Mark B. Stephens

Targeted prevention of excess weight gain and eating disorders in high-risk adolescent girls: a randomized controlled trial

BACKGROUND The high prevalence and incidence of obesity and eating disorders in US adolescent girls are serious health problems. Because of the shared risk factors for obesity and eating disorders, a targeted prevention of both conditions is a priority. OBJECTIVE We determined whether an adapted interpersonal psychotherapy prevention program is more efficacious for reducing excess weight gain and worsening disordered eating than health education in adolescent girls at high risk of obesity and eating disorders. DESIGN A parallel-group, randomized controlled trial was conducted between September 2008 and January 2013 in a university-based laboratory and a federal research hospital. The study included 113 adolescent (12-17-y-old) girls deemed at high risk of adult obesity and eating disorders because of a body mass index (BMI) between the 75th and 97th percentiles and reports of episodes of a loss of control over their eating. Girls were randomly assigned to participate in an adapted interpersonal psychotherapy or a health-education group program for 12 weekly 90-min group sessions. Follow-up assessments occurred immediately after group programs and at 6 and 12 mo. RESULTS Participation in both conditions was associated with decreases in expected BMI gain, age-adjusted BMI metrics, the percentage of fat by using dual-energy X-ray absorptiometry, symptoms of depression and anxiety, and the frequency of loss-of-control eating over 12 mo of follow-up (Ps < 0.001) with no group difference. In follow-up analyses, interpersonal psychotherapy was more efficacious than health education at reducing objective binge eating at the 12-mo follow-up (P < 0.05). CONCLUSIONS The intervention with adolescent girls with loss-of-control eating is associated with lower age-adjusted BMI and percentage of adiposity as well as improved mood symptoms over 1 y. Interpersonal psychotherapy further reduced objective binge eating. Additional research is needed to elucidate the mechanisms by which physical and psychological improvements were observed. This trial was registered at clinicaltrials.gov as NCT00680979.

Dietary Supplements: Physician Knowledge and Adverse Event Reporting.

PURPOSE Dietary supplement (DS) use among US military personnel is widespread. Many consume several different DS with multiple ingredients one or more times each week, representing a potential public health concern. The overall purpose of the study was to assess the knowledge and behaviors of health professionals and physicians regarding patterns of DS use and possible adverse events (AE) associated with DS use. We also determined how providers address the issue of DS with patients and evaluated provider knowledge regarding reporting systems. METHODS Two prospective, cross-sectional, web-based questionnaires were administered. First, health care providers who accessed the Natural Medicines Comprehensive Database to gather evidenced-based information on DS and herbal products were queried. Second, physicians who had graduated from the Uniformed Services University were sent a web-based questionnaire regarding DS knowledge, AE knowledge and reporting, and communication with patients about DS. The frequencies of responses were evaluated. RESULTS Although 60% of the military physicians who responded to the questionnaires believed they had observed AE in association with a DS, only 18% actually reported them. Three of four physician respondents (approximately 73%) did not know how or where to report AE associated with DS. The majority of physicians (66%) routinely asked most of their patients about DS use, and 65% did not have a reliable source of information for herbal and DS products. CONCLUSIONS Information gaps in DS information and AE reporting were identified. A centralized AE reporting system could serve to identify potentially harmful DS for further evaluation. Health professionals need to remain vigilant for AE associated with DS use and better informed on how to report these events.

Obesity and the US military family.

This review discusses the current knowledge and future directions regarding obesity within the US military family (i.e., active‐duty servicemembers, as well as military spouses, children, retirees, and veterans). The increasing rates of overweight and obesity within the US military adversely impact military readiness, limit recruitment, and place a significant financial burden on the Department of Defense.

Commentary: The RIME/EMR scheme: an educational approach to clinical documentation in electronic medical records.

Electronic medical records (EMRs) increasingly are used to document the delivery of patient care. Clinical practices that are involved in medical education are more likely to employ EMRs. Yet, the growing use of EMRs presents a new set of challenges for undergraduate and graduate medical education. EMRs can significantly impact how trainees learn and develop medical decision-making strategies and clinical documentation skills. EMRs also affect how clinical notes are evaluated and how feedback is provided to the learner. To use EMRs effectively, students must learn how narrative elements (how to take and record a medical history and physician examination), data elements (laboratory, radiology, medication, and information from ancillary and consultative services), and system elements (how EMRs function within the context of the health care or hospital system where the student trains) combine in the context of compassionate, competent, and safe patient care. This commentary specifically addresses educational issues surrounding student and resident use of EMR systems. The Reporter-Interpreter-Manager-Educator scheme is one approach to teach and evaluate clinical documentation skills using EMRs in the context of the Accreditation Council for Graduate Medical Education core educational competencies.

Pre-meal affective state and laboratory test meal intake in adolescent girls with loss of control eating

Loss of control eating confers risk for excess weight gain and exacerbated disordered eating. Affect theory proposes that loss of control eating is used to cope with negative mood states. Self-report data suggest that negative affect may contribute to the etiology of loss of control eating, but this theory has not been well-tested using laboratory paradigms. We examined associations between pre-meal affective states and intake during a laboratory test meal. One-hundred and ten adolescent girls with reported loss of control eating whose body mass index fell between the 75th and 97th percentile for age and sex completed state mood ratings prior to a test-meal. Results indicated that pre-meal state negative affect was associated with greater carbohydrate and less protein consumption, as well as greater snack and dessert and less fruit and dairy intake. All girls experienced significant decreases in negative affect from pre- to post-meal, but intake during the meal was unassociated with post-meal affect. In support of affect theory, negative affective states reported among girls with loss of control may be a driving factor for increased energy-dense food intake, which may play a role in excess weight gain.

Health behaviors associated with use of body building, weight loss, and performance enhancing supplements.

PURPOSE To identify health-related behaviors associated with potentially harmful dietary supplements (DS) - body building (BB), weight loss (WL) and performance enhancing (PE), explore common reasons and sources of information for DS use. METHODS Based on the 2005 Survey of 16,146 U.S. military personnel, BB users were dichotomized as yes (regular use - taking any supplement of BB at least once a week in past 12 months) or no; similarly defined for WL and PE. Weighted logistic regression models are used. RESULTS BB, WL and PE were used by 19.4%, 17.0%, and 8.0% of participants, respectively. Significantly more users were overweight or obese: BMI ≥25 (vs. BMI<25); heavy drinkers (vs. abstainers); and users of taking steroids in their lifetime (vs. not). Most common reasons of BB, WL, and PE users wanted to increase muscle mass, lose weight, and improve physical performance (BB: 45.8%, WL: 54.8%, PE: 38.5%). Fewer than 30% discussed dietary supplements use with their healthcare providers. The leading source of dietary supplements information (BB: 27.8%, WL: 23.6%, PE: 30.0%) was magazines. CONCLUSIONS The dietary supplements: BB, WL and PE were used by significant proportions of service members, and associated with risk-taking behaviors that may affect overall military readiness and public health.

Energy drink and energy shot use in the military

Use of energy drinks and energy shots among military personnel is controversial. High amounts of caffeine (the primary active ingredient in these products) may impact performance of military duties. The impact of caffeine overconsumption and potential subsequent side effects that might be experienced by service members with unique roles and responsibilities is a concern. Reported here are the prevalence of use, reasons for use, and side effects associated with consumption of energy drinks and energy shots among several populations of active duty personnel in the US military. A snowball survey was sent to over 10,000 active duty personnel. A total of 586 (∼6% response rate) individuals completed a 30-item electronic survey. Over half of respondents (53%) reported consuming an energy drink at least once in the past 30 days. One in five (19%) reported energy shot consumption in the prior 30 days. One in five (19%) also reported consuming an energy drink in combination with an alcoholic beverage. Age and gender were significantly associated with energy drink consumption. Young male respondents (18-29 years) reported the highest use of both energy drinks and energy shots. Among those reporting energy drink and energy shot use, the most common reasons for consumption were to improve mental alertness (61%) and to improve mental (29%) and physical (20%) endurance. Nearly two-thirds (65%) of users self-reported at least one side effect. The most commonly reported side effects included increased pulse rate/palpitations, restlessness, and difficulty sleeping. Use of energy products among military personnel is common and has the potential to impact warrior health and military readiness.

Electronic health records improve clinical note quality

Background and objective The clinical note documents the clinicians information collection, problem assessment, clinical management, and its used for administrative purposes. Electronic health records (EHRs) are being implemented in clinical practices throughout the USA yet it is not known whether they improve the quality of clinical notes. The goal in this study was to determine if EHRs improve the quality of outpatient clinical notes. Materials and methods A five and a half year longitudinal retrospective multicenter quantitative study comparing the quality of handwritten and electronic outpatient clinical visit notes for 100 patients with type 2 diabetes at three time points: 6 months prior to the introduction of the EHR (before-EHR), 6 months after the introduction of the EHR (after-EHR), and 5 years after the introduction of the EHR (5-year-EHR). QNOTE, a validated quantitative instrument, was used to assess the quality of outpatient clinical notes. Its scores can range from a low of 0 to a high of 100. Sixteen primary care physicians with active practices used QNOTE to determine the quality of the 300 patient notes. Results The before-EHR, after-EHR, and 5-year-EHR grand mean scores (SD) were 52.0 (18.4), 61.2 (16.3), and 80.4 (8.9), respectively, and the change in scores for before-EHR to after-EHR and before-EHR to 5-year-EHR were 18% (p<0.0001) and 55% (p<0.0001), respectively. All the element and grand mean quality scores significantly improved over the 5-year time interval. Conclusions The EHR significantly improved the overall quality of the outpatient clinical note and the quality of all its elements, including the core and non-core elements. To our knowledge, this is the first study to demonstrate that the EHR significantly improves the quality of clinical notes.

Radiation Exposure and Cost Influence Physician Medical Image Decision Making A Randomized Controlled Trial

Background: It is estimated that 20%–40% of advanced medical imaging in the United States is unnecessary, resulting in patient overexposure to radiation and increasing the cost of care. Previous imaging utilization studies have focused on clinical appropriateness. An important contributor to excessive use of advanced imaging may be a physician “knowledge gap” regarding the safety and cost of the tests. Objectives: To determine whether safety and cost information will change physician medical image decision making. Research Design: Double-blinded, randomized controlled trial. Following standardized case presentation, physicians made an initial imaging choice. This was followed by the presentation of guidelines, radiation exposure and health risk, and cost information. Results: Approximately half (57 of 112, 50.9%) of participants initially selected computed tomography (CT). When presented with guideline recommendations, participants did not modify their initial imaging choice (P=0.197). A significant reduction (56.3%, P<0.001) in CT ordering occurred after presentation of radiation exposure/health risk information; ordering changed to magnetic resonance imaging or ultrasound (US). A significant reduction (48.3%, P<0.001) in CT and magnetic resonance imaging ordering occurred after presentation of Medicare reimbursement information; ordering changed to US. The majority of physicians (31 of 40, 77.5%) selecting US never modified their ordering. No significant relationship between physician demographics and decision making was observed. Conclusions: This study suggests that physician decision making can be influenced by safety and cost information and the order in which information is provided to physicians can affect their decisions.

QNOTE: an instrument for measuring the quality of EHR clinical notes

Background and objective The outpatient clinical note documents the clinicians information collection, problem assessment, and patient management, yet there is currently no validated instrument to measure the quality of the electronic clinical note. This study evaluated the validity of the QNOTE instrument, which assesses 12 elements in the clinical note, for measuring the quality of clinical notes. It also compared its performance with a global instrument that assesses the clinical note as a whole. Materials and methods Retrospective multicenter blinded study of the clinical notes of 100 outpatients with type 2 diabetes mellitus who had been seen in clinic on at least three occasions. The 300 notes were rated by eight general internal medicine and eight family medicine practicing physicians. The QNOTE instrument scored the quality of the note as the sum of a set of 12 note element scores, and its inter-rater agreement was measured by the intraclass correlation coefficient. The Global instrument scored the note in its entirety, and its inter-rater agreement was measured by the Fleiss κ. Results The overall QNOTE inter-rater agreement was 0.82 (CI 0.80 to 0.84), and its note quality score was 65 (CI 64 to 66). The Global inter-rater agreement was 0.24 (CI 0.19 to 0.29), and its note quality score was 52 (CI 49 to 55). The QNOTE quality scores were consistent, and the overall QNOTE score was significantly higher than the overall Global score (p=0.04). Conclusions We found the QNOTE to be a valid instrument for evaluating the quality of electronic clinical notes, and its performance was superior to that of the Global instrument.