[Show abstract][Hide abstract] ABSTRACT: Purpose:
Primary care providers (PCPs) play an important role in identifying and counseling obese patients to lose weight, but it is unknown whether PCP referral of patients into a weight loss intervention is associated with greater weight loss. The objectives are to determine if PCP referral is associated with greater 1) weight loss, 2) end of study patient-provider relationship quality, and 3) satisfaction and participation rates in the intervention.
415 obese patients enrolled in the Hopkins POWER trial from six primary care practices in the Baltimore area. We conducted a secondary analysis of results from the trial using longitudinal mixed-effects model and generalized linear model, adjusting for clinic, sex, age, and race. The primary outcome was absolute weight change from baseline to 24 months. Secondary outcomes were patient-provider relationship quality and satisfaction and participation rates in the intervention.
Participants in both PCP and non-PCP referral groups lost a similar amount of weight from baseline to 24 months. PCP referral was not significantly associated with percentage of completed coach contacts, web logins, and satisfaction with trial, but was associated with higher end of study patient-provider relationship quality (p = 0.007).
Our study represents the first of its kind to examine the role of PCP referral of patients into a weight loss trial. While we did not find evidence that PCP referral is associated with increased weight loss, further research is needed to determine how PCPs can use their relationship with patients to promote weight loss and enhance intervention effects.
[Show abstract][Hide abstract] ABSTRACT: Background
Behavioural weight loss programs are effective first-line treatments for obesity and are recommended by the US Preventive Services Task Force. Gaining an understanding of intervention components that are found helpful by different demographic groups can improve tailoring of weight loss programs. This paper examined the perceived helpfulness of different weight loss program components.Methods
Participants (n = 236) from the active intervention conditions of the Practice-based Opportunities for Weight Reduction (POWER) Hopkins Trial rated the helpfulness of 15 different components of a multicomponent behavioural weight loss program at 24-month follow-up. These ratings were examined in relation to demographic variables, treatment arm and weight loss success.ResultsThe components most frequently identified as helpful were individual telephone sessions (88%), tracking weight online (81%) and coach review of tracking (81%). The component least frequently rated as helpful was the primary care providers' general involvement (50%). Groups such as older adults, Blacks and those with lower education levels more frequently reported intervention components as helpful compared with their counterparts.DiscussionWeight loss coaching delivered telephonically with web support was well received. Findings support the use of remote behavioural interventions for a wide variety of individuals.
[Show abstract][Hide abstract] ABSTRACT: Women with pregnancy complications benefit from closer monitoring postpartum and beyond. Increased postpartum emergency room (ER) use may indicate unmet need for outpatient obstetrics and primary care. The purpose of this study was to evaluate whether women with pregnancy complications (gestational diabetes [GDM], gestational hypertension, and preeclampsia) have increased ER use in the first 6 months postpartum, compared with women without these complications.
We conducted a retrospective population-based cohort study using a 2003-2010 Maryland Medicaid managed care claims data set, linked with U.S. Census data. Data included claims for outpatient and ER visits for women aged 12-45 years who were continuously enrolled in Medicaid for at least 100 days of pregnancy and 90 days postpartum. We used logistic regression to calculate the association between pregnancy complications and having ≥1 ER visit in the 6 months postpartum.
We identified 26,074 pregnancies, of which 20% were complicated by GDM, gestational hypertension, or preeclampsia. Of these complicated pregnancies, 42.1% had GDM, 35.4% had gestational hypertension, and 42.5% had preeclampsia (diagnoses were not mutually exclusive). In the 6 months postpartum, 25% of women had ≥1 ER visits. Of the complicated pregnancy group, 27.7% had ≥1 ER visit, versus 23.6% of the comparison group (p<0.0001). In adjusted analyses, women with a pregnancy complication were more likely to have ≥1 ER visit compared with women without these complications (odds ratio [OR]1.14, 95% confidence interval [CI] 1.05-1.23). The strength of association was highest in women under age 25 (OR 1.20, 95% CI 1.09-1.33). Preconception medical comorbidities (type 2 diabetes, chronic hypertension, obesity, asthma, mental health, and substance abuse diagnoses) were also strongly associated with postpartum ER use (OR 1.61, 95% CI 1.51-1.73).
Pregnancy complications increased ER utilization during the 6 months postpartum, especially among women under age 25 years. Interventions that improve discharge planning and early postpartum care may decrease ER use.
No preview · Article · Jul 2015 · Journal of Women's Health
[Show abstract][Hide abstract] ABSTRACT: Pregnancy and the postpartum period provide windows of opportunity to impact perinatal and lifelong preventive health behavior for women and their families, but these opportunities are often missed. Understanding racial/ethnic differences in information and communication technology (ICT) use could inform technology-based interventions in diverse populations.
The objective of the study was to evaluate differences in the use of ICT between racial and ethnic groups as well as by English language proficiency.
We conducted a cross-sectional study of 246 women who were aged 18 years or older and pregnant or within 1 year of delivery. They were recruited from 4 hospital-based outpatient clinics and completed a self-administered survey. We used multivariate regression analysis to evaluate the association between race/ethnicity and ICT (mobile phone/short message service [SMS] text message, Internet, and social network) usage by race/ethnicity and perceived English language proficiency after adjusting for age, income, marital status, and insurance status.
In all, 28% (69/246) of participants were Latina, 40% (98/246) were African American, 23% (56/246) were white, and 9% (23/246) from other racial/ethnic groups. Of the Latinas, 84% (58/69) reported limited English language proficiency and 59% (41/69) were uninsured. More than 90% of all participants reported mobile phone use, but more than 25% (65/246) had changed phone numbers 2 or more times in the past year. Compared to white women, African American women were less likely to SMS text message (OR 0.07, 95% CI 0.01-0.63) and Latinas were less likely to use the Internet to find others with similar concerns (OR 0.23, 95% CI 0.08-0.73). Women with limited English language proficiency were less likely to use the Internet overall (OR 0.30, 95% CI 0.09-0.99) or use email (OR 0.22, 95% CI 0.08-0.63) compared to women with adequate English language proficiency.
Mobile phones are widely available for the delivery of health interventions to low-income, racially diverse pregnant and postpartum women, but disparities in Internet use and SMS text messaging exist. Interventions or programs requiring Web-based apps may have lower uptake unless alternatives are available, such as those adapted for limited English proficiency populations.
No preview · Article · Jul 2015 · Journal of Medical Internet Research
[Show abstract][Hide abstract] ABSTRACT: Objective(1) To determine the nonphysician health profession perceived as best qualified to provide weight management. (2) To examine nutrition professionals' current practice characteristics and perceived challenges and solutions for obesity care. (3) To examine the association between nutrition professionals' quality of training and self-efficacy in weight management.MethodsA 2014 national cross-sectional online survey of 500 U.S. nonphysician health professionals (100 from each: nutrition, nursing, behavioral/mental health, exercise, pharmacy) was analyzed.ResultsNutrition professionals most commonly self-identified as the most qualified group to help patients lose weight (92%), sentiments supported by other health professionals (57%). The most often cited challenge was lack of patient adherence (87%). Among nutrition professionals, 77% reported receiving high-quality training in weight loss counseling. Nutrition professionals who reported high-quality training were significantly more likely to report confidence (95% vs. 48%) and success (74 vs. 50%) in helping obese patients lose weight (P < 0.05) than those reporting lower-quality training.Conclusions
Across all nonphysician health professionals, nutrition professionals were identified as best suited to provide routine weight management counseling to obese patients. Yet nutrition professionals' receipt of high-quality weight management training appears critical to their success in helping patients lose weight.
[Show abstract][Hide abstract] ABSTRACT: Objective
The aim of this study is to evaluate the effects of breastfeeding on maternal weight loss in the 12 months postpartum among U.S. women.
Using data from a national cohort of U.S. women conducted in 2005–2007 (N = 2102), we employed propensity scores to match women who breastfed exclusively and non-exclusive for at least three months to comparison women who had not breastfed or breastfed for less than three months. Outcomes included postpartum weight loss at 3, 6, 9, and 12 months postpartum; and the probability of returning to pre-pregnancy body mass index (BMI) category and the probability of returning to pre-pregnancy weight.
Compared to women who did not breastfeed or breastfed non-exclusively, exclusive breastfeeding for at least 3 months resulted in 3.2 pounds (95% CI: 1.4,4.7) greater weight loss at 12 months postpartum, a 6.0-percentage-point increase (95% CI: 2.3,9.7) in the probability of returning to the same or lower BMI category postpartum; and a 6.1-percentage-point increase (95% CI: 1.0,11.3) in the probability of returning to pre-pregnancy weight or lower postpartum. Non-exclusive breastfeeding did not significantly affect any outcomes.
Our study provides evidence that exclusive breastfeeding for at least three months has a small effect on postpartum weight loss among U.S. women.
No preview · Article · Oct 2014 · Preventive Medicine
[Show abstract][Hide abstract] ABSTRACT: Background:
Obese women are less likely to initiate and continue breastfeeding. We described barriers to breastfeeding and examined the association between support from a health professional and breastfeeding knowledge and practices, by prepregnancy obesity status.
Using data from the Infant Feeding Practices Study II, a cohort of U.S. women (N = 2,997), we performed descriptive statistics to describe barriers to breastfeeding by prepregnancy obesity status. We conducted multivariable regression to examine the association of breastfeeding support from a physician or nonphysician health professional with knowledge of the recommended duration of breastfeeding, breastfeeding initiation, and breastfeeding duration, and whether breastfeeding support had different associations with outcomes by prepregnancy obesity status. Average marginal effects were calculated from regression models to interpret results as percentage-point changes.
Believing that formula was as good as breast milk was the most commonly cited reason for not initiating breastfeeding, and milk supply concerns were cited as reasons for not continuing breastfeeding. Physician breastfeeding support was associated with a 9.4 percentage-point increase (p < .05) in breastfeeding knowledge among obese women, although no increase was observed among nonobese women. Breastfeeding support from a physician or nonphysician health professional was associated with a significantly increased probability of breastfeeding initiation (8.5 and 12.5 percentage points, respectively) and breastfeeding for 6 months (12.5 and 8.4 percentage points, respectively), without differential associations by prepregnancy obesity.
Support for exclusive breastfeeding is an important predictor of breastfeeding initiation and duration among obese and nonobese women. Health educational interventions tailored to obese women might improve their breastfeeding initiation and continuation.
No preview · Article · Sep 2014 · Women s Health Issues
[Show abstract][Hide abstract] ABSTRACT: Objective
Examine the impact of non-physician health professional body mass index (BMI) on obesity care, self-efficacy, and perceptions of patient trust in weight loss advice.MethodsA national cross-sectional internet-based survey of 500 US non-physician health professionals specializing in nutrition, nursing, behavioral/mental health, exercise, and pharmacy collected between January 20 and February 5, 2014 was analyzed.ResultsNormal BMI professionals were more likely than overweight/obese professionals to report success in helping patients achieve clinically significant weight loss (52% vs. 29%, P = 0.01). No differences by health professional BMI about the appropriate patient body weight for weight-related care (initiate weight loss discussions and success in helping patients lose weight), confidence in ability to help patients lose weight, or in perceived patient trust in their advice were observed. Most health professionals (71%) do not feel successful in helping patients lose weight until they are morbidly obese, regardless of BMI.Conclusions
Normal BMI non-physician health professionals report being more successful than overweight and obese health professionals at helping obese patients lose weight. More research is needed to understand how to improve self-efficiency for delivering obesity care, particularly among overweight and class I obese patients.
[Show abstract][Hide abstract] ABSTRACT: Objective:
To determine the prevalence of doctor shopping resulting from differential treatment and to examine associations between this shopping and current primary care relationships.
In 2012, a national internet-based survey of 600 adults receiving primary care in the past year with a BMI ≥ 25 kg/m(2) was conducted. Our independent variable was "switching doctors because I felt treated differently because of my weight." Logistic regression models to examine the association of prior doctor shopping with characteristics of current primary care relationships: duration, trust in primary care provider (PCP), and perceived PCP weight-related judgment, adjusted for patient factors were used.
Overall, 13% of adults with overweight/obesity reported previously doctor shopping resulting from differential treatment. Prior shoppers were more likely to report shorter durations of their current relationships [73% vs. 52%; p = 0.01] or perceive that their current PCP judged them because of their weight [74% vs. 11%; p < 0.01] than nonshoppers. No significant differences in reporting high trust in current PCPs were found.
A subset of patients with overweight/obesity doctor shop resulting from perceived differential treatment. These prior negative experiences have no association with trust in current relationships, but our results suggest that patients may remain sensitive to provider weight bias.
[Show abstract][Hide abstract] ABSTRACT: Cigarette smoking during pregnancy is an important cause of poor maternal and infant health outcomes in the population eligible for Medicaid. These outcomes may be avoided or attenuated by timely, high-quality prenatal care. Using data from the Centers for Disease Control and Prevention's Pregnancy Risk Assessment Monitoring System for the period 2004-10, we examined the effects of two optional state Medicaid enrollment policies on smoking cessation, preterm birth, and having an infant who was small for gestational age. We used a natural experiment to compare outcomes before and after nineteen states adopted either of the two policies. The first policy, presumptive eligibility, permits women to receive prenatal care while their Medicaid application is pending. Its adoption led to a 7.7-percentage-point increase in smoking cessation but did not reduce adverse birth outcomes. The second policy, the unborn-child option, permits states to provide coverage to pregnant women who cannot document their citizenship or residency. Its adoption was not significantly associated with any of the three outcomes. The presumptive-eligibility enrollment policy will continue to be an important tool for promoting timely prenatal care and smoking cessation.
[Show abstract][Hide abstract] ABSTRACT: Pregnancy and childbirth are associated with hemodynamic changes and vascular remodeling. It is not known whether parity is associated with later adverse vascular properties such as larger arterial diameter, wall thickness, and lower distensibility. We used baseline data from 3283 women free of cardiovascular disease aged 45 to 84 years enrolled in the population-based Multi-Ethnic Study of Atherosclerosis. Participants self-reported parity status. Ultrasound-derived carotid artery lumen diameters and brachial artery blood pressures were measured at peak-systole and end-diastole. Common carotid intima-media thickness was also measured. Regression models to determine the association of carotid distensibility coefficient, lumen diameter, and carotid intima-media thickness with parity were adjusted for age, race, height, weight, diabetes mellitus, current smoking, blood pressure medication use, and total and high-density lipoprotein cholesterol levels. The prevalence of nulliparity was 18%. In adjusted models, carotid distensibility coefficient was 0.09×10(-5) Pa(-1) lower (P=0.009) in parous versus nulliparous women. Among parous women, there was a nonlinear association with the greatest carotid distensibility coefficient seen in women with 2 live births and significantly lower distensibility seen in primiparas (P=0.04) or with higher parity >2 (P=0.005). No such pattern of association with parity was found for lumen diameter or carotid intima-media thickness. Parity is associated with lower carotid artery distensibility, suggesting arterial remodeling that lasts beyond childbirth. These long-term effects on the vasculature may explain the association of parity with cardiovascular events later in life.
[Show abstract][Hide abstract] ABSTRACT: Objective
To examine the association between patient-perceived judgments about weight by primary care providers (PCP) and self-reported weight loss.
We conducted a national internet-based survey of 600 adults engaged in primary care with a BMI ≥ 25 kg/m2 in 2012. Our weight loss outcomes included attempted weight loss and achieved ≥ 10% weight loss in the last 12 months. Our independent variable was “feeling judged about my weight by my PCP.” We created an interaction between perceiving judgment and PCP discussing weight loss as an independent variable. We conducted a multivariate logistic regression model adjusted for patient and PCP factors using survey weights.
Overall, 21% perceived that their PCP judged them about their weight. Respondents who perceived judgment were significantly more likely to attempt weight loss [OR 4.67, 95%CI 1.96-11.14]. They were not more likely to achieve ≥ 10% weight loss [OR 0.87, 95%CI 0.42-1.76]. Among patients whose PCPs discussed weight loss, 20.1% achieved ≥ 10% weight loss if they did not perceive judgment by their PCP as compared to 13.5% who perceived judgment.
Weight loss discussions between patients and PCPs may lead to greater weight loss in relationships where patients do not perceive judgment about their weight.
No preview · Article · May 2014 · Preventive Medicine
[Show abstract][Hide abstract] ABSTRACT: Objective
Overweight early in life may contribute to cardiovascular disease mortality through progression to later life obesity or through a cumulative effect of excess weight. Few studies have investigated the relationship between body mass index (BMI) before middle age and cardiovascular disease mortality in women. Using the Child Health and Development Studies cohort of 11,006 pregnant women recruited between 1959 and 1967, we tested the hypothesis that higher self-reported pre-pregnancy BMI is associated with increased stroke and coronary heart disease mortality.
Design and Methods
Cause of death was assessed annually from enrollment through 2007 by linking with California Vital Status Records. We calculated Cox proportional hazards ratios for cause-specific mortality for each BMI category.
Median follow-up was 37 years with 1,839 participant deaths at a mean age of 64.1 years. At higher levels of BMI, participants were older, had higher prevalence of co-morbid conditions, higher parity, and lower family income. In adjusted models, women with higher pre-pregnancy BMI had increased coronary heart disease mortality compared to those with normal BMI. Women who were underweight, overweight, or obese had higher all-cause mortality. Sensitivity analyses confirmed these results.
Pre-pregnancy BMI has a monotonic association with coronary heart disease mortality and a j-shaped association with non-cardiovascular mortality.
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE
We performed a systematic review to identify which genetic variants predict response to diabetes medications.RESEARCH DESIGN AND METHODS
We performed a search of electronic databases (PubMed, EMBASE, and Cochrane Database) and a manual search to identify original, longitudinal studies of the effect of diabetes medications on incident diabetes, HbA(1c), fasting glucose, and postprandial glucose in prediabetes or type 2 diabetes by genetic variation. Two investigators reviewed titles, abstracts, and articles independently. Two investigators abstracted data sequentially and evaluated study quality independently. Quality evaluations were based on the Strengthening the Reporting of Genetic Association Studies guidelines and Human Genome Epidemiology Network guidance.RESULTSOf 7,279 citations, we included 34 articles (N = 10,407) evaluating metformin (n = 14), sulfonylureas (n = 4), repaglinide (n = 8), pioglitazone (n = 3), rosiglitazone (n = 4), and acarbose (n = 4). Studies were not standalone randomized controlled trials, and most evaluated patients with diabetes. Significant medication-gene interactions for glycemic outcomes included 1) metformin and the SLC22A1, SLC22A2, SLC47A1, PRKAB2, PRKAA2, PRKAA1, and STK11 loci; 2) sulfonylureas and the CYP2C9 and TCF7L2 loci; 3) repaglinide and the KCNJ11, SLC30A8, NEUROD1/BETA2, UCP2, and PAX4 loci; 4) pioglitazone and the PPARG2 and PTPRD loci; 5) rosiglitazone and the KCNQ1 and RBP4 loci; and 5) acarbose and the PPARA, HNF4A, LIPC, and PPARGC1A loci. Data were insufficient for meta-analysis.CONCLUSIONS
We found evidence of pharmacogenetic interactions for metformin, sulfonylureas, repaglinide, thiazolidinediones, and acarbose consistent with their pharmacokinetics and pharmacodynamics. While high-quality controlled studies with prespecified analyses are still lacking, our results bring the promise of personalized medicine in diabetes one step closer to fruition.