Impact of participant and interventionist race concordance on weight loss outcomes

Predictors of racial differences in weight loss: the PROPEL trial

OBJECTIVE

Studies have consistently shown that African American individuals lose less weight in response to behavioral interventions, but the mechanisms leading to this result have been understudied.

METHODS

Data were derived from the PROmoting Successful Weight Loss in Primary CarE in Louisiana (PROPEL) study, which was a cluster-randomized, two-arm trial conducted in primary care clinics. In the PROPEL trial, African American individuals lost less weight compared with patients who belonged to other racial groups after 24 months. In the current study, counterfactual mediation analyses among 445 patients in the intervention arm of PROPEL were used to determine which variables mediated the relationship between race and weight loss. The mediators included treatment engagement, psychosocial, and lifestyle factors.

RESULTS

At 6 months, daily weighing mediated 33% (p = 0.008) of the racial differences in weight loss. At 24 months, session attendance and daily weighing mediated 35% (p = 0.027) and 66% (p = 0.005) of the racial differences in weight loss, respectively. None of the psychosocial or lifestyle variables mediated the race-weight loss association.

CONCLUSIONS

Strategies specifically targeting engagement, such as improving session attendance and self-weighing behaviors, among African American individuals are needed to support more equitable weight losses over extended time periods.

Patient and radiologist demographics influence perceptions of screening mammogram reports

OBJECTIVE

To test whether patient and radiologist demographics influence perceptions of screening mammogram reports and the interpreting radiologist.

METHODS

Patients presenting for breast imaging were surveyed. Demographics were collected and each participant was shown five mock screening mammogram reports with BI-RADS 2 findings, each with a recommendation for one year screening. Each report included a picture of the interpreting radiologist who was Black or white and male or female. Participants were asked seven Likert questions about understanding, satisfaction, and trust in the report and radiologist. Generalized estimating equation ordinal logistic regression compared responses based on participant and radiologist demographics.

RESULTS

There were 178 women who participated with a mean age of 55.1 ± 10.2 years. Most participants self-identified as white (71%) or Black (20%) and non-Hispanic (98%) with broad educational representation (28% Bachelor's and 28% Master's degree). After controlling for demographics, Black participants reported greater agreement regarding trust in the report's finding (p=0.037) if the radiologist was also Black. Black participants were less likely to be satisfied in the report quality (p=0.043). Additionally, participants without any college education reported lower agreement that they were satisfied with the report quality (p=0.020) and felt the radiologist cares about his/her patients (p=0.037). There were no significant associations for radiologist gender or participant age.

DISCUSSION

Participant perceptions of screening mammograms and the interpreting radiologist can be influenced by participant and provider race as well as participant education. These findings could have implications for mammography adherence, breast radiologist recruitment, and developing patient centric reports.

Peer-Led, Remote Intervention to Improve Mental Health Outcomes Using a Holistic, Spirituality-Based Approach: Results from a Pilot Study

In the United States, Black communities face a complex mental health burden, with growing attention on addressing these disparities through the lens of holistic wellbeing. Given the dearth of research on faith-based interventions focused on mental health through the lens of holistic wellbeing, this study evaluates the impact of a spirituality-based, peer-led one-group pre-test post-test pilot intervention in a sample of Black individuals in the Bronx, New York City. The eight-session creating healthy culture curriculum, focused on improving mental health and spiritual wellbeing, was collaboratively developed through community partnerships. Post-intervention results indicated significantly reduced odds of moderate to severe depression (AOR:0.20), and increased sense of community, social support, role of religion in health, flourishing, and reduced trouble sleeping. In-depth interviews with participants further highlighted the interconnected role between psychosocial and mental health indicators. Findings support importance of holistically developing, implementing, and evaluating spirituality-based mental health interventions in Black communities.

Rationale and study protocol for a randomized controlled trial to determine the effectiveness of a culturally relevant, stress management enhanced behavioral weight loss intervention on weight loss outcomes of black women

BACKGROUND

Obesity is a persistent public health concern and a risk factor for many chronic diseases including at least 13 different cancers. Adult Black females have the highest prevalence of obesity (57%) compared to other racial/gender groups in the U.S. Although behavioral weight loss (BWL) interventions have demonstrated effectiveness, Black females tend to lose less weight than White counterparts. The higher prevalence of chronic psychological stress reported by Black females may contribute to their disproportionate prevalence of obesity and observed suboptimal weight loss. This study will examine the effectiveness of a 12-month culturally-targeted, stress management-enhanced BWL intervention on weight loss and stress reduction among Black females in a fully-powered randomized, controlled trial.

METHODS

Adult Black females with obesity (n = 340) will be randomized to either a culturally targeted stress management-enhanced BWL intervention (BWL-Stress) or the same BWL intervention alone (BWL-alone). The primary outcome is weight change at month 6. Secondary outcomes will include changes in stress measures (e.g., perceived stress, cortisol), energy intake, and physical activity at month 6. We will also assess process measures (e.g., treatment adherence, treatment burden). Each outcome will also be evaluated at month 12 to assess longer-term effects of the intervention.

DISCUSSION

This novel approach for enhancing an evidence-based BWL program with culturally-targeted stress management strategies for Black females addresses an understudied barrier to effective weight management among a population at high risk for obesity and obesity-related chronic diseases. This study will potentially elucidate psychological or behavioral mechanisms linking our novel intervention to study outcomes. If the intervention is proven to be effective, this study will have significant clinical and public health implications for weight management among Black females.

TRIAL REGISTRATION

This study was registered on ClinicalTrials.gov , identifier NCT04335799t , on April 6, 2020.

Comparative effectiveness of a standard behavioral and physical activity enhanced behavioral weight loss intervention in Black women

Black women typically lose small amounts of weight in behavioral weight loss interventions, partially due to low engagement in physical activity. Culturally relevant enhancement of the physical activity component may improve weight loss. This study compared the effectiveness of a culturally-relevant, physical activity-enhanced behavioral weight loss intervention to a standard behavioral weight loss intervention in Black women (n = 85) over 6 months. The study was conducted in two cohorts from March 2016 to February 2017 at the University of North Carolina at Chapel Hill. Participants had an average age of 48.30 ± 11.02 years with an average body mass index of 36.46 ± 4.50 kg/m². Standard and enhanced groups' weight change (-2.83 kg and -2.08 kg, respectively) and change in physical activity (43.93 min/ week and 15.29 min/week, respectively) did not differ between groups. Significantly more standard group participants lost 5% of baseline weight compared to enhanced group participants. This study produced typical weight loss results in Black women. Behavioral weight loss treatment remains moderately effective for Black women. Strategies to increase attendance and self-monitoring, and the inclusion of cultural contexts to weight-related behaviors are needed to improve outcomes.

Weight loss and improved metabolic outcomes amongst rural African American women in the Deep South: six-month outcomes from a community-based randomized trial

BACKGROUND

Obesity is highly prevalent in African American women, especially those in the rural southern USA, resulting in persistent health disparities.

OBJECTIVE

To test the effectiveness of an evidence-based behavioural weight loss intervention delivered by community health advisors to African American women in the rural south.

DESIGN AND METHODS

Overweight or obese African American women (30-70 years) from eight counties in Mississippi and Alabama participated in a 24-month randomized controlled trial of an evidence-based behavioural weight loss programme augmented with community strategies to support healthy lifestyles (Weight Loss Plus, N = 154) compared to the weight loss programme alone (Weight Loss Only, N = 255). This study reports on 6-month outcomes on primary (weight change) and secondary (waist circumference, blood pressure, lipids, fasting blood glucose) outcomes, coinciding with the completion of the intensive weight loss phase.

RESULTS

Weight Loss Only participants lost an average of 2.2 kg (P < 0.001). Weight Loss Plus participants lost an average of 3.2 kg (P < 0.001). The proportion of the total sample that lost at least 5% of their body weight was 27.1% with no difference between treatment groups. Similarly, we observed statistically significant reductions in blood pressure, waist circumference and triglycerides in each treatment group, with no statistical differences between groups.

CONCLUSION

Trained lay health staff and volunteers from the rural southern USA were able to deliver a translation of a high-intensity behavioural intervention targeted to African American women, resulting in clinically meaningful weight loss and improvement in other metabolic outcomes in a significant proportion of participants.

A Systematic Review of Obesity Disparities Research

CONTEXT

A review of interventions addressing obesity disparities could reveal gaps in the literature and provide guidance on future research, particularly for populations with a high prevalence of obesity and obesity-related cardiometabolic risk.

EVIDENCE ACQUISITION

A systematic review of clinical trials in obesity disparities research that were published in 2011-2016 in PubMed/MEDLINE resulted in 328 peer-reviewed articles. Articles were excluded if they had no BMI, weight, or body composition measure as primary outcome or were foreign (n=201); were epidemiologic or secondary data analyses of clinical trials (n=12); design or protocol papers (n=54); systematic reviews (n=3); or retracted or duplicates (n=9). Forty-nine published trials were summarized and supplemented with a review of ongoing obesity disparities grants being funded by the National, Heart, Lung and Blood Institute.

EVIDENCE SYNTHESIS

Of the 49 peer-reviewed trials, 27 targeted adults and 22 children only or parent-child dyads (5 of 22). Interventions were individually focused; mostly in single settings (e.g., school or community); of short duration (mostly ≤12 months); and primarily used behavioral modification (e.g., self-monitoring) strategies. Many of the trials had small sample sizes and moderate to high attrition rates. A meta-analysis of 13 adult trials obtained a pooled intervention effect of BMI -1.31 (95% CI=-2.11, -0.52, p=0.0012). Institutional review identified 140 ongoing obesity-related health disparities grants, but only 19% (n=27) were clinical trials.

CONCLUSIONS

The reviews call for cardiovascular-related obesity disparities research that is long term and includes population research, and multilevel, policy, and environmental, or "whole of community," interventions.

The elephant in the room: Dialogues about race within cross-cultural supervisory relationships

OBJECTIVES

For centuries, the concept of race, a uniquely pervasive social construct, has often complicated dialogue and interactions between groups of people. This study assessed perceptions and attitudes of faculty and trainees with varied racial backgrounds within graduate medical and psychology programs. Self-reported responses addressed potential barriers and facilitating factors required for meaningful conversations about race.

METHODS

A brief 18-question survey was developed and administered electronically to three professional and academic Listservs within a large metropolitan city in northeast United States. Quantitative and qualitative analysis were conducted using SPSS Statistical Software and Text analyzer.

RESULTS

Results revealed that among participants (N = 57) a majority experienced cross-racial supervision, and more than half indicated engaging in conversations about race within supervision. Respondents endorsed lack of comfort and lack of opportunity/time as significant barriers to discussing race within supervision. When race-related dialogues occurred, a majority of supervisees and supervisors found it beneficial. Most Supervisors of Color(a) actively initiated these conversations in supervision, while White supervisees endorsed the least benefit from these conversations. Contrary to our expectations, few respondents endorsed limited training as a barrier.

DISCUSSION

The current study revealed cross-racial dialogues about race may be occurring frequently in supervisory relationships. Supervisees of Color reported benefiting from these dialogues, in contrast to their White counterparts, who endorsed the least benefit. Lack of comfort in supervisory relationships appears to be a significant barrier to having these conversations. Therefore, it is important for supervisors to create supervisory relationships emphasizing safety and comfort. Directions for future research are discussed.

Patient and Provider Factors Associated With American Indian and Alaska Native Adolescent Tobacco Use Screening

INTRODUCTION

Tobacco use is the leading behavioral cause of death among adults 25 years or older. American Indian (AI) and Alaska Native (AN) communities confront some of the highest rates of tobacco use and of its sequelae. Primary care-based screening of adolescents is an integral step in the reduction of tobacco use, yet remains virtually unstudied. We examined whether delivery of tobacco screening in primary care visits is associated with patient and provider characteristics among AI/AN adolescents.

METHODS

We used a cross-sectional analysis to examine tobacco screening among 4757 adolescent AI/AN patients served by 56 primary care providers at a large tribally managed health system between October 1, 2011 and May 31, 2014. Screening prevalence was examined in association with categorical patient characteristics (gender, age, clinic visited, insurance coverage) and provider characteristics (gender, age, tenure) using multilevel logistic regressions with individual provider identity as the nesting variable.

RESULTS

Thirty-seven percent of eligible patients were screened. Gender of both providers and patients was associated with screening. Male providers delivered screening more often than female providers (odds ratio [OR] 1.6, 95% confidence interval [CI] 0.7-3.9). Male patients had 20% lower odds of screening receipt (OR 0.8, 95% CI 0.7-0.9) than female patients, independent of patient age and provider characteristics. Individual provider identity significantly contributed to variability in the mixed-effects model (variance component 2.2; 95% CI 1.4-3.4), suggesting individual provider effect.

CONCLUSIONS

Low tobacco screening delivery by female providers and the low receipt of screening among younger, male patients may identify targets for screening interventions.

Increases in Network Ties Are Associated With Increased Cohesion Among Intervention Participants

OBJECTIVE

Many behavior change programs are delivered in group settings to manage implementation costs and to foster support and interactions among group members in order to facilitate behavior change. Understanding the group dynamics that evolve in group settings (e.g., weight management, Alcoholics Anonymous) is important, yet rarely measured. This article examined the relationship between social network ties and group cohesion in a group-based intervention to prevent obesity in children.

METHOD

The data reported are process measures from an ongoing community-based randomized controlled trial. A total of 305 parents with a child (3-6 years) at risk of developing obesity were assigned to an intervention that taught parents healthy lifestyles. Parents met weekly for 12 weeks in small consistent groups. Two measures were collected at Weeks 3 and 6: a social network survey (people in the group with whom one discusses healthy lifestyles) and the validated Perceived Cohesion Scale. We used lagged random and fixed effects regression models to analyze the data.

RESULTS

Cohesion increased from 6.51 to 6.71 (t= 4.4,p< .01). Network nominations tended to increase over the 3-week period in each network. In the combined discussion and advice network, the number of nominations increased from 1.76 to 1.95 (z= 2.59,p< .01). Cohesion at Week 3 was the strongest predictor of cohesion at Week 6 (b= 0.55,p< .01). Number of new network nominations at Week 6 was positively related to cohesion at Week 6 (b= 0.06,p< .01). In sum, being able to name new network contacts was associated with feelings of cohesion.

CONCLUSION

This is the first study to demonstrate how network changes affect perceived group cohesion within a behavioral intervention. Given that many behavioral interventions occur in group settings, intentionally building new social networks could be promising to augment desired outcomes.

Systematic review of behavioural interventions with culturally adapted strategies to improve diet and weight outcomes in African American women

Behavioural interventions incorporating features that are culturally salient to African American women have emerged as one approach to address the high rates of obesity in this group. Yet, the systematic evaluation of this research is lacking. This review identified culturally adapted strategies reported in behavioural interventions using a prescribed framework and examined the effectiveness of these interventions for diet and weight outcomes among African American women. Publications from 1 January 1990 through 31 December 2012 were retrieved from four databases, yielding 28 interventions. Seventeen of 28 studies reported significant improvements in diet and/or weight change outcomes in treatment over comparison groups. The most commonly identified strategies reported were 'sociocultural' (reflecting a group's values and beliefs) and 'constituent involving' (drawing from a group's experiences). Studies with significant findings commonly reported constituent-involving strategies during the formative phases of the intervention. Involving constituents early on may uncover key attributes of a target group and contribute to a greater understanding of the heterogeneity that exists even within racial/ethnic groups. Available evidence does not, however, explain how culturally adapted strategies specifically influence outcomes. Greater attention to defining and measuring cultural variables and linking them to outcomes or related mediators are important next steps.

Randomized trial of nutrition education added to internet-based information and exercise at the work place for weight loss in a racially diverse population of overweight women

OBJECTIVE

Obesity in the United States is highly prevalent, approaching 60% for black women. We investigated whether nutrition education sessions at the work place added to internet-based wellness information and exercise resources would facilitate weight and fat mass loss in a racially diverse population of overweight female employees.

METHODS

A total of 199 (average body mass index 33.9±6.3 kg m(-2)) nondiabetic women (57% black) at our institution were randomized to a 6-month program of either internet-based wellness information (WI) combined with dietitian-led nutrition education group sessions (GS) weekly for 3 months and then monthly with shift in emphasis to weight loss maintenance (n=99) or to WI alone (n=100). All were given access to exercise rooms convenient to their work site. Fat mass was measured by dual-energy X-ray absorptiometry.

RESULTS

WI+GS subjects lost more weight than WI subjects at 3 months (-2.2±2.8 vs -1.0±3.0 kg, P>0.001). Weight (-2.7±3.9 vs -2.0±3.9 kg) and fat mass (-2.2±3.1 vs -1.7±3.7 kg) loss at 6 months was significant for WI+GS and WI groups (both P<0.001), but without significant difference between groups (both P>0.10); 27% of the WI+GS group achieved 5% loss of initial weight as did 18% of the WI group (P=0.180). Blacks and whites similarly completed the study (67 vs 74%, P=0.303), lost weight (-1.8±3.4 vs -3.3±5.2 kg, P=0.255) and fat mass (-1.6±2.7 vs -2.5±4.3 kg, P=0.532), and achieved 5% loss of initial weight (21 vs 32%, P=0.189), irrespective of group assignment.

CONCLUSION

Overweight women provided with internet-based wellness information and exercise resources at the work site lost weight and fat mass, with similar achievement by black and white women. Additional weight loss benefit of nutrition education sessions, apparent at 3 months, was lost by 6 months and may require special emphasis on subjects who fail to achieve weight loss goals to show continued value.