Perceived helpfulness of the individual components of a behavioural weight loss program: results from the Hopkins POWER Trial.

BACKGROUND: Behavioural weight loss programs are effective first-line treatments for obesity and are recommended by the US Preventive Services Task Force. Gaining an understanding of intervention components that are found helpful by different demographic groups can improve tailoring of weight loss programs. This paper examined the perceived helpfulness of different weight loss program components. METHODS: Participants (n = 236) from the active intervention conditions of the Practice-based Opportunities for Weight Reduction (POWER) Hopkins Trial rated the helpfulness of 15 different components of a multicomponent behavioural weight loss program at 24-month follow-up. These ratings were examined in relation to demographic variables, treatment arm and weight loss success. RESULTS: The components most frequently identified as helpful were individual telephone sessions (88%), tracking weight online (81%) and coach review of tracking (81%). The component least frequently rated as helpful was the primary care providers' general involvement (50%). Groups such as older adults, Blacks and those with lower education levels more frequently reported intervention components as helpful compared with their counterparts. DISCUSSION: Weight loss coaching delivered telephonically with web support was well received. Findings support the use of remote behavioural interventions for a wide variety of individuals.

Patient-reported outcomes in the practice-based opportunities for weight reduction (POWER) trial.

PURPOSE: To evaluate effects of two behavioral weight-loss interventions (in-person, remote) on health-related quality of life (HRQOL) compared to a control intervention. METHODS: Four hundred and fifty-one obese US adults with at least one cardiovascular risk factor completed five measures of HRQOL and depression: MOS SF-12 physical component summary (PCS) and mental component summary; EuroQoL-5 dimensions single index and visual analog scale; PHQ-8 depression symptoms; and PSQI sleep quality scores at baseline and 6 and 24 months after randomization. Change in each outcome was analyzed using outcome-specific mixed-effects models controlling for participant demographic characteristics. RESULTS: PCS-12 scores over 24 months improved more among participants in the in-person active intervention arm than among control arm participants (P < 0.05, ES = 0.21); there were no other statistically significant treatment arm differences in HRQOL change. Greater weight loss was associated with improvements in most outcomes (P < 0.05 to < 0.0001). CONCLUSIONS: Participants in the in-person active intervention improved more in physical function HRQOL than participants in the control arm did. Greater weight loss during the study was associated with greater improvement in all PRO except for sleep quality, suggesting that weight loss is a key factor in improving HRQOL.

A behavioral weight-loss intervention for persons with serious mental illness in psychiatric rehabilitation centers.

OBJECTIVE: Overweight and obesity are epidemic in populations with serious mental illnesses. We developed and pilot-tested a behavioral weight-loss intervention appropriately tailored for persons with serious mental disorders. METHODS: We conducted a single-arm pilot study in two psychiatric rehabilitation day programs in Maryland, and enrolled 63 overweight or obese adults. The 6-month intervention provided group and individual weight management and group physical activity classes. The primary outcome was weight change from baseline to 6 months. RESULTS: A total of 64% of those potentially eligible enrolled at the centers. The mean age was 43.7 years; 56% were women; 49% were white; and over half had schizophrenia or a schizoaffective disorder. One-third had hypertension and one-fifth had diabetes. In total, 52 (82%) completed the study; others were discharged from psychiatric centers before completion of the study. Average attendance across all weight management sessions was 70% (87% on days participants attended the center) and 59% for physical activity classes (74% on days participants attended the center). From a baseline mean of 210.9 lbs (s.d. 43.9), average weight loss for 52 participants was 4.5 lb (s.d. 12.8) (P<0.014). On average, participants lost 1.9% of body weight. Mean waist circumference change was 3.1 cm (s.d. 5.6). Participants on average increased the distance on the 6-minute walk test by 8%. CONCLUSION: This pilot study documents the feasibility and preliminary efficacy of a behavioral weight-loss intervention in adults with serious mental illness who were attendees at psychiatric rehabilitation centers. The results may have implications for developing weight-loss interventions in other institutional settings such as schools or nursing homes.

An evidence-based review of patient-centered behavioral interventions for hypertension.

INTRODUCTION: While behavioral interventions may be viewed as important strategies to improve blood pressure (BP), an evidence-based review of studies evaluating these interventions may help to guide clinical practice. METHODS: We employed systematic review and meta-analysis of the literature (1970-1999) to assess the independent and additive effects of three behavioral interventions on BP control (counseling, self-monitoring of BP, and structured training courses). RESULTS: Of 232 articles assessing behavioral interventions, 15 (4072 subjects) evaluated the effectiveness of patient-centered counseling, patient self-monitoring of BP, and structured training courses. Pooled results revealed that counseling was favored over usual care (3.2 mmHg [95% CI, 1.2-5.3] improvement in diastolic blood pressure [DBP] and 11.1 mmHg [95% CI, 4.1-18.1] improvement in systolic blood pressure [SBP]) and training courses (10 mmHg improvement in DBP [95% CI, 4.8-15.6]). Counseling plus training was favored over counseling (4.7 mmHg improvement in SBP [95% CI, 1.2-8.2]) and afforded more subjects hypertension control (95% [95% CI, 87-99]) than those receiving counseling (51% [95% CI, 34-66]) or training alone (64% [95% CI, 48-77]). CONCLUSIONS: Evidence suggests that counseling offers BP improvement over usual care, and that adding structured training courses to counseling may further improve BP. However, there is not enough evidence to conclude whether self-monitoring of BP or training courses alone offer consistent improvement in BP over counseling or usual care. The magnitude of BP reduction offered by counseling indicates this may be an important adjunct to pharmacologic therapy.

Factors influencing access to cardiovascular procedures in patients with chronic kidney disease: race, sex, and insurance.

Blacks and women are less likely to undergo invasive cardiac procedures than whites and men in patients with chronic renal disease. We determined the relationship between ethnic and sex differences in access to cardiac procedures as patients progress to ESRD and acquire Medicare insurance. We performed a cohort study of a nationwide random sample of 4,987 patients who progressed to ESRD in 1986 to 1987 and were followed up for 7 years was used. Data were collected from medical charts and Medicare administrative records. Pre-ESRD, the odds of cardiac procedure use were much lower for white women (adjusted odds 0.67 [95% confidence interval (CI) 0.49-0.92]), black men (adjusted odds 0.32 [95% CI 0.20-0.49]), and black women (adjusted odds 0.30 [95%CI 0.18-0.50]) compared with white men. After initiating dialysis therapy, the ethnic and sex differences decreased with odds of receiving a cardiac procedure compared with white men 0.88 (95% CI 0.63-1.21) for white women, 0.66 (95% CI 0.47-0.92) for black men, and 0.75 (95% CI 0.53-1.08) for black women. Patients uninsured pre-ESRD had the largest increase in procedure rates at follow-up. The wide pre-ESRD disparities in cardiac procedure use between white women, black men, and black women compared with white men narrowed substantially with acquisition of Medicare and entry into comprehensive dialysis care. Health insurance contributed to the narrowing of differences. Procedure use for black men still lagged behind the other groups, suggesting the need for closer examination of health needs in this potentially vulnerable group.

A computerized tool for evaluating the effectiveness of preventive interventions.

In identifying appropriate strategies for effective use of preventive services for particular settings or populations, public health practitioners employ a systematic approach to evaluating the literature. Behavioral intervention studies that focus on prevention, however, pose special challenges for these traditional methods. Tools for synthesizing evidence on preventive interventions can improve public health practice. The authors developed a literature abstraction tool and a classification for preventive interventions. They incorporated the tool into a PC-based relational database and user-friendly evidence reporting system, then tested the system by reviewing behavioral interventions for hypertension management. They performed a structured literature search and reviewed 100 studies on behavioral interventions for hypertension management. They abstracted information using the abstraction tool and classified important elements of interventions for comparison across studies. The authors found that many studies in their pilot project did not report sufficient information to allow for complete evaluation, comparison across studies, or replication of the intervention. They propose that studies reporting on preventive interventions should (a) categorize interventions into discrete components; (b) report sufficient participant information; and (c) report characteristics such as intervention leaders, timing, and setting so that public health professionals can compare and select the most appropriate interventions.

Relation of gender and health insurance to cardiovascular procedure use in persons with progression of chronic renal disease.

BACKGROUND: Women often are less likely than men to receive diagnostic and therapeutic invasive procedures for coronary disease. OBJECTIVE: To examine the relation between gender, health insurance, and access to cardiovascular procedures over time in persons with chronic illness. RESEARCH DESIGN: Seven-year longitudinal analyses in a cohort from the United States Renal Data System. SUBJECTS: National random sample of women and men who progressed to end-stage renal disease (ESRD) in 1986 to 1987 and were treated at 303 dialysis facilities (n = 4,987). MEASURES: Medical history and utilization records, physical examination, and laboratory data. MAIN OUTCOME MEASURES: Receipt of a coronary catheterization or revascularization procedure before (baseline) and after (follow-up) the development of ESRD and acquisition of Medicare, adjusted for clinical and socioeconomic variables. RESULTS: At baseline, 5.2% of women and 9.2% of men had undergone a cardiac procedure; the odds of women receiving a procedure were one third lower than for men (adjusted odds ratio 0.66 [95% CI 0.49-0.88]). During follow-up, women were just as likely as men to undergo a procedure (adjusted odds ratio 0.94 [95% CI 0.74-1.20]). Compared with men with baseline private insurance, men and women with other and no insurance had 34% to 81% lower odds of receiving procedures at baseline. Women with private insurance had 42% lower odds of having a procedure at baseline compared with men (adjusted odds ratio 0.58 [95% CI 0.42-0.78]) but had the same odds at follow-up (adjusted odds ratio 1.09 [95% CI 0.82-1.45]). At follow-up, gender differences in procedure use were eliminated for groups with baseline Medicaid or no insurance. CONCLUSIONS: Overall gender differences in cardiac procedure use were narrowed markedly after progression of a serious illness, the assurance of health insurance, and entry into a comprehensive care system. Gender disparities in procedure use for different baseline insurance groups were largely equalized in follow-up. These findings suggest that provision of insurance with disease-managed care for a chronic disease can provide equalized access to care for women.

Use of cardiovascular procedures among black persons and white persons: a 7-year nationwide study in patients with renal disease.

BACKGROUND: Black persons historically undergo fewer invasive cardiovascular procedures than white persons. OBJECTIVE: To determine whether acquisition of Medicare health insurance and comprehensive care for severe illness reduce ethnic disparity in use of cardiovascular procedures. DESIGN: 7-year longitudinal analyses in a cohort from the United States Renal Data System. SETTING: Health care institutions in the United States. PATIENTS: Nationwide random sample of 4987 adult black and white patients with incident end-stage renal disease (ESRD) from 303 dialysis facilities in 1986 to 1987. MEASUREMENTS: Medical history and service use records, physical examination, and laboratory data. Main outcome measures were receipt of a coronary catheterization or revascularization procedure before (baseline) and after (follow-up) development of ESRD and acquisition of Medicare, adjusted for clinical and socioeconomic variables. RESULTS: At baseline, 9.9% of white patients and 2.8% of black patients had had a cardiac procedure; the odds were almost three times greater in white than in black patients (adjusted odds ratio, 2.92 [95% CI, 2.04 to 4.18]). During follow-up, white patients were only 1.4 times more likely than black patients to have a procedure (adjusted relative risk, 1.41 [CI, 1.13 to 1.77]); rates were 7.8% for white persons and 8.5% for black persons. In patients with Medicare coverage before development of ESRD, the initial three-fold difference in procedure use was eliminated over follow-up (odds ratio, 1.05 [CI, 0.56 to 1.60]). For procedures after hospital admission for myocardial infarction or coronary disease, no difference between ethnic groups was seen during follow-up (relative risk, 1.12 [CI, 0.68 to 1.85]). CONCLUSIONS: Differences between ethnic groups in use of cardiovascular procedures narrowed markedly once a serious illness (ESRD) developed and adequate insurance coverage was ensured; the disparity was eliminated in patients with previous Medicare insurance or a stronger indication for a procedure. These findings suggest that almost equal access to care is attainable by combining insurance with delivery of comprehensive, clinically appropriate care.

Altered brainstem sensory processing as assessed by reflex modification procedures in infants at risk for apnea.

Reflex modification procedures were used to test sensory processing in premature infants to examine the relationship between respiratory abnormalities and brainstem neuronal function. A total of 73 premature infants at risk for apnea and/or infants receiving methylxanthine therapy was given a 12-h pneumocardiogram and reflex modification test at a comparable postconceptional age, before discharge. Reflex modification was tested using a controlled eyeblink-eliciting tap to the glabella presented either alone or with a 1 kHz 90-dB SPL tone. The amplitude of the glabellar tap eyeblink and acoustically modified blink were lower in infants discharged on cardiac/apnea monitors (n = 36) than in the unmonitored group (1.44 and 1.59 volts versus 2.15 and 2.39 V, p less than 0.005, respectively). At follow-up, 12 monitored infants had clinically significant apnea after discharge. The records of this subgroup of infants revealed a significantly lower augmentation of the glabellar eyeblink response when compared to all infants screened for respiratory abnormalities and to the other monitored babies (p less than 0.01). The data suggest that abnormalities of the ventilatory pattern and occurrence of clinical apnea in preterm infants may in some measure be related to acoustic sensory processing, implying an alteration of brainstem neuronal function and organization.