Marcia G. Hayes

A Review of Primary Care-Based Childhood Obesity Prevention and Treatment Interventions.

Effective obesity prevention and treatment interventions targeting children and their families are needed to help curb the obesity epidemic. Pediatric primary care is a promising setting for these interventions, and a growing number of studies are set in this context. This review aims to identify randomized controlled trials of pediatric primary care-based obesity interventions. A literature search of 3 databases retrieved 2947 publications, of which 2899 publications were excluded after abstract (n = 2722) and full-text review (n = 177). Forty-eight publications, representing 31 studies, were included in the review. Eight studies demonstrated a significant intervention effect on child weight outcomes (e.g., BMI z-score, weight-for-length percentile). Effective interventions were mainly treatment interventions, and tended to focus on multiple behaviors, contain weight management components, and include monitoring of weight-related behaviors (e.g., dietary intake, physical activity, or sedentary behaviors). Overall, results demonstrate modest support for the efficacy of obesity treatment interventions set in primary care.

Keep it off: A phone-based intervention for long-term weight-loss maintenance

Long-term weight-loss maintenance is notoriously difficult to achieve and promote. As the novelty of weight loss treatment fades, enthusiasm for diet and exercise tends to wane in the maintenance phase. Given the recognition of obesity as a chronic disorder requiring continued engagement in weight-control behaviors, there is a need to identify cost-effective and supportive therapies that can sustain motivation. In this paper, we describe the study design and baseline characteristics of participants enrolled in a trial to evaluate a program (Keep It Off) developed specifically for weight-loss maintenance using therapeutic phone contact with recent weight losers throughout the period in which they are at highest risk for weight regain. In the Keep It Off randomized clinical trial we are evaluating this phone-based intervention that focuses on key weight-loss maintenance behaviors followed by continued self-monitoring, reporting of weight, feedback, and outreach in members of a Minnesota managed-care organization. The goal of the intervention is to flatten the typical relapse curve. Moreover, data from this trial will inform our understanding of weight-loss maintenance, including predictors and behaviors that increase the likelihood of success over the long term.

Healthy Homes/Healthy Kids: A randomized trial of a pediatric primary care-based obesity prevention intervention for at-risk 5–10 year olds☆☆★

Pediatric primary care is an important setting in which to address obesity prevention, yet relatively few interventions have been evaluated and even fewer have been shown to be effective. The development and evaluation of cost-effective approaches to obesity prevention that leverage opportunities of direct access to families in the pediatric primary care setting, overcome barriers to implementation in busy practice settings, and facilitate sustained involvement of parents is an important public health priority. The goal of the Healthy Homes/Healthy Kids (HHHK 5-10) randomized controlled trial is to evaluate the efficacy of a relatively low-cost primary care-based obesity prevention intervention aimed at 5 to 10 year old children who are at risk for obesity. Four hundred twenty one parent/child dyads were recruited and randomized to either the obesity prevention arm or a Contact Control condition that focuses on safety and injury prevention. The HHHK 5-10 obesity prevention intervention combines brief counseling with a pediatric primary care provider during routine well child visits and follow-up telephone coaching that supports parents in making home environmental changes to support healthful eating, activity patterns, and body weight. The Contact Control condition combines the same provider counseling with telephone coaching focused on safety and injury prevention messages. This manuscript describes the study design and baseline characteristics of participants enrolled in the HHHK 5-10 trial.

A new approach to physical activity maintenance: Rationale, design, and baseline data from the Keep Active Minnesota trial

BackgroundSince many individuals who initiate physical activity programs are highly likely to return to a sedentary lifestyle, innovative strategies to efforts to increase the number of physically active older adults who successfully maintain beneficial levels of PA for a substantial length of time are needed.Methods/DesignThe Keep Active Minnesota Trial is a randomized controlled trial of an interactive phone- and mail-based intervention to help 50–70 year old adults who have recently increased their physical activity level, maintain that activity level over a 24-month period in comparison to usual care. Baseline, 6, 12, and 24 month measurement occurred via phone surveys with kilocalories expended per week in total and moderate-to-vigorous physical activity (CHAMPS Questionnaire) as the primary outcome measures. Secondary outcomes include hypothesized mediators of physical activity change (e.g., physical activity enjoyment, self-efficacy, physical activity self-concept), body mass index, and depression. Seven day accelerometry data were collected on a sub-sample of participants at baseline and 24-month follow-up.DiscussionThe Keep Active Minnesota study offers an innovative approach to the perennial problem of physical activity relapse; by focusing explicitly on physical activity maintenance, the intervention holds considerable promise for modifying the typical relapse curve. Moreover, if shown to be efficacious, the use of phone- and mail-based intervention delivery offers potential for widespread dissemination.Trial registrationClinicalTrials.gov Identifier: NCT00283452.

TeenBP: Development and Piloting of an EHR-linked Clinical Decision Support System to Improve Recognition of Hypertension in Adolescents

Context: Blood pressure (BP) is routinely measured in children and adolescents during primary care visits. However, elevated BP or hypertension is frequently not diagnosed or evaluated further by primary care providers. Barriers to recognition include lack of clinician buy-in, competing priorities, and complexity of the standard BP tables. Case Description: We have developed and piloted TeenBP— a web-based, electronic health record (EHR) linked system designed to improve recognition of prehypertension and hypertension in adolescents during primary care visits. Major Themes: Important steps in developing TeenBP included the following: review of national BP guidelines, consideration of clinic workflow, engagement of clinical leaders, and evaluation of the impact on clinical sites. Use of a web-based platform has facilitated updates to the TeenBP algorithm and to the message content. In addition, the web-based platform has allowed for development of a sophisticated display of patient-specific information at the point of care. In the TeenBP pilot, conducted at a single pediatric and family practice site with six clinicians, over a five-month period, more than half of BPs in the hypertensive range were clinically recognized. Furthermore, in this small pilot the TeenBP clinical decision support (CDS) was accepted by providers and clinical staff. Effectiveness of the TeenBP CDS will be determined in a two-year cluster-randomized clinical trial, currently underway at 20 primary care sites. Conclusion: Use of technology to extract and display clinically relevant data stored within the EHR may be a useful tool for improving recognition of adolescent hypertension during busy primary care visits. In the future, the methods developed specifically for TeenBP are likely to be translatable to a wide range of acute and chronic issues affecting children and adolescents.

C-A1-01: Changes in Physical Activity and Nutrition in a Behavioral Intervention Pilot Study - Passport to Brain Wellness

Background/Aims: Increasing concerns about cognitive decline and dementia in the aging populations of most westernized countries suggests the need for interventions that can preserve cognitive function, are cost-effective, and feasibly implemented on a large scale. Empirical evidence is accumulating that points to the potential beneficial effects of cardiovascular fitness, healthy diet, social integration and participation in cognitively stimulating activities in the maintenance of cognitive function. We have developed and pilot tested “Passport,” a multi-component, cognitive-behavioral, phone and mail based intervention to promote such lifestyle changes in older adults. Methods: Cognitively intact (TICS ≥ 31), sedentary (<90 min physical activity[PA] per week) adults aged 61–80 years were recruited from among HealthPartners’ members. Baseline assessments included cognitive function, biomarkers, lifestyle factors, and physical traits. In the first phase, 21 participants were recruited and all assigned (non-randomized) to receive a course book, pedometer, tool kit and 7 bi-weekly phone coaching calls. In the second phase, 42 participants were recruited and randomized to either the Guided Intervention (n=22) or a Self-Directed (n=20) group, who received the study materials but no coaching. We completed 6 month follow-up measures with 58 (92%) subjects, and report here on their PA and nutritional outcomes. Results: The 63 enrolled subjects were female (60%), 70 years old, highly educated (73% college or more), predominantly retired (81%), non-Hispanic White (71%;) and married (65%). On average, they were overweight, BMI M=29.8, normotensive, systolic BP M=122.8, and normocholesterolemic, total serum cholesterol M=189.3. Mixed-model analyses indicated a time*treatment group effect on objectively monitored MVPA (p<.05), with a significant increase in the guided group (7.3 to 16.5mins/day, p<.05). We observed a significant effect of time on saturated fat intake (p<.05), with a significant pre-post reduction among Guided participants (26.1 to 23.4 grams, p<.05). Similar patterns of effects were observed for intake of fruits, vegetables and dietary fiber. Finally, we observed a time effect on intake of fish high in omega-3 fatty acids, driven by an increase in the non-randomized group (p<.05). Conclusions: Passport shows promise for improving aspects of lifestyle behaviors hypothesized to be important for the primary prevention of cognitive decline in older adults.

Changes in cognitive function and plasma biomarkers in a pilot trial of “passport”: a multi-domain intervention to prevent cognitive decline

Background: The most recent definition of the metabolic syndrome (IDF, 2005) sets the abdominal obesity as its central and necessary element. The consequences of the metabolic syndrome and abdominal obesity include endothelial disfunction, premature aging and Alzheimer‘s Disease (AD). Vascular endothelium, thought to indicate a person‘s real biological age, is the centre of vascular pathology. AD is a cognitive consequence of the metabolic syndrome, while premature aging is a result of all the disorders of the energetic metabolism generated by this syndrome. The centrepiece of obesity is the adipocyte. Obesity leads to an increase of the adypocite‘s volume, which triggers chronical inflammation and all the metabolic disordes associated to obesity, including the production of adipokines. Adiponectine, an adipokine produced exclusively by the adipocyte, is the biological marker of the metabolic syndrome.and is in an inversely proportional to the visceral adiposity. Methods: Our aim was to develop a model able to reveal the importance of adiponectine assessment in the metabolic syndrome and its complications, AD and premature aging. The study was a case-control analysis on 2 lots of subjects at age (one of 50 healthy subjects and one of 100 pacients with metabolic syndrome of which some developed premature aging and AD). The method included determinations of adiponectine using an ACRP 30 ELISA kit (normal range: 16,5 6 5,6 mg / ml). Insulinemia, microalbuminuria, glycemia and abdominal circumference, able to provide important additional information while compared with adiponectine levels, were also investigated. Results: The results reached by us are in accordance with other studies that have demonstrated the importance of adiponectine in the prevention of the metabolic syndrome, its direct role in premature aging prevalence due to its antiatherosclerotic action, decrease of the edothelial disfunction and its effect on the vasomotor function of the entothelia (low levels of adiponectine leading to the decrease of the nitric oxide dependent vasodilatation). Conclusions: Being a biological marker of the metabolic syndrome, adiponectine could also be a promising marker candidate for AD and premature aging. That is why controlling this marker may give us a partial but important lead in predicting and controlling these conditions.