Monica W. Gerber

Comparative Effectiveness of Clinical-Community Childhood Obesity Interventions: A Randomized Clinical Trial

Importance Novel approaches to care delivery that leverage clinical and community resources could improve body mass index (BMI) and family-centered outcomes. Objective To examine the extent to which 2 clinical-community interventions improved child BMI z score and health-related quality of life, as well as parental resource empowerment in the Connect for Health Trial. Design, Setting, and Participants This 2-arm, blinded, randomized clinical trial was conducted from June 2014 through March 2016, with measures at baseline and 1 year after randomization. This intent-to-treat analysis included 721 children ages 2 to 12 years with BMI in the 85th or greater percentile from 6 primary care practices in Massachusetts. Interventions Children were randomized to 1 of 2 arms: (1) enhanced primary care (eg, flagging of children with BMI ≥ 85th percentile, clinical decision support tools for pediatric weight management, parent educational materials, a Neighborhood Resource Guide, and monthly text messages) or (2) enhanced primary care plus contextually tailored, individual health coaching (twice-weekly text messages and telephone or video contacts every other month) to support behavior change and linkage of families to neighborhood resources. Main Outcomes and Measures One-year changes in age- and sex-specific BMI z score, child health-related quality of life measured by the Pediatric Quality of Life 4.0, and parental resource empowerment. Results At 1 year, we obtained BMI z scores from 664 children (92%) and family-centered outcomes from 657 parents (91%). The baseline mean (SD) age was 8.0 (3.0) years; 35% were white (n = 252), 33.3% were black (n = 240), 21.8% were Hispanic (n = 157), and 9.9% were of another race/ethnicity (n = 71). In the enhanced primary care group, adjusted mean (SD) BMI z score was 1.91 (0.56) at baseline and 1.85 (0.58) at 1 year, an improvement of −0.06 BMI z score units (95% CI, −0.10 to −0.02) from baseline to 1 year. In the enhanced primary care plus coaching group, the adjusted mean (SD) BMI z score was 1.87 (0.56) at baseline and 1.79 (0.58) at 1 year, an improvement of −0.09 BMI z score units (95% CI, −0.13 to −0.05). However, there was no significant difference between the 2 intervention arms (difference, −0.02; 95% CI, −0.08 to 0.03; P = .39). Both intervention arms led to improved parental resource empowerment: 0.29 units (95% CI, 0.22 to 0.35) higher in the enhanced primary care group and 0.22 units (95% CI, 0.15 to 0.28) higher in the enhanced primary care plus coaching group. Parents in the enhanced primary care plus coaching group, but not in the enhanced care alone group, reported improvements in their child’s health-related quality of life (1.53 units; 95% CI, 0.51 to 2.56). However, there were no significant differences between the intervention arms in either parental resource empowerment (0.07 units; 95% CI, −0.02 to 0.16) or child health-related quality of life (0.89 units; 95% CI, −0.56 to 2.33). Conclusions and Relevance Two interventions that included a package of high-quality clinical care for obesity and linkages to community resources resulted in improved family-centered outcomes for childhood obesity and improvements in child BMI. Trial Registration clinicaltrials.gov Identifier: NCT02124460

Association of premenstrual syndrome and premenstrual dysphoric disorder with bulimia nervosa and binge‐eating disorder in a nationally representative epidemiological sample

OBJECTIVE Bulimia nervosa (BN) and binge-eating disorder (BED) are associated with significant health impairment. Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) comprise both psychological (disturbances in mood and affect) and physiological (bloating and changes in appetite) symptoms that may trigger binge-eating and/or purging. METHOD Female participants were drawn from the Collaborative Psychiatric Epidemiological Surveys, conducted from 2001 to 2003. Weighted multivariable logistic regression modeled the association between lifetime PMS and PMDD and lifetime odds of BN or BED. RESULTS Among 8,694 participants, 133 (1.0%) had BN and 185 (1.8%) BED. Additionally, 366 (4.2%) had PMDD and 3,489 (42.4%) had PMS. Prevalence of PMDD and PMS were 17.4 and 55.4% among those with BN, 10.7 and 48.9% among those with BED and 3.4 and 59.1% among those with subthreshold BED. After adjustment for age, race/ethnicity, income, education, body mass index, age at menarche, birth control use, and comorbid mental health conditions, PMDD was associated with seven times the odds of BN (OR 7.2, 95% CI 2.3, 22.4) and PMS with two times the odds of BN (OR 2.5, 95% CI 1.1, 5.7). Neither PMDD nor PMS were significantly associated with BED. DISCUSSION Women with PMS and PMDD have a higher odds of BN, independent of comorbid mental health conditions. PMS and PMDD may be important comorbidities to BN to consider in clinical settings, and future research should investigate whether PMS and PMDD affect the onset and duration of bulimic symptoms as well as the potential for shared risk factors across disorders.

PTSD and Romantic Relationship Satisfaction: Cluster- and Symptom-Level Analyses.

Previous studies have demonstrated bidirectional associations between posttraumatric stress disorder (PTSD) and romantic relationship dissatisfaction. Most of these studies were focused at the level of the disorder, examining the association between relationship dissatisfaction and having a diagnosis of PTSD or the total of PTSD symptoms endorsed. This disorder-level approach is problematic for trauma theorists who posit symptom-level mechanisms for these effects. In the present study, we examined the prospective, bidirectional associations between PTSD symptom clusters (e.g., reexperiencing) and relationship satisfaction using the data from 101 previously studied individuals who had had a recent motor vehicle accident. We also conducted exploratory analyses examining the prospective, bidirectional associations between individual PTSD symptoms and relationship satisfaction. Participants had completed the PTSD Checklist-Civilian Version and the Relationship Assessment Scale at 4, 10, and 16 weeks after the MVA. We performed time-lagged mixed-effects regressions to examine the effect of lagged relationship satisfaction on PTSD clusters and symptoms, and vice versa. No cluster effects were significant after controlling for a false discovery rate. Relationship satisfaction predicted prospective decreases in reliving the trauma (d = 0.42), emotional numbness (d = 0.46), and irritability (d = 0.49). These findings were consistent with the position that relationship satisfaction affects PTSD through symptom-level mechanisms.

Black-white disparities in the association between posttraumatic stress disorder and chronic illness

OBJECTIVE Non-Latino blacks experience a higher proportion of chronic illness and associated disabilities than non-Latino whites. Posttraumatic stress disorder (PTSD) is associated with a greater risk of chronic illness, although few studies have investigated whether the interaction of PTSD with racial disparities may lead to a greater risk of chronic illness among blacks with PTSD than among whites with PTSD. METHODS We evaluated data from the population-based National Survey of American Life and the National Comorbidity Survey Replication to investigate the association between race, lifetime PTSD and self-reported chronic illness. Weighted linear and Poisson regression models assessed differences in the magnitude of association between PTSD and chronic illness by race on both the additive and multiplicative scales. RESULTS The magnitude of the association between lifetime PTSD and diabetes was greater among blacks (RD 0.07, 95% CI 0.02, 0.11; RR 1.9, 95% CI 1.4, 2.5) than whites (RD 0.004, 95% CI -0.02, 0.03; RR 1.2, 95% CI 0.7, 1.9) on the additive (p=0.017) scale. The magnitude of the association between lifetime PTSD and heart disease was greater among blacks (RD 0.09, 95% CI 0.05, 0.13) than whites (RD 0.04, 95% CI 0.01, 0.07) on the additive scale at a level approaching significance (p=0.051). CONCLUSION A lifetime history of PTSD was associated with a significantly greater risk of diabetes among blacks as compared to whites. These findings suggest that continuous exposure to racial inequalities may be associated with a greater risk of PTSD-related health sequela.

Effects of Before-School Physical Activity on Obesity Prevention and Wellness

INTRODUCTION The effects of Build Our Kids Success-a 12-week, 1-hour before-school physical activity program-on BMI and social-emotional wellness among kindergarten to eighth grade students was examined. STUDY DESIGN This was a nonrandomized trial. SETTING/PARTICIPANTS Participants were from 24 schools in Massachusetts; there were 707 children from kindergarten to eighth grade. INTERVENTION Children registered for Build Our Kids Success in 2015-2016 participated in a 2 days/week or 3 days/week program. Nonparticipating children served as controls. MAIN OUTCOME MEASURES At baseline and 12 weeks, study staff measured childrens heights/weights; children aged ≥8 years completed surveys. Main outcomes were 12-week change in BMI z-score, odds of a lower BMI category at follow-up, and child report of social-emotional wellness. Analyses were completed in March-June 2017. RESULTS Follow-up BMI was obtained from 67% of children and self-reported surveys from 72% of age-eligible children. Children in the 3 days/week group had improvements in BMI z-score (-0.22, 95% CI= -0.31, -0.14) and this mean change was significantly different than the comparison group (-0.17 difference, 95% CI= -0.27, -0.07). Children in the 3 days/week group also had higher odds of being in a lower BMI category at follow-up (OR=1.35, 95% CI=1.12, 1.62); significantly different than the comparison group (p<0.01). Children in the 2 days/week program had no significant changes in BMI outcomes. Children in the 3 days/week group demonstrated improvement in their student engagement scores (0.79 units, p=0.05) and had nonsignificant improvements in reported peer relationships, affect, and life satisfaction versus comparison. The 2 days/week group had significant improvements in positive affect and vitality/energy versus comparison. CONCLUSIONS A 3 days/week before-school physical activity program resulted in improved BMI and prevented increases in child obesity. Both Build Our Kids Success groups had improved social-emotional wellness versus controls. TRIAL REGISTRATION This study is registered at www.clinicaltrials.gov NCT03190135.

A Community Resource Map to Support Clinical–Community Linkages in a Randomized Controlled Trial of Childhood Obesity, Eastern Massachusetts, 2014–2016

Background Novel approaches to health care delivery that leverage community resources could improve outcomes for children at high risk for obesity. Community Context We describe the process by which we created an online interactive community resources map for use in the Connect for Health randomized controlled trial. The trial was conducted in the 6 pediatric practices that cared for the highest percentage of children with overweight or obesity within a large multi-specialty group practice in eastern Massachusetts. Methods By using semistructured interviews with parents and community partners and geographic information systems (GIS), we created and validated a community resource map for use in a randomized controlled trial for childhood obesity. We conducted semistructured interviews with 11 parents and received stakeholder feedback from 5 community partners, 2 pediatricians, and 3 obesity–built environment experts to identify community resources that could support behavior change. We used GIS databases to identify the location of resources. After the resources were validated, we created an online, interactive searchable map. We evaluated parent resource empowerment at baseline and follow-up, examined if the participant families went to new locations for physical activity and food shopping, and evaluated how satisfied the families were with the information they received. Outcome Parents, community partners, and experts identified several resources to be included in the map, including farmers markets, supermarkets, parks, and fitness centers. Parents expressed the need for affordable activities. Parent resource empowerment increased by 0.25 units (95% confidence interval, 0.21–0.30) over the 1-year intervention period; 76.2% of participants were physically active at new places, 57.1% of participant families shopped at new locations; and 71.8% reported they were very satisfied with the information they received. Interpretation Parents and community partners identified several community resources that could help support behavior change. Parent resource empowerment and use of community resources increased over the intervention period, suggesting that community resource mapping should inform future interventions.

Predictors of treatment utilization and unmet treatment need among individuals with posttraumatic stress disorder from a national sample

OBJECTIVE Posttraumatic stress disorder (PTSD) is a chronic psychiatric condition associated with significant disability that often remains untreated. Sociodemographic and family-level factors may serve as predictors of unmet treatment need, identifying groups that would most benefit from policies aimed at increasing access to the mental health care system. METHOD Data from the nationally representative Collaborative Psychiatric Epidemiologic Surveys were used to identify predictors of mental health treatment utilization, both with a mental health specialist and with a general health practitioner, and self-reported unmet treatment need among individuals who endorsed past-year PTSD. We defined unmet treatment need as self-reporting a mental health problem and not accessing mental health care in the general or specialty mental health care system. RESULTS Among 600 participants, predictors of unmet treatment need included being non-Latino black [odds ratio (OR) 2.11, 95% confidence interval (CI) 1.25-3.54], having a high school education versus some college (OR 2.45, 95% CI 1.34-4.48), and being employed or unemployed versus not being in the workforce (OR 1.74, 95% CI 1.00-3.02 and OR 4.95, 95% CI 1.60-15.34, respectively). Recursive partitioning identified younger age and being married as predictors of low treatment utilization. CONCLUSIONS Future research should elucidate barriers to accessing treatment among those with PTSD in these underserved groups.

Neighborhood social cohesion and sleep outcomes in the Native Hawaiian and Pacific Islander National Health Interview Survey

Study Objective Native Hawaiians and Pacific Islanders (NHPIs) have the lowest attainment of healthy sleep duration among all racial and ethnic groups in the United States. We examined associations of neighborhood social cohesion with sleep duration and quality. Methods Cross-sectional analysis of 2464 adults in the NHPI National Health Interview Survey (2014). Neighborhood social cohesion was categorized as a continuous and categorical variable into low (<12), medium (12-14), and high (>15) according to tertiles of the distribution of responses. We used multinomial logistic regression to examine the adjusted odds ratio of short and long sleep duration relative to intermediate sleep duration. We used binary logistic regression for dichotomous sleep quality outcomes. Sleep outcomes were modeled as categorical variables. Results Forty percent of the cohort reported short (<7 hours) sleep duration and only 4% reported long (>9 hours) duration. Mean (SE, range) social cohesion score was 12.4 units (0.11, 4-16) and 23% reported low social cohesion. In multivariable models, each 1 SD decrease in neighborhood social cohesion score was associated with higher odds of short sleep duration (odds ratio [OR]: 1.14, 95% confidence interval [CI]: 1.02, 1.29). Additionally, low social cohesion was associated with increased odds of short sleep duration (OR: 1.53, 95% CI: 1.10, 2.13). No associations between neighborhood social cohesion and having trouble falling or staying asleep and feeling well rested were found. Conclusion Low neighborhood social cohesion is associated with short sleep duration in NHPIs.

Determinants of Binge Eating Symptoms in Children with Overweight/Obesity

BACKGROUND Examining binge eating symptoms before the diagnosis of binge eating disorder in children with obesity could provide important information on prevention of future eating disorders. METHODS We examined the prevalence and multilevel determinants of three binge eating symptoms: (1) sneaking, hiding, or hoarding food; (2) eating in the absence of hunger, and (3) inhibition or embarrassment when eating in front of others among 817 children aged 5-12 years old with overweight/obesity receiving primary care in eastern Massachusetts. We examined the associations of child and parent/household characteristics with the prevalence ratios (PRs) of these three binge eating symptoms. RESULTS Approximately one-third of parents reported that their children would sneak, hide, or hoard food; 40% ate large amounts in the absence of hunger; and 8% were inhibited/embarrassed when eating in front of others. In multivariate analyses, greater screen time was associated with a higher prevalence of sneaking, hiding, or hoarding (PR 1.06, 95% CI: 1.01-1.11). We found that children with severe obesity (PR 1.50, 95% CI: 1.24-1.81 vs. nonsevere obesity) had higher prevalence of eating in the absence of hunger. Increased hours of screen time were associated with higher prevalence of eating in the absence of hunger, (PR: 1.07, 95% CI: 1.03-1.11), whereas longer sleep duration (PR: 0.90, 95% CI: 0.82-0.99) was associated with lower prevalence of eating in the absence of hunger. CONCLUSIONS Eating in the absence of hunger was the most common symptom in our sample and was associated with screen time and sleep. ClinicalTrials.gov NCT01537510.

The association of posttraumatic stress disorder and chronic medical conditions by ethnicity.

Our study extends the literature on associations between posttraumatic stress disorder (PTSD) and chronic medical conditions by assessing differences in the magnitude of these relations by ethnicity. We examined group differences in the magnitude of the relation between PTSD and chronic medical conditions (cardiovascular disease [CVD], hypertension, obesity, diabetes). We obtained data from Latino (n = 3,224) and non-Latino White (n = 4,180) respondents from the Collaborative Psychiatric Epidemiology Surveys. Logistic regression models were constructed to test for the modification of the effect of PTSD on chronic medical conditions by ethnicity and then by nativity. Unadjusted models revealed significant interactions between Latino ethnicity and PTSD for odds of diabetes (OR = 2.18 [Latino] vs. 0.81 [non-Latino White]), CVD (OR = 3.23 [Latino] vs. 1.28 [non-Latino White]), and hypertension (OR = 1.61 [Latino] vs. 0.98 [non-Latino White]). Among U.S.-born Latinos, we found a significant interaction between ethnicity and PTSD for odds of CVD (OR = 4.18 [Latino] vs. 1.28 [non-Latino White]) and diabetes (OR = 2.27 [Latino] vs. 0.81 [non-Latino White]). These findings attenuated in adjusted models with the exception of differences in PTSD and odds of diabetes among Latinos (including aggregated group and U.S. born) compared to non-Latino Whites. Our findings support the need for further research on the complex relations between PTSD and chronic conditions, including the investigation of conditional risk by Latino subgroups. Nuestro estudio profundiza la literatura respecto de la asociación entre el trastorno de estrés postraumático (TEPT) y distintas condiciones médicas evaluando la magnitud de las diferencias en estas asociaciones según grupo étnico. El estudio examinó las diferencias entre grupos en la magnitud de la relación entre el TEPT y condiciones médicas crónicas (enfermedad cardiovascular, obesidad, diabetes, e hipertensión). Los datos obtenidos fueron de participantes Latinos (n = 3,224) y blancos no-Latinos (n = 4,180) de las Encuestas Psiquiátricas Epidemiológicas Colaborativas (Collaborative Psychiatric Epidemiology Surveys). Mediante la construcción de modelos de regresión logística se examinó la modificación del efecto del TEPT en condiciones médicas crónicas según grupo étnico, y después según lugar de nacimiento. Modelos no ajustados resultaron con interacciones significativas entre participantes Latinos y el TEPT teniendo mayores probabilidades de enfermar con diabetes (OR = 2.18 [Latinos] v. 0.81 [blancos no-Latinos), con enfermedad cardiovascular (OR = 3.23 [Latino] v. 1.28 [blancos no-Latinos]), y con hipertensión (OR = 1.61 [Latino] v 0.98 [blancos no-Latinos]). Aquellos participantes Latinos, que nacieron en los EE.UU. obtuvieron una interacción significativa según grupo étnico y el TEPT teniendo mayores probabilidades de tener enfermedad cardiovascular (OR = 4.18 [Latino] v. 1.28 [blancos no-Latinos]) y diabetes (OR = 2.27 [Latino] v. 0.81 [blancos no-Latinos]). Los hallazgos obtenidos fueron atenuados tras la utilización de modelos ajustados excepto en las diferencias entre el TEPT y las probabilidades de diabetes entre Latinos (incluso grupos agregados y nacidos en los EE.UU.) comparados con participantes blancos no-Latinos. Nuestros hallazgos sostienen la importancia de nuevas investigaciones para entender las compleja relación entre el TEPT y condiciones médicas crónicas, particularmente la investigación del riesgo condicional para subgrupos de origen Latino.