Comparative Effectiveness of Cognitive Behavioral Therapy for Chronic Pain and Chronic Pain Self-Management within the Context of Voluntary Patient-Centered Prescription Opioid Tapering: The EMPOWER Study Protocol

Objective. Evidence to date, while sparse, suggests that patients taking long-term opioids require special considerations and protections to prevent potential iatrogenic harms from opioid de-prescribing, such as increased pain or suffering. Following this study protocol, the EMPOWER study seeks to address multiple unmet needs of patients with chronic pain who desire to reduce long-term opioid therapy, and provide the clinical evidence on effective methodology. Methods. EMPOWER applies patient-centered methods for voluntary prescription opioid reduction conducted within a comprehensive, multi-state, 3-arm randomized controlled comparative effectiveness study of three study arms (1) group cognitive behavioral therapy for chronic pain; (2) group chronic pain self-management; and (3) usual care (taper only). Specialized electronic data capture systems collect patient reported symptoms and satisfaction data weekly and monthly during the taper, with real-time clinical alerts and electronic feedback loops informing, documenting, and steering needed care actions. Conclusion. The EMPOWER study seeks to provide granular evidence on patient response to voluntary opioid tapering, and will provide evidence to inform clinical systems changes, clinical care, patient satisfaction, and patient outcomes for opioid reduction.

Long-term Association of Depression Symptoms and Antidepressant Medication Use With Incident Cardiovascular Events in the Look AHEAD (Action for Health in Diabetes) Clinical Trial of Weight Loss in Type 2 Diabetes

OBJECTIVE

To examine whether depression symptoms or antidepressant medication (ADM) use predicts the probability of cardiovascular events in overweight/obese individuals with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Preplanned analyses of depression and incident cardiovascular disease (CVD) were performed in the Look AHEAD (Action for Health in Diabetes) weight loss trial after a median follow-up of 9.6 years. Depression symptoms, assessed with the Beck Depression Inventory (BDI), were analyzed both as a continuous and dichotomized variable (BDI score <10 or ≥10). ADM use was coded from participants' prescription medications. Four composite CVD outcomes were defined in the study protocol. Sex-stratified Cox proportional hazards models were adjusted for a range of baseline covariates.

RESULTS

Depression symptoms were only significantly associated with a composite secondary outcome comprising CVD death, nonfatal myocardial infarction, nonfatal stroke, hospitalized angina, congestive heart failure, peripheral vascular disease, coronary artery bypass graft, and carotid endarterectomy. Significant sex interactions were observed for BDI score and BDI score ≥10. BDI score was significantly associated with higher probability of this composite outcome in men but was not associated with the outcome in women. BDI score ≥10 was positively associated with this composite outcome in men but was negatively associated in women. Exploratory analysis identified a significant BDI ≥10 × ADM use interaction for this composite outcome that differed in men versus women. Men with both BDI score ≥10 and ADM use compared with those with neither had 60% higher probability of the outcome, whereas women with both compared with those with neither had 50% lower probability.

CONCLUSIONS

Sex differences in the association of depression symptoms and ADM use with incident CVD warrant further investigation.

Effects of Longitudinal Glucose Exposure on Cognitive and Physical Function: Results from the Action for Health in Diabetes Movement and Memory Study

OBJECTIVES

To test whether average long-term glucose exposure is associated with cognitive and physical function in middle-aged and younger-old adults with type 2 diabetes mellitus.

DESIGN

Prospective cohort study.

SETTING

Data obtained as part of the Action for Health in Diabetes (Look AHEAD) trial (NCT00017953) and Look AHEAD Movement and Memory ancillary study (NCT01410097).

PARTICIPANTS

Overweight and obese individuals with type 2 diabetes mellitus aged 45 to 76 at baseline (N = 879).

MEASUREMENTS

Glycosylated hemoglobin (HbA1c) was measured at regular intervals over 7 years, and objective measures of cognitive function (Trail-Making Test, Modified Stroop Color-Word Test, Digit Symbol-Coding, Rey Auditory Verbal Learning Test, Modified Mini-Mental State Examination) and physical function (Short Physical Performance Battery, expanded Physical Performance Battery, 400-m and 20-m gait speed) and strength (grip and knee extensor strength) were assessed at the Year 8 or 9 follow-up examination.

RESULTS

Average HbA1c exposure was 7.0 ± 1.1% (53 ± 11.6 mmol/mol), with 57% of participants classified as having HbA1c levels of less than 7% (<53 mmol/mol), 27% having levels of 7% to 8% (53-64 mmol/mol), and 16% having levels of greater than 8% (>64 mmol/mol). After adjustment for age, sex, race, education, smoking status, alcohol intake, knee pain, physical fitness, body mass index, diabetes mellitus medication and statin use, ancillary year visit, and study arm and site, higher HbA1c was associated with worse physical but not cognitive function. Further adjustment for prevalent diabetes mellitus-related comorbidities made all associations nonsignificant. Results did not differ when stratified according to participant baseline age (<60 vs ≥ 60).

CONCLUSION

Results presented here suggest that, in the absence of diabetes mellitus-related complications, longitudinal glucose exposure is not associated with future cognitive and physical function. Optimal management of diabetes mellitus-related comorbidities may prevent or reduce the burden of disability associated with type 2 diabetes mellitus.

Impact of intensive lifestyle intervention on depression and health-related quality of life in type 2 diabetes: the Look AHEAD Trial

OBJECTIVE

We examined the effects of an intensive lifestyle intervention (ILI), compared with a diabetes support and education (DSE) control intervention, on long-term changes in depression symptoms, antidepressant medication (ADM) use, and health-related quality of life (HRQoL) in overweight/obese individuals with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Look AHEAD was a multisite randomized controlled trial of 5,145 overweight/obese participants assigned to ILI (designed to produce weight loss) or DSE and followed for a median of 9.6 years. The Beck Depression Inventory (BDI) was administered at baseline, annually at years 1-4, and again at year 8. Mean BDI scores and incidence of BDI scores ≥10, indicative of likely mild or greater depression, were examined. Annually through year 10, participants reported their ADM use and completed the Medical Outcomes Study Short Form 36 (SF-36) questionnaire, which yields physical component summary (PCS) and mental component summary (MCS) scores.

RESULTS

ILI significantly reduced the incidence of mild or greater depression symptoms (BDI scores ≥10) compared with DSE (hazard ratio [HR] = 0.85; 95% CI 0.75-0.97; P = 0.0145). Although SF-36 PCS scores worsened over time in both groups, ILI participants reported better physical function than DSE throughout the first 8 years (all P values <0.01). There were no significant differences between treatment arms in the proportion of participants who used ADMs or in SF-36 MCS scores.

CONCLUSIONS

ILI for overweight/obese patients with type 2 diabetes may reduce the risk of developing clinically significant symptoms of depression and preserve physical HRQoL. These findings should be considered when evaluating the potential benefits of ILIs.

Readiness redefined: a behavioral task during screening predicted 1-year weight loss in the look AHEAD study

OBJECTIVE

Predicting outcome in weight loss trials from baseline characteristics has proved difficult. Readiness to change is typically measured by self-report.

METHODS

Performance of a behavioral task, completion of food records, from the screening period in the Look AHEAD study (n = 549 at four clinical centers) was assessed. Completeness of records was measured by the number of words and Arabic numerals (numbers) recorded per day, the number of eating episodes per day, and days per week where physical activity was noted. The primary outcome was weight loss at one year.

RESULTS

In univariable analysis, both the number of words recorded and the number of numbers recorded were associated with greater weight loss. In multivariable analysis, individuals who recorded 20-26, 27-33, and ≥34 words per day lost 9.12%, 11.40%, and 12.08% of initial weight, compared to 8.98% for individuals who recorded less than 20 words per day (P values of 0.87, 0.008, and <0.001, respectively, compared to <20 words per day).

CONCLUSIONS

Participants who kept more detailed food records at screening lost more weight after 1 year than individuals who kept sparser records. The use of objective behavioral screening tools may improve the assessment of weight loss readiness.

Baseline predictors of missed visits in the Look AHEAD study

OBJECTIVE

To identify baseline attributes associated with consecutively missed data collection visits during the first 48 months of Look AHEAD—a randomized, controlled trial in 5,145 overweight/obese adults with type 2 diabetes designed to determine the long-term health benefits of weight loss achieved by lifestyle change.

DESIGN AND METHODS

The analyzed sample consisted of 5,016 participants who were alive at month 48 and enrolled at Look AHEAD sites. Demographic, baseline behavior, psychosocial factors, and treatment randomization were included as predictors of missed consecutive visits in proportional hazard models.

RESULTS

In multivariate Cox proportional hazard models, baseline attributes of participants who missed consecutive visits (n 5 222) included: younger age (hazard ratio [HR] 1.18 per 5 years younger; 95% confidence Interval 1.05, 1.30), higher depression score (HR 1.04; 1.01, 1.06), non-married status (HR 1.37; 1.04, 1.82), never self-weighing prior to enrollment (HR 2.01; 1.25, 3.23), and randomization to minimal vs. intensive lifestyle intervention (HR 1.46; 1.11, 1.91).

CONCLUSIONS

Younger age, symptoms of depression, non-married status, never self-weighing, and randomization to minimal intervention were associated with a higher likelihood of missing consecutive data collection visits, even in a high-retention trial like Look AHEAD. Whether modifications to screening or retention efforts targeted to these attributes might enhance long-term retention in behavioral trials requires further investigation.

Effect of intensive lifestyle intervention on sexual dysfunction in women with type 2 diabetes: results from an ancillary Look AHEAD study

OBJECTIVE

Sexual dysfunction is a prevalent problem in obese women with type 2 diabetes. This study examined the effects of intensive lifestyle intervention (ILI) in these women.

RESEARCH DESIGN AND METHODS

Look AHEAD is a 16-center, randomized, controlled trial evaluating the health effects of ILI compared with a control group (diabetes support and education [DSE]). The Look AHEAD Sexual Function Ancillary study included 375 female participants at five Look AHEAD sites. Participants completed the Female Sexual Function Inventory (FSFI) and Beck Depression Inventory (BDI), and assessments of weight and cardiovascular risk factors at baseline and 1 year were made.

RESULTS

At baseline, 50% of the 229 participants who reported being sexually active met criteria for female sexual dysfunction (FSD); only BDI score was related to FSD. One-year weight losses were greater in the ILI group than in the DSE group (7.6 vs. 0.45 kg; P<0.001). Among women with FSD at baseline, those in the ILI group (N=60) compared with those in the DSE group (N=53) were significantly more likely to remain sexually active (83 vs. 64%; P<0.008), reported greater improvement in total FSFI scores and in most FSFI domains (P<0.05), and were more likely to experience remission of FSD (28 vs. 11%; P<0.04) at 1 year. No significant differences between ILI and DSE were seen in women who did not have FSD at baseline.

CONCLUSIONS

Participation in ILI appeared to have beneficial effects on sexual functioning among obese women with diabetes, particularly in those who had FSD at baseline.

One-year changes in symptoms of depression and weight in overweight/obese individuals with type 2 diabetes in the Look AHEAD study

Depressed individuals are frequently excluded from weight loss trials because of fears that weight reduction may precipitate mood disorders, as well as concerns that depressed participants will not lose weight satisfactorily. The present study examined participants in the Look AHEAD study to determine whether moderate weight loss would be associated with incident symptoms of depression and suicidal ideation, and whether symptoms of depression at baseline would limit weight loss at 1 year. Overweight/obese adults with type 2 diabetes (n = 5,145) were randomly assigned to an Intensive Lifestyle Intervention (ILI) or a usual care group, Diabetes Support and Education (DSE). Of these, 5,129 participants completed the Beck Depression Inventory (BDI) and had their weight measured at baseline and 1 year. Potentially significant symptoms of depression were defined by a BDI score ≥10. Participants in ILI lost 8.6 ± 6.9% of initial weight at 1 year, compared to 0.7 ± 4.8% for DSE (P < 0.001, effect size = 1.33), and had a reduction of 1.4 ± 4.7 points on the BDI, compared to 0.4 ± 4.5 for DSE (P < 0.001, effect size = 0.23). At 1 year, the incidence of potentially significant symptoms of depression was significantly lower in the ILI than DSE group (6.3% vs. 9.6%) (relative risk (RR) = 0.66, 95% confidence interval (CI) = 0.5, 0.8; P < 0.001). In the ILI group, participants with and without symptoms of depression lost 7.8 ± 6.7% and 8.7 ± 6.9%, respectively, a difference not considered clinically meaningful. Intentional weight loss was not associated with the precipitation of symptoms of depression, but instead appeared to protect against this occurrence. Mild (or greater) symptoms of depression at baseline did not prevent overweight/obese individuals with type 2 diabetes from achieving significant weight loss.

Impact of a multidisciplinary intervention on antibiotic use for nursing home-acquired pneumonia

BACKGROUND

Academic detailing in nursing homes (NHs) has been shown to improve drug use patterns and adherence to guidelines.

OBJECTIVE

The purpose of this study was to evaluate the impact of a multidisciplinary intervention that included academic detailing on adherence to national nursing home-acquired pneumonia (NHAP) guidelines related to use of antibiotics.

METHODS

This quasi-experimental study evaluated the effects of a 2-year multifaceted and multidisciplinary intervention targeting implementation of national evidence-based guidelines for NHAP. Interventions took place in 8 NHs in Colorado; 8 NHs in Kansas and Missouri served as controls. Interventions included (1) educational sessions for nurses to improve recognition and timely treatment of NHAP symptoms and (2) academic detailing to clinicians by pharmacists regarding diagnostic and prescribing practices. Differences in antibiotic use between groups were compared after 2 intervention years relative to baseline.

RESULTS

A total of 549 episodes of NHAP were evaluated in the intervention group and 574 in the control group. Compared with baseline, 1 facility in the intervention group significantly improved in guideline adherence for optimal antibiotic use (P = 0.007), whereas no facilities in the control group improved. The mean adherence score for optimal antibiotic use in intervention NHs increased from 60% to 66%, whereas the control NHs increased from 32% to 39% (P = 0.3). Mean adherence to guidelines recommending antibiotic use within 4 hours of NHAP diagnosis increased from 57% to 75% in intervention NHs but decreased from 38% to 31% in control NHs (P = 0.0003 for difference). There was no difference between intervention and control NHs for guideline adherence regarding optimal duration of antibiotic use.

CONCLUSIONS

The ability of this multifaceted study to repeatedly remind nursing staff of the importance of timely antibiotic administration contrasts with its limited academic detailing interaction with clinicians. This difference within the intervention may explain the differential impact of the intervention on antibiotic guideline adherence.

Cognitive and behavioral approaches in the treatment of obesity

The research reviewed within this article provides support for both the cognitive and behavioral components of cognitive behavioral weight-loss interventions. Lifestyle based treatments have produced markedly improved results in the past 20 years, in part attributable to changes in treatment structure. Use of pretreatment participant preparation strategies, extended treatment periods with clearly defined weight-loss goals, combining multiple dietary and physical activity strategies, and increasing emphasis on long-term provider contact and relapse prevention have modestly improved long-term weight maintenance. Several investigators have emphasized the need to incorporate additional cognitive components into the cognitive-behavioral treatment of obesity to improve both short- and long-term outcomes. Furthermore, continued insights into metabolic changes producing an energy gap after weight loss should no doubt continue to refine insights into the behavioral requirements of long-term weight loss. Despite increased awareness and behavioral treatment advances, the worldwide prevalence of obesity and weight-related chronic illnesses continues to expound. Behavioral treatment is inherently challenging and time-consuming, and readily available to only a fraction of the population who may benefit from inclusion. Several investigators have cautioned that individual or small group-based interventions are insufficient to serve the population masses requiring treatment, and that continued development of community or Web-based programs, and community-development tactics to increase healthy lifestyles, are needed. The call has been sounded to conceptualize obesity as a chronic health condition requiring lifelong treatment. As such, the conceptualization of cognitive-behavioral therapies as a one-time treatment is passe´ . As the current number of obesity specialists and behaviorally trained professionals is insufficient to combat this problem; an increased emphasis upon training nontraditional weight specialists and nonbehavioral community providers is obviated.

A multifaceted intervention to implement guidelines did not affect hospitalization rates for nursing home-acquired pneumonia

OBJECTIVE

Determine whether a comprehensive approach to implementing national consensus guidelines for nursing home-acquired pneumonia (NHAP) affected hospitalization rates.

DESIGN

Quasi-experimental, mixed-methods, multifaceted, unblinded intervention trial.

SETTING

Sixteen nursing homes (NHs) from 1 corporation: 8 in metropolitan Denver, CO; 8 in Kansas and Missouri during 3 influenza seasons, October to April 2004 to 2007.

PARTICIPANTS

Residents with 2 or more signs and symptoms of systemic lower respiratory tract infection (LRTI); NH staff and physicians were eligible.

INTERVENTION

Multifaceted, including academic detailing to clinicians, within-facility nurse change agent, financial incentives, and nursing education.

MEASUREMENTS

Subjects' NH medical records were reviewed for resident characteristics, disease severity, and care processes. Bivariate analysis compared hospitalization rates for subjects with stable and unstable vital signs between intervention and control NHs and time periods. Qualitative interviews were analyzed using content coding.

RESULTS

Hospitalization rates for stable residents in both NH groups remained low throughout the study. Few critically ill subjects in the intervention NHs were hospitalized in either the baseline or intervention period. In control NHs, 8.7% of subjects with unstable vital signs were hospitalized during the baseline and 33% in intervention year 2, but the difference was not statistically significant (P = .10). Interviews with nursing staff and leadership confirmed there were significant pressures for, and enablers of, avoiding hospitalization for treatment of acute infections.

CONCLUSIONS

Secular pressures to avoid hospitalization and the challenges of reaching NH physicians via academic detailing are likely responsible for the lack of intervention effect on hospitalization rates for critically ill NH residents.

Impact of a weight management program on health-related quality of life in overweight adults with type 2 diabetes

BACKGROUND

Inconsistent findings have been reported regarding improved health-related quality of life (HRQOL) after weight loss. We tested the efficacy of a weight management program for improving HRQOL in overweight or obese adults diagnosed as having type 2 diabetes mellitus.

METHODS

We conducted a randomized multisite clinical trial at 16 outpatient research centers with 2 treatment arms and blinded measurements at baseline and the end of year 1. A total of 5145 participants (mean [SD] age, 58.7 [6.9] years; mean [SD] body mass index [calculated as weight in kilograms divided by height in meters squared], 36.0 [5.9]; 59.5% women; 63.1% white) were randomized to an intensive lifestyle intervention (ILI) or to diabetes support and education (DSE). Main outcome measures included the 36-Item Short-Form Health Survey physical component summary (PCS) and mental health component summary (MCS) scores and Beck Depression Inventory II (BDI-II) scores. Baseline mean (SD) scores were 47.9 (7.9) for PCS, 54.0 (8.1) for MCS, and 5.7 (5.0) for BDI-II.

RESULTS

Improved HRQOL was demonstrated by the PCS and BDI-II scores (P < .001) in the ILI arm compared with the DSE arm. The largest effect was observed for the PCS score (difference, -2.91; 99% confidence interval, -3.44 to -2.37). The greatest HRQOL improvement occurred in participants with the lowest baseline HRQOL levels. Mean (SD) changes in weight (ILI, -8.77 [8.2] kg and DSE, -0.86 [5.0] kg), improved fitness, and improved physical symptoms mediated treatment effects associated with the BDI-II and PCS.

CONCLUSIONS

Overweight adults diagnosed as having type 2 diabetes experienced significant improvement in HRQOL by enrolling in a weight management program that yielded significant weight loss, improved physical fitness, and reduced physical symptoms.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00017953.

Impact of a weight management program on health-related quality of life in overweight adults with type 2 diabetes

BACKGROUND

Inconsistent findings have been reported regarding improved health-related quality of life (HRQOL) after weight loss. We tested the efficacy of a weight management program for improving HRQOL in overweight or obese adults diagnosed as having type 2 diabetes mellitus.

METHODS

We conducted a randomized multisite clinical trial at 16 outpatient research centers with 2 treatment arms and blinded measurements at baseline and the end of year 1. A total of 5145 participants (mean [SD] age, 58.7 [6.9] years; mean [SD] body mass index [calculated as weight in kilograms divided by height in meters squared], 36.0 [5.9]; 59.5% women; 63.1% white) were randomized to an intensive lifestyle intervention (ILI) or to diabetes support and education (DSE). Main outcome measures included the 36-Item Short-Form Health Survey physical component summary (PCS) and mental health component summary (MCS) scores and Beck Depression Inventory II (BDI-II) scores. Baseline mean (SD) scores were 47.9 (7.9) for PCS, 54.0 (8.1) for MCS, and 5.7 (5.0) for BDI-II.

RESULTS

Improved HRQOL was demonstrated by the PCS and BDI-II scores (P < .001) in the ILI arm compared with the DSE arm. The largest effect was observed for the PCS score (difference, -2.91; 99% confidence interval, -3.44 to -2.37). The greatest HRQOL improvement occurred in participants with the lowest baseline HRQOL levels. Mean (SD) changes in weight (ILI, -8.77 [8.2] kg and DSE, -0.86 [5.0] kg), improved fitness, and improved physical symptoms mediated treatment effects associated with the BDI-II and PCS.

CONCLUSIONS

Overweight adults diagnosed as having type 2 diabetes experienced significant improvement in HRQOL by enrolling in a weight management program that yielded significant weight loss, improved physical fitness, and reduced physical symptoms.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00017953.

Cognitive and behavioral approaches in the treatment of obesity

Cognitive behavioral interventions have formed the cornerstone of obesity treatment for the past two decades. These techniques, often combined with diet and exercise strategies, have been shown to produce weight losses of sufficient magnitude so as to reduce health risks. Though success in producing short-term weight loss is improving, many factors, including a metabolic energy gap, continue to challenge long-term weight maintenance results. This article reviews the unique influence of cognitive, behavioral, and metabolic factors on weight loss and weight-loss maintenance, and how future treatment packages might be modified to improve long-term weight loss outcomes.

The use of motivational interviewing in weight loss

Within the past two decades, motivational interviewing has emerged as a useful strategy to help individuals develop motivation to change health behavior and sustain those efforts. This article reviews the preliminary but burgeoning literature that supports the effectiveness of motivational interviewing strategies in promoting positive changes in a variety of health behaviors, including dietary change, activity increases, and regimen adherence. A variety of adaptations of the motivational interviewing process are discussed as relevant to making this treatment strategy increasingly applicable to a variety of health care settings.

Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes: one-year results of the look AHEAD trial

OBJECTIVE

The effectiveness of intentional weight loss in reducing cardiovascular disease (CVD) events in type 2 diabetes is unknown. This report describes 1-year changes in CVD risk factors in a trial designed to examine the long-term effects of an intensive lifestyle intervention on the incidence of major CVD events.

RESEARCH DESIGN AND METHODS

This study consisted of a multicentered, randomized, controlled trial of 5,145 individuals with type 2 diabetes, aged 45-74 years, with BMI >25 kg/m2 (>27 kg/m2 if taking insulin). An intensive lifestyle intervention (ILI) involving group and individual meetings to achieve and maintain weight loss through decreased caloric intake and increased physical activity was compared with a diabetes support and education (DSE) condition.

RESULTS

Participants assigned to ILI lost an average 8.6% of their initial weight vs. 0.7% in DSE group (P < 0.001). Mean fitness increased in ILI by 20.9 vs. 5.8% in DSE (P < 0.001). A greater proportion of ILI participants had reductions in diabetes, hypertension, and lipid-lowering medicines. Mean A1C dropped from 7.3 to 6.6% in ILI (P < 0.001) vs. from 7.3 to 7.2% in DSE. Systolic and diastolic pressure, triglycerides, HDL cholesterol, and urine albumin-to-creatinine ratio improved significantly more in ILI than DSE participants (all P < 0.01).

CONCLUSIONS

At 1 year, ILI resulted in clinically significant weight loss in people with type 2 diabetes. This was associated with improved diabetes control and CVD risk factors and reduced medicine use in ILI versus DSE. Continued intervention and follow-up will determine whether these changes are maintained and will reduce CVD risk.

Binge eating disorder and night eating syndrome in adults with type 2 diabetes

OBJECTIVE

To determine the prevalence of binge eating disorder (BED) and night eating syndrome (NES) among applicants to the Look AHEAD (Action for Health in Diabetes) study.

RESEARCH METHODS AND PROCEDURES

The Eating Disorders Examination-Questionnaire (EDE-Q) and the Night Eating Questionnaire (NEQ) were used to screen patients. Phone interviews were conducted using the EDE for those who reported at least eight episodes of objective binge eating in the past month and using the Night Eating Syndrome History and Interview for those who scored > or =25 on the NEQ. Recruitment at four sites (Birmingham, n = 200; Houston, n = 259; Minneapolis, n = 182; and Philadelphia, n = 204) yielded 845 participants (58% women; mean age = 60.1 +/- 6.7 years; mean BMI = 36.2 +/- 6.3 kg/m(2)).

RESULTS

Screening scores were met by 47 (5.6%) applicants on the EDE-Q and 71 (8.4%) on the NEQ. Of the 85% (40/47) who completed the EDE interview, 12 were diagnosed with BED, representing 1.4% of the total sample. Of the 72% (51/71) who completed the Night Eating Syndrome History and Interview, 32 were diagnosed with NES, equal to 3.8% of the total sample. Three participants had both BED and NES. Participants with eating disorders were younger, heavier, and reported more eating pathology than those without eating disorders.

DISCUSSION

Among obese adults with type 2 diabetes, NES was reported more frequently than BED, which, in turn, was less common than expected.

Stress fractures in elite cross-country athletes

This retrospective and comparative survey investigates an unusual number of stress fractures seen within a Division I college cross-country team. An anonymous questionnaire-designed to observe factors known to increase stress fracture incidence-was distributed to members of the current and previous seasons' teams. Running surface, sleep hours, intake of calcium, and shoe type were among the factors investigated. Eleven lower extremity stress fractures were found in nine athletes. Athletes with stress fractures reported significantly fewer workouts per week on the new track. All other study parameters had no statistically significant effect on stress fractures in these athletes.

Correlates of health-related quality of life in overweight and obese adults with type 2 diabetes

OBJECTIVE

This paper describes and examines conceptually relevant correlates of health-related quality of life (HRQL) in overweight or obese persons with type 2 diabetes. Research Design and Procedures: The investigation was a cross-sectional study of 5145 overweight or obese adults with type 2 diabetes between the ages of 45 and 74 years. Analyses examined the relationship that demographic characteristics, disease burden, and cardiovascular fitness had with HRQL: the Short Form 36 (SF-36) and the Beck Depression Inventory (BDI) II.

RESULTS

Means for the SF-36 physical component summary (PCS) scores, the mental component summary scores, and the BDI-II were as follows: 47.0, 54.0, and 5.7. Less desirable PCS scores were related to several comorbidities, insulin use, physical complaints, a high BMI, low metabolic equivalent (MET) capacity, and lower education. Interactions between categories of obesity and MET capacity revealed that greater BMI was related to lower PCS scores when individuals had lower MET capacities yet was absent for those individuals who had higher MET capacities. In addition, although greater BMI was associated with more severe depressive symptomatology, this association was the most dramatic for those with class III obesity who had low MET capacity.

DISCUSSION

Although participants in Look AHEAD had a favorable profile on the SF-36 and the BDI-II at baseline, lower PCS scores were related to disease severity and the presence of other comorbidities. More important, although the temporal ordering of associations cannot be determined in a cross-sectional design, the interactions between obesity class and MET capacity suggest that the adverse effect of BMI on PCS and BDI-II scores may be buffered by higher MET capacities.