Kimberly A. Gudzune

National survey of US primary care physicians’ perspectives about causes of obesity and solutions to improve care

Objective To describe physician perspectives on the causes of and solutions to obesity care and identify differences in these perspectives by number of years since completion of medical school. Design National cross-sectional online survey from 9 February to 1 March 2011. Setting USA. Participants 500 primary care physicians. Main Measures We evaluated physician perspectives on: (1) causes of obesity, (2) competence in treating obese patients, (3) perspectives on the health professional most qualified to help obese patients lose or maintain weight and (4) solutions for improving obesity care. Results Primary care physicians overwhelmingly supported additional training (such as nutrition counselling) and practice-based changes (such as having scales report body mass index) to help them improve their obesity care. They also identified nutritionists/dietitians as the most qualified providers to care for obese patients. Physicians with fewer than 20 years since completion of medical school were more likely to identify lack of information about good eating habits and lack of access to healthy food as important causes of obesity. They also reported feeling relatively more successful helping obese patients lose weight. The response rate for the survey was 25.6%. Conclusions Our results indicate a perceived need for improved medical education related to obesity care.

Strategies to prevent weight gain in workplace and college settings: A systematic review

OBJECTIVE To compare the effectiveness of self-management, dietary, physical activity, and/or environmental strategies for the prevention of weight gain among adults in work and college settings. METHOD We conducted a systematic review of work/college-based studies that intervened on adults using one or more of the above strategies with follow up over at least a 12-month period. We excluded studies with a weight loss component. Our weight outcomes included body mass index (BMI), weight, and waist circumference. RESULTS We included 7 work- and 2 college-based interventional studies, which all used combinations of different strategies. There was moderate strength of evidence that work/college-based combination interventions prevented weight gain of ≥0.5kg over 12months as compared to control; however, we were unable to perform meta-analysis due to substantial heterogeneity in the intervention strategies and study populations. These programs did not prevent BMI gain or waist circumference increase. CONCLUSION While we found limited evidence that work/college-based interventions employing a combination of strategies prevent adult weight gain, the combination of personalized diet and physical activity counseling for the individual along with the promotion of healthy lifestyle changes in the environment may be a promising strategy to explore in future research.

Body Mass Index and Colon Cancer Screening: A Systematic Review and Meta-Analysis

Background: Obesity is associated with increased colon cancer mortality and lower rates of mammography and Pap testing. Methods: We conducted a systematic review to determine whether obesity is associated with lower rates of colon cancer screening. We searched the PubMed, CINAHL, and Cochrane Library databases. Two investigators reviewed citations, abstracts, and articles independently. Two investigators abstracted study information sequentially and evaluated quality independently using standardized forms. We included all studies in our qualitative syntheses. We used random effects meta-analyses to combine those studies providing screening results by the following body mass index (BMI) categories: Normal, 18.5–24.9 kg/m2 (reference); overweight, 25–29.9 kg/m2; class I obesity, 30–34.9 kg/m2; class II obesity, 35–39.9 kg/m2; and class III obesity, ≥ 40 kg/m2. Results: Of 5,543 citations, we included 23 articles. Almost all studies were cross-sectional and ascertained BMI and screening through self-report. BMI was not associated with colon cancer screening overall. The subgroup of obese white women reported lower rates of colon cancer screening compared with those with a normal BMI with combined ORs (95% CI) of 0.87 (0.82–0.93), 0.80 (0.65–0.99), and 0.73 (0.58–0.94) for class I, II, and III obesity, respectively. Results were similar among white men with class II obesity. Conclusions: Overall, BMI was not associated with colon cancer screening. Obese white men and women may be less likely to undergo colon cancer screening compared with those with a normal BMI. Impact: Further investigation of this disparity may reduce the risk of obesity-related colon cancer death. Cancer Epidemiol Biomarkers Prev; 21(5); 737–46. ©2012 AACR.

Insights from the POWER Practice-Based Weight Loss Trial: A Focus Group Study on the PCP’s Role in Weight Management

ABSTRACTBACKGROUNDDespite U.S. Preventive Services Task Force recommendations, few primary care providers (PCPs) counsel obese patients about weight loss. The POWER practice-based weight loss trial used health coaches to provide weight loss counseling, but PCPs referred their patients and reviewed their patients’ progress reports. This trial provided a unique opportunity to understand PCPs’ actual and desired roles in a multi-component weight loss intervention.OBJECTIVE1) To explore the PCP role, inclusive of and beyond the trial’s intended role, in a practice-based weight loss trial; and 2) to elicit recommendations by PCPs for wider dissemination of the successful multi-component program.DESIGNQualitative focus group study of PCPs with ≥ 4 patients enrolled in trial.PARTICIPANTSTwenty-six out of 30 PCPs from six community practices participated between June and August 2010.MAIN MEASURESWe used a semi-structured moderator guide. Focus groups were audio-recorded and transcribed verbatim. Two investigators independently coded transcripts for thematic content, identified meaningful segments within the responses and assigned codes using an editing style analysis. Atlas.ti software was used for organization/analysis.MAIN RESULTSWe identified five major themes related to the PCP’s role in patients’ weight management: (1) refer patients into program, provide endorsement; (2) provide accountability for patients; (3) “cheerlead” for patients during visits; (4) have limited role in weight management; and (5) maintain the long-term trusting relationship through the ups and downs. PCPs provided several recommendations for wider dissemination of the program into primary care practices, highlighting the need for specific feedback from coaches as well as efficient, integrated processes.CONCLUSIONSWeight loss programs have the potential to partner with PCPs to build upon the patient–provider relationship to improve patient accountability and sustain behavior change. However, rather than directing the weight loss, PCPs preferred a peripheral role by utilizing health coaches.Despite U.S. Preventive Services Task Force recommendations, few primary care providers (PCPs) counsel obese patients about weight loss. The POWER practice-based weight loss trial used health coaches to provide weight loss counseling, but PCPs referred their patients and reviewed their patients’ progress reports. This trial provided a unique opportunity to understand PCPs’ actual and desired roles in a multi-component weight loss intervention. 1) To explore the PCP role, inclusive of and beyond the trial’s intended role, in a practice-based weight loss trial; and 2) to elicit recommendations by PCPs for wider dissemination of the successful multi-component program. Qualitative focus group study of PCPs with ≥ 4 patients enrolled in trial. Twenty-six out of 30 PCPs from six community practices participated between June and August 2010. We used a semi-structured moderator guide. Focus groups were audio-recorded and transcribed verbatim. Two investigators independently coded transcripts for thematic content, identified meaningful segments within the responses and assigned codes using an editing style analysis. Atlas.ti software was used for organization/analysis. We identified five major themes related to the PCP’s role in patients’ weight management: (1) refer patients into program, provide endorsement; (2) provide accountability for patients; (3) “cheerlead” for patients during visits; (4) have limited role in weight management; and (5) maintain the long-term trusting relationship through the ups and downs. PCPs provided several recommendations for wider dissemination of the program into primary care practices, highlighting the need for specific feedback from coaches as well as efficient, integrated processes. Weight loss programs have the potential to partner with PCPs to build upon the patient–provider relationship to improve patient accountability and sustain behavior change. However, rather than directing the weight loss, PCPs preferred a peripheral role by utilizing health coaches.

Doctor shopping by overweight and obese patients is associated with increased healthcare utilization

Negative interactions with healthcare providers may lead patients to switch physicians or “doctor shop.” We hypothesized that overweight and obese patients would be more likely to doctor shop, and as a result, have increased rates of emergency department (ED) visits and hospitalizations as compared to normal weight nonshoppers.

Provider communication quality: Influence of patients’ weight and race

OBJECTIVE To examine the relationship between patient weight and provider communication quality and determine whether patient race/ethnicity modifies this association. METHODS We conducted a cross-sectional analysis with 2009-2010 medical expenditures panel survey-household component (N=25,971). Our dependent variables were patient report of providers explaining well, listening, showing respect, and spending time. Our independent variables were patient weight status and patient weight-race/ethnicity groups. Using survey weights, we performed multivariate logistic regression to examine the adjusted association between patient weight and patient-provider communication measures, and whether patient race/ethnicity modifies this relationship. RESULTS Compared to healthy weight whites, obese blacks were less likely to report that their providers explained things well (OR 0.78; p=0.02) or spent enough time with them (OR 0.81; p=0.04), and overweight blacks were also less likely to report that providers spent enough time with them (OR 0.78; p=0.02). Healthy weight Hispanics were also less likely to report adequate provider explanations (OR 0.74; p=0.04). CONCLUSION Our study provides preliminary evidence that overweight/obese black and healthy weight Hispanic patients experience disparities in provider communication quality. PRACTICE IMPLICATION Curricula on weight bias and cultural competency might improve communication between providers and their overweight/obese black and healthy weight Hispanic patients.

Laboratory Testing for and Diagnosis of Nutritional Deficiencies in Pregnancy Before and After Bariatric Surgery

OBJECTIVE Bariatric surgery can reduce the risk of obesity-related complications of pregnancy, but may cause essential nutrient deficiencies. To assess adherence to laboratory testing guidelines, we examined frequency of testing for and diagnosis of deficiency during preconception and pregnancy using claims data in women with a delivery and bariatric surgery. METHODS Retrospective analysis of claims from seven Blue Cross/Blue Shield plans between 2002 and 2008. We included women with a delivery and bariatric surgery within the study period. We used common procedural terminology (CPT) and ICD-9 codes to define laboratory testing and deficiencies for iron, folate, vitamin B12, vitamin D, and thiamine. Using Students t-test and chi-square testing, we compared frequency of laboratory tests and diagnoses during 12 months preconception and 280 days of pregnancy between women with pregnancy before versus after surgery. We used multivariate logistic regression to evaluate for predictors of laboratory testing. RESULTS We identified 456 women with pregnancy after bariatric surgery and 338 before surgery. The frequency of testing for any deficiency was low (9%-51%), but higher in those with pregnancy after surgery (p<0.003). The most common deficiency was vitamin B12 (12%-13%) with pregnancy after surgery (p<0.006). Anemia and number of health provider visits were independent predictors of laboratory testing. CONCLUSION Women with pregnancy after bariatric surgery were tested for and diagnosed with micronutrient deficiencies more frequently than those with pregnancy before surgery. However, most laboratory testing occurred in less than half the women and was triggered by anemia. Increased testing may help identify nutrient deficiencies and prevent consequences for maternal and child health.

A community-engaged cardiovascular health disparities research training curriculum: Implementation and preliminary outcomes

To overcome cardiovascular disease (CVD) disparities impacting high-risk populations, it is critical to train researchers and leaders in conducting community-engaged CVD disparities research. The authors summarize the key elements, implementation, and preliminary outcomes of the CVD Disparities Fellowship and Summer Internship Programs at the Johns Hopkins University Schools of Medicine, Nursing, and Bloomberg School of Public Health. In 2010, program faculty and coordinators established a transdisciplinary CVD disparities training and career development fellowship program for scientific investigators who desire to conduct community-engaged clinical and translational disparities research. The program was developed to enhance mentorship support and research training for faculty, postdoctoral fellows, and predoctoral students interested in conducting CVD disparities research. A CVD Disparities Summer Internship Program for undergraduate and preprofessional students was also created to provide a broad experience in public health and health disparities in Baltimore, Maryland, with a focus on CVD. Since 2010, 39 predoctoral, postdoctoral, and faculty fellows have completed the program. Participating fellows have published disparities-related research and given presentations both nationally and internationally. Five research grant awards have been received by faculty fellows. Eight undergraduates, one postbaccalaureate, and two medical professional students representing seven universities have participated in the summer undergraduate internship. Over half of the undergraduate students are applying to or have been accepted into medical or graduate school. The tailored CVD health disparities training curriculum has been successful at equipping varying levels of trainees (from undergraduate students to faculty) with clinical research and public health expertise to conducting community-engaged CVD disparities research.

Increasing access to fresh produce by pairing urban farms with corner stores: a case study in a low-income urban setting

OBJECTIVE Our objective was to pilot collaborations between two urban farms with two corner stores to increase access to fresh produce in low-income neighbourhoods. DESIGN We conducted a pre-post evaluation of two farm-store collaborations using quantitative distribution and sales data. Using semi-structured interviews, we qualitatively assessed feasibility of implementation and collaboration acceptability to farmers and storeowners. SETTING Low-income urban neighbourhoods in Baltimore, MD, USA in 2012. SUBJECTS Pair #1 included a 0·25 acre (0·1 ha) urban farm with a store serving local residents and was promoted by the neighbourhood association. Pair #2 included a 2 acre (0·8 ha) urban farm with a store serving bus commuters. RESULTS Produce was delivered all nine intervention weeks in both pairs. Pair #1 produced a significant increase in the mean number of produce varieties carried in the store by 11·3 (P<0·01) and sold 86 % of all items delivered. Pair #2 resulted in a non-significant increase in the number of produce varieties carried by 2·2 (P=0·44) and sold 63 % of all items delivered. CONCLUSIONS Our case study suggests that pairing urban farms with corner stores for produce distribution may be feasible and could be a new model to increase access to fruits and vegetables among low-income urban neighbourhoods. For future programmes to be successful, strong community backing may be vital to support produce sales.

A systematic review of commercial weight loss programmes’ effect on glycemic outcomes among overweight and obese adults with and without type 2 diabetes mellitus

We examined the glycemic benefits of commercial weight loss programmes as compared with control/education or counselling among overweight and obese adults with and without type 2 diabetes mellitus (T2DM).