E. Amy Janke

Overview of the relationship between pain and obesity: What do we know? Where do we go next?

Overweight/obesity and pain are significant problems of increasing prevalence; understanding the relationship between the two is the focus of a growing body of research. Findings from this review support a likely relationship between increasing weight and pain conditions such as osteoarthritis and low back pain. Longitudinal studies suggest overweight/obesity early in life is a risk factor for pain, and the co-occurrence of pain and overweight/obesity negatively affects quality of life. The mechanism of relationship is unknown but is hypothesized to include mechanical and metabolic abnormalities, possibly secondary to lifestyle choices. Observations from a few studies demonstrate that treatments for obesity reduce pain secondary to weight loss. Few studies examine both pain and weight as primary outcomes, and variability in measurement makes comparisons and conclusions difficult. Research should focus on expanding knowledge about mechanisms of the relationship between pain and obesity, testing explanatory models addressing their co-occurrence, and developing treatments that most effectively target this comorbidity.

Integrating Technology Into Standard Weight Loss Treatment: A Randomized Controlled Trial

BACKGROUND A challenge in intensive obesity treatment is making care scalable. Little is known about whether the outcome of physician-directed weight loss treatment can be improved by adding mobile technology. METHODS We conducted a 2-arm, 12-month study (October 1, 2007, through September 31, 2010). Seventy adults (body mass index >25 and ≤40 [calculated as weight in kilograms divided by height in meters squared]) were randomly assigned either to standard-of-care group treatment alone (standard group) or to the standard and connective mobile technology system (+mobile group). Participants attended biweekly weight loss groups held by the Veterans Affairs outpatient clinic. The +mobile group was provided personal digital assistants to self-monitor diet and physical activity; they also received biweekly coaching calls for 6 months. Weight was measured at baseline and at 3-, 6-, 9-, and 12-month follow-up. RESULTS Sixty-nine adults received intervention (mean age, 57.7 years; 85.5% were men). A longitudinal intent-to-treat analysis indicated that the +mobile group lost a mean of 3.9 kg more (representing 3.1% more weight loss relative to the control group; 95% CI, 2.2-5.5 kg) than the standard group at each postbaseline time point. Compared with the standard group, the +mobile group had significantly greater odds of having lost 5% or more of their baseline weight at each postbaseline time point (odds ratio, 6.5; 95% CI, 2.5-18.6). CONCLUSIONS The addition of a personal digital assistant and telephone coaching can enhance short-term weight loss in combination with an existing system of care. Mobile connective technology holds promise as a scalable mechanism for augmenting the effect of physician-directed weight loss treatment. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00371462.

A systematic review of psychosocial interventions to improve cancer caregiver quality of life

To evaluate and estimate the effect of psychosocial interventions on improving the quality of life (QoL) of adult cancer caregivers.

The more pain I have, the more I want to eat: obesity in the context of chronic pain.

Providers frequently report pain as a barrier to weight loss, and initial evidence suggests individuals with chronic pain and obesity experience reduced treatment success. However, scant evidence informs our understanding of how this comorbidity negatively influences treatment outcome. More effective programs might be designed with (i) insight into the patients experience of comorbid chronic pain and obesity and (ii) improved understanding of the behavioral linkages between the experience of pain, engagement in health behaviors, and obesity treatment outcomes. Thirty adult primary care patients with mean BMI = 36.8 (SD 8.9) and average 0–10 pain intensity = 5.6 (SD 1.9) participated in semistructured, in‐depth interviews. Transcriptions were analyzed using the constant comparative method. Five themes emerged indicating that patients with comorbid chronic pain and obesity experience: depression as magnifying the comorbid physical symptoms and complicating treatment; hedonic hunger triggered by physical pain and associated with depression and shame; emotional or “binge” eating in response to pain; altered dietary choices in response to pain; and low self‐efficacy for physical activity due to pain. Individuals with chronic pain and obesity may be less responsive to traditional interventions that fail to address the symbiotic relationship between the two conditions. These individuals are at‐risk for depressive symptoms and eating and activity patterns that sustain the comorbidity and make treatment problematic, and they may respond to pain with behaviors that promote weight gain, poor health and low mood. Further research is needed to examine behavioral mechanisms that promote comorbid pain and obesity, and to develop targeted treatment modules.

A closer look at pain and hepatitis C: preliminary data from a veteran population.

An association between the hepatitis C virus (HCV) and various pain diagnoses, including arthritis, fibromyalgia, and peripheral neuropathy, has been reported. In this article, we review the literature on the relationship between HCV and pain, highlighting current knowledge as well as methodological issues that exist in many studies. We also present preliminary findings from a survey conducted at two Department of Veterans Affairs facilities to assess the scope and impact of pain on functioning in veterans with HCV. Our results indicate that pain is very prevalent within this population and that HCV-positive veterans who experience persistent pain have significant depressive symptoms and engage in high-risk behaviors, such as cigarette smoking and alcohol use. Finally, we draw upon our review and preliminary results to propose areas of future rehabilitative research and to address the implications for clinicians working with patients with comorbid HCV and pain.

Psychosocial Issues in Hepatitis C: A Qualitative Analysis

BACKGROUND Despite demonstrated prevalence of psychosocial problems among hepatitis C (HCV) patients, little is known about how these problems develop, why they are sustained, and how clinical providers can effectively intervene. OBJECTIVE The authors used a qualitative approach to investigate the nature of psychosocial issues in HCV. METHOD Focus groups were conducted with HCV patients. RESULTS Participants discussed significant feelings of anger, depression, and stigma associated with the diagnosis and noted that these feelings/experiences isolated them from potential sources of social support. CONCLUSION Results have important implications for clinical providers and suggest pathways by which HCV-related psychosocial factors may interact with and affect quality of life.

A systematic review of the effects of experimental fasting on cognition.

Numerous investigations have been conducted on the impact of short-term fasting on cognition in healthy individuals. Some studies have suggested that fasting is associated with executive function deficits; however, findings have been inconsistent. The lack of consensus regarding the impact of short-term fasting in healthy controls has impeded investigation of the impact of starvation or malnutrition in clinical groups, such as anorexia nervosa (AN). One method of disentangling these effects is to examine acute episodes of starvation experimentally. The present review systematically investigated the impact of short-term fasting on cognition. Studies investigating attentional bias to food-related stimuli were excluded so as to focus on general cognition. Ten articles were included in the review. The combined results are equivocal: several studies report no observable differences as a result of fasting and others show specific deficits on tasks designed to test psychomotor speed, executive function, and mental rotation. This inconsistent profile of fasting in healthy individuals demonstrates the complexity of the role of short-term fasting in cognition; the variety of tasks used, composition of the sample, and type and duration of fasting across studies may also have contributed to the inconsistent profile. Additional focused studies on neuropsychological profiles of healthy individuals are warranted in order to better develop an understanding of the role of hunger in cognition.

PDA+: A Personal Digital Assistant for Obesity Treatment - An RCT testing the use of technology to enhance weight loss treatment for veterans

BackgroundObese adults struggle to make the changes necessary to achieve even modest weight loss, though a decrease in weight by as little as 10% can have significant health benefits. Failure to meet weight loss goals may in part be associated with barriers to obesity treatment. Wide-spread dissemination of evidence-based obesity treatment faces multiple challenges including cost, access, and implementing the programmatic characteristics on a large scale.AimsThe PDA+: A Personal Digital Assistant for Obesity Treatment randomized controlled trial (RCT) was designed to test whether a PDA-based behavioral intervention enhances the effectiveness of the existing group weight loss treatment program at VA Medical Centers Managing Overweight/Obese Veterans Everywhere (MOVE!). We also aim to introduce technology as a way to overcome systemic barriers of traditional obesity treatment.Methods/DesignVeterans enrolled in the MOVE! group at the Hines Hospital VAMC with BMI ≥ 25 and ≤ 40 and weigh < 400 pounds, experience chronic pain (≥ 4 on the NRS-I scale for ≥ 6 months prior to enrollment) and are able to participate in a moderate intensity exercise program will be recruited and screened for eligibility. Participants will be randomized to receive either: a) MOVE! treatment alone (Standard Care) or b) Standard Care plus PDA (PDA+). Those randomized to PDA+ will record dietary intake, physical activity, and weight on the PDA. In addition, they will also record mood and pain intensity, and receive biweekly telephone support for the first 6-months of the 12-month study. All participants will attend in-person lab sessions every three months to complete questionnaires and for the collection of anthropomorphic data. Weight loss and decrease in pain level intensity are the primary outcomes.DiscussionThe PDA+ trial represents an important step in understanding ways to improve the use of technology in obesity treatment. The trial will address barriers to obesity care by implementing effective behavioral components of a weight loss intervention and delivering high intensity, low cost obesity treatment. This RCT also tests an intervention approach supported by handheld technology in a population traditionally considered to have lower levels of technology literacy.Trial RegistrationClinicalTrials.gov: NCT00371462

Patient’s experience with comorbidity management in primary care: a qualitative study of comorbid pain and obesity

AIM The aim of this research is to examine perceptions of those with comorbid chronic pain and obesity regarding their experience of comorbidity management in primary care settings. BACKGROUND Chronic pain and obesity are common comorbidities frequently managed in primary care settings. Evidence suggests individuals with this comorbidity may be at risk for suboptimal clinical interactions; however, treatment experiences and preferences of those with comorbid chronic pain and obesity have received little attention. METHODS Semi-structured interviews conducted with 30 primary care patients with mean body mass index=36.8 and comorbid persistent pain. The constant comparative method was used to analyze data. FINDINGS Participants discussed frustration with a perceived lack of information tailored to their needs and a desire for a personalized treatment experience. Participants found available medical approaches unsatisfying and sought a more holistic approach to management. Discussions also focused around the need for providers to initiate efforts at education and motivation enhancement and to show concern for and understanding of the unique difficulties associated with comorbidity. Findings suggest providers should engage in integrated communication regarding weight and pain, targeting this multimorbidity using methods aligned with priorities discussed by patients.

Increasing the public health impact of evidence-based interventions in behavioral medicine: new approaches and future directions

The dissemination and implementation of evidence-based behavioral medicine interventions into real world practice has been limited. The purpose of this paper is to discuss specific limitations of current behavioral medicine research within the context of the RE-AIM framework, and potential opportunities to increase public health impact by applying novel intervention designs and data collection approaches. The MOST framework has recently emerged as an alternative approach to development and evaluation that aims to optimize multicomponent behavioral and bio-behavioral interventions. SMART designs, imbedded within the MOST framework, are an approach to optimize adaptive interventions. In addition to innovative design strategies, novel data collection approaches that have the potential to improve the public-health dissemination include mHealth approaches and considering environment as a potential data source. Finally, becoming involved in advocacy via policy related work may help to improve the impact of evidence-based behavioral interventions. Innovative methods, if increasingly implemented, may have the ability to increase the public health impact of evidence-based behavioral interventions to prevent disease.