Differences in weight-loss outcomes among race-gender subgroups by behavioural intervention delivery mode: An analysis of the POWER trial

Prior in-person behavioural intervention studies have documented differential weight loss between men and women and by race, with Black women receiving the least benefit. Remotely delivered interventions are now commonplace, but few studies have compared outcomes by race-gender groups and delivery modality. We conducted a secondary analysis of POWER, a randomized trial (NCT00783315) designed to determine the effectiveness of 2 active, lifestyle-based, weight loss interventions (remote vs. in-person) compared to a control group. Participants with obesity and at least one cardiovascular disease risk factor (N = 415) were recruited in the Baltimore, MD area. Data from 233 white and 170 Black individuals were used for this analysis. Following an intention-to-treat approach, we compared the mean percent weight loss at 24 months by race-gender subgroups using repeated-measures, mixed-effects models. Everyone lost weight in the active interventions however, weight loss differed by race and gender. white and Black men had similar results for both interventions (white: in-person (-7.6%) remote (-7.4%); Black: in-person (-4.7%) remote (-4.4%)). In contrast, white women lost more weight with the in-person intervention (in-person (-7.2%) compared to the remote (-4.4%)), whereas Black women lost less weight in the in-person group compared to the remote intervention at 24 months (-2.0% vs. -3.0%, respectively; p for interaction <.001). We found differences between the effectiveness of the 2 weight loss interventions-in-person or remote-in white and Black women at 24 months. Future studies should consider intervention modality when designing weight loss interventions for women.

Psychosocial factors and subsequent risk of hospitalizations with peripheral artery disease: The Atherosclerosis Risk in Communities (ARIC) Study

BACKGROUND AND AIMS

Psychosocial factors are associated with increased risk of cardiovascular disease (CVD). However, associations with peripheral artery disease (PAD) remain uncharacterized. We aimed to compare associations of psychosocial factors with the risk of PAD and two other major atherosclerotic CVD: coronary heart disease (CHD) and ischemic stroke, in the Atherosclerosis Risk in Communities (ARIC) Study.

METHODS

In 11,104 participants (mean age 56.7 [SD 5.7] years) without a clinical history of PAD and CHD/stroke at baseline (1990-1992), we evaluated four psychosocial domains: depressive/fatigue symptoms by the Maastricht Questionnaire, social support by the Interpersonal Evaluation List, social networks by the Lubben Scale, and trait anger by the Spielberger Scale. PAD was defined as hospitalizations with diagnosis or related procedures. CHD included adjudicated coronary heart disease and stroke included ischemic stroke.

RESULTS

We observed 397 PAD and 1940 CHD/stroke events during a median follow-up of 23.1 years. Higher depressive/fatigue symptoms and less social support were significantly associated with incident PAD (adjusted hazard ratios for top vs. bottom quartile 1.65 [95%CI, 1.25-2.19] and 1.40 [1.05-1.87], respectively). When these factors were simultaneously modeled, only depressive/fatigue symptoms remained significant. Incident CHD/stroke was not associated with either of depressive/fatigue symptoms or social support. Social networks and trait anger were not independently associated with PAD or CHD/stroke.

CONCLUSIONS

Depressive/fatigue symptoms and social support (especially the former) were independently associated with the risk of hospitalizations with PAD but not CHD/stroke in the general population. Our results support the importance of depressive/fatigue symptoms in vascular health and suggest the need of including PAD when studying the impact of psychosocial factors on CVD.

Abstract 16363: An 18-month Smoking Cessation Intervention Incorporating Pharmacotherapy and Behavioral Counseling Improves Tobacco Abstinence Rates in Adult Smokers With Serious Mental Illness (smi) in Community Mental Health Settings: Results of a Randomized Clinical Trial

Introduction: Tobacco smoking is the largest contributor to markedly elevated CVD and preventable death in persons with SMI. Trials of combined pharmacologic and behavioral treatments improve abstinence rates, but have targeted those ready to quit right away, and evidence-based treatments are rarely used in the community. Weight gain often accompanies abstinence. Our objective was to determine the effectiveness of an 18m smoking cessation pharmacotherapy and behavioral counseling intervention incorporating weight management and physical activity in persons with SMI.

Hypothesis: The active intervention is more effective than control in achieving biochemically validated, 7-day point prevalence smoking abstinence at 18m.

Methods: We conducted an RCT in 4 community mental health settings in 192 smokers with SMI, stratified by readiness to quit within 30d or in 1 to 6m. The active intervention group was offered 18m of 1 st -line cessation pharmacotherapy, smoking cessation and weight management counseling tailored to readiness to quit, and support for physical activity. Controls received a quit line referral.

Results: Mean(SD) age was 49.6(11.7); cigarettes/day 12.1(9.5); BMI 32.0(7.6) kg/m 2 ; 49% were male, 48% African-American, 62% willing to quit in 30d, 95% completed 18m follow-up. At 18m, 27.8% of active group and 6.3% of controls achieved 7d smoking abstinence (p<0.0001); adjusted odds ratio 6.0 (95% CI: 2.3 –15.6; p=0.0002). There was no significant modification of intervention effect on abstinence by readiness to quit. Mean difference in weight change over 18m between active and control was not significant (3.5 lbs, 95% CI: -3.3 –10.3; p=0.32).

Conclusions: Offering 18m of evidence-based cessation treatment in the community substantially increased smoking abstinence without significant weight gain in SMI. Implementing best practice guidelines to treat all smokers regardless of readiness to quit should improve CVD health in this high-risk population.

The use of peer mentors to enhance a smoking cessation intervention for persons with serious mental illnesses

OBJECTIVE

We evaluated a well-specified peer mentor program that enhanced a professionally led smoking cessation group for persons with serious mental illnesses.

METHOD

Participants were 8 peer mentors, persons with serious mental illnesses who had successfully quit smoking, and 30 program participants, persons with serious mental illnesses enrolled in a 6-month intervention. Peer mentors were trained and then helped to deliver a smoking cessation group and met with program participants individually. We assessed the mentors' skills after training, their fidelity to the model, and the program's feasibility and acceptability. We also measured the smoking outcomes of the program participants including change in exhaled carbon monoxide, a measure of recent smoking, and aspects of the peer mentor-program participant relationship.

RESULTS

Peer mentors attained a mean score of 13.6/14 on role play assessments after training and delivered the intervention with fidelity as assessed by adherence and competence ratings (mean scores of 97% and 93%, respectively). The feasibility and acceptability of the intervention was demonstrated in that 28/30 participants met with their peer mentors regularly and only 1 participant and no peer mentor discontinued in the study. Both parties rated the interpersonal alliance highly, mean of 5.9/7. The program participants had a decline in carbon monoxide levels and number of cigarettes smoked per day (repeated measures ANOVA F = 6.04, p = .008; F = 15.87, p < .001, respectively). A total of 22/30 (73%) made a quit attempt but only 3 (10%) achieved sustained abstinence.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Our study adds to the growing literature about peer-delivered interventions.

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

PURPOSE

To evaluate effects of two behavioral weight-loss interventions (in-person, remote) on health-related quality of life (HRQOL) compared to a control intervention.

METHODS

Four hundred and fifty-one obese US adults with at least one cardiovascular risk factor completed five measures of HRQOL and depression: MOS SF-12 physical component summary (PCS) and mental component summary; EuroQoL-5 dimensions single index and visual analog scale; PHQ-8 depression symptoms; and PSQI sleep quality scores at baseline and 6 and 24 months after randomization. Change in each outcome was analyzed using outcome-specific mixed-effects models controlling for participant demographic characteristics.

RESULTS

PCS-12 scores over 24 months improved more among participants in the in-person active intervention arm than among control arm participants (P < 0.05, ES = 0.21); there were no other statistically significant treatment arm differences in HRQOL change. Greater weight loss was associated with improvements in most outcomes (P < 0.05 to < 0.0001).

CONCLUSIONS

Participants in the in-person active intervention improved more in physical function HRQOL than participants in the control arm did. Greater weight loss during the study was associated with greater improvement in all PRO except for sleep quality, suggesting that weight loss is a key factor in improving HRQOL.

Post-myocardial-infarction quality of care among disabled Medicaid beneficiaries with and without serious mental illness

OBJECTIVE

The objective was to examine the association between serious mental illness and quality of care for myocardial infarction among disabled Maryland Medicaid beneficiaries.

METHODS

We conducted a retrospective cohort study of disabled Maryland Medicaid beneficiaries with myocardial infarction from 1994 to 2004. Cardiac procedures and guideline-based medication use were compared for persons with and without serious mental illness.

RESULTS

Of the 633 cohort members with myocardial infarction, 137 had serious mental illness. Serious mental illness was not associated with differences in receipt of cardiac procedures or guideline-based medications. Overall use of guideline-based medications was low; 30 days after the index hospitalization for myocardial infarction, 19%, 35% and 11% of cohort members with serious mental illness and 22%, 37% and 13% of cohort members without serious mental illness had any use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, beta-blockers and statins, respectively. Study participants with and without serious mental illness had similar rates of mortality. Overall, use of beta-blockers [hazard ratio 0.93, 95% confidence interval (CI) 0.90-0.97] and statins (hazard ratio 0.93, 95% CI 0.89-0.98) was associated with reduced risk of mortality.

CONCLUSIONS

Quality improvement programs should consider how to increase adherence to medications of known benefit among disabled Medicaid beneficiaries with and without serious mental illness.

Is serious mental illness associated with earlier death among persons with HIV? Ten year follow up in Maryland Medicaid Recipients

BACKGROUND/OBJECTIVE

In the general population serious mental illness (SMI) is associated with earlier mortality. The objective of this study was to determine if SMI was associated with an increased risk of death among Maryland Medicaid beneficiaries with HIV.

METHODS

This was a retrospective cohort study of adult Maryland Medicaid recipients with HIV receiving antiretroviral therapy (ART) after January 1, 1997. SMI was defined as a specialty mental health visit and an ICD-9 diagnosis of 1) schizophrenia or related psychoses, 2) bipolar disorder or 3) major depressive disorder. Cox proportional hazards regression models were used to estimate the hazard ratios for total mortality. Analyses were adjusted for demographic characteristics, % days on ART, outpatient visits and comorbid medical conditions.

RESULTS

Overall, 623 individuals received ART after treatment inception. The total number of deaths was 278, out of which 60 deaths were in the SMI group (38.5%) and 211 in the non-SMI group (45%) (p=0.05). In multivariable analysis, SMI was not associated with mortality. Increasing age, AIDS defining illness, renal failure, cerebrovascular disease, congestive heart failure, chronic liver disease and substance abuse were independently associated with mortality, while increased percent days of HIV medication use and number of outpatient medical visits were associated with improved survival.

CONCLUSIONS

In this sample, SMI is not associated with earlier death in patients with HIV infection. ART use and primary care engagement among HIV infected individuals are associated with improved survival irrespective of an SMI diagnosis.

Injury risk and severity in a sample of Maryland residents with serious mental illness

OBJECTIVE

Adults with serious mental illness experience premature mortality and heightened risk for medical disease, but little is known about the burden of injuries in this population. The objective of this study was to describe injury incidence among persons with serious mental illness.

METHODS

We conducted a retrospective cohort study of 6234 Maryl and Medicaid recipients with serious mental illness from 1994-2001. Injuries were classified using the Barell Matrix. Relative risks were calculated to compare injury rates among the study cohort with injury rates in the United States population. Cox proportional hazards modeling with time dependent covariates was used to assess factors related to risk of injury and injury-related death.

RESULTS

Forty-three percent of the Maryland Medicaid cohort had any injury diagnosis. Of the 7298 injuries incurred, the most common categories were systemic injuries due to poisoning (10.4%), open wounds to the head/face (8.9%), and superficial injuries, fractures, and sprains of the extremities (8.6%, 8.5%, and 8.4%, respectively). Injury incidence was 80% higher and risk for fatal injury was more than four and a half times higher among the cohort with serious mental illness compared to the general population. Alcohol and drug abuse were associated with both risk of injury and risk of injury-related death with hazard ratios of 1.87 and 4.76 at the p<0.05 significance level, respectively.

CONCLUSIONS

The superficial, minor nature of the majority of injuries is consistent with acts of minor victimization and violence or falls. High risk of fatal and non-fatal injury among this group indicates need for increased injury prevention efforts targeting persons with serious mental illness and their caregivers.

A nutritional intervention to reduce the calorie content of meals served at psychiatric rehabilitation programs

To assess the effectiveness of an intervention to reduce the calorie content of meals served at two psychiatric rehabilitation programs. Intervention staff assisted kitchen staff with ways to reduce calories and improve the nutritional quality of meals. Breakfast and lunch menus were collected before and after a 6-month intervention period. ESHA software was used to determine total energy and nutrient profiles of meals. Total energy of served meals significantly decreased by 28% at breakfast and 29% at lunch for site 1 (P < 0.05); total energy significantly decreased by 41% at breakfast for site 2 (P = 0.018). Total sugars significantly decreased at breakfast for both sites (P ≤ 0.001). In general, sodium levels were high before and after the intervention period. The nutrition intervention was effective in decreasing the total energy and altering the composition of macro-nutrients of meals. These results highlight an unappreciated opportunity to improve diet quality in patients attending psychiatric rehabilitation programs.

Comparative effectiveness of weight-loss interventions in clinical practice

BACKGROUND

Obesity and its cardiovascular complications are extremely common medical problems, but evidence on how to accomplish weight loss in clinical practice is sparse.

METHODS

We conducted a randomized, controlled trial to examine the effects of two behavioral weight-loss interventions in 415 obese patients with at least one cardiovascular risk factor. Participants were recruited from six primary care practices; 63.6% were women, 41.0% were black, and the mean age was 54.0 years. One intervention provided patients with weight-loss support remotely--through the telephone, a study-specific Web site, and e-mail. The other intervention provided in-person support during group and individual sessions, along with the three remote means of support. There was also a control group in which weight loss was self-directed. Outcomes were compared between each intervention group and the control group and between the two intervention groups. For both interventions, primary care providers reinforced participation at routinely scheduled visits. The trial duration was 24 months.

RESULTS

At baseline, the mean body-mass index (the weight in kilograms divided by the square of the height in meters) for all participants was 36.6, and the mean weight was 103.8 kg. At 24 months, the mean change in weight from baseline was -0.8 kg in the control group, -4.6 kg in the group receiving remote support only (P<0.001 for the comparison with the control group), and -5.1 kg in the group receiving in-person support (P<0.001 for the comparison with the control group). The percentage of participants who lost 5% or more of their initial weight was 18.8% in the control group, 38.2% in the group receiving remote support only, and 41.4% in the group receiving in-person support. The change in weight from baseline did not differ significantly between the two intervention groups.

CONCLUSIONS

In two behavioral interventions, one delivered with in-person support and the other delivered remotely, without face-to-face contact between participants and weight-loss coaches, obese patients achieved and sustained clinically significant weight loss over a period of 24 months. (Funded by the National Heart, Lung, and Blood Institute and others; ClinicalTrials.gov number, NCT00783315.).

Evaluation of “Depression in Primary Care” Innovations

Key stakeholders and executive decision makers in health care system require clear and convincing data of the value of chronic illness care models for the primary care treatment of depression. Well-conceived and conducted evaluations provide this necessary information. This case study describes the experience of a large, nonprofit health care system's experience with implementing and evaluating a quality improvement program for integrating depression management into primary care. The commentary that follows discusses specific evaluation questions that are relevant to each of the stakeholder groups involved in deciding whether or not to continue supporting such programs.

Prevalence of chronic obstructive pulmonary disease among those with serious mental illness

OBJECTIVE

Individuals with serious mental illness have elevated smoking rates, and smoking is a significant risk factor for chronic obstructive pulmonary disease (COPD). The goal was to determine the prevalence of COPD among those with serious mental illness.

METHOD

The authors surveyed a random sample of 200 adults with serious mental illness with questions from the National Health and Nutrition Examination Study III that were previously used to estimate the national prevalence of COPD. They compared the prevalence of COPD in the sample to a randomly selected matched subset of national comparison subjects.

RESULTS

The prevalence of COPD was 22.6%. Those with serious mental illness were significantly more likely to have chronic bronchitis (19.5% versus 6.1%) and emphysema (7.9% versus 1.5%) than the comparison subjects.

CONCLUSIONS

The prevalence of COPD is significantly higher among those with serious mental illness than comparison subjects. Improved primary and secondary prevention is warranted.

To whom do psychiatrists offer smoking-cessation counseling?

OBJECTIVE

Individuals with mental illness have high rates of tobacco dependence; however, little is known about what influences a psychiatrist's decision to offer smoking-cessation counseling to smoking patients.

METHOD

Using the National Ambulatory Medical Care Survey, the authors identified 1,610 psychiatric office visits for patients who smoke. They investigated the relationship between patient and visit characteristics and smoking-cessation counseling with logistic regression.

RESULTS

Psychiatrists offered cessation counseling at 12.4% of the visits for smoking patients. The adjusted probability of receiving smoking-cessation counseling was significantly higher for those older than 50; for those with a medical diagnosis of obesity, hypertension, or diabetes mellitus; for those in a rural location; and for those having an initial visit. Those with bipolar affective disorder were more likely to receive smoking-cessation counseling than those with depression.

CONCLUSIONS

Psychiatrists may be missing opportunities to offer smoking-cessation counseling to patients who smoke.

A computerized tool for evaluating the effectiveness of preventive interventions

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

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

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