Megan A. McVay

A comparison of delay discounting among smokers, substance abusers, and non-dependent controls

Previous studies have shown that smokers and substance-dependent individuals discount rewards that are available after a delay more than individuals without a history of substance dependence. However, it is not clear whether delay discounting is similar among smokers and substance-dependent individuals. Further, the influence of the combination of smoking and other substance dependence on delay discounting remains unknown. The present study compared the performance of four groups of individuals on a delay discounting task. The groups were (a) heavy smokers with comorbid substance dependence, (b) heavy smokers with no history of substance dependence, (c) never smokers with comorbid substance dependence, and (d) never smokers with no history of substance dependence. Analysis revealed that individuals who smoked and/or were dependent on another substance discounted delayed rewards more than individuals with no history of smoking or other substance dependence. No differences in the task performance of heavy smokers and substance-dependent individuals were found. Notably, participants who were dependent on multiple substances did not discount delayed rewards more than those dependent on only one substance. Overall, findings indicate that smoking and other substance dependence are similarly related to delay discounting.

Patient predictors of follow-up care attendance in Roux-en-Y gastric bypass patients

BACKGROUND Multidisciplinary care after bariatric surgery is important for long-term safety and optimal weight loss, yet many patients do not attend follow-up appointments. We sought to identify demographic, psychosocial, and weight-related variables that were associated with medical and behavioral health appointment attendance after bariatric surgery. METHODS A retrospective chart review was conducted with consecutive patients (n=538) obtaining first-time Roux-en-Y gastric bypass surgery between August 2009 and August 2010. Demographic and psychosocial data were compared between high (>50%) and low (≤50%) medical appointment attendees and high (>50%) and low (≤50%) behavioral health group attendees in their first postoperative year. Percentage excess weight loss at 6 months after surgery was evaluated as a predictor of 12-month appointment attendance. RESULTS High medical appointment attendees were more likely to be older, be Caucasian, and have lower phobic anxiety than low medical appointment attendees. High behavioral health attendees had shorter travel distance to the clinic and lower levels of hostility, anxiety, and phobic anxiety compared with low attendees. In multivariate analyses, race/ethnicity and phobic anxiety remained significant predictors of medical attendance, while travel distance to clinic predicted behavioral health attendance. Six-month percent excess weight loss predicted medical appointment attendance at 12 months. CONCLUSION The identified predictors of poor attendance at medical and behavioral bariatric surgery follow-up appointments should inform efforts to increase follow-up and improve surgical outcomes.

Effects of Brief Mindfulness Instructions on Reactions to Body Image Stimuli Among Female Smokers: An Experimental Study

INTRODUCTION Recent research has shown that body image stimuli increase negative affect and smoking urges among female smokers. Mindfulness (paying attention to present-moment experience with an attitude of nonjudgmental acceptance) may be a useful technique to minimize the influence of body dissatisfaction on negative affect, smoking urges, and smoking behavior. METHODS This study investigated whether mindfulness influences how female college smokers respond to a body image challenge. The study used a 2 × 2 factorial design with body image challenge (trying on a bathing suit vs. looking at a purse) crossed with instructions (mindfulness vs. silence). Female smokers (n = 64; M (age) = 20.03 [± 1.77], 87.5% Caucasian) were randomly assigned to one of four conditions: Purse + Silence (n = 16), Body Image + Silence (n = 15), Purse + Mindfulness (n = 15), and Body Image + Mindfulness (n = 18).

Effect of Allowing Choice of Diet on Weight Loss: A Randomized Trial

Context Permitting a choice in the diet to follow has been proposed as a means to improve weight-loss efforts. Contribution This randomized trial found that patients who were allowed to choose their diets did not lose more weight than those whose diets were assigned to them. Caution Only 2 diet choices were offered. Implication The ability to choose a diet might not improve weight-loss results. Various dietary approaches have been shown to be effective for weight management, alleviation of risk factors, and disease prevention (19). Regardless of the approach, greater adherence to dietary recommendations has been the best predictor of weight loss (10). Therefore, new strategies that maximize dietary adherence are needed to help patients experience the maximum health benefits. Allowing persons to choose among evidence-based dietary strategies intuitively holds promise for improving dietary adherence because it is patient-centered, offering the opportunity to select a diet on the basis of food preferences or other factors that patients may value. If allowing choice among diets improves weight outcomes, as has been suggested (1113), various dietary approaches could be made available to those seeking weight loss and strategies could be developed to facilitate choice. In this double-randomized preference trial, we evaluated whether participants who were allowed the opportunity to choose between 2 diets would lose more weight than those randomly assigned to a diet. Methods Setting and Participants Details of the study protocol have been reported elsewhere (14). Participants were recruited from clinics of the Durham Veterans Affairs Medical Center (VAMC) in Durham, North Carolina, between May 2011 and June 2012. Participants were eligible if they had a body mass index (BMI) of at least 30 kg/m2, a regular VAMC provider, access to a telephone, and reliable transportation. Participants were ineligible for the following reasons: aged 75 years or older, serum creatinine level greater than 132.6 mol/L (>1.5 mg/dL) (men) or greater than 114.9 mol/L (>1.3 mg/dL) (women), liver disease, type 1 diabetes, hemoglobin A1c level of 12% or greater, daily insulin use, unstable heart disease, organ transplant, blood pressure of 160/100 mmHg or greater, fasting triglyceride level of 6.8 mmol/L (600 mg/dL) or greater, low-density lipoprotein cholesterol level of 4.9 mmol/L (190 mg/dL) or greater, pregnancy, breastfeeding, lack of birth control if premenopausal, dementia, severe psychiatric illness, recent substance abuse, recent weight-loss attempt, or presence of a pacemaker or defibrillator. Outpatients who met entry criteria for age, BMI, and VAMC provider and lived within a 50-mile radius were mailed a letter inviting them to call if they were interested in participating. Patients could also self-refer via advertisements posted in clinics or could be referred by health care personnel. Research assistants assessed eligibility using the electronic medical record; a telephone screen; and an in-person screen, at which written, informed consent was obtained. Potential participants who expressed a strong aversion to one of the diets were informed that they might be randomly assigned to that diet and should enroll only if that would be acceptable. The Institutional Review Board of the Durham VAMC approved the study. Randomization We randomly assigned eligible participants in parallel fashion and a 1:1 ratio to the choice or comparator group by using a computerized random-number generator in blocks of fewer than 10, stratified by sex, BMI (<40 or 40 kg/m2), and diagnosis of type 2 diabetes. Comparator participants underwent a second 1:1 randomization to either the low-carbohydrate diet (LCD) or the low-fat diet (LFD). Only the study statisticians were aware of the randomization sequence. The project coordinator entered final eligibility data into the database, which automatically generated the group assignment for eligible participants. Participants were not made aware of their assignment and were thus not considered randomly assigned until their first group visit. Interventions Choice Group Procedures At the first group visit, choice group participants received summary results from the Geiselman Food Preference Questionnaire (FPQ), which was administered at the screening visit and indicated which of the 2 diet options their preferences aligned with (15). The FPQ uses a Likert scale of 1 (dislike extremely) to 9 (like extremely) to assess preferences for 72 foods that are common sources of macronutrients in the typical U.S. diet. Participants scoring higher in the Low Carbohydrate/High Protein summary category of the FPQ were advised that their food preferences aligned best with the LCD, whereas those scoring higher in the Low Fat/High Simple Sugar or Low Fat/High Complex Carbohydrate categories were advised that their preferences aligned best with the LFD. Participants then received verbal and printed information about the 2 diets, including foods emphasized and deemphasized, sample menus, and evidence for safety and efficacy. Participants were asked not to discuss their decision with other study participants but were allowed to consult with nonparticipants. Participants were advised that they could use all of this information to inform their choice of diet. The following week, the study dietitian called participants to elicit their diet choice, with diet counseling starting at the subsequent group visit. At this stage of enrollment, participants in each of 4 cohorts (approximately 50 per cohort) were placed into 4 small groups of approximately 12 participants each (choice-LCD, choice-LFD, comparator-LCD, and comparator-LFD). At week 12, choice participants had the option of switching to the other diet, in which case they received personal counseling for the new diet and subsequently joined the corresponding choice diet group. Comparator Group Procedures At the first group visit, comparator group participants learned of their diet assignment and received an overview of the study design and procedures but were advised not to begin the diet until the subsequent study visit to parallel the timeline of the choice group. Comparator participants then received counseling specific to their randomly assigned diet for the duration of the study. Procedures Common to All Participants Group sessions occurred every 2 weeks for 24 weeks, then every 4 weeks for 24 weeks, with a telephone call from the dietitian between these monthly sessions. In both groups, sessions consisted of measurements followed by group counseling by a single study dietitian. Counseling consisted of dietary and physical activity topics as well as behavioral elements (such as mindful eating and planning for high-risk situations). A pocket guide to counting calories, fat, and carbohydrates was provided (16). Participants were advised to strive for 30 minutes of moderate-intensity aerobic physical activity 5 days per week (17). A study physician was available as needed for antihypertensive or antiglycemic medication adjustments that followed an algorithm (Appendix Figures 1, 2, 3, and 4). Appendix Figure 1. Initial diabetes medication adjustment. HbA1c = hemoglobin A1c; Met = metformin; Secret = secretagogues; TZD = thiazolidinediones. Appendix Figure 2. Medication adjustment for follow-up hypoglycemia in patients taking medication in addition to metformin. GLP-1 = glucagon-like peptide-1. Appendix Figure 3. Medication adjustment for follow-up hypoglycemia in patients taking metformin only. am = morning; bid = twice daily; pm = evening; qd = every day. Appendix Figure 4. Medication adjustment for hypertensive patients taking medication. The telephone counseling focused on individual goal setting and problem solving and incorporated principles of motivational interviewing (18). Using a script, the dietitian helped the patient identify and rank possible goals and then develop and refine action plans (19). The dietitian recorded the goals and action plans electronically so that progress could be assessed during subsequent calls. Dietary Interventions Participants received a book and printed handouts specific to the diet they were following (20, 21). For the LCD, carbohydrate intake was initially restricted to approximately 20 g/d, but calories were not restricted (7, 22). Participants were instructed on how to increase carbohydrate intake gradually as they neared their weight-loss goal or if cravings threatened adherence. For the LFD, intake of total fat was restricted to less than 30% of the daily energy intake, intake of saturated fat was restricted to less than 10% of the daily energy intake, intake of cholesterol was restricted to less than 300 mg/d (21, 23), and energy intake was restricted by subtracting 500 kcal from the daily maintenance energy requirement (24). Outcome Measures Body weight, the primary outcome, was measured at each of the 19 visits at the same time of day on a standardized digital scale with participants in light clothing and shoes removed. Secondary outcomes were measured every 12 weeks for a total of 5 measurements. Waist circumference was measured with a nonelastic tape measure placed on the skin horizontally at the iliac crest (23). Dietary adherence was assessed using the Block Brief 2000 Food Frequency Questionnaire (FFQ), which assesses more than 70 food items (25). A summary measure of dietary adherence was calculated because the LCD and LFD have different dietary goals. The measure was calculated beginning at 12 weeks because dietary adherence did not apply at baseline. The calculation was the percentage of deviation from the goal macronutrient intake, with lower values considered to be greater adherence. For the LFD, the goal was no more than 30% of daily calories from fat. For the LCD, the goal was no more than 10% of daily calories from carbohydrates, based on our previous study showing that this was the mean percentage intake at 2 weeks (22). Weig

Smoking cessation in peri- and postmenopausal women: a review.

A substantial portion of smokers are peri- or postmenopausal women. Cigarette smoking and menopause have overlapping negative health consequences and may act synergistically to contribute to worse health outcomes in this population. Little is known about issues specific to peri- and postmenopausal women attempting to quit smoking; however, it can be hypothesized that they face unique challenges in quitting smoking. Particularly, negative affect and vasomotor menopausal symptoms may make smoking cessation particularly challenging in this group of women. Peri- and postmenopausal women are also more prone to weight gain following smoking cessation, and concerns about postcessation weight gain may contribute to reduced motivation to quit smoking or to relapse to smoking. Recent evidence suggests that estrogen level may be positively associated with nicotine reward, which may aid in the smoking cessation efforts of postmenopausal women while possibly contributing to worse outcomes in perimenopausal women. Unfortunately, no known studies have compared premenopausal women with peri- or postmenopausal women on smoking cessation outcome variables. Studies in postmenopausal women indicate that hormone therapy (HT) use does not affect nicotine withdrawal, smoking cessation outcomes, or weight gain following smoking cessation; however, a lack of randomized trials limits the strength of these conclusions. Evidence of the effects of HT on mood following smoking cessation is conflicting. Further research is needed to identify the unique factors influencing smoking cessation in peri- and postmenopausal women and to develop and test interventions that target these variables in a way that improves cessation rates among this population.

Unique relationships between facets of mindfulness and eating pathology among female smokers

Female smokers often have higher levels of eating disorder symptoms than non-smokers, and concerns about eating and weight might interfere with smoking cessation. Thus, it is critical to identify factors to promote healthier eating and body image in this population. Initial research suggests that specific aspects of trait mindfulness predict lower body dissatisfaction and eating disorder symptoms among non-smokers. However, these relationships are unknown among smokers. The current study examined associations between facets of trait mindfulness and eating disorder symptoms in 112 college female smokers (83% Caucasian; mean age 20 years, SD=1.69). After controlling for relevant sociodemographic variables, Describing and Nonjudging facets of mindfulness predicted lower bulimic symptoms and body dissatisfaction (ps<.05), while Acting with Awareness predicted lower bulimic and anorexic symptoms, ps<.05. Observing predicted higher anorexic symptoms, p<.05. These results suggest that specific mindfulness facets are related to lower eating disorder symptoms among smokers, whereas other facets are not associated or have a positive relationship with these symptoms. Mindfulness-based interventions focusing on Describing, Nonjudging, and Acting with Awareness may help to reduce eating pathology among female smokers, which could potentially improve smoking cessation rates in this population.

Maintenance of Weight Loss After Initiation of Nutrition Training: A Randomized Trial

Interventions targeting dietary change, physical activity, and behavioral strategies yield clinically significant weight loss of at least 5% (1, 2). After this weight loss, most people tend to regain 1 to 2 kg per year, with faster rates of regain in the earlier years (3). To reduce weight regain, various strategies have been evaluated, including sequential dieting, meal replacements, medications, and behavioral approaches (4). Behavioral approaches help people learn and habitualize behaviors for navigating situations that might lead to lapses and relapse (5). One behavioral approach is teaching patients maintenance-specific skills thought to differ from initiation-specific skills (68). Some trials evaluating maintenance skills did not have a specific weight loss requirement, so maintenance-specific skills could not be fully tested (913). One notable exception is the WLM (Weight Loss Maintenance) trial, in which participants who lost at least 4 kg were randomly assigned to an Internet, a personal contact, or a self-directed maintenance intervention (14). Although the personal contact group had modestly less regain at 30 months than the other 2 groups, the intervention was resource intensive, involving monthly telephone calls and in-person visits every 4 months. Efficacious maintenance interventions are needed to help participants adopt maintenance-specific skills while being delivered in a resource-conserving way. We evaluated the efficacy of a maintenance intervention compared with usual care among patients who lost at least 4 kg in a weight loss program. Our innovative maintenance intervention focused on cognitive and behavioral processes involved in weight loss maintenance and was designed to conserve resources by being delivered primarily by telephone with decreasing frequency of contact. Methods Design Overview The design was a 2-group, parallel, randomized, controlled trial. Patients who lost at least 4 kg during a 16-week weight loss program were randomly assigned 1:1 to the maintenance or usual care group. The primary hypothesis was the group difference in mean weight regain at week 56; all follow-up weight measurements were assessed by blinded personnel. The first patient gave informed consent on 20 August 2012; the last date of follow-up was 18 December 2015. The study protocol was approved by the institutional review boards of Durham Veterans Affairs (VA) Medical Center and Duke University Medical Center before data collection. Although body composition was specified in the protocol, these specific data from the bioelectric impedance scales were not entered into our database. Setting Participants were recruited from 3 primary care clinics at the VA Medical Center in Durham and Raleigh, North Carolina. Group sessions were held at the Duke Center for Living and comprised patients from the 3 VA clinics. Eligibility Screening and Participants The study was conducted in 6 cohorts, each recruited over 6 to 8 weeks. Eligibility for the weight loss initiation program was determined in a 3-step process involving an electronic medical record data pull, a screening telephone call, and an in-person screening visit. Details of screening procedures were reported and are available in the protocol (Supplement 1) (15). In brief, patients identified via the data pull were mailed a recruitment letter. Patients called study staff in response to the recruitment letters or flyers posted at the VA clinics, or study staff called patients referred by providers through a consult in the electronic medical record. Patients who passed the telephone screen were scheduled for an in-person visit to determine their final eligibility, and eligible patients provided written informed consent. To be included in the study, patients had to be aged 18 to 75 years, have a body mass index (BMI) of 30 kg/m2 or greater, have a primary care provider, agree to attend visits, and have access to a telephone and reliable transportation. Exclusion criteria included liver disease; type 1 diabetes; most recent hemoglobin A1c in past 6 months 12% or greater; average systolic blood pressure over the past year and most recent blood pressure 160 mm Hg or greater; history of weight loss surgery; dementia, severe psychiatric illness, or substance abuse; weight loss of 10 lb or more in the previous 3 months; current enrollment in a lifestyle program; current weight loss medication; pregnancy or plans to become pregnant in the next 6 months; breastfeeding; lack of birth control if premenopausal; organ transplant recipient; heart issues in the past 3 months; cancer not in remission; pacemaker or defibrillator (because of the use of a bioelectronic impedance scale); emotional problems that would impede intervention adherence or interacting in a group environment; and inability to stand for measurements. Eligible patients were offered up to 6 group meeting times and chose one that they would attend every 2 weeks for 16 weeks (8 sessions total). Supplement. Study Protocol and Technical Appendix: Methods and SAS Code The weight loss program was an abbreviated version of a previous protocol that focused on calorie and fat restriction (16). It included education and strategies for behavior initiation as outlined in our theoretical model, including goal setting and self-monitoring of dietary intake and physical activity. Weight loss of 4 kg or more during this program was the final eligibility criterion for randomization; thus, recording of weight within 1 week of the first scheduled group visit (week 16) and at the end of the weight loss initiation intervention (week 0) was required for patients to be considered for random assignment. A uniform 4-kg criterion was used because it is clinically significant for the average participant (17) and was used in a previous weight loss maintenance trial (14). Randomization and Interventions Patients were randomly assigned 1:1 to maintenance intervention or usual care within initial weight loss strata (<10 kg vs. 10 kg) in block sizes of 4. The randomization scheme was generated via a uniform random-number generator and loaded into a tracking database. It could be accessed only by the study statistician or information technology personnel. Either the studys registered dietitian or the project coordinator randomly assigned the participants by using the tracking database, and participants were given their assignment by telephone within 1 week after their week-0 visit. Intervention participants were asked to return at week 2 for the first maintenance group session, whereas usual care participants were scheduled for the follow-up visit at week 14. The first participant was randomly assigned on 31 January 2013. The maintenance intervention involved transitions from initiation to maintenance skills and from group visits to individual telephone calls, as well as decreased frequency of contact (18). The intervention period was 42 weeks, followed by 14 weeks of no contact. Group visits occurred at weeks 2, 6, and 10. Individual telephone calls were made at weeks 4, 8, 12, 16, 20, 24, 32, and 40. Group sessions addressed maintenance caloric intake, weight self-monitoring, increasing and maintaining physical activity, obtaining social support from friends and family, and relapse prevention. All calls had a uniform structure that focused on 4 maintenance constructs outlined in our theoretical model and were deemed acceptable in a pilot test: satisfaction with outcomes, relapse-prevention planning, self-monitoring, and social support (19). To make salient satisfaction with outcomes, participants reviewed before and after photographs and were asked to discuss outcomes of weight loss that continued to motivate them. They then identified high-risk situations in which relapse might occur and developed a plan to navigate those situations. Next, they specified a frequency of self-weighing and used a 1.36-kg (3-lb) regain relapse threshold. If relapse occurred, the registered dietitian guided the patient to reinitiate and self-monitor his or her diet or physical activity. Finally, participants identified a primary support person and supportive behaviors and were encouraged to share their plans with their support person. The group sessions and telephone calls were delivered by 1 of 2 registered dieticians. Training included a review of theoretical principles and calls with mock participants, with feedback from the investigators. A co-investigator attended each group session and used a fidelity checklist to ensure that all protocoled elements were addressed. All maintenance telephone calls were recorded. Each week, the principal investigator, at least 1 co-investigator, and the registered dietitians met for 1 hour to review randomly selected intervention calls, and the investigators completed fidelity checklists and provided feedback. Usual care was chosen as the comparator to mimic the typical patient experience of no further intervention after participating in a weight loss program. The VAs MOVE! clinical weight loss program (20) was not used as a comparator because it focuses on weight loss. MOVE! and referral to a nutritionist were available as part of usual care. Participants in the intervention group were asked not to enroll in MOVE! or other lifestyle programs or to consult a nutritionist during the intervention, whereas usual care participants were told they could do both. In a post hoc chart review, we determined that 2 participants randomly assigned to usual care and 3 to the intervention group attended a MOVE! orientation visit but had no further involvement in the program during the 56-week maintenance phase. Outcomes and Follow-up All participants were scheduled for assessment appointments at weeks 0, 14, 26, 42, and 56 (weight loss initiation occurred at week 16 to week 0). All measurements were conducted by a research associate blinded to group assignment. Participants received

Obesity-Related Health Status Changes and Weight-Loss Treatment Utilization

20 for the first 4 visits and

Eating disorder pathology and menstrual cycle fluctuations in eating variables in oral contraceptive users and non-users

40 for the assessment

Actual medical and pharmacy costs for bariatric surgery: 6-year follow-up.

BACKGROUND Behavioral weight-loss treatment can improve health, yet it is underutilized. Factors leading to initiation of weight-loss treatment are not well characterized. In particular, it is unknown whether changes in obesity-related health status contribute to weight-loss treatment initiation. PURPOSE To determine if recent weight change or diagnosis of an obesity-related comorbidity was associated with utilization of a behavioral weight-loss program in an integrated healthcare setting. METHODS In a retrospective cohort study of 45,272 Veterans Affairs (VA) patients with BMI >30, logistic regression was used to examine whether recent weight change or obesity-related comorbidities newly diagnosed in the past 6 months were associated with initiation of a VA behavioral weight management program (called MOVE!) in 2010 or sustained MOVE! use (eight or more sessions). Weight change in prior year was categorized as >3% weight loss; weight stable (<3% change); or weight gain of 3%-4.9%, 5%-9.9%, or ≥10%. Data were analyzed in 2013. RESULTS Patients were 91% male, 68% white, and had a mean age of 58 years. Patients were more likely to initiate treatment if they had ≥3% weight gain (3%-4.9%: OR=1.64, 95% CI=1.52, 1.77; 5%-9.9%: OR=1.99, 95% CI=1.84, 2.16; ≥10%: OR=2.68, 95% CI=2.32, 3.10) or were newly diagnosed with any obesity-related comorbidity (ORs: 2.14-3.59). Weight change and new comorbidity diagnoses were not associated, however, with sustained MOVE! use. CONCLUSIONS Adverse obesity-related health events were associated with initiation of behavioral weight-loss treatment offered in an integrated healthcare setting.