Raymond G. Boyle

Binge eating disorder, weight control self-efficacy, and depression in overweight men and women

OBJECTIVE: To examine binge eating, depression, weight self-efficacy, and weight control success among obese individuals seeking treatment in a managed care organization.DESIGN: Gender-stratified analyses of associations between binge eating, depression, weight self-efficacy, and weight change, using data from a randomized clinical trial that compared low-cost telephone-based, mail-based, and usual care interventions for weight loss.SUBJECTS: A total of 1632 overweight individuals (460 men, 1172 women; mean age: 50.7 y; mean body mass index: 34.2 kg/m2) were recruited from a large Midwestern US managed care organization.MEASUREMENTS: Height and weight were measured by study personnel at baseline, and self-reported weight was assessed at 6 and 12 months; self-reported depression status, binge eating, and self-efficacy for weight control were assessed at baseline.RESULTS: Lifetime prevalence rates for depression and probable binge eating disorder were high. Weight self-efficacy was inversely related to weight in both men and women. For women, depression was associated with lower weight self-efficacy and higher body weight. Women reporting depression or lower weight self-efficacy at baseline had less weight loss success at 6 and 12 months. Depression, binge eating disorder, and weight self-efficacy were not significantly associated with weight loss success in men.CONCLUSION: Negative emotional states are highly prevalent and predict poor treatment outcomes, particularly for obese women. As obese women with clinical depression typically are excluded from intervention studies, further research on how to address the intersection of obesity intervention and mood management may be warranted.

Mail and phone interventions for weight loss in a managed-care setting: Weigh-To-Be one-year outcomes

OBJECTIVE: To describe methods, recruitment success, and 1-y results of a study evaluating the effectiveness of phone- and mail-based weight-loss interventions in a managed care setting.DESIGN: Randomized clinical trial with three groups, that is, usual care, mail intervention, and phone intervention.SUBJECTS: In total, 1801 overweight members of a managed-care organization (MCO).MEASUREMENTS: Height, weight, medical status, and weight-loss history were measured at baseline. Participation in intervention activities was monitored for 12 months in the two active treatment groups. Self-reported weight was obtained at 6 and 12 months.RESULTS: More individuals assigned to mail treatment started it (88%) than did those assigned to phone treatment (69%). However, program completion rates were higher in the phone (36%) than mail (7%) intervention. The mean weight losses were 1.93, 2.38, and 1.47 kg at 6 months in the mail, phone, and usual care groups, respectively. The differences between the phone and usual care groups were statistically significant. The mean weight losses at 12 months did not differ by treatment group (2.28 kg mail, 2.29 kg phone, and 1.92 kg usual care). Greater weight loss was seen in men, older participants, and those with no prior experience in a weight-loss program. Heavier participants and those who reported current treatment for depression lost less weight.CONCLUSION: Although mail- and phone-based weight-loss programs can be delivered to large numbers of people in an MCO setting, additional work is needed to enhance their clinical efficacy as well as to assess their costs.

Stages of Change for Physical Activity, Diet, and Smoking among HMO Members with Chronic Conditions

Purpose. This paper investigated whether stage of change for health behaviors was associated with the presence of chronic conditions. Design. A stratified cross-sectional survey by mail with telephone follow-up. Settings. This study was conducted at a mixed-model HMO with 650,000 members based in Minnesota. Subjects. The sample consisted of a random sample of 8000 HMO members age 40 or over with systematic oversampling of members with hypertension, diabetes, dyslipidemia, or heart disease. Measures. In addition to demographics, readiness to change for physical activity, fat intake, fruit and vegetable intake, and smoking were assessed. Results. The adjusted response rate was 82.4%. In a logistic regression analysis, members with one or more than one chronic condition had greater readiness to change for three out of four risk factors compared to members with no chronic conditions. Conclusions. The stage-of-change distribution of HMO members with chronic conditions suggests that members at highest risk of adverse health outcomes have the greatest readiness to change behavioral risk factors. Based on these observations, targeted, stage-specific efforts to support behavior change are likely to be both acceptable and effective in HMO members with chronic conditions. Improving stage of change for behavioral risk factors for members with diabetes may present special problems and opportunities.

Measuring dependence in smokeless tobacco users.

Two scales based on the Fagerstrom Tolerance Questionnaire were developed to measure dependence in smokeless tobacco users. The total score for both scales correlated positively with saliva cotinine levels in subjects, and several individual items produced equally positive correlations. Regression analyses yielded two subsets of three items from each scale that predicted cotinine level. Reports of using smokeless tobacco within 30 min of waking served as a predictor in both models. For the purposes of measuring smokeless tobacco dependence, attention should be given to individual items correlated with saliva cotinine levels that could be used to determine the direction of cessation efforts. Future research should also develop additional items specific to the use of snuff or chewing tobacco and eliminate questions not contributing to the overall scale.

Smoking and Cessation Behaviors Among Young Adults of Various Educational Backgrounds

OBJECTIVES We sought to determine whether the educational backgrounds of young adult smokers (aged 18 to 24 years) affect their cessation attitudes or behaviors in ways that could be used to improve smoking interventions. METHODS We surveyed 5580 members of the HealthPartners health plan and conducted a follow-up survey 12 months later of current and former smokers. Respondents were divided into subgroups according to educational level. RESULTS Higher levels of education were associated with lower smoking rates (16% among students in 4-year colleges, 31% among those in technical or 2-year colleges, and 48% among those with a high school education or less) as well as less frequent or heavy smoking. However, number of quit attempts in the past year, level of interest in quitting, and smoking relapse rates did not vary according to educational level. Seventy-three percent of those who had attempted to quit had not used some form of assistance. CONCLUSIONS Rates of smoking among young adults, especially those at low educational levels, are relatively high. However, most members of this age group are interested in quitting, regardless of educational background.

Letter: Effects of tobacco excise taxes on the use of smokeless tobacco products in the USA

Data from the September 1985 Current Population Survey are used to estimate the effects of tobacco excise taxes and state laws restricting smoking in public places on the likelihood of current use of cigarettes or smokeless tobacco (ST) products (moist snuff or chewing tobacco) among males in the USA. The results indicate that higher ST excise tax rates are associated with a reduced probability of ST use, whereas higher cigarette excise tax rates are associated with an increased probability of ST use, holding other factors constant. State laws restricting smoking have no apparent effect on ST use.

How to define e-cigarette prevalence? Finding clues in the use frequency distribution

Objective E-cigarette use has rapidly increased. Recent studies define prevalence using a variety of measures; competing definitions challenge cross-study comparison. We sought to understand patterns of use by investigating the number of days out of the past 30 days when adults had used e-cigarettes. Design We used the 2014 Minnesota Adult Tobacco Survey, a random digit dial population survey (n=9304 adults). Questions included ever using e-cigarettes, number of days used in the past 30 days and reasons for use. Smoking status was determined by combustible cigarette use. Histograms of e-cigarette use were visually inspected for current, former and never smokers with any 30-day e-cigarette use. Different definitions of current use were compared. Results Use ≤5 days in the past 30 days demarcated a cluster of infrequent users at the low end of the distribution. Among those with use in the past 30 days, infrequent users were the majorities of current (59%) and never smokers (89.5%), but fewer than half of former smokers (43.2%). Infrequent users were more likely to cite curiosity and less likely to cite quitting/cutting down other tobacco use as reasons for use. Conclusions Defining adult prevalence as any use in the past 30 days may include experimenters unlikely to continue use, and is of questionable utility for population surveillance of public health trends over time. Defining prevalence as >5 days excludes those infrequent users.

The comparative and cumulative effects of a dietary restriction and exercise on weight loss.

Objective:To assess the independence of changes made in diet and physical activity for weight loss; and, to examine the comparative and cumulative effects of these behavioral changes on weight loss outcomes.Design:The observational study is based on longitudinal data collected from 674 women and 288 men enrolled in a 2-year weight loss program introduced into a managed care setting.Measurements:The outcome variable was body mass index (BMI) change from baseline to 2-year follow-up. Primary independent variables were changes in physical activity and dietary fat intake, assessed as continuous measures using the Paffenbarger Physical Activity Questionnaire and Block Fat Screener Questionnaire, respectively. Two-way ANCOVA was used to assess the relative effect on BMI of behavioral changes.Results:Study results showed no preference for diet or physical activity change as a weight loss strategy. For both genders, the relationship between the two behaviors was synergistic rather than compensatory. Examination of the comparative benefits of behavioral changes indicated that, for women and men, restricting fat intake was more effective than increasing exercise for weight loss. While fat restrictions alone contributed to weight loss in both genders, exercise alone provided weight loss benefits to men, only. The cumulative effect of weight loss behaviors varied by gender. In women, an interaction was observed. The response of weight to fat restriction was greater among those who increased their exercise moderately or substantially. In men, there was no interaction; exercise increases helped to offset weight gain or provided small weight loss benefits at all levels of dietary fat change.Conclusion:Dietary changes appeared to be more effective than increased physical activity for weight loss. For women, the cumulative effect of concomitant changes in diet and exercise on weight loss was more than additive.

Is Making Smoking Status a Vital Sign Sufficient to Increase Cessation Support Actions in Clinical Practice

BACKGROUND There is widespread belief that adding smoking status to the list of vital signs in medical practice will lead to an increased likelihood that physicians will offer more cessation support for smokers during office visits. This article evaluates the impact of introducing routine use of smoking status as a vital sign on clinician cessation support in a primary care setting. METHODS A total of 429 adult health plan members who were smokers and recent quitters from 2 primary care clinics in Minneapolis, Minn, were administered a 28-item questionnaire by telephone. The instrument included questions about patient health status, smoking status, advice about smoking, clinic actions during the most recent visit, satisfaction with clinic actions, and intention to change smoking. Comparisons were made with a cohort of smoking patients before and after smoking status was used as a vital sign, using 2-tailed t tests for continuous variables and chi-square analysis for categorical variables. RESULTS Patient self-report of receiving advice about smoking in the past year (about 66%) was unchanged after smoking status was implemented as a vital sign. Medical chart documentation of tobacco use increased from 38.0% to 78.4% of all encounters, whereas documentation of advice about smoking decreased from 33.5% to 18.8%. Except for identification of tobacco use before implementation of the guideline, none of the specific activities recommended in the guideline occurred at very high levels. CONCLUSION Implementing smoking status as a vital sign appears to have increased the documentation of tobacco use but had little effect on specific implementation actions. Overall, the findings suggest that more consistent identification of tobacco use alone will not lead to guideline-recommended changes in cessation support actions by clinicians. Greater environmental changes will be needed if tobacco guideline goals are to be achieved.

Treatment of spit tobacco users with transdermal nicotine system and mint snuff.

The purpose of this study was to examine the effects of nicotine patch and mint snuff (a nonnicotine product) on craving, withdrawal symptoms, and treatment outcome. This study involved a 2 x 2 factorial design, with Active Nicotine Versus Placebo Patch as one of the factors and Mint Snuff Versus No Mint Snuff as the other factor. Spit tobacco users (N = 402, n = 100-101 in each condition) were randomly assigned to 1 of the 4 treatment conditions for a period of 10 weeks. Treatment outcome was measured up to 62 weeks. The results showed that the nicotine patch was effective in increasing short-term abstinence over the placebo patch and in reducing craving and withdrawal signs and symptoms from spit tobacco. Although mint snuff was not effective in enhancing treatment outcome, it reduced craving and withdrawal symptoms. No interaction effects were observed. At this time, the use of the nicotine patch and mint snuff should be primarily considered for the reduction of craving and withdrawal symptoms.