Etienne Phipps

One-Year Results of the Think Health! Study of Weight Management in Primary Care Practices

The Think Health! study evaluated a behavioral weight loss program adapted from the Diabetes Prevention Program (DPP) lifestyle intervention to assist primary care providers (PCPs) and auxiliary staff acting as lifestyle coaches (LCs) in offering weight loss counseling to their patients. In a randomized trial conducted at five clinical sites, study participants were randomly assigned in a 1:1 ratio within each site to either “Basic Plus” (n = 137), which offered PCP counseling every 4 months plus monthly LC visits during the first year of treatment, or “Basic” (n = 124), which offered only PCP counseling every 4 months. Participants were primarily (84%) female, 65% African American, 16% Hispanic American, and 19% white. In the 72% of participants in each treatment group with a 12‐month weight measurement, mean (95% CI) 1‐year weight changes (kg) were −1.61 (−2.68, −0.53) in Basic Plus and −0.62 (−1.45, 0.20) in Basic (difference: 0.98 (−0.36, 2.33); P = 0.15). Results were similar in model‐based estimates using all available weight data for randomized participants, adjusting for potential confounders. More Basic Plus (22.5%) than Basic (10.2%) participants lost ≥5% of their baseline weight (P = 0.022). In a descriptive, nonrandomized analysis that also considered incomplete visit attendance, mean weight change was −3.3 kg in Basic Plus participants who attended ≥5 LC visits vs. + 0.53 kg in those attending <5 LC visits. We conclude that the Basic Plus approach of moderate‐intensity counseling by PCPs and their staff can facilitate modest weight loss, with clinically significant weight loss in high program attenders.

A pilot study of cancer knowledge and screening behaviors of Vietnamese and Cambodian women.

Breast and cervix cancer screening behaviors, while suboptimal in all Americans, are of particular concern in minority females. Little is known about cancer knowledge and screening behavior in Southeast Asian populations in the United States. We interviewed 38 Southeast Asian women of Cambodian or Vietnamese origin living in the Philadelphia, Pennsylvania, area. A telephone interview was conducted by bilingual/bicultural interviewers. Seventy-one percent (95% confidence interval [CI], 54% to 85%) of women in the study did not know what cancer was and 74% were unable to identify a cancer prevention strategy. Greater knowledge about cancer and identification of preventive measures were associated with employment outside the home, more years of education, and age, but not with length of time in the United States. Cancer education programs need to identify the patients level of knowledge about cancer, elicit and respectfully address beliefs about causality and prevention, and ensure that health information is provided in a language understandable to the patient.

Design, recruitment and start up of a primary care weight loss trial targeting African American and Hispanic adults

Primary care offices are critical access points for obesity treatment, but evidence for approaches that can be implemented within these settings is limited. The Think Health! (¡Vive Saludable!) Study was designed to assess the feasibility and effectiveness of a behavioral weight loss program, adapted from the Diabetes Prevention Program, for implementation in routine primary care. Recruitment of clinical sites targeted primary care practices serving African American and Hispanic adults. The randomized design compares (a) a moderate-intensity treatment consisting of primary care provider counseling plus additional counseling by an auxiliary staff member (i.e., lifestyle coach), with (b) a low-intensity, control treatment involving primary care provider counseling only. Treatment and follow up duration are 1 to 2 years. The primary outcome is weight change from baseline at 1 and 2 years post-randomization. Between November 2006 and January 2008, 14 primary care providers (13 physicians; 1 physician assistant) were recruited at five clinical sites. Patients were recruited between October 2007 and November 2008. A total of 412 patients were pre-screened, of whom 284 (68.9%) had baseline assessments and 261 were randomized, with the following characteristics: 65% African American; 16% Hispanic American; 84% female; mean (SD) age of 47.2 (11.7) years; mean (SD) BMI of 37.2(6.4) kg/m(2); 43.7% with high blood pressure; and 18.4% with diabetes. This study will provide insights into the potential utility of moderate-intensity lifestyle counseling delivered by motivated primary care clinicians and their staff. The study will have particular relevance to African Americans and women.

Impact of a Rewards-Based Incentive Program on Promoting Fruit and Vegetable Purchases

Objectives. We assessed the impact of a rewards-based incentive program on fruit and vegetable purchases by low-income families. Methods. We conducted a 4-phase prospective cohort study with randomized intervention and wait-listed control groups in Philadelphia, Pennsylvania, in December 2010 through October 2011. The intervention provided a rebate of 50% of the dollar amount spent on fresh or frozen fruit and vegetables, reduced to 25% during a tapering phase, then eliminated. Primary outcome measures were number of servings of fruit and of vegetables purchased per week. Results. Households assigned to the intervention purchased an average of 8 (95% confidence interval [CI] = 1.5, 16.9) more servings of vegetables and 2.5 (95% CI = 0.3, 9.5) more servings of fruit per week than did control households. In longitudinal price-adjusted analyses, when the incentive was reduced and then discontinued, the amounts purchased were similar to baseline. Conclusions. Investigation of the financial costs and potential benefits of incentive programs to supermarkets, government agencies, and other stakeholders is needed to identify sustainable interventions.

How gastroenterologists inform patients of results after lower endoscopy

OBJECTIVE:Little is known about how gastroenterologists communicate endoscopic findings and biopsy results to their patients. We sought to determine the factors that may influence this behavior.METHODS:A survey questionnaire was developed and mailed to the 80 members of the Delaware Valley Society for GI Endoscopy. Information was obtained on the demographic characteristics and responses to six case vignettes prepared to examine communication patterns. We determined possible influences of conscious sedation and the benignity or severity of findings on communication practices.RESULTS:Sixty-one surveys (76%) were completed and analyzed. Endoscopists immediately inform patients of normal results. For abnormal results, 92% would immediately inform nonsedated patients versus 79% that would inform sedated patients (p < 0.008). Analysis of responses to the case vignettes indicated that 82% of endoscopists would immediately reassure the patient about a benign appearing (<1 cm) polyp, but only 70% would do so for a polyp >2 cm (p < 0.01). In contrast, when presented with a frank malignancy, 94% would inform the patient. Eighty-four percent of endoscopists would telephone results of a benign pathology report, but only 34% would telephone report a dysplastic lesion (p < 0.001). There was no correlation between the response rate and various demographic parameters such as physician age, type of, or length of time in practice.CONCLUSIONS:Gastroenterologists usually report normal findings immediately, but are less likely to do so after use of sedation or encountering abnormal findings. Most of those surveyed would use the telephone to communicate abnormal findings.

The Use of Financial Incentives to Increase Fresh Fruit and Vegetable Purchases in Lower- Income Households: Results of a Pilot Study

Identifying effective strategies to promote healthier eating in underserved populations is a public health priority. In this pilot study, we examined the use of financial incentives to increase fresh fruit and vegetable purchases in low-income households (N=29). Participants received pre-paid coupons to buy fresh produce at the study store during the intervention period. Purchases were compared among the three study phases (baseline, intervention, and follow-up). A financial incentive provided by study coupons increased the average weekly purchase of fresh fruit but was less successful with fresh vegetables. These findings underscore the need for specific targeting of vegetable selection and preparation to exploit this strategy more fully.

Using rewards-based incentives to increase purchase of fruit and vegetables in lower-income households: design and start-up of a randomized trial

OBJECTIVE To report the design and baseline results of a rewards-based incentive to promote purchase of fruit and vegetables by lower-income households. DESIGN A four-phase randomized trial with wait-listed controls. In a pilot study, despite inadequate study coupon use, purchases of fresh fruit (but not vegetables) increased, but with little maintenance. In the present study, credits on the study store gift card replace paper coupons and a tapering phase is added. The primary outcome is the number of servings of fresh and frozen fruit and vegetables purchased per week. SETTING A large full-service supermarket located in a predominantly minority community in Philadelphia, Pennsylvania, USA. SUBJECTS Fifty-eight households, with at least one child living in the home. RESULTS During the baseline period, households purchased an average of 3·7 servings of fresh vegetables and an average of less than 1 serving of frozen vegetables per week. Households purchased an average of 1·9 servings of fresh fruit per week, with little to no frozen fruit purchases. Overall, the range of fresh and frozen produce purchased during this pre-intervention period was limited. CONCLUSIONS At baseline, produce purchases were small and of limited variety. The study will contribute to understanding the impact of financial incentives on increasing the purchases of healthier foods by lower-income populations.

Buying food on sale: a mixed methods study with shoppers at an urban supermarket, Philadelphia, Pennsylvania, 2010-2012.

Introduction The obesity epidemic has drawn attention to food marketing practices that may increase the likelihood of caloric overconsumption and weight gain. We explored the associations of discounted prices on supermarket purchases of selected high-calorie foods (HCF) and more healthful, low-calorie foods (LCF) by a demographic group at high risk of obesity. Methods Our mixed methods design used electronic supermarket purchase data from 82 low-income (primarily African American female) shoppers for households with children and qualitative data from focus groups with demographically similar shoppers. Results In analyses of 6,493 food purchase transactions over 65 weeks, the odds of buying foods on sale versus at full price were higher for grain-based snacks, sweet snacks, and sugar-sweetened beverages (odds ratios: 6.6, 5.9, and 2.6, respectively; all P < .001) but not for savory snacks. The odds of buying foods on sale versus full price were not higher for any of any of the LCF (P ≥ .07). Without controlling for quantities purchased, we found that spending increased as percentage saved from the full price increased for all HCF and for fruits and vegetables (P ≤ .002). Focus group participants emphasized the lure of sale items and took advantage of sales to stock up. Conclusion Strategies that shift supermarket sales promotions from price reductions for HCF to price reductions for LCF might help prevent obesity by decreasing purchases of HCF.

Women, minorities and organ donation in transplantation

Women and members of minority groups have had a troubling and complex place in the history of American medicine. For the most part, neither has occupied a position of power or privilege in the medical establishment, either as patients or providers. Ethical concerns regarding fair treatment and respect for persons who are members of these populations extend to many aspects of organ transplantation: from identification of a patient as a transplant candidate to the use of living donors. In addition, because organ transplantation involves limited, scarce resources and heightened scrutiny over allocation decisions, it also provides a window into how societal values about individual and social worth are embodied in American medicine. The experiences of powerlessness and, at times, outright abuse of women and minorities as patients and research subjects, set an uneasy stage for examining the organ transplantation enterprise. Negative health effects as a result of poverty, decreased access to health care and lack of familiarity with mainstream medicine, all have consequences social and medical for how organ transplantation is situated as a complex arm of organized medicine. The consideration of beliefs and experiences of both patients and providers is essential to any discussion involving diverse populations and organ transplantation. For physicians, who in the case of organ transplantation are

Two-Year Results of Think Health! ¡Vive Saludable!: A Primary Care Weight-Management Trial: Think Health! Primary Care Trial 2-Year Results

Think Health! ¡Vive Saludable! evaluated a moderate‐intensity, lifestyle behavior‐change weight‐loss program in primary care over 2 years of treatment. Final analyses examined weight‐change trajectories by treatment group and attendance.