipitation of symptoms of depression, but instead appeared to protect against this occurrence. Mild (or greater) symptoms of depression at baseline did not prevent overweight/obese individuals with type 2 diabetes from achieving significant weight loss.

Self-reported influences of hopelessness, health literacy, lifestyle action, and patient inertia on blood pressure control in a hypertensive emergency department population.

Background:In response to almost universally recorded poor blood pressure (BP) control rates, we developed a novel health paradigm model to examine the mindset behind BP control barriers. This approach, termed patient inertia (PtInert), is defined as an individual’s failure to take responsibility for health conditions and proactive change. Methods:PtInert was evaluated through a survey instrument conducted in 85 subjects with a prior history of hypertension seen in an emergency department. The survey tool encompassed the Wide Range Achievement Test 4, the brief symptom inventory, and a PtInert questionnaire. Results:Fifty percent of patients reported slight psychological distress (psychosomatic > anxiety > depression), with 61% possessing hopelessness surrounding complications from high BP no matter their actions. An unanticipated finding was that patients who had a low reading proficiency (83.1 + 16.4 Wide Range Achievement Test 4 standard score) self-reported high levels of hypertension health literacy. Less than half of patients transferred this health literacy into lifestyle changes in diet, exercise, and medication adherence. Although patients felt that they could control their BP and frequently thought about better BP control, 55% of the subjects had uncontrolled hypertension (>140/90 mm Hg). Conclusion:Hypertensive patients visiting our emergency department perceive themselves to have adequate hypertension health-related literacy that was not transferred into hypertension health protective behavioral practices. Psychological distress and a sense of hopelessness surrounding BP control contribute to the lack of protective behavioral health practices. Further evaluations of PtInert methods to promote successful proactive change and adherence warrant further study.

The associations of multiple dimensions of discrimination and abdominal fat in African American adults: the Jackson Heart Study.

BackgroundDiscrimination may be adversely associated with abdominal obesity, but few studies have examined associations with abdominal fat.PurposeThe purpose of this study was to examine whether discrimination was independently associated with visceral (VAT) and subcutaneous (SAT) fat and whether these associations differed by sex and age.MethodsParticipants self-reported experiences of everyday and lifetime discrimination. The main reason for and the coping response to these experiences were also reported. VAT and SAT were quantified by computed tomography.ResultsIn fully adjusted models, higher reports of everyday discrimination were associated with greater SAT, but not VAT, volumes in men only: SAT increased by 3.6 (standard error = 1.8) cm3 for each unit increase in the everyday discrimination score. In women, higher reports of lifetime non-racial discrimination were associated with greater VAT (71.6 ± 32.0, P < 0.05) and SAT (212.6 ± 83.6, P < 0.05), but these relationships were attenuated after controlling for body mass index.ConclusionsThese cross-sectional findings do not fully support the independent hypothesis of discrimination and abdominal fat. Additional investigations involving longitudinal designs are warranted.

Factors influencing enrollment of African Americans in the Look AHEAD trial

Background Many factors have been identified that influence the recruitment of African Americans into clinical trials; however, the influence of eligibility criteria may not be widely appreciated. We used the experience from the Look AHEAD (Action for Health in Diabetes) trial screening process to examine the differential impact eligibility criteria had on the enrollment of African Americans compared to other volunteers. Methods Look AHEAD is a large randomized clinical trial to examine whether assignment to an intensive lifestyle intervention designed to produce and maintain weight loss reduces the long-term risk of major cardiovascular events in adults with type 2 diabetes. Differences in the screening, eligibility, and enrollment rates between African Americans and members of other racial/ethnic groups were examined to identify possible reasons. Results Look AHEAD screened 28,735 individuals for enrollment, including 6226 (21.7%) who were self-identified African Americans. Of these volunteers, 12.9% of the African Americans compared to 19.3% of all other screenees ultimately enrolled (p < 0.001). African Americans no more often than others were lost to follow-up or refused to attend clinic visits to establish eligibility. Furthermore, the enrollment rates of individuals with histories of cardiovascular disease and diabetes therapy did not markedly differ between the ethnic groups. Higher prevalence of adverse levels of blood pressure, heart rate, HbA1c, and serum creatinine among African American screenees accounted for the greater proportions excluded (all p < 0.001). Conclusions Compared to non-African Americans, African American were more often ineligible for the Look AHEAD trial due to comorbid conditions. Monitoring trial eligibility criteria for differential impact, and modifying them when appropriate, may ensure greater enrollment yields.

Emergency Department Patients Self‐Report Higher Patient Inertia, Hopelessness, and Harmful Lifestyle Choices Than Community Counterparts

J Clin Hypertens (Greenwich). 2012;14:828–835. ©2012 Wiley Periodicals, Inc.

Constructing common cohorts from trials with overlapping eligibility criteria: Implications for comparing effect sizes between trials

Background Comparing findings from separate trials is necessary to choose among treatment options, however differences among study cohorts may impede these comparisons. Purpose As a case study, to examine the overlap of study cohorts in two large randomized controlled clinical trials that assess interventions to reduce risk of major cardiovascular disease events in adults with type 2 diabetes in order to explore the feasibility of cross-trial comparisons Methods The Action for Health in Diabetes (Look AHEAD) and The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trials enrolled 5145 and 10,251 adults with type 2 diabetes, respectively. Look AHEAD assesses the efficacy of an intensive lifestyle intervention designed to produce weight loss; ACCORD tests pharmacological therapies for control of glycemia, hyperlipidemia, and hypertension. Incidence of major cardiovascular disease events is the primary outcome for both trials. A sample was constructed to include participants from each trial who appeared to meet eligibility criteria and be appropriate candidates for the other trial’s interventions. Demographic characteristics, health status, and outcomes of members and nonmembers of this constructed sample were compared. Results Nearly 80% of Look AHEAD participants were projected to be ineligible for ACCORD; ineligibility was primarily due to better glycemic control or no early history of cardiovascular disease. Approximately 30% of ACCORD participants were projected to be ineligible for Look AHEAD, often for reasons linked to poorer health. The characteristics of participants projected to be jointly eligible for both trials continued to reflect differences between trials according to factors likely linked to retention, adherence, and study outcomes. Limitations Accurate ascertainment of cross-trial eligibility was hampered by differences between protocols. Conclusions Despite several similarities, the Look AHEAD and ACCORD cohorts represent distinct populations. Even within the subsets of participants who appear to be eligible and appropriate candidates for trials of both modes of intervention, differences remained. Direct comparisons of results from separate trials of lifestyle and pharmacologic interventions are compromised by marked differences in enrolled cohorts. Clinical Trials 2009; 6: 416—429. http://ctj.sagepub.com

Preliminary findings exploring the social determinants of Black males' lay health perspectives.

The unequal discussion of Black males’ health is a pressing social problem. This study addressed Black males’ lay perspectives regarding their health, illness, and mortality, with attention to the determinants of men’s health, prevention, lifestyle, and opportunities for health promotion using an exploratory/qualitative research methodology. Participants were 68 Black males aged 15 to 68 years, with an average age of 44 years (SD = 14.5). The narratives represented a complex interplay of biopsychosocial factors, ranging from intrapersonal attitudes, interpersonal experiences to discussions about community and public policy injustices. Five prominent themes emerged: (a) lack of chronic disease awareness, (b) fatalism, (c) fear and anxiety of academic–medical settings, (d) hyperactive masculinity fatigue, and (e) the gay–straight divide. The term Tired Black Male Health syndrome was coined in the forum. Implications of these findings are discussed in the context of culturally relevant strategies for improving Black male community health engagement.

Behavioral and Emotional Problem Scales of the Behavioral Assessment for Children of African Heritage (BACAH) Culturally Valid Measurement of Psychological Functioning in Black Children

Using extensive African American community input, Black researchers developed the Behavioral Assessment for Children of African Heritage (BACAH). Information regarding its strength dimensions is published but not its behavioral and emotional problem scales. Rational (i.e., expert opinion and mathematical) procedures grouped BACAH problem item responses from 1,465 youth, parent, and teacher informants into eight cross-informant scales labeled Anxiety-, Attention/Hyperactive-, Conduct-, Depression-, Hypomania/Mania-, Oppositional-Defiance-, Self-Destructive-, and Reality-Contact-Problems. Data analyses showed no response bias across child gender, socioeconomic status, or age groupings, but bias emerged across informant type, referral status, and rating scale type (i.e., presence and magnitude vs. concern levels regarding problems). Item linking reduced this bias. Items on each BACAH scale discriminate well for problem levels they assess and capably measure children’s problem levels, ranging from moderately below to above the mean. This study’s foundation and findings provide professionals and their test respondents with culturally valid, user friendly, economical, and highly flexible, clinical/research tools to assess Black children’s functioning.

Addressing Risk Factors for Neurocognitive Decline and Alzheimer’s Disease Among African Americans in the Era of Health Disparities

More than any other time in the past, the world is now paying attention to the public health implications of neurological health, ranging from cognitive aging, and mild cognitive impairment to neurodegenerative conditions such Alzheimer’s disease. It is estimated that every 69 seconds someone develops AD related symptoms, and by 2050, the rate of developing this condition will be about every 33 seconds (Alzheimers Association 2011). As a leading public interest organization, the national Alzheimer’s Association 2011 report also mentions that in 2010, 14.9 million family members and friends provided 17 billion hours of unpaid care to those with Alzheimer’s and other types of dementia, a care valued at

Factors Associated with Label Preference and Mental Health Quality of Life among College-Aged African American Sexual Minority Men

202.6 billion. Adverse neurocognitive functioning is now front and center of public health concerns as more than 5.4. million people are living with Alzheimer’s disease (AD). Within the continuum of health disparities, we are now learning that risk for Alzheimer’s disease (AD) is 14-100% more likely for African Americans when compared to Caucasian Americans (Taylor, Sloan et al. 2004; Manly 2008; Weiner 2008). For all too many African Americans, the biopsychosocial threats to brain health and neurocognitive functioning are profoundly influenced by seen and unseen factors, ranging from inequalities in education, health, neighborhoods and communities, vocational opportunities, and access to wellness promoting resources. The cumulative effect of acute and chronic inequalities may be expressed through a differentially higher burden for brain-behavior vulnerability. Hence, identifying factors that are leading to an increased risk for adverse neurocognitive health and wellbeing is of highest priority in the black community.