Prevalence of obese patients in a primary care setting

Obesity Is Indirectly Associated with Sudden Cardiac Arrest through Various Risk Factors

Although obesity is a well-established risk factor of cardiovascular event, the linkage between obesity and sudden cardiac arrest (SCA) is not fully understood. Based on a nationwide health insurance database, this study investigated the impact of body weight status, measured by body-mass index (BMI) and waist circumference, on the SCA risk. A total of 4,234,341 participants who underwent medical check-ups in 2009 were included, and the influence of risk factors (age, sex, social habits, and metabolic disorders) was analyzed. For 33,345,378 person-years follow-up, SCA occurred in 16,352 cases. The BMI resulted in a J-shaped association with SCA risk, in which the obese group (BMI ≥ 30) had a 20.8% increased risk of SCA compared with the normal body weight group (18.5 ≤ BMI < 23.0) (p < 0.001). Waist circumference showed a linear association with the risk of SCA, with a 2.69-fold increased risk of SCA in the highest waist circumference group compared with the lowest waist circumference group (p < 0.001). However, after adjustment of risk factors, neither BMI nor waist circumference was associated with the SCA risk. In conclusion, obesity is not independently associated with SCA risk based on the consideration of various confounders. Rather than confining the findings to obesity itself, comprehensive consideration of metabolic disorders as well as demographics and social habits might provide better understanding and prevention of SCA.

Impact of Oxygen Saturation on Mortality in Obese and Non-obese Critically Ill Patients With Mechanical Ventilation: A Retrospective Observational Study

Background

The main aim of this study was to evaluate the effect of oxygen saturation on mortality in critically ill patients with mechanical ventilation according to obesity status.

Methods

We conducted an observational study in mechanically ventilated patients admitted to the ICU retrospectively. Demographic, arterial blood gas, ventilator setting, interventions, and peripheral oxygen saturation (Spo₂) during the first 24 h were recorded and analyzed between non-obese and obese patients. The main exposure included Spo₂, time-weighted mean Spo₂ (TWM-Spo₂), and proportion of time spent in different Spo₂ (PTS-Spo₂) levels. The primary outcome was hospital mortality. We used multivariable logistic regression models to assess the relationship between Spo₂ and mortality, as well as the interaction between PTS-Spo₂ and obesity status.

Results

A total of 25,100 patients were included, of which 10,564 (42%) were obese patients. After adjusting for confounders, compared with TWM-Spo₂ of 94–98%, TWM-Spo₂ of < =88% (OR 3.572; CI [2.343, 5.455]; p < 0.001) and of 89–93% (OR 1.514; CI [1.343, 1.706]; p < 0.001) were both associated with higher risk of mortality. PTS-Spo₂ of 99–100% was associated with increased risk of mortality for obese patients (OR 1.028; 95% CI 1.010–1.046; p = 0.002; P_{interaction =} 0.001), while PTS-Spo₂ of 89–93% was associated with increased risk of mortality (OR 1.089; 95% CI 1.051–1.128; p < 0.001; P_{interaction =} 0.001) for non-obese patients.

Conclusions

For obese and non-obese critically ill patients with mechanical ventilation, the impact of oxygen saturation on hospital mortality is different.

Incidence of Obesity at 1 and 3 Years Among Community Dwelling Adults: A Population-Based Study

OBJECTIVE

This study determined the incidence rates for obesity among adult patients ages 20 and older empaneled in primary care practice in Midwest United States to potentially identify an optimum timeframe for initiating intervention.

BACKGROUND

Primary care practice patients are likely to reflect underlying community trends in overweight and obesity; however, data on overweight and obesity in primary care patients is limited. While childhood incidence rates of obesity have been well reported, there is still a paucity of data on the incidence of obesity among adult population; literature has mainly focused on its prevalence.

METHODS

Medical record review of identified cohort with BMI data was conducted. Population was stratified by age and sex and overweight category was subdivided into tertiles.

RESULTS

Majority of 40 390 individuals who comprised the final population and had follow-up data, consisted of adults ages 40 to 69 years (47.5%), female (59.8%) of non-Hispanic ethnicity (95.9%) with 21 379 (52.8%) falling in weight category of overweight. Incidence of obesity was 7% at 1 year and 16% at 3 years follow-up. Highest percentages of individuals who became obese at 1 and 3 years were in age category of 40 to 69 years among men and 20 to 39 years among women. In Cox regression analysis, there was statistically significant association to developing obesity among all tertile groups in the overweight category. Age and particularly gender appeared to be modifying factors to likelihood of developing obesity.

CONCLUSION

Study results suggest that while obesity incidence is higher among certain age groups in both genders, middle-aged women, and men in all tertiles of overweight category are at highest risk and may be the optimum population to target for weight loss interventions. Findings support the initiation of population-based interventions before onset of obesity.

A systematic review of weight-related communication trainings for physicians

Obesity is a leading cause of preventable death in the USA. Given the high number of adults seeking routine health care services, physicians have an opportunity to address weight loss during routine clinical encounters. It's often reported that physicians lack the training to address weight. Training programs are implemented in medical settings to prepare physicians to have conversations with patients. Yet, the degree of consistency among training programs and factors associated with better outcomes is unclear. The purpose of this study is to systematically review literature in physician communication trainings related to weight-to compare the content, outcomes, and implementation of existing studies examining weight-related communication training programs for physicians and determine factors associated with physician and patient outcomes. Articles were extracted from PubMed, Proquest, and Embase. Search terms included: health communication, physician training, weight, and obesity. Studies implementing a training program addressing weight among physicians were included. Trainings using either motivational interviewing (MI) or 5 As (Ask, Advise, Assess, Assist, and Arrange) framework found improvements in physicians' communication skills. A small number of trainings including experiential components were also associated with improvements in positive physician outcomes. Findings suggest trainings based in MI or 5 As framework improve physicians' communication skills, but few programs affected patient outcomes. Gaps remain with trainings that can demonstrate weight loss in patients. While work is needed to enhance the effects of these trainings on patient outcomes, data suggest that trainings should be longer in duration and include an experiential component.

Loneliness in Primary Care Patients: Relationships With Body Mass Index and Health Care Utilization

Purpose

Rates of loneliness and obesity have increased in recent decades. Loneliness and obesity independently have been found to be risk factors for negative physical and mental health outcomes. This study examined the rates and interrelationships of loneliness, body mass index (BMI), and health care utilization in a primary care setting.

Methods

A cross-sectional survey of adult patients presenting for outpatient care at 7 family medicine clinical practices in Pennsylvania was conducted. Survey questions included self-reported measures of loneliness, height/weight, number of health care visits, and potential confounders (eg, sociodemographic variables, health status). Bivariate and multivariable linear regression models were used to analyze associations among loneliness, BMI, and health care utilization.

Results

In all, 464 eligible patients returned surveys for an overall response rate of 26%. Mean (standard deviation) loneliness score was 4.2 (1.7), mean BMI was 30.4 (7.6), and mean number of visits in year prior was 2.7 (3.6). On bivariate analysis, BMI was positively associated with loneliness (effect estimate: 0.50; P=0.03). On multivariable analysis, BMI was negatively associated with attending religious services and self-reported physical health and positively associated with self-reported mental health (P<0.05 for all), but not associated with loneliness. While not associated with loneliness, health care utilization was negatively associated with Hispanic ethnicity, marital status, and self-reported physical health (P<0.05 for all).

Conclusions

Given the detrimental effects loneliness and obesity have on health outcomes, it might be prudent for health care providers to prioritize health concerns for their patients by assessing loneliness and counseling regarding associated risks, particularly in patients with obesity.

Effect of Bimagrumab vs Placebo on Body Fat Mass Among Adults With Type 2 Diabetes and Obesity: A Phase 2 Randomized Clinical Trial

IMPORTANCE

Antibody blockade of activin type II receptor (ActRII) signaling stimulates skeletal muscle growth. Previous clinical studies suggest that ActRII inhibition with the monoclonal antibody bimagrumab also promotes excess adipose tissue loss and improves insulin resistance.

OBJECTIVE

To evaluate the efficacy and safety of bimagrumab on body composition and glycemic control in adults with type 2 diabetes and overweight and obesity.

DESIGN, SETTING, AND PARTICIPANTS

This double-masked, placebo-controlled, 48-week, phase 2 randomized clinical trial was conducted among adults with type 2 diabetes, body mass index between 28 and 40, and glycated hemoglobin (HbA1c) levels between 6.5% and 10.0% at 9 US and UK sites. The trial was conducted from February 2017 to May 2019. Only participants who completed a full treatment regimen were included in analysis.

INTERVENTIONS

Patients were randomized to intravenous infusion of bimagrumab (10 mg/kg up to 1200 mg in 5% dextrose solution) or placebo (5% dextrose solution) treatment every 4 weeks for 48 weeks; both groups received diet and exercise counseling.

MAIN OUTCOMES AND MEASURES

The primary end point was least square mean change from baseline to week 48 in total body fat mass (FM); secondary and exploratory end points were lean mass (LM), waist circumference (WC), HbA1c level, and body weight (BW) changes from baseline to week 48.

RESULTS

A total of 75 patients were randomized to bimagrumab (n = 37; 23 [62.2%] women) or placebo (n = 38; 12 [31.6%] women); 58 (77.3%) completed the 48-week study. Patients at baseline had a mean (SD) age of 60.4 (7.7) years; mean (SD) BMI of 32.9 (3.4); mean (SD) BW of 93.6 (14.9) kg; mean (SD) FM of 35.4 (7.5) kg; and mean (SD) HbA1c level of 7.8% (1.0%). Changes at week 48 for bimagrumab vs placebo were as follows: FM, -20.5% (-7.5 kg [80% CI, -8.3 to -6.6 kg]) vs -0.5% (-0.18 kg [80% CI, -0.99 to 0.63 kg]) (P < .001); LM, 3.6% (1.70 kg [80% CI, 1.1 to 2.3 kg]) vs -0.8% (-0.4 kg [80% CI, -1.0 to 0.1 kg]) (P < .001); WC, -9.0 cm (80% CI, -10.3 to -7.7 cm) vs 0.5 cm (80% CI, -0.8 to 1.7 cm) (P < .001); HbA1c level, -0.76 percentage points (80% CI, -1.05 to -0.48 percentage points) vs -0.04 percentage points (80% CI, -0.23 to 0.31 percentage points) (P = .005); and BW, -6.5% (-5.9 kg [80% CI, -7.1 to -4.7 kg]) vs -0.8% (-0.8 kg [80% CI, -1.9 to 0.3 kg]) (P < .001). Bimagrumab's safety and tolerability profile was consistent with prior studies.

CONCLUSIONS AND RELEVANCE

In this phase 2 randomized clinical trial, ActRII blockade with bimagrumab led to significant loss of FM, gain in LM, and metabolic improvements during 48 weeks in patients with overweight or obesity who had type 2 diabetes. ActRII pathway inhibition may provide a novel approach for the pharmacologic management of excess adiposity and accompanying metabolic disturbances.

TRIAL REGISTRATION

ClinicalTrials.gov number: NCT03005288.

Double burden of malnutrition in persons with obesity

A paradoxical double challenge has emerged in the last decades with respect to nutrition and nutrition-related clinical conditions. Hunger-related undernutrition continues to represent an unacceptable burden, although its prevalence has been encouragingly reduced worldwide. On the other hand, the prevalence of overweight and obesity, defined as fat excess accumulation with negative impact on individual health, has dramatically increased due to increasingly pervasive obesogenic lifestyle changes. Undernutrition and obesity may coexist in world regions, Countries and even smaller communities and households, being referred to as double burden of malnutrition. It is however important to point out that fat accumulation and obesity may also induce additional nutritional derangements in affected individuals, both directly through metabolic and body composition changes and indirectly through acute and chronic diseases with negative impact on nutritional status. In the current narrative review, associations between fat accumulation in obesity and malnutrition features as well as their known causes will be reviewed and summarized. These include risk of loss of skeletal muscle mass and function (sarcopenia) that may allow for malnutrition diagnosis also in overweight and obese individuals, thereby introducing a new clinically relevant perspective to the obesity-related double burden of malnutrition concept.

Efficacy of a mindful-eating programme to reduce emotional eating in patients suffering from overweight or obesity in primary care settings: a cluster-randomised trial protocol

INTRODUCTION

Little is known about the applicability of mindfulness-based interventions in Spanish adults with overweight/obesity. The objective of the present study protocol is to describe the methods that will be used in a cluster randomised trial (CRT) that aims to evaluate the effectiveness of a mindfulness eating (ME) programme to reduce emotional eating (EE) in adults with overweight/obesity in primary care (PC) settings.

METHODS AND ANALYSIS

A CRT will be conducted with approximately 76 adults with overweight/obesity from four PC health centres (clusters) in the city of Zaragoza, Spain. Health centres matched to the average per capita income of the assigned population will be randomly allocated into two groups: 'ME +treatment as usual (TAU)' and 'TAU alone'. The ME programme will be composed of seven sessions delivered by a clinical psychologist, and TAU will be offered by general practitioners. The primary outcome will be EE measured by the Dutch Eating Behaviour Questionnaire (DEBQ) at post test as primary endpoint. Other outcomes will be external and restrained eating (DEBQ), binge eating (Bulimic Investigatory Test Edinburgh), eating disorder (Eating Attitude Test), anxiety (General Anxiety Disorder-7), depression (Patient Health Questionnaire-9), mindful eating (Mindful Eating Scale), dispositional mindfulness (Five Facet Mindfulness Questionnaire) and self-compassion (Self-Compassion Scale). Anthropometric measures, vital signs and blood tests will be taken. A primary intention-to-treat analysis on EE will be conducted using linear mixed models. Supplementary analyses will include secondary outcomes and 1-year follow-up measures; adjusted models controlling for sex, weight status and levels of anxiety and depression; the complier average causal effect of treatment; and the clinical significance of improvements.

ETHICS AND DISSEMINATION

Positive results of this study may have a significant impact on one of the most important current health-related problems. Approval was obtained from the Ethics Committee of the Regional Authority. The results will be submitted to peer-reviewed journals, and reports will be sent to participants.

TRIAL REGISTRATION NUMBER

NCT03927534 (5/2019).

Gender- and Age-Related Changes in Trunk Muscle Composition Using Chemical Shift Encoding-Based Water⁻Fat MRI

Ageing, sarcopenia, and malnutrition are associated with quantitative and qualitative changes of body composition. There are several imaging modalities, including magnetic resonance imaging (MRI), for the assessment of trunk muscle tissue composition. In this study, we investigated the gender- and age-related changes in trunk muscle composition using chemical shift encoding-based water–fat MRI. A total of 79 healthy volunteers (26 men: 38.9 ± 10.4 years; 53 women: 39.5 ± 15.0 years) underwent 3T axial MRI using a six-echo multi-echo 3D spoiled gradient echo sequence, allowing for the calculation of the proton density fat fraction (PDFF) in the trunk muscles. PDFF of the abdominal, psoas, and erector spinae muscles were determined. We detected significant positive correlations for abdominal muscle PDFF with age (r = 0.638, p = 0.0001) in men, and for abdominal muscle PDFF (r = 0.709, p = 0.0001) and erector spinae muscle PDFF (r = 0.674, p = 0.0001) with age in women. After adjustment for body mass index (BMI), only the correlation of age and abdominal muscle PDFF in women remained significant (r = 0.631, p = 0.0001). The findings of this study suggest that an increasing fat deposition in muscle is driven primarily by age, rather than BMI, in women. These results further support that PDFF can be considered a valid imaging biomarker of trunk muscle composition.

A study paradigm integrating prospective epidemiologic cohorts and electronic health records to identify disease biomarkers

Defining the full spectrum of human disease associated with a biomarker is necessary to advance the biomarker into clinical practice. We hypothesize that associating biomarker measurements with electronic health record (EHR) populations based on shared genetic architectures would establish the clinical epidemiology of the biomarker. We use Bayesian sparse linear mixed modeling to calculate SNP weightings for 53 biomarkers from the Atherosclerosis Risk in Communities study. We use the SNP weightings to computed predicted biomarker values in an EHR population and test associations with 1139 diagnoses. Here we report 116 associations meeting a Bonferroni level of significance. A false discovery rate (FDR)-based significance threshold reveals more known and undescribed associations across a broad range of biomarkers, including biometric measures, plasma proteins and metabolites, functional assays, and behaviors. We confirm an inverse association between LDL-cholesterol level and septicemia risk in an independent epidemiological cohort. This approach efficiently discovers biomarker-disease associations.

Biomarker identification requires prohibitively large cohorts with gene expression and phenotype data. The approach introduced here learns polygenic predictors of expression from genetic and expression data, used to infer biomarker levels in patients with genetic and disease information.

Effects of medical trainees' weight-loss history on perceptions of patients with obesity

CONTEXT

Medical professionals often express weight-biased attitudes. Prior research suggests that people who overcome a challenge are critical of individuals who struggle to overcome the same challenge. Thus, medical trainees who have successfully achieved and maintained weight loss may express greater weight bias and more critical attitudes toward patients with obesity who fail to overcome these challenges.

OBJECTIVES

This study was designed to determine the effects of medical trainees' weight-loss history on weight-biased attitudes and responses to patients with varying weight-loss outcomes.

METHODS

An online survey was completed by 219 medical students and internal medicine residents. Participants' weight-biased attitudes were assessed before they were randomly assigned to read one of three patient vignettes in which the patient lost no weight, lost/regained weight, or lost/maintained weight. Independent measures included trainee gender, trainee weight loss and maintenance, and the three experimental conditions of patient outcomes. Dependent measures included the Anti-Fat Attitudes (AFA) Questionnaire's Willpower and Dislike subscales, ratings (on a scale of 1-7) of compassion, frustration, and blame toward the patients presented in the vignettes, and perceptions of the physician-patient alliance. All analyses controlled for trainee body mass index.

RESULTS

Among trainees, 67.1% reported having successfully lost weight. Of those who had lost weight, 79.5% reported maintaining their weight loss. Trainees who had successfully lost/maintained weight expressed less compassion toward patients across vignettes (5.4 ± 1.2 versus 5.9 ± 1.2; p<0.05), and more blame toward the patient who lost/regained weight than did trainees who had lost/regained weight (3.4 ± 1.3 versus 2.3 ± 1.3; p<0.01). Overall, the patient who did not lose weight was viewed most negatively, followed by the patient who lost/regained (all p-values < 0.05). Female (but not male) trainees who had successfully lost weight expressed stronger weight-biased attitudes on the AFA scales than did those who had never lost weight (all p-values < 0.01).

CONCLUSIONS

Medical trainees' personal success with weight loss and maintenance may negatively affect their perceptions of patients with obesity who struggle with weight management.

Somatic symptom severity among primary care patients who are obese: examining the unique contributions of anxiety sensitivity, discomfort intolerance, and health anxiety

Prior research indicates the common presentation of somatic symptoms and obesity in primary care settings, as well as links between obesity and somatic symptoms. Anxiety sensitivity, discomfort intolerance, and health anxiety are three variables relevant to somatic symptoms. How those three variables relate to somatic symptom severity among individuals who are obese and the unique variance accounted for by each variable in somatic symptom severity remains unexamined. Among a large sample of primary care patients who are obese (N = 342), anxiety sensitivity, discomfort intolerance, and health anxiety collectively accounted for 35% of variance in somatic symptom severity beyond the effects of sociodemographic variables, body mass index, medical morbidity, and depression severity. Health anxiety accounted for the largest amount of unique variance in somatic symptom severity, potentially supporting the relevance of health anxiety to the presentation of increased somatic symptoms among patients who are obese.

Feasibility of automated pre-screening for lifestyle and behavioral health risk factors in primary care

BACKGROUND

Screening of primary care patients for unhealthy behaviors and mental health issues is recommended by numerous governing bodies internationally, yet evidence suggests that provider-initiated screening is not routine practice. The objective of this study was to implement systematic pre-screening of primary care patients for common preventive health issues on a large scale.

METHODS

Patients registered for non-acute visits to one of 40 primary care providers from eight clinics in an Academic Medical Center health care network in the United States from May, 2012 to May, 2014 were contacted one- to three-days prior to their visit. Patients were invited to complete a questionnaire using an Interactive Voice Response (IVR) system. Six items assessed pain, smoking, alcohol use, physical activity, concern about weight, and mood.

RESULTS

The acceptance rate among eligible patients reached by phone was 65.6 %, of which 95.5 % completed the IVR-Screen (N = 8,490; mean age 57; 57 % female). Sample demographics were representative of the overall primary care population from which participants were drawn on gender, race, and insurance status, but participants were slightly older and more likely to be married. Eighty-seven percent of patients screened positive on at least one item, and 59 % endorsed multiple problems. The majority of respondents (64.2 %) reported being never or only somewhat physically active. Weight concern was reported by 43.9 % of respondents, 36.4 % met criteria for unhealthy alcohol use, 23.4 % reported current pain, 19.6 % reported low mood, and 9.4 % reported smoking.

CONCLUSIONS

The percent endorsement for each behavioral health concern was generally consistent with studies of screening using other methods, and contrasts starkly with the reported low rates of screening and intervention for such concerns in typical PC practice. Results support the feasibility of IVR-based, large-scale pre-appointment behavioral health/ lifestyle risk factor screening of primary care patients. Pre-screening in this population facilitated participation in a controlled trial of brief treatment for unhealthy drinking, and also could be valuable clinically because it allows for case identification and management during routine care.

Interventions for body weight reduction in obese patients during short consultations: an open-label randomized controlled trial in the Japanese primary care setting

BACKGROUND

Family physicians should maintain regular contact with obese patients to ensure they effectively reduce their body weight. However, family physicians in Japan have on average only 6 (min) per consultation, and conventional interventions for body weight reduction require a longer consultation or additional manpower. A brief intervention within the limited consultation time available is therefore needed. Here we investigated the effectiveness of a brief weight reduction intervention for obese patients and the related factors for reducing body weight during routine consultations in the primary care setting.

METHOD

We conducted an open-label randomized controlled trial at a family medicine clinic in Fukushima, Japan from January 2010 to June 2011. Patients aged 30 to 69 years with body mass index ≥25 who were diagnosed with hypertension, dyslipidemia, and/or type 2 diabetes mellitus were randomly assigned to the intervention or control group. At every consultation, body weight in the intervention group was measured by a family physician who provided weight reduction advice in addition to usual care. The primary outcome was body weight change at 1-year follow up. Analysis was done by intention to treat.

RESULT

We randomly assigned 29 participants to the intervention group and 21 to the control group. Forty participants (80 %) remained in the trial until the 1-year follow up. At follow up, the median body weight change from baseline was not significantly different between the groups (p = 0.68), at -0.8 (interquartile range [IQR] -2.5 to 1.0) kg in the intervention group and 0.2 (IQR -2.4 to 0.8) kg in the control group.

CONCLUSION

We devised an intervention method for physicians to measure body weight and advise on weight reduction during routine consultations. In our setting, this method did not extend the consultation time, but also had no significant additional effects on body weight reduction in moderately obese patients.

TRIAL REGISTRATION

This trial is registered with the UMIN Clinical Trial Registry (UMIN000002967).

Prevalence of comorbid depression and obesity in general practice: a cross-sectional survey

Background

General practice is a common setting for the provision of weight-management advice, as well as the treatment of depression. While there is some evidence of a reciprocal relationship between obesity and depression, there are limited data about the rates of depression among general practice patients who are underweight, normal weight, overweight, and obese.

Aim

To explore the prevalence of depression among underweight, normal weight, overweight, and obese general practice patients.

Design and setting

A cross-sectional survey was conducted in 12 Australian general practices.

Method

Patients aged ≥18 years and older who were presenting for general practice care were eligible to participate. Consenting patients completed a touchscreen computer survey assessing self-reported weight and height. Depression was assessed by the Patient Health Questionnaire-9 (PHQ-9), with a score of ≥10 used to indicate possible depression.

Results

Data were obtained from 3361 participants. The prevalence of depression was 24% (95% confidence interval [CI] = 11.86 to 39.28) among underweight participants, 11% (95% CI = 8.5 to 14.0) among normal weight participants, 12% (95% CI = 0.9 to 15.2) among overweight participants, and 23% (95% CI = 17.8 to 29.0) among obese participants. The prevalence of depression was higher for women than for men across all weight categories except underweight.

Conclusion

Weight and depression demonstrated a U-shaped relationship, with higher prevalence of depression observed among underweight and obese general practice patients. These conditions may act as red flags for opportunistic screening of depression in the general practice setting.

Direct observation of weight counselling in primary care: alignment with clinical guidelines

Primary care physicians provide care to a disproportionate number of overweight and obese patients and are uniquely positioned to help patients manage their weight in the context of a continuity relationship. The US National Heart, Lung and Blood Institute (NHLBI) developed evidence-based guidelines for the effective and efficient care of overweight/obese patients, but little is known about the use of these guidelines in practice. To determine the content of weight discussions and assess the elements of the NHLBI guidelines that were accomplished, office visits of 544 adult, overweight/obese patients to 28 primary care physicians were observed and audio recorded. Associations between type of weight management discussion and patient, physician and visit characteristics were examined. Fifty per cent (n = 270) of visits included weight discussions; 47% and 38% included use of at least one NHLBI assessment or treatment element during discussions about weight, respectively. Only 35% (n = 193) of discussions included an assessment and treatment strategy; none included all NHLBI-recommended elements. Overall, adherence to guidelines was poor, particularly with regard to reporting body mass index to the patient, measuring waist circumference and setting realistic weight loss goals. Weight discussions did not clearly vary by the patient, physician or visit characteristics examined. These findings suggest opportunities to develop and further tailor resources for improved physician training in patient weight management communication and treatment techniques that are both consistent with current standards for effective, evidence-based care and efficient enough for routine use during busy primary care visits.

Provider and staff perceptions of veterans' attrition from a national primary care weight management program

BACKGROUND

Overweight and obesity are growing problems for primary care. Although effective weight management programs exist, these programs experience significant attrition, which limits effectiveness.

OBJECTIVES

This study examined provider and staff perceptions of attrition from the Veterans Health Administration MOVE!(®) Weight Management Program as an initial step toward understanding attrition from primary care-based programs.

PARTICIPANTS

MOVE!(®) clinicians, primary care providers, and other staff members who interacted with patients about participating in MOVE!(®) (n=754) from Department of Veterans Affairs medical centers throughout the United States. Respondents were predominantly female (80.8%), Caucasian (79.2%), and trained as nurses (L.P.N., R.N., or N.P.; 50%).

MEASURE

Participants completed a web-mediated survey; items assessed agreement with personal and programmatic reasons for dropout, and allowed respondents to indicate the number one reason for dropout in an open-ended format. This survey was adapted from an existing tool designed to capture patient perceptions.

RESULTS

Respondents indicated that veterans experienced practical barriers to attendance (eg, transportation and scheduling difficulties) and desire for additions to the program (eg, a live exercise component). Low motivation was the primary factor identified by respondents as associated with dropout, particularly as noted by MOVE!(®) clinicians (versus other providers/staff; P<0.01).

CONCLUSIONS

These findings suggest that programmatic changes, such as adding additional meeting times or in-session exercise time, may be of benefit to MOVE!(®). In addition, increasing the use of techniques such as Motivational Interviewing among providers who refer patients to MOVE!(®) may improve participant engagement in MOVE!(®) and other primary care-based weight management programs. Further research is needed to effectively identify those likely to withdraw from weight management programs before achieving their goals, and the reasons for withdrawal.

Body mass index and depressive symptoms in primary care settings: examining the moderating roles of smoking status, alcohol consumption and vigorous exercise

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Depressive symptoms and obesity are highly prevalent in primary care settings. Depressive symptoms and obesity are positively related; as body weight increases, individuals are more likely to display depressive symptoms.

WHAT THIS STUDY ADDS

This study examines the moderating roles of health behaviours (alcohol use, smoking status and vigorous exercise) on the relationship between body mass index and depressive symptoms. Exercise attenuates the relationship between depressive symptoms and obesity. Primary care patients often report multiple health risk behaviours and symptoms, including obesity and depressive symptomatology. This study examined the relationship between body mass index (BMI) and depressive symptomatology among primary care patients and tested its moderation by health behaviours. Primary care patients (n = 497) completed self-report questionnaires. Using three multilevel models, we tested the moderation of health behaviours on the BMI-depressive symptoms relationship. After controlling for relevant covariates, BMI was positively related to depressive symptoms. Smokers reported more depressive symptoms (P < 0.01), whereas vigorous exercisers reported fewer (P < 0.001). Alcohol consumption was not related to depressive symptoms (P > 0.05). Only vigorous exercise significantly moderated the BMI-depression relationship (P < 0.05). BMI is positively related to depressive symptoms among patients who do not participate in vigorous activity, suggesting that vigorous activity reduces the risk for depressive symptoms among patients with higher BMI.

The Stanford Leisure-Time Activity Categorical Item (L-Cat): a single categorical item sensitive to physical activity changes in overweight/obese women

BACKGROUND

Physical activity is essential for chronic disease prevention, yet <40% of overweight/obese adults meet the national activity recommendations. For time-efficient counseling, clinicians need a brief, easy-to-use tool that reliably and validly assesses a full range of activity levels, and, most importantly, is sensitive to clinically meaningful changes in activity. The Stanford Leisure-Time Activity Categorical Item (L-Cat) is a single item comprising six descriptive categories ranging from inactive to very active. This novel methodological approach assesses national activity recommendations as well as multiple clinically relevant categories below and above the recommendations, and incorporates critical methodological principles that enhance psychometrics (reliability, validity and sensitivity to change).

METHODS

We evaluated the L-Cat's psychometrics among 267 overweight/obese women who were asked to meet the national activity recommendations in a randomized behavioral weight-loss trial.

RESULTS

The L-Cat had excellent test-retest reliability (κ=0.64, P<0.001) and adequate concurrent criterion validity; each L-Cat category at 6 months was associated with 1059 more daily pedometer steps (95% CI 712-1407, β=0.38, P<0.001) and 1.9% greater initial weight loss at 6 months (95% CI -2.4 to -1.3, β=-0.38, P<0.001). Of interest, L-Cat categories differentiated from each other in a dose-response gradient for steps and weight loss (Ps<0.05) with excellent face validity. The L-Cat was sensitive to change in response to the trial's activity component. Women increased one L-Cat category at 6 months (M=1.0±1.4, P<0.001); 55.8% met the recommendations at 6 months whereas 20.6% did at baseline (P<0.001). Even among women not meeting the recommendations at both baseline and 6 months (n=106), women who moved 1 L-Cat categories at 6 months lost more weight than those who did not (M=-4.6%, 95% CI -6.7 to -2.5, P<0.001).

CONCLUSIONS

Given strong psychometrics, the L-Cat has timely potential for clinical use such as tracking activity changes via electronic medical records, especially among overweight/obese populations who are unable or unlikely to reach national recommendations.

Academia da Cidade: um serviço de promoção da saúde na rede assistencial do Sistema Único de Saúde

Analisar o perfil de saúde e nutricional dos usuários do Sistema Único de Saúde ingressantes em uma Academia da Cidade, de Belo Horizonte, Minas Gerais durante triênio. Estudo transversal com usuários > 20 anos. Coletaram-se dados sociodemográficos, de saúde, hábitos e consumo alimentar, e antropometria. Realizado testes Kolmogorov-Smirnov, ANOVA, Kruskal-Wallis, Qui-Quadrado e Exato de Fisher. Observou-se elevada prevalência de indivíduos hipertensos (41,6%), com excesso de peso (70,6%) e riscos metabólicos associados à obesidade (67,6%). Cerca de 40% dos ingressantes apresentavam de 1 a 3 doenças crônicas e mais de 65% utilizavam medicamentos diariamente. Houve inadequação no consumo diário de frutas e hortaliças (75,3%), gordura aparente da carne (72,4%) e bebidas açucaradas (54,2%). Apresentavam baixa escolaridade e renda, além de inadequações alimentares e elevadas prevalências de HAS, excesso de peso e riscos metabólicos o que sugere a busca, dos usuários, pelo serviço de promoção da saúde para o tratamento de doenças. O que ilustra a percepção curativista demonstrando ainda a escassez de iniciativas de cuidado à saúde na população. Denota-se a necessidade de se rever as ações nos diferentes níveis de atenção à saúde, visando promover maior integralidade do cuidado prestado.

Development of an online diabetes prevention lifestyle intervention coaching protocol for use in primary care practice

PURPOSE

The translation of an evidence-based lifestyle intervention to an online delivery format has the potential to provide an effective treatment option for obesity in primary care practice. Research is needed, however, to standardize e-counseling procedures to promote the training of health coaches and the dissemination to primary care settings. This article describes the development of an online lifestyle intervention coaching protocol adapted from the Diabetes Prevention Program lifestyle intervention curriculum.

CONCLUSIONS

The delivery of patient counseling via the Internet may enable the dissemination of high-quality lifestyle advice to prevent diabetes in patients whose schedules or geographic constraints prohibit their participation in in-person counseling sessions.

Prevalência e fatores associados à obesidade em mulheres usuárias de serviços de pronto-atendimento do Sistema Único de Saúde no sul do Brasil

A obesidade é uma das principais epidemias modernas, sendo importante problema de saúde pública e estando associado a um aumento de doenças crônicas. O objetivo deste estudo é investigar a prevalência de sobrepeso e obesidade e seus fatores associados em mulheres de 20 a 59 anos, usuárias de serviços de pronto atendimento do Sistema Único de Saúde. Realizou-se entrevista padronizada e foram tomadas as medidas antropométricas em 440 mulheres. O modelo de Poisson foi usado para avaliar a associação entre obesidade e características selecionadas. A prevalência de sobrepeso e obesidade (64,3%) e de obesidade central (44,1%) em usuárias de serviços de pronto atendimento é maior do que a encontrada na população geral e está associada a um aumento do número de agravos à saúde. Atividade física insuficiente (RP=1,44; IC 95% 1,24-1,66), história de três ou mais gestações (RP=1,45; IC 95% 1,05-2,00), idade maior que 50 anos (RP=1,34; IC 95% 1,00-1,82) e obesidade central estão associadas a uma prevalência maior de obesidade. A implantação de políticas de saúde voltadas para a prevenção da obesidade certamente terá um impacto importante na prevenção primária de doenças crônicas na população feminina.

Antidepressant effects on insulin sensitivity and proinflammatory cytokines in the depressed males

Growing evidence suggests that mood disorder is associated with insulin resistance and inflammation. Thus the effects of antidepressants on insulin sensitivity and proinflammatory responses will be a crucial issue for depression treatment. In this study, we enrolled 43 non-diabetic young depressed males and adapted standard testing procedures to assess glucose metabolism during 4-week hospitalization. Before and after the 4-week antidepressant treatment, participants underwent oral glucose tolerance test (OGTT) and frequently sampled intravenous glucose tolerance test (FSIGT). Insulin sensitivity (S_I), glucose effectiveness (S_G), acute insulin response, and disposition index (DI) were estimated using the minimal model method. The plasma levels of C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and adiponectin were measured. The Hamilton depression rating scale (HAM-D) total scores were reduced significantly during the course of treatment. There were no significant changes in the parameters of S_I, S_G, and DI. Compared to drug naïve status, the level of plasma IL-6 was significantly elevated (0.77 to 1.30 pg/ml; P = .001) after antidepressant therapy. However, the concentrations of CRP, TNF-α, and adiponectin showed no differences during the course of treatment. The results suggest that antidepressants may promote stimulatory effect on the IL-6 production in the early stage of antidepressant treatment.

Prevalence of obesity in primary care using different anthropometric measures--results of the German Metabolic and Cardiovascular Risk Project (GEMCAS)

BACKGROUND

Obesity is one of the greatest challenges in primary health care. The BMI describes fat mass and waist circumference (WC) fat distribution and total metabolic and cardiovascular risk. It was aim of the present study to assess the prevalence of a) overweight and obesity and b) an increased and high WC in adults seeking primary care in Germany and to describe the associations of both measures with cardiovascular risk factors and prognosis.

METHODS

This was a point prevalence study with 1,511 primary care physicians and 35,869 adult patients in 2005. Bodyweight, height and waist circumference was measured and blood samples taken to determine the presence of cardiovascular risk factors, including lipids, blood pressure, fasting glucose, low physical activity, smoking and family history of myocardial infarction. We calculated rate ratios stratified for age and gender.

RESULTS

There was a high prevalence of overweight (45.7% male [95%CI 44.9-46.5]; 30.6% female [95%CI 30.0-31.2]) and obesity (24.7% male [95%CI 24.0-25.4]; 23.3% female [95%CI 22.8-23.9]). 36.4% of male [95%CI 35.6-37.2] and 41.5% of female [95%CI 40.8-42.1] had a high WC (male > 102, female > 88 cm). A high WC in addition to an overweight BMI identified patients with more risk factors (male: mean of 3.93 risk factors (RF) at a WC > 102 cm vs. 2.88 RF in patients < or = 94 cm; female 3.58 RF at a WC > 88 cm vs. 2.41 RF < or = 80 cm).

CONCLUSION

There is a high prevalence of obesity (24.7% of male and 23.3% of female) and, in particular, abdominal obesity (36.4% of male and 41.5% of female) in adults attending a primary care physician in Germany. The determination of the BMI is sufficient to assess risk in normal weight and obese patients, while a high WC identifies high risk patients from within the overweight group.

Discussing weight with obese primary care patients: physician and patient perceptions

OBJECTIVE

To evaluate patient-provider agreement on whether weight and related behaviors were discussed during routine visits.

DESIGN

Post-visit survey assessments of patients and providers.

PARTICIPANTS

Obese patients make up the majority of all patients seen in primary care (PC). The patients and physicians were recruited at the time of PC visits.

MEASUREMENTS AND MAIN RESULTS

Percent patient-physician agreement and patient, provider and practice characteristics associated with agreement. Patients (456) and physicians (30) agreed about whether or not they discussed weight, physical activity (PA), and diet for 61% of office visits. There was disagreement on one of the items (weight, PA, or diet) for 23% of office visits, and for 2 or more of the items for 16% of the visits. Agreement was relatively greater for discussing weight than for discussing diet or physical activity. Physicians reported discussing weight issues more often than did patients. Overall patient-physician agreement was 0.51-0.59 (weighted Kappa statistic). In a multivariate analyses of factors associated with patient-physician agreement, health insurance (odds ratio [OR]=3.67, p value = 0.002), physician description of patient weight status (OR = 2.27, p value = 0.002), patient report of how weight relates to health (OR = 1.70, p value = 0.04), and female patient gender (OR = 1.62, p = value = 0.02) were significantly related to agreement.

CONCLUSIONS

Patients and providers disagreed about whether or not weight issues were discussed in a large number of primary care encounters in this study. Physicians may be able to improve care for their obese patients by focusing discussions on specific details of diet and physical activity behaviors, and by clarifying that patients perceive weight-related information has been shared.

Overweight and obesity are associated with psychiatric disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions

OBJECTIVE

This study evaluated associations between body mass index (BMI) and psychiatric disorders.

METHODS

Data from 41,654 respondents in the National Epidemiologic Survey on Alcohol and Related Conditions were analyzed.

RESULTS

After controlling for demographics, the continuous variable of BMI was significantly associated with most mood, anxiety, and personality disorders. When persons were classified into BMI categories of underweight, normal weight, overweight, obese, and extremely obese, both obese categories had significantly increased odds of any mood, anxiety, and alcohol use disorder, as well as any personality disorder, with odds ratios (ORs) ranging from 1.21 to 2.08. Specific Diagnostic and Statistical Manual of Mental Disorders-revision IV mood and personality disorders associated with obesity included major depression, dysthmia, and manic episode (ORs, 1.45-2.70) and antisocial, avoidant, schizoid, paranoid, and obsessive-compulsive personality disorders (ORs, 1.31-2.55). Compared with normal weight individuals, being moderately overweight was significantly associated with anxiety and some substance use disorders, but not mood or personality disorders. Specific anxiety disorders that occurred at significantly higher rates among all categories of persons exceeding normal weight were generalized anxiety, panic without agoraphobia, and specific phobia (ORs, 1.23-2.60). Being underweight was significantly related to only a few disorders; it was positively related to specific phobia (OR, 1.31) and manic episode (OR, 1.83), and negatively associated with social phobia (OR, 0.60), panic disorder with agoraphobia (OR, 0.40), and avoidant personality disorder (OR, 0.59).

CONCLUSION

These data provide a systematic and comprehensive assessment of the association between body weight and psychiatric conditions. Interventions addressing weight loss may benefit from integrating treatment for psychiatric disorders.