Protocol for a cluster-randomized controlled trial of a technology-assisted health coaching intervention for weight management in primary care: The GEM (goals for eating and moving) study

INTRODUCTION

Over one-third of American adults have obesity with increased risk of chronic disease. Primary care providers often do not counsel patients about weight management due to barriers such as lack of time and training. To address this problem, we developed a technology-assisted health coaching intervention called Goals for Eating and Moving (GEM) to facilitate obesity counseling within the patient-centered medical home (PCMH) model of primary care. The objective of this paper is to describe the rationale and design of a cluster-randomized controlled trial to test the GEM intervention when compared to Enhanced Usual Care (EUC).

METHOD

We have randomized 19 PCMH teams from two NYC healthcare systems (VA New York Harbor Healthcare System and Montefiore Medical Group practices) to either the GEM intervention or EUC. Eligible participants are English and Spanish-speaking primary care patients (ages 18-69 years) with obesity or who are overweight with comorbidity (e.g., arthritis, sleep apnea, hypertension). The GEM intervention consists of a tablet-delivered goal setting tool, a health coaching visit and twelve telephone calls for patients, and provider counseling training. Patients in the EUC arm receive health education materials. The primary outcome is mean weight loss at 1 year. Secondary outcomes include changes in waist circumference, diet, and physical activity. We will also examine the impact of GEM on obesity-related provider counseling competency and attitudes.

CONCLUSION

If GEM is found to be efficacious, it could provide a structured approach for improving weight management for diverse primary care patient populations with elevated cardiovascular disease risk.

A technology-assisted health coaching intervention vs. enhanced usual care for Primary Care-Based Obesity Treatment: a randomized controlled trial

Background

Goals for Eating and Moving (GEM) is a technology-assisted health coaching intervention to improve weight management in primary care at the Veterans Health Administration (VHA) that we designed through prior rigorous formative studies. GEM is integrated within the patient-centered medical home and utilizes student health coach volunteers to counsel patients and encourage participation in VHA’s intensive weight management program, MOVE!. The primary aim of this study was to determine the feasibility and acceptability of GEM when compared to Enhanced Usual Care (EUC). Our secondary aim was to test the impact of GEM on weight, diet and physical activity when compared to EUC.

Methods

Veterans with a Body Mass Index ≥30 kg/m² or 25–29.9 kg/m² with comorbidities (n = 45) were recruited in two phases and randomized to GEM (n = 22) or EUC (n = 23). We collected process measures (e.g. number of coaching calls completed, number and types of lifestyle goals, counseling documentation) and qualitative feedback on quality of counseling and acceptability of call duration. We also measured weight and behavioral outcomes.

Results

GEM participants reported receiving high quality counseling from health coaches and that call duration and frequency were acceptable. They received 5.9 (SD = 3.7) of 12 coaching calls on average, and number of coaching calls completed was associated with greater weight loss at 6-months in GEM participants (Spearman Coefficient = 0.71, p < 0.001). Four participants from GEM and two from EUC attended the MOVE! program. PCPs completed clinical reminders in 12% of PCP visits with GEM participants. Trends show that GEM participants (n = 21) tended to lose more weight at 3-, 6-, and 12-months as compared to EUC, but this was not statistically significant. There were no significant differences in diet or physical activity.

Conclusions

We found that a technology assisted health coaching intervention delivered within primary care using student health coaches was feasible and acceptable to Veteran patients. This pilot study helped elucidate challenges such as low provider engagement, difficulties with health coach continuity, and low patient attendance in MOVE! which we have addressed and plan to test in future studies.

Trial registration

NCT03006328 Retrospectively registered on December 30, 2016.

Electronic supplementary material

The online version of this article (10.1186/s40608-018-0226-0) contains supplementary material, which is available to authorized users.

Clinicopathologic Significance of Cathepsin B and Urokinase-type Plasminogen Activator Immunostaining in Colorectal Adenocarcinoma

Acetone-fixed cryostat sections of 52 colorectal adenocarcinomas (26 stage B, 26 stage C) were immunostained with antibodies for two "invasion-associated" proteolytic enzymes—cathepsin B and urokinase-type plasminogen activator. Cathepsin B immu nostaining of neoplastic cells was observed in 21 tumors (40%). It was generally accompanied by staining among peritumoral host cells. There was no correlation be tween neoplastic cell cathepsin B staining and tumor stage (stage B, 42% positive vs stage C, 38% positive) however staining was more frequent in tumors that recurred (cathepsin B negative, 23% recurred vs cathepsin B positive, 48% recurred, P = .05-.06,25 months follow-up). Significant neoplastic cell urokinase-type plasminogen activator staining was present in only six cases (12%); however, peritumoral spindle and inflammatory cells exhibited positivity in 35% of tumors. There was no correlation between host cell derived urokinase-type plasminogen activator staining and either node metastasis or patient outcome. Tumors that stained for both neoplastic cell ca thepsin B and stromal cell urokinase-type plasminogen activator (12%) characterized a morphologically and clinically aggressive subset, compared to cases that stained for only one (51%) or neither (37%) enzyme (both positive, 83% recurred, 83% poorly differentiated vs neither positive, 26% recurred, 5% poorly differentiated). These data imply that invasion-associated proteases are derived from heterogeneous cellular sources in colorectal tumors. Further, synergistic protease activity may promote aggres sive clinical behavior accounting, in part, for the adverse prognostic significance of poor differentiation. Int J Surg Pathol 1(4):227-234, 1994

Impact of breast carcinoma on African-American women: the Detroit experience

BACKGROUND

National and regional population-based data have demonstrated substantially worse outcome in African-American patients with breast carcinoma when compared with white patients, as well as a younger age distribution among African-American patients with breast carcinoma. The extent to which various socioeconomic, environmental, lifestyle, and genetic factors interact to account for this ethnicity-related disparity in survival is poorly understood. Greater than one-half of the inner-city population of Detroit, Michigan is African American, and greater metropolitan Detroit has been one of the contributing registries for the Surveillance, Epidemiology, and End Results (SEER) program since its inception in 1973. The impact of breast carcinoma on African Americans in the Detroit area is therefore well documented and provides significant insight into the history, epidemiology, and biology of this major public health care problem.

METHODS

A review of the medical literature published over the past 20 years regarding African-American patients with breast carcinoma was performed. The pertinent findings were summarized in the context of advances made in breast carcinoma screening, treatment, and risk reduction during that period.

RESULTS

The large African-American population of Detroit is a major factor contributing to the excessive breast carcinoma mortality rate reported for this city, which is one of the highest in the United States. Improvements in early detection of breast carcinoma by using screening mammography have been apparent in the earlier stage distributions of breast carcinoma observed in both white and African-American patients; however, progress has lagged substantially for the latter group. Detroit SEER registry data also have shown a younger age distribution of African-American patients with breast carcinoma and higher rates of estrogen receptor negative tumors. Finally, preliminary data from health maintenance organizations have suggested improved breast carcinoma outcome for African Americans who possess greater socioeconomic benefits, but disparities in disease stage at presentation persist.

CONCLUSIONS

The diverse Detroit community is ideally suited for breast carcinoma screening programs and clinical investigations that seek to address and overcome ethnicity-related survival disparities and barriers to health care. Findings from these studies can be correlated with results from similar projects in other geographic areas.

Clinicopathologic Significance of Ductal Carcinoma in situ in Breast Core Needle Biopsies With Invasive Cancer

To assess whether the presence and amount of intraductal component (IC) in diagnostic needle core biopsies (NCB) is predictive of an extensive IC (EIC), the authors evaluated 50 invasive ductal carcinomas diagnosed with NCB, and then excised via lumpectomy, with regard to the extent of IC in both the NCB and subsequent lumpectomy specimen. These parameters were compared with each other and with the lumpectomy margin status. Extent of IC in the NCB was evaluated by dividing the number of ducts that contained IC by the total number of tissue cores. A ratio of more than 0.5 was considered EIC (EICc). IC extent in the lumpectomy was established by estimating the percentage of the tumor corresponding to IC and was considered extensive (EIC(L)) if more than 25% and if there was presence of IC away from the invasive tumor. The mean size of resected tumors was 1.6 +/- 0.7 cm. In 29 cases (58%) there was no IC in the NCB (NegICc), 11 cases (22%) exhibited nonextensive IC (NEICc), and 10 cases (20%) demonstrated EICc. A total of 7%, 36%, and 70% of the NegICc, NEICc, and EICc cases respectively had EIC(L)(p < 0.0001). The presence of EIC(L) correlated significantly with close or positive margin status for in situ disease (EIC(L) positive, 12 of 13 [92%] vs EIC(L) negative, 11 of 37 [30%]; p = 0.004). None of the NegICc, 27% of NEICc, and 40% of EICc had a positive margin for in situ neoplasm in the lumpectomy specimen (p = 0.004), and 24%, 18%, and 50% had positive margins for invasive neoplasm (p = not significant). The authors conclude that EICc predicts EIC(L) and constitutes a risk factor for positive lumpectomy margin status-particularly for in situ tumor. EICc may thus be of clinical value in identifying a subset of patients that requires a wider local excision.

The value of postlumpectomy mammogram in the management of breast cancer patients presenting with suspiciouis microcalcifications

PURPOSE

It is recommended that patients with breast cancer who present with mammographically detected microcalcification should undergo postlumpectomy mammogram with magnification views to ensure adequate removal of all clinically demonstrable disease. The value of postlumpectomy mammogram has not been adequately examined in the literature. This report aims to quantify the value of such a study.

MATERIALS AND METHODS

Retrospective review identified 90 breast cancer patients referred to our department between 1992 and 1997 who met all of the following criteria: (1) patients were considered for breast conserving management; (2) patients had suspicious microcalcifications on diagnostic mammograms; (3) the mammographic lesions were thought to be removed entirely on postexcision specimen radiographs; (4) surgical excisions were thought to be adequate on the basis of a review of the histologic pathology reports; and (5) postlumpectomy mammograms with magnification views were obtained. Fifty patients had invasive adenocarcinoma and 40 patients had ductal carcinoma in situ. The margins of last resection were clear, close, or focally involved in 70, 13, and seven patients, respectively. Patient records were reviewed to determine whether postlumpectomy mammograms demonstrated residual microcalcifications.

RESULTS

Sixteen patients (17%) were found to have residual microcalcifications on postlumpectomy mammograms. Twelve patients underwent either local re-excision (seven patients) or simple mastectomy (five patients). Re-excision was not performed in four patients. Residual malignant cells were found in eight patients (67% of the re-excision group and 9% of the whole group). Six of these patients had their tumors initially resected with clear margins and the remaining two patients had their tumors initially resected with close margins.

CONCLUSIONS

Postlumpectomy mammograms with magnification views detected residual clinical disease in a significant proportion of patients. Our result supports the routine use of this test, even when satisfactory postexcision specimen radiographs and adequate lumpectomy resection margins are obtained. This finding is particularly true for patients with ductal carcinoma in situ.

[Study on the incidence of Sarcocystis spp. in Dutch cattle using various methods]

Comparative studies were done to test the practicability of various methods of detection in bovine sarcosporidiosis. Macroscopic examination of meat, trichinoscopy and artificial digestion were carried out using meat from the heart and oesophagus. A total of ninety-one random animals were involved. It was concluded that artificial digestion of trypsin is the method of choice (practical, sensitive). As much as 100 per cent of the animals were found to be infected with Sarcocystis spp.

Clinical application of organ specific isoamylases

Since hyperamylasemia with or without abdominal pain is a frequently encountered problem, serum isoamylase analysis in 52 patients was done to see if the organ source of the amylase would be helpful in a clinical setting. Four patterns of hyperamylasemia were found: 1) AMY1 (salivary) hyperamylasemia; 2) AMY2 (pancreatic) hyperamylasemia; 3) Both AMY1 and AMY2 amylase elevated; and 4) macroamylasemia. A variety of conditions other than pancreatitis were associated with hyperamylasemia, and some patients who were thought on clinical grounds to have pancreatitis had raised levels of AMY1 (salivary) amylase. This study suggests that hyperamylasemia alone is a poor indicator of pancreatic disease, and that isoamylase analysis will improve the accuracy with which amylase determinations are used.

Sepsis, glucose intolerance, and protein malnutrition: a metabolic paradox

Glucose intolerance and its hormonal influence was examined in patients with sepsis. Eighteen patients were included in the protocol, which studied the response to a standard intravenous glucose tolerance test (GTT) in the postoperative stressed, septic, and septic protein malnourished (depressed albumin level) states. Four groups could be defined: stress (1), sepsis with depressed albumin level and normal glucose tolerance (2), sepsis with mild glucose intolerance and normal albumin levels (3), and sepsis with severe glucose intolerance and depressed albumin (4). Serial hormone levels were measured during the GTT, including insulin, glucagon, epinephrine, and human growth hormone values. Each group demonstrated a characteristic hormone profile. In a comparison with controls, group 2 was associated with mild suppression of insulin; group 3 exhibited mild glucose intolerance, hyperglucagonemia, and increased insulin; and group 4 demonstrated severe glucose intolerance, hyperglucagonemia, and marked suppression of growth hormone production.

The sepsis-glucose intolerance riddle: a hormonal explanation

Glucose intolerance has been commonly observed in sepsis and has been attributed to a multitude of endocrine and metabolic disorders. From 1977 to 1978, 19 patients were studied using intravenous glucose tolerance tests to evaluate this phenomenon; 15 patients presented with ongoing sepsis and four patients served as stress controls. Glucose intolerance was found to be a significant finding in less than 40% of the septic group. This state of intolerance was noted to be associated with a high mortality rate (60%), whereas glucose tolerance in sepsis was associated with a much improved mortality rate (10%). Hormone levels were correlated with glucose tolerance curves using the parameters of insulin, glucagon, growth hormone, cortisol, and epinephrine levels. Glucose intolerance and a high mortality rate were linked to sustained hyperglucagonemia, which was unresponsive to glucose challenge, and to marked suppression of growth hormone. This apparently represents a decompensated peripheral metabolic energy deficit, which results in the increased mortality rate.