Kathleen M. McTigue

Effects of diet and physical activity interventions on weight loss and cardiometabolic risk factors in severely obese adults: a randomized trial.

CONTEXT The prevalence of severe obesity is increasing markedly, as is prevalence of comorbid conditions such as hypertension and type 2 diabetes mellitus; however, apart from bariatric surgery and pharmacotherapy, few clinical trials have evaluated the treatment of severe obesity. OBJECTIVE To determine the efficacy of a weight loss and physical activity intervention on the adverse health risks of severe obesity. DESIGN, SETTING, AND PARTICIPANTS Single-blind randomized trial conducted from February 2007 through April 2010 at the University of Pittsburgh. Participants were 130 (37% African American) severely obese (class II or III) adult participants without diabetes recruited from the community. INTERVENTIONS One-year intensive lifestyle intervention consisting of diet and physical activity. One group (initial physical activity) was randomized to diet and physical activity for the entire 12 months; the other group (delayed physical activity) had the identical dietary intervention but with physical activity delayed for 6 months. MAIN OUTCOME MEASURES Changes in weight. Secondary outcomes were additional components comprising cardiometabolic risk, including waist circumference, abdominal adipose tissue, and hepatic fat content. RESULTS Of 130 participants randomized, 101 (78%) completed the 12-month follow-up assessments. Although both intervention groups lost a significant amount of weight at 6 months, the initial-activity group lost significantly more weight in the first 6 months compared with the delayed-activity group (10.9 kg [95% confidence interval {CI}, 9.1-12.7] vs 8.2 kg [95% CI, 6.4-9.9], P = .02 for group × time interaction). Weight loss at 12 months, however, was similar in the 2 groups (12.1 kg [95% CI, 10.0-14.2] vs 9.9 kg [95% CI, 8.0-11.7], P = .25 for group × time interaction). Waist circumference, visceral abdominal fat, hepatic fat content, blood pressure, and insulin resistance were all reduced in both groups. The addition of physical activity promoted greater reductions in waist circumference and hepatic fat content. CONCLUSION Among patients with severe obesity, a lifestyle intervention involving diet combined with initial or delayed initiation of physical activity resulted in clinically significant weight loss and favorable changes in cardiometabolic risk factors. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00712127.

Obesity in Older Adults: A Systematic Review of the Evidence for Diagnosis and Treatment

Objective: Although obesity is increasing in older U.S. adults, treatment is controversial in this age group. We sought to examine evidence concerning obesitys health‐related risks, diagnostic methods, and treatment outcomes in older individuals.

Mortality, Health Outcomes, and Body Mass Index in the Overweight Range A Science Advisory From the American Heart Association

Health hazards of obesity have been recognized for centuries, appearing, for example, in writings attributed to Hippocrates. From the later decades of the 20th century through the present, there have been numerous epidemiological studies of the relationship between excess weight and the total, or all-cause, mortality rate,1 a critical cumulative measure of the public health impact of any health condition. Using body mass index (BMI), an indicator of relative weight for height (weight [kg]/height [m]2) and a frequently used surrogate for assessment of excess body fat, these studies have found linear, U-shaped, or J-shaped relationships between total mortality and BMI. That is, in some studies, both the thin and the obese were more likely to die than those in between. There is, however, always a point at which increasing BMI is associated with increasing mortality risk, but the BMI at which this occurs varies across studies and populations.2 Currently,3 overweight in adults is defined as a BMI of 25.0 to <30.0 kg/m2 and obesity as a BMI of ≥30.0 kg/m2 (Table 1). A number of studies have found no significant relationship between BMI in the overweight range and mortality rate4 and have shown the nadir of mortality risk to be in the overweight range. In particular, commentaries in both the lay press5–7 and scientific literature2,8,9 subsequent to recent reports from National Health and Nutrition Examination Surveys (NHANES)10,11 have highlighted the confusion and controversy regarding this issue. Some have interpreted the recent data to mean that overweight is not detrimental to health and is not in itself a public health concern and that drawing attention to the need for weight loss in this range will have negative effects on the health and well-being of the general population.8 Others have argued …

The Pittsburgh Girls Study: Overview and Initial Findings

The Pittsburgh Girls Study is a longitudinal, community–based study of 2,451 girls who were initially recruited when they were between the ages of 5 and 8 years. The primary aim of the study was testing developmental models of conduct disorder, major depressive disorder, and their co-occurrence in girls. In the current article, we summarize the published findings from the past 5 years of the PGS and place those results in the context of what it known to date about developmental psychopathology in girls. Key results suggest that DSM–IV mental disorders tend to have an insidious onset often beginning with subsyndromal symptom manifestation, and that there appear to be shared and unique developmental precursors to disorder in subgroups of girls based on race and poverty.

Using the Internet to translate an evidence-based lifestyle intervention into practice.

Despite evidence-based recommendations for addressing obesity in the clinical setting, lifestyle interventions are lacking in practice. The objective of this study was to translate an evidence-based lifestyle program into the clinical setting by adapting it for delivery via the Internet. We adapted the Diabetes Prevention Programs lifestyle curriculum to an online format, comprising 16 weekly and 8 monthly lessons, and conducted a before-and-after pilot study of program implementation and feasibility. The program incorporates behavioral tools such as e-mail prompts for online self-monitoring of diet, physical activity, and weight, and automated weekly progress reports. Electronic counseling provides further support. Physician referral, automated progress reports, and as-needed communication with lifestyle coaches integrate the intervention with clinical care. We enrolled 50 patients from a large academic general internal practice into a pilot program between November 16, 2006 and February 11, 2007. Patients with a body mass index (BMI) =25 kg/m2, at least one weight-related cardiovascular risk factor, and Internet access were eligible if referring physicians felt the lifestyle goals were safe and medically appropriate. Participants were primarily female (76%), with an average age of 51.94 (standard deviation [SD] 10.82), and BMI of 36.43 (SD 6.78). At 12 months of enrollment, 50% of participants had logged in within 30 days. On average, completers (n = 45) lost 4.79 (SD 8.55) kg. Systolic blood pressure dropped 7.33 (SD 11.36) mm Hg, and diastolic blood pressure changed minimally (+0.44 mm Hg; SD 9.27). An Internet-based lifestyle intervention may overcome significant barriers to preventive counseling and facilitate the incorporation of evidence-based lifestyle interventions into primary care.

Weight Loss Through Living Well Translating an Effective Lifestyle Intervention Into Clinical Practice

Purpose To translate the Diabetes Prevention Program (DPP) lifestyle intervention into a clinical setting and evaluate its effectiveness. Methods The authors implemented a group-based version of the DPP lifestyle curriculum in a large academic medicine practice. It is delivered by a nurse educator over 12 weekly sessions with optional reenrollment, available on a self-pay basis, and implemented using existing clinical resources (eg, electronic medical record referrals, scheduling, conference rooms, communication technology). The program was evaluated using a controlled before-after design, including all patients referred between April 1, 2005, and February 1, 2007. Patients with a body mass index (BMI) ≥25 kg/m2 were eligible if their primary care providers felt the program was medically appropriate and safe. Change in weight (kg) and frequency of achieving ≥7% weight loss were examined. Results Referred patients were primarily female (84%), with an average age of 49.91 years (SE, 1.46) and average BMI of 39.65 kg/m2 (SE, 0.73). Among eligible patients, 93% of enrollees and 80% of nonenrollees had follow-up weights recorded within the evaluation window. Over 1 year, mean weight change was —5.19 kg (95% confidence interval [CI], —7.71 to —2.68) among enrollees and +0.21 kg (CI, —1.0 to 1.93) among nonenrollees (P < .001). A ≥7% loss was found for 27% of enrollees and 6% of nonenrollees ( P = .001). Conclusions An evidence-based lifestyle intervention can be effectively translated into the clinical setting. Use of existing resources may facilitate patient flow and minimize cost. This provider-integrated preventive care approach may provide a model for incorporating knowledge from behavioral science into clinical care.

Living With Diabetes Normalizing the Process of Managing Diabetes

Purpose The purpose of this qualitative study was to explore perceptions of people with diabetes about their experience of living with and managing their diabetes. Methods This study was part of a larger study of patients with diabetes who used a novel computer portal system for access to information about diabetes and to their health care providers for enhanced communication. The research method used for this portion of the study was grounded theory methodology, a particular kind of qualitative research method. Results A central theme generated from the data was “normalizing an identity as a person with diabetes.” The participants described themselves as diabetic; they took on an identity in which having diabetes was central. They struggled with how to become “a person with diabetes” rather than a “diabetic person.” Conclusions For people who are diagnosed with diabetes, there is a struggle to become a person with diabetes rather than a diabetic person and to manage the lifestyle changes that are mandated by this role/identity. One way of dealing or coping with this new identity is to begin to “normalize” these lifestyle changes—to view them as healthy living for all people, those with and without diabetes. This will then have implications for interventions—encouraging healthy lifestyles among people with diabetes rather than emphasizing that people with diabetes are “different from” the general population.

Interest in the Use of Computerized Patient Portals: Role of the Provider–Patient Relationship

BackgroundBioinformatics experts are developing interactive patient portals to help those living with diabetes and other chronic diseases to better manage their conditions. However, little is known about what influences patients’ desires to use this technology.ObjectiveTo discern the impact of the provider–patient relationship on interest in using a web-based patient portal.DesignQualitative analysis of focus groups.ParticipantsTen focus groups involving 39 patients (range 2–7) recruited from four primary care practices.ApproachA qualitative approach was used, which involved reading transcribed texts until a consensus was reached on data interpretation. An intercoder reliability kappa score (0.89) was determined by comparing the provider–patient relationship talk selected by the two coders. A conceptual framework was developed, which involved the development and refinement of a codebook and the application of it to the transcripts.ResultsInterest in the portal was linked to dissatisfaction with the provider–patient relationship, including dissatisfaction with provider communication/responsiveness, the inability to obtain medical information, and logistical problems with the office. Disinterest in the portal was linked to satisfaction with the provider–patient relationship, including provider communication/responsiveness, difficulty in using the portal, and fear of losing relationships and e-mail contact with the provider. No patient identified encrypted e-mail communication through the portal as an advantage.ConclusionsPromoting the use of computerized portals requires patient-based adaptations. These should include ease of use, direct provider e-mail, and reassurances that access and interpersonal relationships will not be lost. Education is needed about privacy concerns regarding traditional e-mail communication.

Geographic Variations in Stroke Incidence and Mortality Among Older Populations in Four US Communities

Background and Purpose— Stroke is a leading cause of death and disability in the US. There is limited data on geographic variations in stroke incidence among older US populations who experience the majority of stroke burden. The purpose of this study was to compare stroke incidence and mortality rates in 4 US communities. Methods— Participants in the Cardiovascular Health Study (CHS) who had no history of stroke at baseline (n=5639) were followed for 10 or 7 years in predominantly white (n=5002) and black (n=637) participants, respectively. Incident stroke was validated by a stroke adjudication committee after ascertainment at annual visits, interim telephone contacts, and review of Medicare hospitalization data. Results— The 2000 US population age and sex standardized total stroke incidence rate for all CHS participants was 17.7 per 1000 person-years (95% CI: 15.9, 19.5). The rate was significantly lower in Allegheny County, Pennsylvania 9.6/1000 person-years (95% CI: 7.7, 11.5) than Forsyth County, North Carolina 19.2/1000 person-years (95% CI: 15.6, 22.8), Sacramento County, California 20.7/1000 person-years (95% CI: 16.9, 24.5), and Washington County, Maryland 19.8/1000 person-years (95% CI: 16.1, 23.5). The lower stroke incidence rate in Allegheny County was consistent in gender, race, and age groups. Though not statistically significant, stroke mortality was also lower in Allegheny County than other 3 sites. The 1-month case fatality rate was similar in the 4 sites for all strokes, and by stroke types. Conclusions— Understanding geographic variations in stroke incidence may be an important step in improving preventive practices of stroke.

Patient Difficulty Using Tablet Computers to Screen in Primary Care

BackgroundPatient-administered computerized questionnaires represent a novel tool to assist primary care physicians in the delivery of preventive health care.ObjectiveThe aim of this study was to assess patient-reported ease of use with a self-administered tablet computer-based questionnaire in routine clinical care.DesignAll patients seen in a university-based primary care practice were asked to provide routine screening information using a touch-screen tablet computer-based questionnaire. Patients reported difficulty using the tablet computer after completion of their first questionnaire.PatientsTen thousand nine hundred ninety-nine patients completed the questionnaire between January 2004 and January 2006.MeasurementsWe calculated rates of reporting difficulty (no difficulty, some difficulty, or a lot of difficulty) using the tablet computers based on patient age, sex, race, educational attainment, marital status, and number of comorbid medical conditions. We constructed multivariable ordered logistic models to identify predictors of increased self-reported difficulty using the computer.ResultsThe majority of patients (84%) reported no difficulty using the tablet computers to complete the questionnaire, with only 3% reporting a lot of difficulty. Significant predictors of reporting more difficulty included increasing age [odds ratio (OR) 1.05, 95% confidence interval (CI) 1.05–1.05)]; Asian race (OR 2.3, 95% CI 1.8–2.9); African American race (OR 1.4, 95% CI 1.2–1.6); less than a high school education (OR 3.0, 95% CI 2.6–3.4); and the presence of comorbid medical conditions (1–2: OR 1.3, 95% CI 1.2–1.5; ≥3: OR 1.7 95% CI 1.5–2.1).ConclusionsThe majority of primary care patients reported no difficulty using a self-administered tablet computer-based questionnaire. While computerized questionnaires present opportunities to collect routine screening information from patients, attention must be paid to vulnerable groups.