Randa M. Kutob

Intervention in Overweight Children Improves Body Mass Index (BMI) and Physical Activity

Background: Childhood obesity is a growing epidemic in family medicine with few clinical treatment options. We implemented and evaluated a group office-visit intervention by family physicians for overweight children and their parents, emphasizing nutrition and physical activity within a resiliency psychosocial model. Methods: The intervention lasted for 3 months, with half of the children crossing over to intervention after 6 months in the study. Participants included 35 children who met eligibility criteria of being in third through fifth grades and having a body mass index (BMI) above the 85th percentile. The 3-month, 12-session intervention, “Choices,” included topics on nutrition, physical activity, and resiliency. The sessions were developed for delivery by a family physician and a nutritionist who received training in positive psychology and resilience skills. Main outcome measures were BMI z scores for age and sex and z scores for weight by age and sex, as well as qualitative interviews to understand individual and family processes. Results: The intervention resulted in a significant effect on one primary outcome, BMI z score (−0.138 per 9 months [P = .017]) and a trend toward significance on the weight for age z score (−0.87 per 9 months [P = .09]). The net shift of activity from the low metabolic equivalents (METs) to the high METs had an intervention effect of 2.84 METs (P = .037). Families reported lasting changes in behaviors and attitudes. Discussion: The innovative approach used in this study demonstrated modest efficacy in reducing BMI z score, changing physical activity levels, and possibly shifting family dynamics.

Pilot study of impact of medical-legal partnership services on patients' perceived stress and wellbeing.

Medical-legal partnerships (MLPs) bring legal services into health care settings to address patients’ unmet legal needs. This pilot project examined whether MLP services impact patients’ perceptions of stress and wellbeing. Methods. Providers referred patients with legal concerns to the Tucson Family Advocacy Program (TFAP), an MLP within a family medicine clinic. Stress levels and wellbeing were assessed before and after legal services using self-administered 10-item Perceived Stress Scale (PSS-10) and Measure Yourself Concerns and Wellbeing (MYCaW) instruments. Results. Sixty-seven participants completed pre- and post-service questionnaires. Within this group, the mean PSS-10 score decreased 8.1 points. Wellbeing scores improved by 1.8 points. Individual changes in perceived stress were strongly related to participants’ level of concern regarding the particular legal issues addressed. Conclusions. Services in patient-centered medical homes to address unmet legal needs have the potential to reduce perceived stress and improve overall wellbeing. Additional studies concerning MLPs and patient outcomes are needed.

Families United/Familias Unidas Development and Implementation of a Family-Based Group Office Visit Model for the Primary Prevention of Type 2 Diabetes

Purpose The purpose of this study is to describe the development and implementation of a new diabetes prevention intervention that combines the benefits of family support with the group office model. Intensive lifestyle modification can effectively delay the onset of type 2 diabetes, yet health providers are challenged in translating these results to their patients. The group outpatient visit model can provide a means to address prevention issues in a financially sustainable manner. Methods Materials from the Diabetes Prevention Program and a previously developed group office visit program were combined to create the Families United/Familias Unidas curriculum. The session content utilized a multiculturally tailored approach designed to help participants decrease portion size, decrease carbohydrate intake, increase physical activity, and increase resiliency. Adults aged 18 to 70 were recruited who had any diabetes risk factors but did not have diabetes. Eligible participants enlisted a support person, aged 14 to 70, to join them in the 6-month group office visit intervention. Results Twenty-nine pairs (n = 58) of primary participants plus support persons were recruited. Participants’ average age was 45; 74% were female; 56.9% identified themselves as white and 37.9% as Hispanic/Latino. Over one-third had 4 or more diabetes risk factors. Twelve family group office visits were delivered over 6 months. The attendance rate for those who attended at least one session was 72%. Conclusions Group office visits can provide a new sustainable model for diabetes prevention and are a natural fit for primary care physicians in collaboration with other health care professionals, such as dieticians or diabetes educators.

Families United/Familias Unidas: family group office visits to reduce risk factors for type 2 diabetes.

Purpose The purpose of the Families United/Familias Unidas study was to evaluate the feasibility and efficacy of group office visits on reducing diabetes risk in a multiethnic, primary care population. Methods Adults, ages 18 to 70 years, with any diabetes risk factor were recruited to attend 12 group office visits over 6 months. Each participant identified 1 support person, age 14 to 70 years, to accompany them. Data were collected at baseline, postintervention, 6 months, and 12 months. Primary outcome measures were reduction in the total number of predefined, modifiable risk factors (ie, body mass index ≥25 kg/m2; waist circumference ≥88 cm [women], ≥102 cm [men]; blood pressure ≥140/90 mm Hg; hemoglobin A1C ≥5.7%; fasting insulin ≥15 µU/mL; glycemic index ≥52.5% [women], ≥53.4% [men]; and physical activity <150 min/wk). Results Thirty-nine participants/supporters completed the intervention (mean age 47.8 ± 12.3 years, 69.2% female, 61.5% white, 35.9% Latino). Risk reduction analysis included only participants/supporters who remained paired at the intervention’s end (n = 36). At baseline, primary participants (n = 18) had an average of 4.8 ± 1.6 (standard error) predefined risk factors; supporters (n = 18), 4.1 ± 1.4. Primary participants’ risk factors decreased approximately 15% immediately after the 6-month intervention (absolute reduction of 1.1 risk factors) and increased to ~20% reduction 1 year postintervention (absolute reduction of 1.4 risk factors). Risk reduction was primarily due to decreases in dietary glycemic index and fasting insulin levels. Conclusions Group visits provide an innovative and potentially efficacious model of diabetes prevention in multiethnic patients with heterogeneous risk factors.

Artificially sweetened beverages, sugar-sweetened beverages, plain water, and incident diabetes mellitus in postmenopausal women: the prospective Women’s Health Initiative observational study

Background: Sugar-sweetened beverages (SSBs) have been associated with an increased risk of diabetes mellitus (DM), whereas the association with artificially sweetened beverages (ASBs) is unclear.Objective: We aimed to evaluate the associations of ASB and SSB consumption with the risk of developing DM and the potential benefit of replacing SSBs with ASBs or water.Design: The national Womens Health Initiative recruited a large prospective cohort of postmenopausal women between 1993 and 1998. ASB, SSB, and water consumption was measured by lifestyle questionnaires, and DM was self-reported.Results: Of 64,850 women, 4675 developed diabetes over an average of 8.4 y of follow-up. ASBs and SSBs were both associated with an increased risk of DM with an HR of 1.21 (95% CI: 1.08, 1.36) comparing ASB consumption of ≥2 serving/d to never or <3 serving/mo, and an HR of 1.43 (95% CI: 1.17, 1.75) comparing SSB consumption of ≥2 serving/d to <1 serving/wk (1 serving = one 12-ounce can or 355 mL). Subgroup analysis found an increased risk of DM associated with ASBs only in the obese group. Modeling the substitution of SSBs with an equal amount of ASBs did not significantly reduce the risk of developing DM. However, statistically substituting 1 serving of ASBs with water was associated with a significant risk reduction of 5% (HR: 0.95; 95% CI: 0.91, 0.99), whereas substituting 1 serving of SSBs with water was associated with a risk reduction of 10% (HR: 0.90; 95% CI: 0.85, 0.95).Conclusions: ASBs were associated with a 21% increased risk of developing DM, approximately half the magnitude of SSBs (associated with a 43% increased risk). Replacing ASBs and SSBs with water could potentially reduce the risk. However, caution should be taken in interpreting these results as causal because both residual confounding and reverse causation could explain these results.

Using standardized patients to teach cross-cultural communication skills

US medical education requires cultural competence training, yet educators know how challenging this requirement can be to implement. Pre-clinical students may not believe that a patient’s culture can affect medical care, or may believe that to be ‘‘culturally competent,’’ one must somehow understand every different racial or ethnic group – an impossible task. Traditionally, cultural competence training used a categorical approach which stressed the acquisition of cultural knowledge about specific, ethnicity-based groups of patients. In contrast, the skills-based approach provides tools for students to uncover and explore their patients’ own sense of culture and their explanatory models of disease, followed by the negotiation of a treatment plan that includes input from the patient. This method avoids the pitfalls of ‘‘knowledge-based’’ approaches by avoiding stereotyping of ethnic groups, while providing the skills to successfully navigate clinical encounters with patients from all ethnic backgrounds. We developed a four-hour cultural competence workshop for pre-clinical students that consisted of several components, largely modeled on the work of Kleinman (1980). It included role plays focused on eliciting the health care beliefs of standardized patients. The workshop was evaluated using a modified Cultural Competence Assessment Tool (CCAT) in a pre/post-test design. Of the 228 students who attended, 54.4% were female, 65% were white, 12.1% were Asian/Pacific Islander, and 8.9% were Hispanic/Latino. Preand post-CCATs could be matched for 157 students. Total CCAT score increased significantly from preto post-administration (109.62 pre-test to 114.18 post-test, p5 0.001). The greatest increase was seen in the subscale that measured elicitation of health beliefs (average subscale score of 3.34 pre-test to 3.71 post-test, p5 0.001) Role plays using standardized patients were rated more highly than other workshop components and may be the most effective means to deliver cultural competence content in a short period of time. This workshop demonstrated that a brief, skills-based curriculum can help students understand cross-cultural patient dynamics. The built-in flexibility of this approach is more suitable to the increasingly diverse population of the US, and offers a better method for teaching cultural competence than knowledge-based models. A detailed version of this study is available from the first author.

Relationship Between Marital Transitions, Health Behaviors, and Health Indicators of Postmenopausal Women: Results from the Women's Health Initiative

BACKGROUND Historically, marital status has been associated with lower mortality and transitions into marriage were generally accompanied by improved health status. Conversely, divorce has been associated with increased mortality, possibly mediated by changes in health behaviors. METHODS This study uses data from a prospective cohort of 79,094 postmenopausal women participating in the Womens Health Initiative Observational Study (WHI-OS) to examine the relationship between marital transition and health indicators (blood pressure, waist circumference, body mass index [BMI]) as well as health behaviors (diet pattern, alcohol use, physical activity, and smoking) in a sample of relatively healthy and employed women. Linear and logistic regression modeling were used to test associations, controlling for confounding factors. RESULTS Womens transitions into marriage/marriage-like relationship after menopause were associated with greater increase in BMI (β = 0.22; confidence interval (95% CI), 0.11-0.33) and alcohol intake (β = 0.08; 95% CI, 0.04-0.11) relative to remaining unmarried. Divorce/separation was associated with a reduction in BMI and waist circumference, changes that were accompanied by improvements in diet quality (β = 0.78, 95% CI, 0.10-1.47) and physical activity (β = 0.98, 95% CI, 0.12-1.85), relative to women who remained married. CONCLUSION Contrary to earlier literature, these findings among well-educated, predominantly non-Hispanic white women suggest that marital transitions after menopause are accompanied by modifiable health outcomes/behaviors that are more favorable for women experiencing divorce/separation than those entering a new marriage.