Adding evidence-based behavioral weight loss strategies to a statewide wellness campaign: a randomized clinical trial

OBJECTIVES

We determined the efficacy and cost-effectiveness of adding an evidence-based Internet behavioral weight loss intervention alone or combined with optional group sessions to ShapeUp Rhode Island 2011 (SURI), a 3-month statewide wellness campaign.

METHODS

We randomized participants (n = 230; body mass index = 34.3 ±6.8 kg/m(2); 84% female) to the standard SURI program (S) or to 1 of 2 enhanced programs: SURI plus Internet behavioral program (SI) or SI plus optional group sessions (SIG). The primary outcome was weight loss at the end of the 3-month program.

RESULTS

Weight losses differed among all 3 conditions (S: 1.1% ±0.9%; SI: 4.2% ±0.6%; SIG: 6.1% ±0.6%; Ps ≤ .04). Both SI and SIG increased the percentage of individuals who achieved a 5% weight loss (SI: 42%; SIG: 54%; S: 7%; Ps < .001). Cost per kilogram of weight loss was similar for S ($39) and SI ($35); both were lower than SIG ($114).

CONCLUSIONS

Although weight losses were greatest at the end of SURI with optional group sessions, the addition of an Internet behavioral program was the most cost-effective method to enhance weight losses.

Restorative yoga and metabolic risk factors: the Practicing Restorative Yoga vs. Stretching for the Metabolic Syndrome (PRYSMS) randomized trial

AIMS

Intensive lifestyle change prevents type 2 diabetes but is difficult to sustain. Preliminary evidence suggests that yoga may improve metabolic factors. We tested a restorative yoga intervention vs. active stretching for metabolic outcomes.

METHODS

In 2009-2012, we conducted a 48-week randomized trial comparing restorative yoga vs. stretching among underactive adults with the metabolic syndrome at the Universities of California, San Francisco and San Diego. We provided lifestyle counseling and a tapering series of 90-min group classes in the 24-week intervention period and 24-week maintenance period. Fasting and 2-h glucose, HbA1c, triglycerides, HDL-cholesterol, insulin, systolic blood pressure, visceral fat, and quality of life were assessed at baseline, 6- and 12-months.

RESULTS

180 participants were randomized and 135 (75%) completed the trial. At 12 months, fasting glucose decreased more in the yoga group than in the stretching group (-0.35 mmol/L vs. -0.03 mmol/L; p=0.002); there were no other significant differences between groups. At 6 months favorable changes within the yoga group included reductions in fasting glucose, insulin, and HbA1c and an increase in HDL-cholesterol that were not sustained at 1 year except changes in fasting glucose. The stretching group had a significant reduction in triglycerides at 6 months which was not sustained at 1 year but had improved quality of life at both time-points.

CONCLUSIONS

Restorative yoga was marginally better than stretching for improving fasting glucose but not other metabolic factors.

Long-term efficacy and safety of questionnaire-based initiation of urgency urinary incontinence treatment

OBJECTIVE

The objective of the study was to determine the longer-term efficacy and safety of initiating treatment for urgency-predominant urinary incontinence (UUI) in women diagnosed using a simple questionnaire rather than an extensive evaluation.

STUDY DESIGN

Women completing a 12 week randomized controlled trial of fesoterodine therapy for UUI diagnosed by questionnaire were invited to participate in a 9 month, open-label continuation study. UUI and voiding episodes were collected using voiding diaries. Participant satisfaction was measured by questionnaire. Safety was assessed by the measurement of postvoid residual volume and adverse event monitoring; if necessary, women underwent a specialist evaluation. The longitudinal changes in UUI and voiding episodes were evaluated using linear mixed models adjusting for baseline.

RESULTS

Of the 567 women completing the randomized trial, 498 (87.8%) took at least 1 dose of medication during this open-label study. Compared with the baseline visit in the randomized trial, fesoterodine was associated with a reduction in total incontinence episodes per day and urgency incontinence episodes per day at the end of the open-label study (adjusted mean [SE], 4.6 [0.12] to 1.2 [0.13] and 3.9 [0.11] to 0.9 [0.11], respectively, P < .0001 for both). Most women were satisfied with treatment (89%, 92%, and 93% at 3, 6, and 9 months, respectively). Twenty-six women experienced 28 serious adverse events, 1 of which was considered possibly treatment related. Twenty-two women had a specialist evaluation: 5 women's incontinence was misclassified by the 3 Incontinence Questions; none experienced harm because of misclassification.

CONCLUSION

Using a simple validated questionnaire to diagnose and initiate treatment for UUI in community-dwelling women is safe and effective, allowing timely treatment by primary care practitioners.

Preterm delivery and low birth weight in singleton pregnancies conceived by women with and without a history of infertility

OBJECTIVE

To determine predictors of low birth weight (LBW) and preterm delivery (PTD) in singleton pregnancies conceived by women with and without a history of infertility.

DESIGN

Retrospective cohort study.

SETTING

Eleven infertility clinics in northern California.

PATIENT(S)

Three groups of women who carried singleton pregnancies to ≥20 weeks' gestation: 542 infertile women who conceived after treatment, 441 infertile women who conceived spontaneously, and 1,008 fertile women for comparison.

INTERVENTION(S)

Chart review.

MAIN OUTCOME MEASURE(S)

Association of LBW or PTD with infertility treatment, maternal age, parity, obesity, or development of gestational diabetes.

RESULT(S)

Infertile women who conceived with treatment were more likely to be obese, develop gestational diabetes, and have ovarian, ovulatory, or male factor infertility than infertile women who conceived spontaneously. Infertile women who conceived after treatment had 1.61 times greater odds of having an LBW infant. Nulliparity was an independent predictor of LBW and PTD in all three groups after controlling for maternal age, history of infertility, infertility treatment, obesity, and gestational diabetes.

CONCLUSION(S)

Nulliparous women and women with a history of infertility who conceive a singleton after treatment may be at increased odds for having an LBW infant. Infertile women do not appear to be at increased odds for PTD.

Pharmacologic treatment for urgency-predominant urinary incontinence in women diagnosed using a simplified algorithm: a randomized trial

OBJECTIVE

The purpose of this study was to evaluate clinical outcomes associated with the initiation of treatment for urgency-predominant incontinence in women diagnosed by a simple 3-item questionnaire.

STUDY DESIGN

We conducted a multicenter, double-blinded, 12-week randomized trial of pharmacologic therapy for urgency-predominant incontinence in ambulatory women diagnosed by the simple 3-item questionnaire. Participants (N = 645) were assigned randomly to fesoterodine therapy (4-8 mg daily) or placebo. Urinary incontinence was assessed with the use of voiding diaries; postvoid residual volume was measured after treatment.

RESULTS

After 12 weeks, women who had been assigned randomly to fesoterodine therapy reported 0.9 fewer urgency and 1.0 fewer total incontinence episodes/day, compared with placebo (P ≤ .001). Four serious adverse events occurred in each group, none of which was related to treatment. No participant had postvoid residual volume of ≥ 250 mL after treatment.

CONCLUSION

Among ambulatory women with urgency-predominant incontinence diagnosed with a simple 3-item questionnaire, pharmacologic therapy resulted in a moderate decrease in incontinence frequency without increasing significant urinary retention or serious adverse events, which provides support for a streamlined algorithm for diagnosis and treatment of female urgency-predominant incontinence.

Urinary incontinence self-report questions: reproducibility and agreement with bladder diary

INTRODUCTION AND HYPOTHESIS

This study aims to measure self-report urinary incontinence questions' reproducibility and agreement with bladder diary.

METHODS

Data were analyzed from the Reproductive Risk of Incontinence Study at Kaiser. Participating women reporting at least weekly incontinence completed self-report incontinence questions and a 7-day bladder diary. Self-report question reproducibility was assessed and agreement between self-reported and diary-recorded voiding and incontinence frequency was measured. Test characteristics and area under the curve were calculated for self-reported incontinence types using diary as the gold standard.

RESULTS

Five hundred ninety-one women were included and 425 completed a diary. The self-report questions had moderate reproducibility and self-reported and diary-recorded incontinence and voiding frequencies had moderate to good agreement. Self-reported incontinence types identified stress and urgency incontinence more accurately than mixed incontinence.

CONCLUSIONS

Self-report incontinence questions have moderate reproducibility and agreement with diary, and considering their minimal burden, are acceptable research tools in epidemiologic studies.

Parturition events and risk of urinary incontinence in later life

AIMS

To examine the association between specific events during vaginal deliveries and urinary incontinence later in life.

METHODS

A retrospective cohort study of 1,521 middle-aged and older women with at least one vaginal delivery who were long-term members of an integrated health delivery system. Age, race/ethnicity, current incontinence status, medical, surgical history, pregnancy and parturition history, menopausal status, hormone replacement, health habits, and general health were obtained by questionnaire. Labor and delivery records, archived since 1948, were abstracted by professional medical record abstractors to obtain parturition events including induction, length of labor stages, type of anesthesia, episiotomy, instrumental delivery, and birth weight. The primary dependent variable was current weekly urinary incontinence (once per week or more often) versus urinary incontinence less than monthly (including no incontinence) in past 12 months. Associations of parturition events and later incontinence were assessed in multivariate analysis with logistic regression.

RESULTS

The mean age of participants was 56 years. After adjustment for multiple risk factors, weekly urinary incontinence significantly associated with age at first birth (P = 0.036), greatest birth weight (P = 0.005), and ever having been induced for labor (OR = 1.51; 95%CI = 1.06-2.16, P = 0.02). Risk of incontinence increased from OR = 1.35 (95%CI = 0.92-1.97, P = 0.12) for women with one induction to OR = 2.67 (95%CI = 1.25-5.71, P = 0.01) for women with two or more inductions (P = 0.01 for trend). No other parturition factors were associated with incontinence.

CONCLUSIONS

Younger age at first birth, greatest birth weight, and induction of labor were associated with an increased risk of incontinence in later life.

Symptom resolution after hysterectomy and alternative treatments for chronic pelvic pain: does depression make a difference?

OBJECTIVE

The purpose of this study was to determine whether depression influences treatment outcomes and to identify predictors of symptom resolution among women with chronic pelvic pain (CPP).

STUDY DESIGN

Analysis of 701 women with CPP in the Study of Pelvic Problems, Hysterectomy and Intervention Alternatives prospective cohort study, which included 153 women (22%) with depression. We conducted multivariable analyses to evaluate the influence of depression on pre-/posttreatment differences in symptoms and health-related quality of life and to identify other predictors of symptom improvement.

RESULTS

CPP treatments included hysterectomy (9%), other surgical treatments (9%), hormonal medications (50%), narcotic analgesics (47%), physical therapy (12%), and nonprescription medications (93%). Depression predicted lower gains in health perception (P < .05) but not in symptom resolution, sexual functioning, or other aspects of health-related quality of life. Symptom resolution was predicted by hysterectomy (P < .001), entering menopause (P < .001), and pretreatment satisfaction with sex (P = .039).

CONCLUSION

Depression does not influence substantially treatment-related gains in CPP symptom resolution and health-related quality of life. Coexisting depression should not delay treatment for CPP.

Women with diabetes: understanding urinary incontinence and help seeking behavior

PURPOSE

We examined the association of urinary incontinence with diabetes status and race, and evaluated beliefs about help seeking for incontinence in a population based cohort of women with vs without diabetes.

MATERIALS AND METHODS

We performed a cross-sectional analysis of 2,270 middle-aged and older racially/ethnically diverse women in the Diabetes Reproductive Risk factors for Incontinence Study at Kaiser. Incontinence, help seeking behavior and beliefs were assessed by self-report questionnaires and in-person interviews. We compared incontinence characteristics in women with and without diabetes using univariate analysis and multivariate models.

RESULTS

Women with diabetes reported weekly incontinence significantly more than women without diabetes (weekly 35.4% vs 25.7%, p <0.001). Race prevalence patterns were similar in women with and without diabetes with the most vs the least prevalence of incontinence in white and Latina vs black and Asian women. Of women with diabetes 42.2% discussed incontinence with a physician vs 55.5% without diabetes (p <0.003). Women with diabetes were more likely than those without diabetes to report the belief that incontinence is rare (17% vs 6%, p <0.001).

CONCLUSIONS

Incontinence is highly prevalent in women with diabetes. Race prevalence patterns are similar in those with and without diabetes. Understanding help seeking behavior is important to ensure appropriate patient care. Physicians should be alert for urinary incontinence since it is often unrecognized and, thus, under treated in women with diabetes.

Incidence of and risk factors for change in urinary incontinence status in a prospective cohort of middle-aged and older women: the reproductive risk of incontinence study in Kaiser

PURPOSE

Urinary incontinence is a dynamic condition that can progress and regress but few groups have examined risk factors for change in incontinence status.

MATERIAL AND METHODS

We used stratified random sampling to construct a racially and ethnically diverse, population based cohort of 2,109 women 40 to 69 years old. Data were collected by questionnaires and medical record review. A second survey approximately 5 years later was completed by 1,413 women (67%) from the original cohort. The frequency of urinary incontinence was categorized as less than weekly, weekly and daily. Change in incontinence status was defined as new onset incontinence, incontinence progression or regression between frequency categories and resolution of incontinence. Predictor variables were demographics, body mass index and other medical conditions. We used logistic regression to estimate the adjusted OR and 95% CI.

RESULTS

Compared to white nonHispanic women, black women were less likely to have incontinence progression (OR 0.46, 95% CI 0.24-0.88). New onset incontinence was more common in women with a higher body mass index at baseline (p = 0.006) and those who experienced increased body mass index (p = 0.03) or decreased general health (p = 0.007) during the study. Participants with chronic obstructive pulmonary disorder at baseline were more likely to report incontinence progression (OR 2.64, 95% CI 1.22-5.70). Baseline incontinence type was not significantly associated with the risk of change in continence status independent of frequency.

CONCLUSIONS

Identifying risk factors for change in incontinence status may be important to develop interventions to decrease the burden of incontinence in the general population.

A motivation-focused weight loss maintenance program is an effective alternative to a skill-based approach

Objective

Maintaining weight loss is a major challenge in obesity treatment. Individuals often indicate that waning motivation prompts cessation of effective weight management behaviors. Therefore, a novel weight loss maintenance program that specifically targets motivational factors was evaluated.

Design

Overweight women (N=338; 19% African American) with urinary incontinence were randomized to lifestyle obesity treatment or control and followed for 18 months. All participants in lifestyle (N=226) received the same initial six-month group behavioral obesity treatment and were then randomized to 1) a novel motivation-focused maintenance program (N=113) or 2) a standard skill-based maintenance approach (N=113).

Main Outcome Measure

Weight assessed at baseline, 6, and 18 months.

Results

Both treatment groups (motivation-focused and skill-based) achieved comparable 18-month weight losses (−5.48% for motivation-focused vs −5.55% in skill-based, p=0.98), and both groups lost significantly more than controls (−1.51%; p=.0012 in motivation-focused and .0021 in skill-based).

Conclusions

A motivation-focused maintenance program offers an alternative, effective approach to weight maintenance expanding available evidence-based interventions beyond traditional skill-based programs.

Increased risk of high-grade prostate cancer among infertile men

BACKGROUND

It has been reported that fatherhood status may be a risk factor for prostate cancer. In the current study, the authors examined the subsequent occurrence of prostate cancer in a cohort of men evaluated for infertility to determine whether male infertility is a risk factor for prostate cancer.

METHODS

A total of 22,562 men who were evaluated for infertility from 1967 to 1998 were identified from 15 California infertility centers and linked to the California Cancer Registry. The incidence of prostate cancer was compared with the incidence in an age-matched and geography-matched sample of men from the general population. The risk of prostate cancer in men with and those without male factor infertility was modeled using a Cox proportional hazards regression model.

RESULTS

A total of 168 cases of prostate cancer that developed after infertility were identified. Men evaluated for infertility but not necessarily with male factors were not found to have an increased risk of cancer compared with the general population (standardized incidence ratio [SIR], 0.9; 95% confidence interval [95% CI], 0.8-1.1). This risk was found to be highest for men with male factor infertility who developed high-grade prostate cancer (SIR, 2.0; 95% CI, 1.2-3.0). On multivariate analyses, men with male factor infertility were found to be 2.6 times more likely to be diagnosed with high-grade prostate cancer (hazard ratio, 2.6; 95% CI, 1.4-4.8).

CONCLUSIONS

Men with male factor infertility were found to have an increased risk of subsequently developing high-grade prostate cancer. Male infertility may be an early and identifiable risk factor for the development of clinically significant prostate cancer.

Increased risk of testicular germ cell cancer among infertile men

BACKGROUND

The risk of testicular cancer is thought to be higher among men seeking infertility treatment compared with the general population. Confirmation of this risk in a large US cohort of at-risk patients is lacking. This study explored the association between male infertility and subsequent development of testicular cancer in a US-based cohort.

METHODS

A total of 51 461 couples evaluated for infertility from 1967 to 1998 were recruited from 15 California infertility centers. We linked data on 22 562 identified male partners to the California Cancer Registry. The incidence of testicular cancer in this cohort was compared with the incidence in an age-matched sample of men from the general population using the Surveillance Epidemiology and End Results program. We analyzed the risk for testicular cancer in men with and without male factor infertility using a Cox proportional hazards regression model.

RESULTS

Thirty-four post-infertility-diagnosis cases of histologically confirmed testicular cancer were identified. Men seeking infertility treatment had an increased risk of subsequently developing testicular cancer (standardized incidence ratio, 1.3; 95% confidence interval, 0.9-1.9), with a markedly higher risk among those with known male factor infertility (2.8; 1.5-4.8). In multivariable analysis, men with male factor infertility were nearly 3 times more likely to develop testicular cancer compared with those without (hazard ratio, 2.8; 95% confidence interval, 1.3-6.0).

CONCLUSION

Men with male factor infertility have an increased risk of subsequently developing testicular cancer, suggesting the existence of common etiologic factors for infertility and testicular cancer.

Effect of Noncancerous Pelvic Problems on Health-Related Quality of Life and Sexual Functioning

OBJECTIVE

To assess the effect of abnormal uterine bleeding and pelvic pain and pressure on health-related quality of life and sexual functioning and assess treatment satisfaction.

METHODS

This is a cross-sectional study of 1,493 sociodemographically diverse women who were seeking care for noncancerous pelvic problems and who had not undergone hysterectomy. Participants were asked about symptoms, attitudes, health-related quality of life, sexual functioning, and treatment satisfaction. Preference for current health was measured using the time tradeoff metric, which asked respondents to estimate the number of years of life they would be willing to trade off to not have a uterine condition. Multivariable logistic regression was used to identify determinants of treatment satisfaction.

RESULTS

Most (82.7%) participants reported a complete lack of or only partial symptom resolution, and 42.3% reported that their pelvic problems interfered with their ability to have and enjoy sex. Mean Short Form-12 Physical (43-49) and Mental (41-44) Component Summary scores were substantially lower than population norms for women aged 40-49 years. Mean current health time tradeoff scores ranged from 0.78 to 0.88. Satisfaction with Western medicines ranged from 31.3% (progestin intrauterine device) to 58.2% (opiates) and with uterine-preserving surgery from 20.0% (dilation and curettage) to 51.0% (myomectomy); 27.7 % of the women who used acupuncture were satisfied. Participants with lower educational attainment, greater symptom resolution, and less interference of pelvic problems with sex were more likely to be satisfied.

CONCLUSION

Noncancerous pelvic problems are associated with serious decrements in health-related quality of life and sexual functioning and low rates of treatment satisfaction.

LEVEL OF EVIDENCE

II.

Bed rest after embryo transfer: a randomized controlled trial

OBJECTIVE

To determine whether bed rest after embryo transfer leads to improved pregnancy rates (PR).

DESIGN

Randomized controlled trial.

SETTING

University reproductive health clinic.

PATIENT(S)

Women undergoing IVF.

INTERVENTION(S)

Patients undergoing 164 cycles of IVF were randomized to 30 minutes of bed rest after embryo transfer or immediate discharge from the clinic.

MAIN OUTCOME MEASURE(S)

Clinical PR defined by visualized fetal heart beat and ongoing PR defined by viable intrauterine gestation beyond 11 weeks.

RESULT(S)

The clinical and ongoing PR for both groups were 50% and 46.3%, respectively, with no statistically significant difference between the two groups.

CONCLUSION(S)

Thirty minutes of bed rest after embryo transfer does not improve PR.

Potential association between infertility and spinal neural tube defects in offspring

BACKGROUND

We examined the possible association between infertility and spinal neural tube defects (NTDs).

METHODS

This is a nested case-control study within the Kaiser Permanente Medical Care Program (KPMCP) in Northern California. Among a birth cohort of 110,624 singleton infants > or = 36 weeks gestation, 1994-1997, we electronically identified cases of spinal NTDs and confirmed the diagnosis by chart review. Controls (n = 1,608) were randomly selected from the birth population. History of infertility was defined as: (1) physician diagnosis of infertility; (2) prescription for an infertility medication noted in the KPMCP pharmacy; and/or (3) evaluation at 1 of 15 infertility clinics in Northern California.

RESULTS

Eighteen infants diagnosed with spinal NTDs (prevalence 1.6/10,000) included 13 with spina bifida cystica and 5 with spina bifida occulta. Case mothers were more likely to have a history of infertility (4/18 vs. 96/1,608, OR 4.3, 95% CI 1.01-14.0), and to have been prescribed clomiphene citrate within the window spanning 60 days before to 15 days after conception (3/18 vs. 32/1,608, OR 11.7, 95% CI 2.0-44.8).

CONCLUSION

This exploratory study suggests that infertility may be associated with an increased risk of spinal NTDs among liveborn, term infants.