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Xu J, Ma C, Hirschey R, Liu J, Neidre DB, Nielsen ME, Keyserling TC, Tan X, Song L. Associations of role, area deprivation index, and race with health behaviors and body mass index among localized prostate cancer patients and their partners. J Cancer Surviv 2024:10.1007/s11764-024-01625-z. [PMID: 38888710 DOI: 10.1007/s11764-024-01625-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 05/29/2024] [Indexed: 06/20/2024]
Abstract
PURPOSE To examine the associations of role (localized prostate cancer (PCa) patient vs. their intimate partner), area deprivation index (ADI-higher scores indicating higher neighborhood deprivation levels), and race (Black/African American (AA) vs. White) with health behaviors and body mass index (BMI) among PCa patients and partners. The behaviors include smoking, alcohol consumption, diet quality, sedentary behaviors, and physical activity (PA). METHODS This study used the baseline data collected in a clinical trial. Given the nested structure of the dyadic data, multi-level models were used. RESULTS Significant role-race interaction effects on smoking, ADI-race effects on alcohol consumption, and role-ADI effects on BMI were found. Meanwhile, patients smoked more cigarettes, decreased alcohol consumption, had less healthful diets, spent longer time watching TV, did fewer sedentary hobbies, had more confidence in PA, and had higher BMIs than their partners. High ADI was independently associated with lower odds of drinking alcohol, using computer/Internet, and doing non-walking PA, and higher BMI compared to low ADI controlling for role and race. Black/AA dyads had less smoking amount and alcohol consumption and higher sedentary time and BMI than White dyads when adjusted for role and ADI. CONCLUSIONS This study identified significant interaction and main effects of role, ADI, or race on health behaviors and BMI. IMPLICATIONS FOR CANCER SURVIVORS Future behavioral interventions should address divergent individual needs between patients and partners, social and neighborhood barriers, and cultural indicators of racial groups to promote healthful behaviors and improve the quality of survivorship for PCa patients and partners.
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Affiliation(s)
- Jingle Xu
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Chunxuan Ma
- School of Nursing, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Rachel Hirschey
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jia Liu
- School of Nursing, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Daria B Neidre
- School of Nursing, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Matthew E Nielsen
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Thomas C Keyserling
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Xianming Tan
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lixin Song
- School of Nursing, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
- Mays Cancer Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
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Alick CL, Braxton D, Skinner H, Alexander R, Ammerman AS, Keyserling TC, Samuel-Hodge CD. Rural African American Women With Severe Obesity: A Cross-Sectional Analysis of Lifestyle Behaviors and Psychosocial Characteristics. Am J Health Promot 2023; 37:1060-1069. [PMID: 37505193 PMCID: PMC10631280 DOI: 10.1177/08901171231190597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
PURPOSE To examine differences in lifestyle behavioral and psychosocial factors between rural African American women with Class 3 obesity and those with overweight, and Class 1-2 obesity. DESIGN Cross-sectional study. SETTING Rural Southeastern United States. SUBJECTS Participants included 289 African American women with a mean age of 56 years, 66% with a high school education or less, and a mean body mass index (BMI) of 38.6 kg/m2; 35% (n = 102) were classified with Class 3 obesity. MEASURES We objectively measured height, weight, and physical activity steps/day. Self-reported dietary and physical activity behaviors, general health-related quality of life, mental health, and social support were measured with validated surveys. ANALYSIS Chi-Square analysis for categorical variables and analysis of variance (ANOVA) - via multiple linear regression - for continuous variables. RESULTS There were no significant demographic differences between BMI groups, except for age, where women with Class 3 obesity were on average younger (51 vs 58 y, P < .001). Although dietary behaviors did not differ significantly between groups, we observed significant group differences in self-reported and objective measures of physical activity. The age-adjusted difference in means for self-reported total physical activity minutes/wk. was 91 minutes, with women categorized with Class 3 obesity reporting significantly fewer weekly minutes than those with overweight/Class 1-2 obesity (64.3 vs 156.4 min/wk. respectively, P < .01). Among psychosocial variables, only in the physical component scores of health-related quality of life did we find significant group differences - lower physical well-being among women with Class 3 obesity compared to those with overweight/Class 1-2 obesity (P = .02). CONCLUSION For African American women with Class 3 obesity living in rural setting, these findings suggest behavioral weight loss interventions may need to target physical activity strategies that address physical, psychosocial, and environmental barriers.
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Affiliation(s)
- Candice L. Alick
- Center for Health Promotion & Disease Prevention, University of North Carolina, Chapel Hill, NC, USA
| | - Danielle Braxton
- Department of Health Promotion, North Carolina Wesleyan College, Rocky Mount, NC, USA
| | - Harlyn Skinner
- Department of Biological Science, Center for Human Health and the Environment, North Carolina State University, Chapel Hill, NC, USA
| | - Ramine Alexander
- Department of Family and Consumer Sciences, Food and Nutritional Sciences, North Carolina Agricultural & Technical State University, Greensboro, NC, USA
| | - Alice S. Ammerman
- Department of Nutrition, Gillings School of Global Public Health, Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC, USA
| | - Thomas C. Keyserling
- Internal Medicine, UNC School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Carmen D. Samuel-Hodge
- Department of Nutrition, Gillings School of Global Public Health, Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC, USA
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Samuel-Hodge CD, Ziya Gizlice, Allgood SD, Bunton AJ, Erskine A, Leeman J, Cykert S. A Hybrid Implementation-Effectiveness Study of a Community Health Worker-Delivered Intervention to Reduce Cardiovascular Disease Risk in a Rural, Underserved Non-Hispanic Black Population: The CHANGE Study. Am J Health Promot 2022; 36:948-958. [PMID: 35422132 PMCID: PMC9198395 DOI: 10.1177/08901171221078272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate the implementation and effectiveness of the Carolina Heart Alliance Networking for Greater Equity (CHANGE) Program, an adapted evidence-based cardiovascular disease risk reduction intervention delivered by Community Health Workers (CHW) to rural adults. DESIGN Hybrid implementation-effectiveness study with a pre-post design. SETTING North Carolina Federally Qualified Health Center and local health department in a rural, medically underserved area. SAMPLE Participants (n = 255) included 87% Non-Hispanic Black with a mean age of 57 years; 84% had diagnosed hypertension, 55% had diabetes, and 65% had hypercholesterolemia. INTERVENTION A CHW-delivered, low-intensity, 4-month behavioral lifestyle intervention promoting a southern-style Mediterranean dietary pattern and physical activity. MEASURES We measured number and representativeness of participants reached and retained, intervention delivery fidelity, weight, blood pressure, and self-reported dietary and physical activity behaviors. ANALYSIS Pre-post changes at 4 months were analyzed using paired t-tests. RESULTS Study participants completed 90% of planned intervention contacts; 87% were retained. Intervention delivery fidelity measures showed participants receiving a mean of 3.5 counseling visits, 2.7 booster calls, and on average completing 1.7 modules, setting 1.8 goals, and receiving 1.3 referrals per visit. There were significant mean reductions in systolic (-2.5 mmHg, P < .05) and diastolic blood pressure (-2.1 mmHg, P < .01); the proportion of participants with systolic blood pressure <130 increased by 7 % points (P = .05), and diastolic pressure <80 by 9 percentage points (P < .01). Dietary behaviors improved significantly with average weekly servings of nuts increased by .5 serving (P < .0001), and fruits and vegetables by .8 daily serving (P < .0001). Physical activity also increased on average by 45 min./week (P < .001). Weight did not change significantly. CONCLUSIONS The CHANGE program showed both implementation and program effectiveness and adds to the evidence supporting CHW-delivered lifestyle interventions to reduce CVD risk among rural, Non-Hispanic Black, and medically underserved populations.
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Affiliation(s)
- Carmen D. Samuel-Hodge
- Gillings School of Global Public Health, Department of Nutrition, Center for Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for Health Promotion and Disease Prevention, Chapel Hill, NC, USA
| | - Ziya Gizlice
- Center for Health Promotion and Disease Prevention, Chapel Hill, NC, USA
| | | | - Audrina J. Bunton
- Cecil G Sheps Center for Health Services Research, Chapel Hill, NC, USA
| | - Amber Erskine
- Center for Health Promotion and Disease Prevention, Chapel Hill, NC, USA
| | - Jennifer Leeman
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Samuel Cykert
- School of Medicine, Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Song L, Guo P, Tan X, Chen RC, Nielsen ME, Birken SA, Koontz BF, Northouse LL, Mayer DK. Enhancing survivorship care planning for patients with localized prostate cancer using a couple-focused web-based, mHealth program: the results of a pilot feasibility study. J Cancer Surviv 2021; 15:99-108. [PMID: 32681304 PMCID: PMC7855003 DOI: 10.1007/s11764-020-00914-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 07/07/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To examine the feasibility of an enhanced survivorship care plan (ESCP) that integrated the web-based program Patient Education Resources for Couples (PERC) into a standardized survivorship care plan (SCP) and estimated the outcomes of ESCPs versus SCPs. METHODS In this randomized pilot trial, localized prostate cancer (PC) patients and partners (i.e., couple) were randomly assigned to ESCP that contained a link to PERC or to SCP that contained a link to general PC information on the National Cancer Institute website. Couples completed assessments measuring quality of life (QOL), appraisal of symptoms, and coping resources at baseline (T1) and 4-6 months later (T2). We examined feasibility (e.g., recruitment and retention) using descriptive statistics. Linear mixed models examined changes in couples' outcomes over time and Poisson regression examined differences in patient healthcare utilization. RESULTS Sixty-two couples completed T1 surveys (recruitment rate 41.6%) and were randomly assigned to receive ESCP (n = 31) or SCP (n = 31). Twenty-eight (ESCP) and 25 (SCP) couples completed T2 surveys (retention rates = 90.3% vs. 80.7%). ESCP participants (70%) reviewed webpages consistent with patients' symptoms. ESCP patients reported greater program satisfaction (p = 0.02) and better urinary symptom scores (p < 0.01) than SCP patients. CONCLUSIONS Delivering ESCPs that embed a web-link to a couple-focused, tailored program is feasible and can potentially improve patient outcomes. The promising results need to be validated in a larger definitive trial using a diverse sample. IMPLICATIONS FOR CANCER SURVIVORS SCPs, enhanced using a web-based intervention (e.g., PERC), may help PC cancer survivors better manage their urinary symptoms. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT04350788.
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Affiliation(s)
- Lixin Song
- School of Nursing, University of North Carolina (UNC), Carrington Hall, Chapel Hill, NC, 27599-7460, USA.
- Lineberger Comprehensive Cancer Center, UNC, Chapel Hill, NC, USA.
| | - Peiran Guo
- School of Nursing, University of North Carolina (UNC), Carrington Hall, Chapel Hill, NC, 27599-7460, USA
| | - Xianming Tan
- Lineberger Comprehensive Cancer Center, UNC, Chapel Hill, NC, USA
| | - Ronald C Chen
- University of Kansas Medical Center, Kansas City, USA
| | - Matthew E Nielsen
- Lineberger Comprehensive Cancer Center, UNC, Chapel Hill, NC, USA
- School of Medicine, UNC, Chapel Hill, NC, USA
| | - Sarah A Birken
- Gillings School of Global Public Health, UNC, Chapel Hill, NC, USA
| | | | | | - Deborah K Mayer
- School of Nursing, University of North Carolina (UNC), Carrington Hall, Chapel Hill, NC, 27599-7460, USA
- Lineberger Comprehensive Cancer Center, UNC, Chapel Hill, NC, USA
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Samuel-Hodge CD, Gizlice Z, Allgood SD, Bunton AJ, Erskine A, Leeman J, Cykert S. Strengthening community-clinical linkages to reduce cardiovascular disease risk in rural NC: feasibility phase of the CHANGE study. BMC Public Health 2020; 20:264. [PMID: 32085707 PMCID: PMC7035725 DOI: 10.1186/s12889-020-8223-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 01/15/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Community Health Workers (CHW) are recommended for delivery of interventions to prevent cardiovascular disease, but there is insufficient evidence to guide implementation of CHW interventions in rural, medically underserved areas. METHODS Using a hybrid implementation-effectiveness design, we evaluated the implementation and effectiveness of an adapted, evidence-based cardiovascular disease risk reduction intervention among rural high-risk adults. CHWs at a community health center and local health department recruited, enrolled and counseled participants during 4 monthly home visits and 3 brief phone contacts. Participant data collection included pre- and post-intervention measurements of blood pressure, weight, and dietary and physical activity behaviors. We evaluated implementation with measures of intervention reach and delivery fidelity. Statistical analyses included descriptive statistics and paired t-tests. RESULTS Study participants (n = 105) had a mean age of 62 years and included 88% Non-Hispanic Blacks and 82% females. Recruitment strategies resulted in the enrollment of 38% of interested and eligible participants who received 80% of the planned intervention visits and phone contacts. Mean differences in pre-/post-intervention measures showed significant mean reductions in blood pressure (- 5.4 mmHg systolic, p = .006; - 2.3 mmHg diastolic, p = .04) and body weight (- 3.8 lb., p = .02). Self-reported dietary and physical activity behaviors also improved significantly. CONCLUSION This feasibility study demonstrated preliminary implementation and program effectiveness of a CHW-delivered intervention to reduce cardiovascular disease risk factors. Additionally, it identified areas for future refinements to strategies that strengthen community-clinical linkages with an integrated role of CHWs in rural health care delivery. If results from this feasibility study can be enhanced in a larger sample, there would be significant potential to positively impact the excess burden of chronic diseases that adversely impact rural, low-income, and medically underserved populations. TRIAL REGISTRATION ClinicalTrials.gov: NCT03582696.
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Affiliation(s)
- Carmen D. Samuel-Hodge
- Gillings School of Global Public Health, Department of Nutrition, Center for Promotion and Disease Prevention, University of North Carolina at Chapel Hill, 1700 Martin Luther King Jr. Blvd., Room 216, CB #7426, Chapel Hill, NC 27599-7426 USA
| | - Ziya Gizlice
- Center for Health Promotion & Disease Prevention, 1700 Martin Luther King Jr. Blvd. CB# 7426, Chapel Hill, NC 27599-7426 USA
| | - Sallie D. Allgood
- School of Nursing, University of North Carolina at Chapel Hill, Carrington Hall, CB # 7460, Chapel Hill, NC 27599-7460 USA
| | - Audrina J. Bunton
- Cecil G Sheps Center for Health Services Research, 725 Martin Luther King Jr. Blvd. CB# 7590, Chapel Hill, NC 27599-7590 USA
| | - Amber Erskine
- Center for Health Promotion & Disease Prevention, 1700 Martin Luther King Jr. Blvd. CB# 7426, Chapel Hill, NC 27599-7426 USA
| | - Jennifer Leeman
- School of Nursing, University of North Carolina at Chapel Hill, Carrington Hall, CB # 7460, Chapel Hill, NC 27599-7460 USA
| | - Samuel Cykert
- School of Medicine, Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, 145 N Medical Drive, CB# 7165, Chapel Hill, NC 27599-7165 USA
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Jones SA, Li Q, Aiello AE, O'Rand AM, Evenson KR. Correlates of changes in walking during the retirement transition: The Multi-Ethnic Study of Atherosclerosis. Prev Med Rep 2018; 11:221-230. [PMID: 30210994 PMCID: PMC6129965 DOI: 10.1016/j.pmedr.2018.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 06/27/2018] [Accepted: 07/03/2018] [Indexed: 01/10/2023] Open
Abstract
Retirement from employment involves disruption in daily routines and has been associated with positive and negative changes in physical activity. Walking is the most common physical activity among older Americans. The factors that influence changes in walking after retirement are unknown. The study objective was to identify correlates of within-person change in recreational walking (for leisure) and transport walking (to get places) during the retirement transition among a multi-ethnic cohort of adults (N = 928) from six US communities. Correlates were measured at the individual (e.g., gender), interpersonal (e.g., social support), and community (e.g., density of walking destinations) levels at study exams between 2000 and 2012. Comparing pre- and post-retirement measures (average 4.5 years apart), 50% of participants increased recreational walking by 60 min or more per week, 31% decreased by 60 min or more per week, and 19% maintained their recreational walking. Forty-one percent of participants increased transport walking by 60 min or more per week, 40% decreased by 60 min or more per week, and 19% maintained their transport walking after retirement. Correlates differed for recreational and transport walking and for increases compared to decreases in walking. Self-rated health, chronic conditions, and perceptions of the neighborhood walking environment were associated with changes in both types of walking after retirement. Further, some correlates differed by gender and retirement age. Findings can inform the targeting of interventions to promote walking during the retirement transition.
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Affiliation(s)
- Sydney A. Jones
- Department of Epidemiology, University of North Carolina at Chapel Hill, 123 W. Franklin St., Suite 410, Building C, Chapel Hill, NC 27599, USA
| | - Quefeng Li
- Department of Biostatistics, University of North Carolina at Chapel Hill, 3101 McGavran-Greenberg Hall, CB#7420, Chapel Hill, NC 27599-7420, USA
| | - Allison E. Aiello
- Department of Epidemiology, University of North Carolina at Chapel Hill, 123 W. Franklin St., Suite 410, Building C, Chapel Hill, NC 27599, USA
| | - Angela M. O'Rand
- Department of Sociology, Duke University, 417 Chapel Dr. Box 90088, Durham, NC 27708-0088, USA
| | - Kelly R. Evenson
- Department of Epidemiology, University of North Carolina at Chapel Hill, 123 W. Franklin St., Suite 410, Building C, Chapel Hill, NC 27599, USA
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Jilcott Pitts SB, Keyserling TC, Johnston LF, Evenson KR, McGuirt JT, Gizlice Z, Whitt OR, Ammerman AS. Examining the Association between Intervention-Related Changes in Diet, Physical Activity, and Weight as Moderated by the Food and Physical Activity Environments among Rural, Southern Adults. J Acad Nutr Diet 2017; 117:1618-1627. [PMID: 28606554 PMCID: PMC5623155 DOI: 10.1016/j.jand.2017.04.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 04/10/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Few studies have been conducted in rural areas assessing the influence of community-level environmental factors on residents' success improving lifestyle behaviors. OBJECTIVE Our aim was to examine whether 6-month changes in diet, physical activity, and weight were moderated by the food and physical activity environment in a rural adult population receiving an intervention designed to improve diet and physical activity. DESIGN We examined associations between self-reported and objectively measured changes in diet, physical activity, and weight, and perceived and objectively measured food and physical activity environments. Participants were followed for 6 months. PARTICIPANTS/SETTING Participants were enrolled in the Heart Healthy Lenoir Project, a lifestyle intervention study conducted in Lenoir County, located in rural southeastern North Carolina. Sample sizes ranged from 132 to 249, depending on the availability of the data. INTERVENTION Participants received four counseling sessions that focused on healthy eating (adapted Mediterranean diet pattern) and increasing physical activity. POTENTIAL MODERATING FACTORS Density of and distance to food and physical activity venues, modified food environment index, Walk Score, crime, and perceived nutrition and physical activity neighborhood barriers were the potential mediating factors. OUTCOME MEASURES Diet quality, physical activity, and weight loss were the outcomes measured. STATISTICAL ANALYSES Statistical analyses included correlation and linear regression and controlling for potential confounders (baseline values of the dependent variables, age, race, education, and sex). RESULTS In adjusted analysis, there was an inverse association between weight change and the food environment, suggesting that participants who lived in a less-healthy food environment lost more weight during the 6-month intervention period (P=0.01). Also, there was a positive association between self-reported physical activity and distance to private gyms (P=0.04) and an inverse association between private gym density and pedometer-measured steps (P=0.03), indicating that those who lived farther from gyms and in areas with lower density of gyms had greater increases in physical activity and steps, respectively. CONCLUSIONS Contrary to our hypotheses, results indicated that those living in less-favorable food and physical activity environments had greater improvements in diet, physical activity, and weight, compared to those living in more favorable environments. Additional research should be undertaken to address these paradoxical findings and, if confirmed, to better understand them.
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Embree GGR, Samuel-Hodge CD, Johnston LF, Garcia BA, Gizlice Z, Evenson KR, DeWalt DA, Ammerman AS, Keyserling TC. Successful long-term weight loss among participants with diabetes receiving an intervention promoting an adapted Mediterranean-style dietary pattern: the Heart Healthy Lenoir Project. BMJ Open Diabetes Res Care 2017; 5:e000339. [PMID: 28405344 PMCID: PMC5372065 DOI: 10.1136/bmjdrc-2016-000339] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 02/02/2017] [Accepted: 02/20/2017] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE To examine weight change by diabetes status among participants receiving a Mediterranean-style diet, physical activity, and weight loss intervention adapted for delivery in the southeastern USA, where rates of cardiovascular disease (CVD) are disproportionately high. RESEARCH DESIGN AND METHODS The intervention included: Phase I (months 1-6), an individually tailored intervention promoting a Mediterranean-style dietary pattern and increased walking; Phase II (months 7-12), option of a 16-week weight loss intervention for those with BMI≥25 kg/m2 offered as 16 weekly group sessions or 5 group sessions and 10 phone calls, or a lifestyle maintenance intervention; and Phase III (months 13-24), weight loss maintenance intervention for those losing ≥8 pounds with all others receiving a lifestyle maintenance intervention. Weight change was assessed at 6, 12, and 24-month follow-up. RESULTS Baseline characteristics (n=339): mean age 56, 77% female, 65% African-American, 124 (37%) with diabetes; mean weight 103 kg for those with diabetes and 95 kg for those without. Among participants with diabetes, average weight change was -1.2 kg (95% CI -2.1 to -0.4) at 6 months (n=92), -1.5 kg (95% CI -2.9 to -0.2) at 12 months (n=96), and -3.7 kg (95% CI -5.2 to -2.1) at 24 months (n=93). Among those without diabetes, weight change was -0.4 kg (95% CI -1.4 to 0.6) at 24 months (n=154). CONCLUSIONS Participants with diabetes experienced sustained weight loss at 24-month follow-up. High-risk US populations with diabetes may experience clinically important weight loss from this type of lifestyle intervention. TRIAL REGISTRATION NUMBER NCT01433484.
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Affiliation(s)
- Genevieve G R Embree
- Ambulatory Care Physician, Durham VA Medical Center, Durham, North Carolina, USA
| | - Carmen D Samuel-Hodge
- Department of Nutrition, Center for Health Promotion and Disease Prevention, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Larry F Johnston
- Center for Health Promotion and Disease Prevention, University of North Carolina , Chapel Hill, North Carolina , USA
| | - Beverly A Garcia
- Center for Health Promotion and Disease Prevention, University of North Carolina , Chapel Hill, North Carolina , USA
| | - Ziya Gizlice
- Center for Health Promotion and Disease Prevention, University of North Carolina , Chapel Hill, North Carolina , USA
| | - Kelly R Evenson
- Department of Epidemiology , Gillings School of Global Public Health, University of North Carolina , Chapel Hill, North Carolina , USA
| | - Darren A DeWalt
- Division of General Medicine and Clinical Epidemiology , School of Medicine, University of North Carolina , Chapel Hill, North Carolina , USA
| | - Alice S Ammerman
- Department of Nutrition, Center for Health Promotion and Disease Prevention, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Thomas C Keyserling
- Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, North Carolina, USA; Division of General Medicine and Clinical Epidemiology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
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Keyserling TC, Samuel-Hodge CD, Pitts SJ, Garcia BA, Johnston LF, Gizlice Z, Miller CL, Braxton DF, Evenson KR, Smith JC, Davis GB, Quenum EL, Elliott NTM, Gross MD, Donahue KE, Halladay JR, Ammerman AS. A community-based lifestyle and weight loss intervention promoting a Mediterranean-style diet pattern evaluated in the stroke belt of North Carolina: the Heart Healthy Lenoir Project. BMC Public Health 2016; 16:732. [PMID: 27495295 PMCID: PMC4975883 DOI: 10.1186/s12889-016-3370-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 07/23/2016] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Because residents of the southeastern United States experience disproportionally high rates of cardiovascular disease (CVD), it is important to develop effective lifestyle interventions for this population. METHODS The primary objective was to develop and evaluate a dietary, physical activity (PA) and weight loss intervention for residents of the southeastern US. The intervention, given in eastern North Carolina, was evaluated in a 2 year prospective cohort study with an embedded randomized controlled trial (RCT) of a weight loss maintenance intervention. The intervention included: Phase I (months 1-6), individually-tailored intervention promoting a Mediterranean-style dietary pattern and increased walking; Phase II (months 7-12), option of a 16-week weight loss intervention for those with BMI ≥ 25 kg/m(2) offered in 2 formats (16 weekly group sessions or 5 group sessions and 10 phone calls) or a lifestyle maintenance intervention; and Phase III (months 13-24), weight loss maintenance RCT for those losing ≥ 8 lb with all other participants receiving a lifestyle maintenance intervention. Change in diet and PA behaviors, CVD risk factors, and weight were assessed at 6, 12, and 24 month follow-up. RESULTS Baseline characteristics (N = 339) were: 260 (77 %) females, 219 (65 %) African Americans, mean age 56 years, and mean body mass index 36 kg/m(2). In Phase I, among 251 (74 %) that returned for 6 month follow-up, there were substantial improvements in diet score (4.3 units [95 % CI 3.7 to 5.0]), walking (64 min/week [19 to 109]), and systolic blood pressure (-6.4 mmHg [-8.7 to -4.1]) that were generally maintained through 24 month follow-up. In Phase II, 138 (57 group only, 81 group/phone) chose the weight loss intervention and at 12 months, weight change was: -3.1 kg (-4.9 to -1.3) for group (N = 50) and -2.1 kg (-3.2 to -1.0) for group/phone combination (N = 75). In Phase III, 27 participants took part in the RCT. At 24 months, weight loss was -2.1 kg (-4.3 to 0.0) for group (N = 51) and -1.1 kg (-2.7 to 0.4) for combination (N = 72). Outcomes for African American and whites were similar. CONCLUSIONS The intervention yielded substantial improvement in diet, PA, and blood pressure, but weight loss was modest. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01433484.
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Affiliation(s)
- Thomas C. Keyserling
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, School of Medicine, CB 7110, University of North Carolina, 5039 Old Clinic Building, Chapel Hill, NC 27599 USA
- Center for Health Promotion and Disease Prevention (a CDC Prevention Research Center), CB 7426, University of North Carolina, Chapel Hill, NC 27599 USA
| | - Carmen D. Samuel-Hodge
- Center for Health Promotion and Disease Prevention (a CDC Prevention Research Center), CB 7426, University of North Carolina, Chapel Hill, NC 27599 USA
- Department of Nutrition, Gillings School of Global Public Health, CB 7461, University of North Carolina, Chapel Hill, NC 27599 USA
| | - Stephanie Jilcott Pitts
- Department of Public Health, Brody School of Medicine, East Carolina University, Lakeside Annex 8, 600 Moye Blvd, MS 660, Greenville, NC 27834 USA
| | - Beverly A. Garcia
- Center for Health Promotion and Disease Prevention (a CDC Prevention Research Center), CB 7426, University of North Carolina, Chapel Hill, NC 27599 USA
| | - Larry F. Johnston
- Center for Health Promotion and Disease Prevention (a CDC Prevention Research Center), CB 7426, University of North Carolina, Chapel Hill, NC 27599 USA
| | - Ziya Gizlice
- Center for Health Promotion and Disease Prevention (a CDC Prevention Research Center), CB 7426, University of North Carolina, Chapel Hill, NC 27599 USA
| | - Cassandra L. Miller
- Center for Health Promotion and Disease Prevention (a CDC Prevention Research Center), CB 7426, University of North Carolina, Chapel Hill, NC 27599 USA
| | - Danielle F. Braxton
- Center for Health Promotion and Disease Prevention (a CDC Prevention Research Center), CB 7426, University of North Carolina, Chapel Hill, NC 27599 USA
- Department of Nutrition, Gillings School of Global Public Health, CB 7461, University of North Carolina, Chapel Hill, NC 27599 USA
| | - Kelly R. Evenson
- Department of Epidemiology, Gillings School of Global Public Health, CB 8050, University of North Carolina, Chapel Hill, NC 27599 USA
| | - Janice C. Smith
- Center for Health Promotion and Disease Prevention (a CDC Prevention Research Center), CB 7426, University of North Carolina, Chapel Hill, NC 27599 USA
| | - Gwen B. Davis
- Center for Health Promotion and Disease Prevention (a CDC Prevention Research Center), CB 7426, University of North Carolina, Chapel Hill, NC 27599 USA
| | - Emmanuelle L. Quenum
- Greene County Health Department, 225 Kingold Blvd, Suite B, Snow Hill, North Carolina 28580 USA
| | - Nadya T. Majette Elliott
- Student Health Services, East Carolina University, 1000 East 5th St, MS 408, Greenville, NC 27858 USA
| | - Myron D. Gross
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN 55455 USA
| | - Katrina E. Donahue
- Department of Family Medicine, School of Medicine, CB 7595, University of North Carolina, Chapel Hill, NC 27599 USA
| | - Jacqueline R. Halladay
- Department of Family Medicine, School of Medicine, CB 7595, University of North Carolina, Chapel Hill, NC 27599 USA
- Cecil G. Sheps Center for Health Services Research, School of Medicine, CB 7590, University of North Carolina, Chapel Hill, NC 27599 USA
| | - Alice S. Ammerman
- Center for Health Promotion and Disease Prevention (a CDC Prevention Research Center), CB 7426, University of North Carolina, Chapel Hill, NC 27599 USA
- Department of Nutrition, Gillings School of Global Public Health, CB 7461, University of North Carolina, Chapel Hill, NC 27599 USA
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Mama SK, Leach HJ, Soltero EG, Lee RE. Improved Physical Activity Screening Enhances Intervention Effectiveness in Ethnic Minority Women. Health Promot Pract 2016; 18:54-61. [DOI: 10.1177/1524839916657325] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study identified inconsistencies in physical activity (PA) reported at screening and baseline of a 6-month health promotion intervention and explored how these inconsistencies influenced intervention effectiveness in African American and Hispanic women. Participants completed a telephone screener to determine eligibility for a PA intervention. Inactive participants (≤90 minutes of PA/week) were invited to a baseline assessment, where they completed the International Physical Activity Questionnaire, measuring work, transportation, gardening/housework, and leisure-time PA. Women returned after 6 months to complete an identical post-intervention assessment. Despite being screened as inactive, baseline Questionnaire data indicated that 85.0% of participants (N = 274, M age = 44.6 years, M body mass index = 34.8 kg/m2) were active (>90 minutes of PA/week). Women who reported any work-related PA were 20.9 times more likely to be active at baseline than those who did not (p < .001). Participants who were inactive at both screening and baseline reported greater increases in domestic and gardening PA and total PA from baseline to postintervention (ps < .05). Overweight/obese ethnic minority women may misreport being physically inactive during screening if specific questions about type of PA are not included. Post hoc analyses controlling for screening inaccuracies may improve effectiveness of PA interventions and help intervention programs reach women who may benefit the most.
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Cavallo DN, Sisneros JA, Ronay AA, Robbins CL, Jilcott Pitts SB, Keyserling TC, Ni A, Morrow J, Vu MB, Johnston LF, Samuel-Hodge CD. Assessing the Feasibility of a Web-Based Weight Loss Intervention for Low-Income Women of Reproductive Age: A Pilot Study. JMIR Res Protoc 2016; 5:e30. [PMID: 26920252 PMCID: PMC4788741 DOI: 10.2196/resprot.4865] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 09/04/2015] [Accepted: 11/14/2015] [Indexed: 11/20/2022] Open
Abstract
Background Low-income women of reproductive age are at increased risk for obesity and resulting increases in the risk of maternal/fetal complications and mortality and morbidity. Very few weight-loss interventions, however, have been targeted to this high-risk group. Based on the high prevalence of social media use among young and low-income individuals and previous successes using group formats for weight-loss interventions, the use of social media as a platform for weight-loss intervention delivery may benefit low-income women of reproductive age. Objective Examine the feasibility of delivering group-based weight-loss interventions to low-income women of reproductive age using face-to-face meetings and Web-based modalities including social media. Methods Participants attended a family planning clinic in eastern North Carolina and received a 5-month, group- and Web-based, face-to-face weight-loss intervention. Measures were assessed at baseline and 20 weeks. Results Forty participants enrolled, including 29 (73%) African American women. The mean body mass index of enrollees was 39 kg/m2. Among the 12 women who completed follow-up, mean weight change was -1.3 kg. Participation in the intervention was modest and retention at 5 months was 30%. Returnees suggested sending reminders to improve participation and adding activities to increase familiarity among participants. Conclusions Engagement with the intervention was limited and attrition was high. Additional formative work on the barriers and facilitators to participation may improve the intervention’s feasibility with low-income women of reproductive age.
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Affiliation(s)
- David N Cavallo
- Case Western Reserve University, Department of Nutrition, Cleveland, OH, United States.
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Jilcott Pitts SB, Keyserling TC, Johnston LF, Smith TW, McGuirt JT, Evenson KR, Rafferty AP, Gizlice Z, Garcia BA, Ammerman AS. Associations between neighborhood-level factors related to a healthful lifestyle and dietary intake, physical activity, and support for obesity prevention polices among rural adults. J Community Health 2015; 40:276-84. [PMID: 25096764 DOI: 10.1007/s10900-014-9927-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
We examined cross-sectional associations among neighborhood- and individual-level factors related to a healthful lifestyle and dietary intake, physical activity (PA), and support for obesity prevention polices in rural eastern North Carolina adults. We examined perceived neighborhood barriers to a healthful lifestyle, and associations between neighborhood barriers to healthy eating and PA, participants' support for seven obesity prevention policies, and dependent variables of self-reported dietary and PA behaviors, and measured body mass index (BMI) (n = 366 study participants). We then used participants' residential addresses and Geographic Information Systems (GIS) software to assess neighborhood-level factors related to access to healthy food and PA opportunities. Correlational analyses and adjusted linear regression models were used to examine associations between neighborhood-level factors related to a healthful lifestyle and dietary and PA behaviors, BMI, and obesity prevention policy support. The most commonly reported neighborhood barriers (from a list of 18 potential barriers) perceived by participants included: not enough bicycle lanes and sidewalks, not enough affordable exercise places, too much crime, and no place to buy a quick, healthy meal to go. Higher diet quality was inversely related to perceived and GIS-assessed neighborhood nutrition barriers. There were no significant associations between neighborhood barriers and PA. More perceived neighborhood barriers were positively associated with BMI. Support for obesity prevention policy change was positively associated with perceptions of more neighborhood barriers. Neighborhood factors that promote a healthful lifestyle were associated with higher diet quality and lower BMI. Individuals who perceived more neighborhood-level barriers to healthy eating and PA usually supported policies to address those barriers. Future studies should examine mechanisms to garner such support for health-promoting neighborhood changes.
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Affiliation(s)
- Stephanie B Jilcott Pitts
- Department of Public Health, East Carolina University, Lakeside Annex 8, 600 Moye Blvd, MS 660, Greenville, NC, 27834, USA,
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Chang MW, Hales D, Brown R, Ward D, Resnicow K, Nitzke S. Validation of PIN 3 physical activity survey in low-income overweight and obese young mothers. BMC Public Health 2015; 15:121. [PMID: 25885482 PMCID: PMC4331310 DOI: 10.1186/s12889-015-1493-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 01/29/2015] [Indexed: 11/12/2022] Open
Abstract
Background Existing physical activity surveys have not been validated for use with low-income overweight and obese young mothers. This study aimed to validate the Pregnancy Infection and Nutrition 3 (PIN3) physical activity survey and to explore whether its validity varied by race/ethnicity and body mass index (BMI) category when including or excluding child and adult care activities in the target population. Methods Participants were recruited from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and were asked to fill out the PIN3 survey and wear an Actigraph accelerometer. Validity was assessed (N = 42) using Spearman correlation coefficient. Results Regardless of inclusion or exclusion of child and adult care activity, the PIN3 survey showed evidence of validity for moderate (correlation coefficients 0.33 [p = 0.03]; 0.40 [p = 0.08]) but not vigorous (−0.01 [p = 0.91]; −0.06 [p = 0.69]) physical activity. The mean minutes per week spent in moderate, vigorous and moderate-vigorous physical activity measured by the PIN3 were substantially higher than when measured by accelerometer, for example, 588 (PIN3) versus 148 (accelerometer) minutes per week. Also, correlations between self-reported and objective monitored activity varied substantially by race/ethnicity and BMI category, for example, 0.29 (p = 0.18) for overweight women versus 0.57 (p = 0.007) for obese women; 0.27 (p = 0.20) for African American versus 0.66 (p = 0.001) for white. Conclusions The PIN3 survey may be adequate for many applications where quick and practical assessments are needed for moderate physical activity data in low-income overweight and obese young mothers. The substantial differences in mean minutes per week between the PIN3 and accelerometer may be due to over-reported physical activity by the study participants. Trial registration Clinical Trials Number: NCT01839708
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Affiliation(s)
- Mei-Wei Chang
- Michigan State University, College of Nursing, 1355 Bogue Street, RM C346, East Lansing, MI, 48824, USA.
| | - Derek Hales
- University of North Carolina-Chapel Hill, School of Public Health, Gillings School of Global Public Health, Chapel Hill, NC, USA.
| | - Roger Brown
- University of Wisconsin-Madison, School of Nursing, 600 Highland Avenue, Madison, WI, 53792, USA.
| | - Dianne Ward
- University of North Carolina-Chapel Hill, School of Public Health, Gillings School of Global Public Health, Chapel Hill, NC, USA.
| | - Ken Resnicow
- University of Michigan, School of Public Health, 1415 Washington Heights, Ann Arbor, Michigan, 48104, USA.
| | - Susan Nitzke
- Department of Nutritional Sciences, University of Wisconsin-Madison, 1415 Linden Drive, Madison, WI, 53706, USA.
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Keyserling TC, Sheridan SL, Draeger LB, Finkelstein EA, Gizlice Z, Kruger E, Johnston LF, Sloane PD, Samuel-Hodge C, Evenson KR, Gross MD, Donahue KE, Pignone MP, Vu MB, Steinbacher EA, Weiner BJ, Bangdiwala SI, Ammerman AS. A comparison of live counseling with a web-based lifestyle and medication intervention to reduce coronary heart disease risk: a randomized clinical trial. JAMA Intern Med 2014; 174:1144-57. [PMID: 24861959 PMCID: PMC4142754 DOI: 10.1001/jamainternmed.2014.1984] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Most primary care clinicians lack the skills and resources to offer effective lifestyle and medication (L&M) counseling to reduce coronary heart disease (CHD) risk. Thus, effective and feasible CHD prevention programs are needed for typical practice settings. OBJECTIVE To assess the effectiveness, acceptability, and cost-effectiveness of a combined L&M intervention to reduce CHD risk offered in counselor-delivered and web-based formats. DESIGN, SETTING, AND PARTICIPANTS A comparative effectiveness trial in 5 diverse family medicine practices in North Carolina. Participants were established patients, aged 35 to 79 years, with no known cardiovascular disease, and at moderate to high risk for CHD (10-year Framingham Risk Score [FRS], ≥10%). INTERVENTIONS Participants were randomized to counselor-delivered or web-based format, each including 4 intensive and 3 maintenance sessions. After randomization, both formats used a web-based decision aid showing potential CHD risk reduction associated with L&M risk-reducing strategies. Participants chose the risk-reducing strategies they wished to follow. MAIN OUTCOMES AND MEASURES The primary outcome was within-group change in FRS at 4-month follow-up. Other measures included standardized assessments of blood pressure, blood lipid levels, lifestyle behaviors, and medication adherence. Acceptability and cost-effectiveness were also assessed. Outcomes were assessed at 4 and 12 months. RESULTS Of 2274 screened patients, 385 were randomized (192 counselor; 193 web): mean age, 62 years; 24% African American; and mean FRS, 16.9%. Follow-up at 4 and 12 months included 91% and 87% of the randomized participants, respectively. There was a sustained reduction in FRS at both 4 months (primary outcome) and 12 months for both counselor-based (-2.3% [95% CI, -3.0% to -1.6%] and -1.9% [95% CI, -2.8% to -1.1%], respectively) and web-based groups (-1.5% [95% CI, -2.2% to -0.9%] and -1.7% [95% CI, -2.6% to -0.8%] respectively). At 4 months, the adjusted difference in FRS between groups was -1.0% (95% CI, -1.8% to -0.1%) (P = .03), and at 12 months, it was -0.6% (95% CI, -1.7% to 0.5%) (P = .30). The 12-month costs from the payer perspective were $207 and $110 per person for the counselor- and web-based interventions, respectively. CONCLUSIONS AND RELEVANCE Both intervention formats reduced CHD risk through 12-month follow-up. The web format was less expensive. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01245686.
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Affiliation(s)
- Thomas C Keyserling
- Division of General Medicine and Clinical Epidemiology, School of Medicine, University of North Carolina, Chapel Hill2Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill
| | - Stacey L Sheridan
- Division of General Medicine and Clinical Epidemiology, School of Medicine, University of North Carolina, Chapel Hill2Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill3Cecil G. Sheps Center for Health Services R
| | - Lindy B Draeger
- Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill
| | - Eric A Finkelstein
- Health Services and Systems Research Program, Duke-National University of Singapore Graduate Medical School, Singapore
| | - Ziya Gizlice
- Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill
| | - Eliza Kruger
- Health Services and Systems Research Program, Duke-National University of Singapore Graduate Medical School, Singapore
| | - Larry F Johnston
- Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill
| | - Philip D Sloane
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill5Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill
| | - Carmen Samuel-Hodge
- Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill6Department of Nutrition, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
| | - Kelly R Evenson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
| | - Myron D Gross
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis
| | - Katrina E Donahue
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill5Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill
| | - Michael P Pignone
- Division of General Medicine and Clinical Epidemiology, School of Medicine, University of North Carolina, Chapel Hill3Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill
| | - Maihan B Vu
- Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill
| | | | - Bryan J Weiner
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
| | - Shrikant I Bangdiwala
- Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill11Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
| | - Alice S Ammerman
- Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill5Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill6Department of Nutrition, Gillings School of Global Public Health, Un
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