Modern statistical methods for handling missing repeated measurements in obesity trial data: beyond LOCF

Ketogenic diet but not free-sugar restriction alters glucose tolerance, lipid metabolism, peripheral tissue phenotype, and gut microbiome: RCT

Restricted sugar and ketogenic diets can alter energy balance/metabolism, but decreased energy intake may be compensated by reduced expenditure. In healthy adults, randomization to restricting free sugars or overall carbohydrates (ketogenic diet) for 12 weeks reduces fat mass without changing energy expenditure versus control. Free-sugar restriction minimally affects metabolism or gut microbiome but decreases low-density lipoprotein cholesterol (LDL-C). In contrast, a ketogenic diet decreases glucose tolerance, increases skeletal muscle PDK4, and reduces AMPK and GLUT4 levels. By week 4, the ketogenic diet reduces fasting glucose and increases apolipoprotein B, C-reactive protein, and postprandial glycerol concentrations. However, despite sustained ketosis, these effects are no longer apparent by week 12, when gut microbial beta diversity is altered, possibly reflective of longer-term adjustments to the ketogenic diet and/or energy balance. These data demonstrate that restricting free sugars or overall carbohydrates reduces energy intake without altering physical activity, but with divergent effects on glucose tolerance, lipoprotein profiles, and gut microbiome.

Randomization, design and analysis for interdependency in aging research: no person or mouse is an island

Investigators traditionally use randomized designs and corresponding analysis procedures to make causal inferences about the effects of interventions, assuming independence between an individual's outcome and treatment assignment and the outcomes of other individuals in the study. Often, such independence may not hold. We provide examples of interdependency in model organism studies and human trials and group effects in aging research and then discuss methodologic issues and solutions. We group methodologic issues as they pertain to (1) single-stage individually randomized trials; (2) cluster-randomized controlled trials; (3) pseudo-cluster-randomized trials; (4) individually randomized group treatment; and (5) two-stage randomized designs. Although we present possible strategies for design and analysis to improve the rigor, accuracy and reproducibility of the science, we also acknowledge real-world constraints. Consequences of nonadherence, differential attrition or missing data, unintended exposure to multiple treatments and other practical realities can be reduced with careful planning, proper study designs and best practices.

Detection of changes of functioning over time after asthma exacerbation in children with the use of PROMIS domains

OBJECTIVES

Patient reported outcome measures, such as the Patient Reported Outcomes Measurement Information System (PROMIS) may be utilized to understand experiences of patients. The purpose of this study was to determine the ability of PROMIS domains to detect changes in pain, physical functioning, and asthma impact over time for children experiencing asthma exacerbation.

METHODS

Our prospective cohort study included children presenting to the emergency department (ED) for asthma exacerbation. Children completed PROMIS surveys in the ED, 7-10 days, and 1-3 months post-discharge. We used linear mixed models adjusted for age, gender, acute care utilization, and child global health to determine changes in PROMIS T-scores. We used self-reported child health response (Much better now versus a little better now or worse) at discharge as an anchor to determine if change in PROMIS scores corresponded with changes in health. A change was statistically significant if the 95% CI did not include 0.

RESULTS

Our study included 63 children who presented to the ED for acute asthma exacerbation. We identified that children improved significantly in all domains over time. There was improvement over time following discharge from ED for all pain and physical functioning domains, and asthma impact. Using the clinical anchor, those with considerable improvement in asthma symptoms had improved T scores from 4-17.

CONCLUSIONS

PROMIS domains of pain, physical functioning, depression, fatigue, peer relationships, and asthma impact are responsive to changes in health states over time. These domains may be used to measure clinically significant change in children experiencing asthma exacerbation.

Are Biases Related to Attrition, Missing Data, and the Use of Intention to Treat Related to the Magnitude of Treatment Effects in Physical Therapy Trials?: A Meta-Epidemiological Study

ABSTRACT

The objective of this study was to determine the association between biases related to attrition, missing data, and the use of intention to treat and changes in effect size estimates in physical therapy randomized trials. A meta-epidemiological study was conducted. A random sample of randomized controlled trials included in meta-analyses in the physical therapy discipline were identified. Data extraction including assessments of the use of intention to treat principle, attrition-related bias, and missing data was conducted independently by two reviewers. To determine the association between these methodological issues and effect sizes, a two-level analysis was conducted using a meta-meta-analytic approach. Three hundred ninety-three trials included in 43 meta-analyses, analyzing 44,622 patients contributed to this study. Trials that did not use the intention-to-treat principle (effect size = -0.13, 95% confidence interval = -0.26 to 0.01) or that were assessed as having inappropriate control of incomplete outcome data tended to underestimate the treatment effect when compared with trials with adequate use of intention to treat and control of incomplete outcome data (effect size = -0.18, 95% confidence interval = -0.29 to -0.08).Researchers and clinicians should pay attention to these methodological issues because they could provide inaccurate effect estimates. Authors and editors should make sure that intention-to-treat and missing data are properly reported in trial reports.

Errors in the implementation, analysis, and reporting of randomization within obesity and nutrition research: a guide to their avoidance

Randomization is an important tool used to establish causal inferences in studies designed to further our understanding of questions related to obesity and nutrition. To take advantage of the inferences afforded by randomization, scientific standards must be upheld during the planning, execution, analysis, and reporting of such studies. We discuss ten errors in randomized experiments from real-world examples from the literature and outline best practices for their avoidance. These ten errors include: representing nonrandom allocation as random, failing to adequately conceal allocation, not accounting for changing allocation ratios, replacing subjects in nonrandom ways, failing to account for non-independence, drawing inferences by comparing statistical significance from within-group comparisons instead of between-groups, pooling data and breaking the randomized design, failing to account for missing data, failing to report sufficient information to understand study methods, and failing to frame the causal question as testing the randomized assignment per se. We hope that these examples will aid researchers, reviewers, journal editors, and other readers to endeavor to a high standard of scientific rigor in randomized experiments within obesity and nutrition research.

Randomized trial of a novel lifestyle intervention compared with the Diabetes Prevention Program for weight loss in adult dependents of military service members

BACKGROUND

Lifestyle interventions are the first-line treatment for obesity, but participant weight loss is typically low.

OBJECTIVES

We evaluated the efficacy of an alternative lifestyle intervention [Healthy Weight for Living (HWL)] compared with a modified Diabetes Prevention Program (m-DPP). HWL was based on a revised health behavior change model emphasizing hunger management and the development of healthy food preferences. m-DPP was a standard Diabetes Prevention Program implemented with counselor time matched to HWL. Participants were adult dependents of military personnel and had overweight or obesity.

METHODS

Participants were randomly assigned to HWL (n = 121) or m-DPP (n = 117), delivered primarily by group videoconference with additional midweek emails. The primary outcome was 12-mo weight change. Secondary outcomes included 6-mo changes in cardiometabolic risk factors and diet. Intention-to-treat (ITT) and complete case (CC) analyses were performed using linear mixed models.

RESULTS

Retention did not differ between groups (72% and 66% for HWL and m-DPP at 12 mo, respectively; P = 0.30). Mean ± SE adjusted 12-mo weight loss in the ITT cohort was 7.46 ± 0.85 kg for HWL and 7.32 ± 0.87 kg for m-DPP (P = 0.91); in the CC cohort, it was 7.83 ± 0.82 kg for HWL and 6.86 ± 0.88 kg for m-DPP (P = 0.43). Thirty-eight percent of HWL and 30% of m-DPP completers achieved ≥10% weight loss (P = 0.32). Improvements in systolic blood pressure, LDL cholesterol, triglycerides, fasting glucose, general health, sleep, and mood were similar across groups; improvements in diastolic blood pressure were greater in m-DPP. Adjusted group mean reductions in energy intake were not significantly different between groups, but HWL participants were more adherent to their dietary prescription for lower glycemic index and high fiber and protein (P = 0.05 to <0.001 for ITT).

CONCLUSIONS

HWL and m-DPP showed equivalent and clinically impactful mean weight loss with cardiometabolic benefits. These results identify an alternative approach for behavioral treatment of overweight and obesity.This trial was registered at clinicaltrials.gov as NCT02348853.

Free-Living Energy Balance Behaviors Are Associated With Greater Weight Loss During a Weight Loss Program

Introduction: Free-living movement (physical activity [PA] and sedentary behavior [SB]) and eating behaviors (energy intake [EI] and food choice) affect energy balance and therefore have the potential to influence weight loss (WL). This study explored whether free-living movement and/or eating behaviors measured early (week 3) in a 14-week WL programme or their change during the intervention are associated with WL in women. Methods: In the study, 80 women (M ± SD age: 42.0 ± 12.4 years) with overweight or obesity [body mass index (BMI): 34.08 ± 3.62 kg/m²] completed a 14 week WL program focused primarily on diet (commercial or self-led). Body mass (BM) was measured at baseline, and again during week 2 and 14 along with body composition. Free-living movement (SenseWear Armband) and eating behavior (weighed food diaries) were measured for 1 week during week 3 and 12. Hierarchical multiple regression analyses examined whether early and early-late change in free-living movement and eating behavior were associated with WL. The differences in behavior between clinically significant weight losers (CWL; ≥5% WL) and non-clinically significant weight losers (NWL; ≤ 3% WL) were compared. Results: The energy density of food consumed [β = 0.45, p < 0.001] and vigorous PA [β = -0.30, p < 0.001] early in the intervention (regression model 1) and early-late change in light PA [β = -0.81 p < 0.001], moderate PA [β = -1.17 p < 0.001], vigorous PA [β = -0.49, p < 0.001], total energy expenditure (EE) [β = 1.84, p < 0.001], and energy density of food consumed [β = 0.27, p = 0.01] (regression model 2) significantly predicted percentage change in BM. Early in the intervention, CWL consumed less energy dense foods than NWL [p = 0.03]. CWL showed a small but significant increase in vigorous PA, whereas NWL showed a slight decrease in PA [p = 0.04]. Conclusion: Both early and early-late change in free-living movement and eating behaviors during a 14 week WL program are predictors of WL. These findings demonstrate that specific behaviors that contribute to greater EE (e.g., vigorous PA) and lower EI (e.g., less energy-dense foods) are related to greater WL outcomes. Interventions targeting these behaviors can be expected to increase the effectiveness of WL programs.

Examining the effects of stress and psychological distress on smoking abstinence in cancer patients

INTRODUCTION

Cancer patients who smoke report more stress and psychological distress than patients who do not smoke. It is unclear how these emotional symptoms may modify smoking behavior in cancer patients. We examined the influence of a smoking cessation intervention for cancer patients on stress and distress, and the effects of these symptoms on smoking abstinence.

METHODS

Mixed-methods secondary analysis of data from the Smokefree Support Study, a two-site randomized controlled trial examining the efficacy of Intensive (IT; n = 153) vs. Standard Treatment (ST; n = 150) for smoking cessation in newly diagnosed cancer patients. Stress coping, perceived stress, distress, and anxiety were self-reported at baseline, 3, and 6 months. Abstinence was biochemically-confirmed at 6 months. A subset of patients (n = 72) completed qualitative exit-interviews.

RESULTS

Patients were on average, 58 years old, 56% female, and smoked a median of 10 cigarettes/day. There were no significant treatment group × time interactions or main effects of treatment group on stress or distress measures (p's > 0.05), however there were significant main effects of time suggesting symptom improvements on each measure in both study groups (p's < 0.05). In adjusted logistic regression models, lower levels anxiety at 3 months predicted confirmed smoking abstinence at 6 months (p = .03). Qualitatively, at 6 months, patients reported their stress and smoking were connected and that the cessation counseling was helpful.

CONCLUSIONS

Cancer patients enrolled in a smoking cessation trial report decreases in stress, distress and anxiety over time, and anxiety symptoms may impact smoking cessation success at follow-up resulting in an important intervention target.

Effectiveness of collaborative care in reducing suicidal ideation: An individual participant data meta-analysis

To assess whether CC is more effective at reducing suicidal ideation in people with depression compared with usual care, and whether study and patient factors moderate treatment effects.

METHOD

We searched Medline, Embase, PubMed, PsycINFO, CINAHL, CENTRAL from inception to March 2020 for Randomised Controlled Trials (RCTs) that compared the effectiveness of CC with usual care in depressed adults, and reported changes in suicidal ideation at 4 to 6 months post-randomisation. Mixed-effects models accounted for clustering of participants within trials and heterogeneity across trials. This study is registered with PROSPERO, CRD42020201747.

RESULTS

We extracted data from 28 RCTs (11,165 patients) of 83 eligible studies. We observed a small significant clinical improvement of CC on suicidal ideation, compared with usual care (SMD, -0.11 [95%CI, -0.15 to -0.08]; I², 0·47% [95%CI 0.04% to 4.90%]). CC interventions with a recognised psychological treatment were associated with small reductions in suicidal ideation (SMD, -0.15 [95%CI -0.19 to -0.11]). CC was more effective for reducing suicidal ideation among patients aged over 65 years (SMD, - 0.18 [95%CI -0.25 to -0.11]).

CONCLUSION

Primary care based CC with an embedded psychological intervention is the most effective CC framework for reducing suicidal ideation and older patients may benefit the most.

Power and sample size for random coefficient regression models in randomized experiments with monotone missing data

Random coefficient regression (also known as random effects, mixed effects, growth curve, variance component, multilevel, or hierarchical linear modeling) can be a natural and useful approach for characterizing and testing hypotheses in data that are correlated within experimental units. Existing power and sample size software for such data are based on two variance component models or those using a two-stage formulation. These approaches may be markedly inaccurate in settings where more variance components (i.e., intercept, rate of change, and residual error) are warranted. We present variance, power, sample size formulae, and software (R Shiny app) for use with random coefficient regression models with possible missing data and variable follow-up. We illustrate sample size and study design planning using data from the Alzheimer's Disease Neuroimaging Initiative (ADNI) database. We additionally examine the drivers of variability to better inform study design.

A nurse-led intervention for fear of cancer progression in advanced cancer: A pilot feasibility study

PURPOSE

To assess the feasibility, acceptability, and preliminary effects of a nurse-led intervention for managing fear of cancer progression in advanced cancer patients.

METHODS

A single group mixed methods study was conducted in patients with stage III or IV gynecologic or lung cancer (n = 31) with dysfunctional levels of fear of progression or distress. The intervention consisted of seven videoconferencing sessions with skills practice. Feasibility measures included enrollment rate, attendance, attrition, and home practice adherence. Acceptability was based on exit interview responses. Content analysis was used to analyze the qualitative data. Participants completed quantitative questionnaires assessing fear of progression and secondary outcomes at baseline, eight, and 12 weeks. Linear mixed model analysis was used to assess changes in outcome measures.

RESULTS

The average enrollment rate was seven participants/month over 4.5 months. Participants attended a mean of 5.3 of seven sessions. Attrition rate was 30%. The analysis showed improvements over time in fear of progression and exploratory outcomes. Participants reported feeling calmer and more focused. The skills practice helped to manage anxiety and fears. Themes included: Struggling with fears, Refocusing the fears, and Realizing/reaffirming what is important in life. The most beneficial components included the values clarification exercise, detached mindfulness and worry postponement practices.

CONCLUSION

The intervention was acceptable; most feasibility criteria were met. Preliminary data suggest that the intervention reduced fear of progression and improved secondary outcomes. The intervention required a significant time commitment by participants, which may have contributed to increased attrition. To decrease burden, we will shorten the intervention.

Attrition, missing data, compliance, and related biases in randomized controlled trials of rehabilitation interventions: towards improving reporting and conduct

INTRODUCTION

Attrition, missing data, compliance, and related biases can influence the magnitude of treatment effects in randomized controlled trials (RCTs). It is unclear which items should be considered when reporting and evaluating the influence of these biases in trial reports in the rehabilitation field. The aim was to describe which individual items considering attrition, missing data, compliance, and related biases are included in quality tools used in rehabilitation research. In addition, we aimed to determine whether the existing reporting guidelines, such as the CONSORT and its extensions include all relevant items related to these biases when reporting RCTs in the area of rehabilitation.

EVIDENCE ACQUISITION

Comprehensive literature searches and a systematic approach to identify tools and items looking at attrition, missing data, compliance and related biases in rehabilitation were performed. We extracted individual items linked to these biases from all quality tools. We calculated the frequency of quality items used across tools and compared them to those found in the CONSORT statement and its extensions. A list of items to be potentially added to the CONSORT statement was generated.

EVIDENCE SYNTHESIS

Three new tools to assess the conduct and reporting of trials in the rehabilitation field were found. From these tools, 28 items were used to evaluate the reporting as well as the conduct of trials considering attrition, missing data, compliance, and related biases in the rehabilitation field. However, our team found that some of these items lack specificity in the information required and therefore more research is needed to determine a core set of items used for reporting as well as assessing the risk of bias (RoB) of RCT in the rehabilitation field.

CONCLUSIONS

Although many items have been described by existing tools and the CONSORT statement (and its extensions) that deal with attrition, missing data, compliance, and related biases, several gaps in reporting were identified. It is crucial that future research investigate a core set of items to be used in the field of rehabilitation to facilitate the reporting as well as the conduct of RCTs.

Reported nutrient intake over 7 years after Roux-en-Y gastric bypass in the Longitudinal Assessment of Bariatric Surgery-3 (LABS-3) psychosocial study

BACKGROUND

Bariatric surgery is the most effective therapy for severe obesity. It reduces gastric capacity and may modify regulation of appetite, satiety, insulin, and other physiologic processes, resulting in weight loss.

OBJECTIVE

Long-term data on postsurgical nutrient intake are lacking.

SETTING

The Longitudinal Assessment of Bariatric Surgery-3 psychosocial study.

METHODS

Reported dietary intake was assessed in a subset of participants (n = 72) of the Longitudinal Assessment of Bariatric Surgery-3 psychosocial study who underwent Roux-en-Y gastric bypass surgery. Two 24-hour diet recalls at presurgery and annual assessments over 7 years were obtained. Reported diets were evaluated for energy, macro- and micronutrient intake, and assessed for adequacy by comparison to the dietary reference intakes.

RESULTS

After surgery, reported intake of total energy, and all macronutrients were significantly reduced. At least a quarter of participants reported protein intake below the recommended dietary allowance. Over half of participants reported intake of several vitamins (C, D, A, E, thiamin, folate) and minerals (zinc, calcium) below recommended levels over 7 years. Compared with presurgery, reported energy intake was reduced over 7 years. This study was registered at ClinicalTrials.gov as NCT02495142.

CONCLUSIONS

The reduction in energy resulted in intakes below the dietary reference intakes for many micronutrients among the majority of participants and below the recommended dietary allowance for protein in a substantial subgroup. These data support continued long-term nutrition education, monitoring, and supplementation.

Association Between Concussion History and Factors Relating to Cognitive, Behavioral, and Emotional Health Among American High School Athletes: A Cross-sectional Analysis

BACKGROUND

The cognitive, behavioral, and emotional deficits that may be associated with sports-related concussions among adolescents are unclear.

PURPOSE

To examine the association between reported concussion history and factors relating to cognitive, behavioral, and emotional health among a population-based sample of US high school-aged adolescents.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Participants included a representative sample of US high school student-athletes who reported a concussion history (in the past 12 months) and relevant behaviors/outcomes within 3 domains: cognitive (academics, difficulty concentrating), behavioral (drinking and driving, carrying a weapon, physically fighting, tobacco use, marijuana use, binge drinking), and emotional (symptoms of depression, suicidal thoughts/actions). The adjusted relative odds of experiencing 0 and at least 1, 2, 3, or ≥4 concussions were modeled while mutually adjusting for the behaviors of interest in addition to age, race/ethnicity, and sleep problems. Data were reported in sex stratum.

RESULTS

A total of 13,268 participants were included in the unweighted data set. Overall, 14.5% (95% CI, 12.9%-16.2%) of female and 18.1% (95% CI, 16.4%-19.8%) of male student-athletes had at least 1 concussion in the past 12 months. As compared with those who reported not engaging in any of the behaviors deleterious to health or having had any of the negative health outcomes (composite score of 0), female athletes with composite scores of 1 to 4, 5 to 7, and 8 to 11 were 1.94 (95% CI, 1.55-2.43), 3.13 (95% CI, 2.30-4.33), and 6.05 (95% CI, 3.75-9.75) times more likely to have a recent history of concussions after accounting for relevant factors. As compared with those having a composite score of 0, male athletes with composite scores of 1 to 4, 5 to 7, and 8 to 11 were 2.03 (95% CI, 1.58-2.59), 3.80 (95% CI, 2.71-5.34), and 8.23 (95% CI, 4.91-13.77) times more likely to have a recent history of concussions after accounting for relevant factors.

CONCLUSION

Self-reported concussions among US high school athletes is related to several deleterious health behaviors and outcomes. These associations should be confirmed in longitudinal analyses.

Efficacy of high-intensity laser therapy on arthropathy of the hands in patients with systemic lupus erythematosus: a double-blinded, randomized controlled trial

OBJECTIVE

To determine the efficacy of high-intensity laser therapy (HILT) on arthropathy of the hands in patients with systemic lupus erythematosus.

DESIGN

A double-blinded randomized, controlled study.

SETTING

Outpatient setting.

PARTICIPANTS

Fifty patients, 30-50-years-old, suffering from arthropathy of the hands were randomly assigned either into the experimental group, received HILT plus the routine physical therapy program or the control group, received sham HILT plus the same routine physical therapy program.

INTERVENTION

All treatment interventions were applied at a frequency of three sessions per week for eight weeks.

OUTCOME MEASURES

Handgrip strength, joints swelling counts, joints tenderness counts, visual analog scale (VAS) were measured before and after eight-weeks of interventions.

RESULTS

There were statistically significant differences in handgrip strength, joint swelling count, joint tenderness count and VAS in favor of the study group (P < 0.05). After eight-weeks of intervention, the mean (SD) for handgrip strength, joint swelling counts, joint tenderness count, and pain score was 28.34 ± 8.3 kg, 4.4 ± 2.18, 5 ± 2.1, and 35.6 ± 13.87 mm in the study group, and 22.96 ± 8.76 kg, 7.36 ± 2.14, 9.08 ± 1.63, and 58.8 ± 10.54 mm in the control group, respectively. The MD (95%CI) for handgrip strength, joint swelling counts, joint tenderness count, and pain score was 5.38(0.53,10.23) kg, -2.96(-4.19, -1.73), -4.08(-5.15, -3.01), and -23.2(-30.2, -16.2) mm between groups, respectively.

CONCLUSIONS

Adding HILT to the routine physical therapy program might be more effective than routine physical therapy program alone in improving handgrip strength, decreasing joint swelling counts, joint tenderness counts, and pain in patients with arthropathy of the hands.

Can PROMIS domains of pain and physical functioning detect changes in health over time for children with sickle cell disease?

BACKGROUND

The Patient-Reported Outcomes Measurement Information System (PROMIS) includes multiple domains that measure pain and physical functioning which are valid and reliable for use in children with sickle cell disease. The responsiveness of these measures to detect changes in health status over time among children with sickle cell disease is unknown.

PROCEDURE

We conducted a prospective cohort study of children presenting to emergency department (ED) with vaso-occlusive crises. Children completed PROMIS surveys in the ED and at two follow-up time points (7-10 days and 1-3 months) after their acute care visit. Linear mixed models were used to determine if there were significant changes in PROMIS T scores over time. We used a patient's global assessment of change in pain question to anchor the changes in PROMIS scores (mean and 95% confidence interval). A change was considered statistically significant if the 95% CI did not include 0.

RESULTS

We found that patients improved significantly in all domains 1 to 3 months after discharge from an acute care visit for pain. In addition, the pain and physical stress experience domains were responsive to change 7 to 10 days after discharge. Using the anchor of change in pain, for children who had considerable improvement in pain, there were significant changes in PROMIS T scores ranging from 6 to 15.

CONCLUSIONS

Relevant PROMIS domains detect changes in children experiencing acute vaso-occlusive crises. These domains can be used in research and clinic settings to measure clinically relevant change in children with sickle cell disease.

Changes in weight and weight-related quality of life in a multicentre, randomized trial of aripiprazole versus standard of care

Background

This is a secondary analysis of clinical trial data collected in 12 European countries. We examined changes in weight and weight-related quality of life among community patients with schizophrenia treated with aripiprazole (ARI) versus standard of care (SOC), consisting of other marketed atypical antipsychotics (olanzapine, quetiapine, and risperidone).

Method

Five-hundred and fifty-five patients whose clinical symptoms were not optimally controlled and/or experienced tolerability problems with current medication were randomized to ARI (10–30 mg/day) or SOC. Weight and weight-related quality of life (using the IWQOL-Lite) were assessed at baseline, and weeks 8, 18 and 26. Random regression analysis across all time points using all available data was used to compare groups on changes in weight and IWQOL-Lite. Meaningful change from baseline was also assessed.

Results

Participants were 59.7% male, with a mean age of 38.5 years (SD 10.9) and mean baseline body mass index of 27.2 (SD 5.1). ARI participants lost an average of 1.7% of baseline weight in comparison to a gain of 2.1% by SOC participants (p < 0.0001) at 26 weeks. ARI participants experienced significantly greater increases in physical function, self-esteem, sexual life, and IWQOL-Lite total score. At 26 weeks, 20.7% of ARI participants experienced meaningful improvements in IWQOL-Lite score, versus 13.5% of SOC participants. A clinically meaningful change in weight was also associated with a meaningful change in quality of life (p < 0.001). A potential limitation of this study was its funding by a pharmaceutical company.

Conclusions

Compared to standard of care, patients with schizophrenia treated with aripiprazole experienced decreased weight and improved weight-related quality of life over 26 weeks. These changes were both statistically and clinically significant.

The Effect of The Daily Mile on Primary School Children's Aerobic Fitness Levels After 12 Weeks: A Controlled Trial

The Daily Mile (TDM) is a school-based physical activity intervention encompassing a 15-minute run at least three times per week. This study aimed to determine (1) the effects of performing TDM for 12 weeks on Dutch primary school children's aerobic fitness levels and (2) if additional personal support for teachers impacted the effectiveness of TDM. Nine Dutch primary schools (n = 659 children, grades 5-8) were allocated to a control (no TDM), intervention (12 weeks TDM) or intervention-plus (12 weeks TDM, additional personal support) group. The Shuttle Run Test (SRT) was used to assess aerobic fitness at baseline and follow-up. Data were analyzed using a multiple-imputed dataset and multilevel linear regression models to account for the clustering of students within classes and classes within schools. The regression analyses were adjusted for sex and age. Compared with the control group, significant intervention effects of TDM on SRT score were observed for the intervention group (β = 1.1; 95% CI: 0.8; 1.5) and the intervention-plus group (β = 0.6; 95% CI 0.3; 0.9). Additional personal support had no impact on the effectiveness of TDM. These results suggest that performing TDM at least three times per week for approximately 12 weeks increases primary school children's aerobic fitness. Additional personal support did not improve the effectiveness of TDM on aerobic fitness within this period. These results contribute to the body of evidence surrounding TDM, but further research is needed regarding long-term implementation of TDM.

Effects of kinesiotaping and exercise program on patients with obesity-induced coccydynia: a randomized, double-blinded, sham-controlled clinical trial

OBJECTIVE

To investigate the effect of kinesiotaping and a designed exercise program versus sham kinesiotaping and the same exercise program on pain, range of motion, and activities of daily living in obese patients suffering from coccydynia.

DESIGN

A double-blinded, randomized, sham-controlled trial.

SETTING

Outpatient, Cairo University hospitals.

PARTICIPANTS

Sixty patients with coccydynia randomized equally into kinesiotape plus exercise and sham kinesiotape plus exercise groups.

INTERVENTION

The kinesiotape was worn for three days and replaced for three weeks. Each patient practiced exercises for three weeks.

OUTCOME MEASURES

All patients were examined by visual analogue scale (VAS) for rating pain, Modified Modified Schober Test (MMST), and Oswestry Disability Index (ODI). All outcomes were measured at baseline, three weeks postintervention, and four weeks follow-up.

RESULTS

There were no statistically significant differences between groups at baseline (P < 0.05), but there were statistically significant differences between groups for pain score, MMST, and ODI at post and follow-up data in favor of the kinesiotape group (P < 0.001). For the three weeks postintervention, mean (SD) for pain score, MMST, and ODI was 33.07 ± 3.8, 6.6 ± 0.7, and 8.7 ± 2.1 in the study group and 39.9 ± 4.7, 5.8 ± 1.4, and 14.4 ± 2.7 in the control group, respectively. For the four weeks follow-up, mean (SD) for pain score, MMST, and ODI was 32.2 ± 3.4, 7.13 ± 0.6, and 7.2 ± 1.8 in the study group and 40.9 ± 4.4, 6.6 ± 0.75, and 13 ± 2 in the control group, respectively.

CONCLUSION

Experimental kinesiotape intervention and exercise program provided significant improvements in pain, range of motion, and disability. It is suggested as an adjunctive therapy in treating obese patients with coccydynia.

The effects of small-scale physical and social environmental interventions on walking behaviour among Dutch older adults living in deprived neighbourhoods: results from the quasi-experimental NEW.ROADS study

PURPOSE

Improving the physical and social conditions of residential neighbourhoods may increase walking, especially among older people. Evidence on the effects of physical and social environmental interventions, and particularly the combination of both, on walking behaviour is scarce. We evaluated the effects of a small-scale physical environmental intervention (designated walking route), a social environmental intervention (neighbourhood walking group) and the combination of both on walking behaviour of older adults living in deprived neighbourhoods.

METHODS

Survey data of 644 older adults residing in four deprived neighbourhoods of Rotterdam, the Netherlands, were used to compare changes in walking behaviour over time (weekly minutes spent recreational walking, utilitarian walking and total walking) of those exposed to 1) a designated walking route (physical condition), 2) walking groups (social condition), 3) walking routes and walking groups (combined condition), and 4) no intervention (control condition). Measurements took place at baseline (T0), and 3 months (T1) and 9 months (T2) after the intervention. Data were analysed on a multiple imputed dataset, using multi-level negative binomial regression models, adjusting for clustering of observations within individuals. All models were adjusted for demographic covariates.

RESULTS

Total time spent walking per week increased between T0 and T1 for all conditions. The Incidence Rate Ratio (IRR) for the physical condition was 1.46 (95% CI:1.06;2.05) and for the social intervention 1.52 (95%CI:1.07;2.16). At T2, these differences remained significant for the physical condition, but not for the social condition and the combined condition. These findings were mirrored for utilitarian walking. No evidence was found for an effect on recreational walking.

CONCLUSION

Implementing small scale, feasible, interventions in a residential neighbourhood may increase total and utilitarian walking behaviour among older adults.

Effect of Weight Loss via Severe vs Moderate Energy Restriction on Lean Mass and Body Composition Among Postmenopausal Women With Obesity: The TEMPO Diet Randomized Clinical Trial

IMPORTANCE

Severely energy-restricted diets are the most effective dietary obesity treatment. However, there are concerns regarding potential adverse effects on body composition.

OBJECTIVE

To compare the long-term effects of weight loss via severe vs moderate energy restriction on lean mass and other aspects of body composition.

DESIGN, SETTING, AND PARTICIPANTS

The Type of Energy Manipulation for Promoting Optimum Metabolic Health and Body Composition in Obesity (TEMPO) Diet Trial was a 12-month, single-center, randomized clinical trial. A total of 101 postmenopausal women, aged 45 to 65 years with body mass index (calculated as weight in kilograms divided by height in meters squared) from 30 to 40, who were at least 5 years after menopause, had fewer than 3 hours of structured physical activity per week, and lived in the Sydney metropolitan area of New South Wales, Australia, were recruited between March 2013 and July 2016. Data analysis was conducted between October 2018 and August 2019.

INTERVENTION

Participants were randomized to either 12 months of moderate (25%-35%) energy restriction with a food-based diet (moderate intervention) or 4 months of severe (65%-75%) energy restriction with a total meal replacement diet followed by moderate energy restriction for an additional 8 months (severe intervention). Both interventions had a prescribed protein intake of 1.0 g/kg of actual body weight per day, and physical activity was encouraged but not supervised.

MAIN OUTCOMES AND MEASURES

The primary outcome was whole-body lean mass at 12 months after commencement of intervention. Secondary outcomes were body weight, thigh muscle area and muscle function (strength), bone mineral density, and fat mass and distribution, measured at 0, 4, 6, and 12 months.

RESULTS

A total of 101 postmenopausal women were recruited (mean [SD] age, 58.0 [4.2] years; mean [SD] weight, 90.8 [9.1] kg; mean [SD] body mass index, 34.4 [2.5]). Compared with the moderate group at 12 months, the severe group lost more weight (effect size, -6.6 kg; 95% CI, -8.2 to -5.1 kg), lost more whole-body lean mass (effect size, -1.2 kg; 95% CI, -2.0 to -0.4 kg), and lost more thigh muscle area (effect size, -4.2 cm2; 95% CI, -6.5 to -1.9 cm2). However, decreases in whole-body lean mass and thigh muscle area were proportional to total weight loss, and there was no difference in muscle (handgrip) strength between groups. Total hip bone mineral density (effect size, -0.017 g/cm2; 95% CI, -0.029 to -0.005 g/cm2), whole-body fat mass (effect size, -5.5 kg; 95% CI, -7.1 to -3.9 kg), abdominal subcutaneous adipose tissue (effect size, -1890 cm3; 95% CI, -2560 to -1219 cm3), and visceral adipose tissue (effect size, -1389 cm3; 95% CI, -1748 to -1030 cm3) loss were also greater for the severe group than for the moderate group at 12 months.

CONCLUSIONS AND RELEVANCE

Severe energy restriction had no greater adverse effect on relative whole-body lean mass or handgrip strength compared with moderate energy restriction and was associated with 2-fold greater weight and fat loss over 12 months. However, there was significantly greater loss of total hip bone mineral density with severe vs moderate energy restriction. Therefore, caution is necessary when implementing severe energy restriction in postmenopausal women, particularly those with osteopenia or osteoporosis.

TRIAL REGISTRATION

anzctr.org.au Identifier: 12612000651886.

Associations between change in sedentary behavior and outcome in standard behavioral weight loss treatment

Sedentary behavior, particularly in prolonged periods, is an important determinant of health. Little research exploring changes in sedentary behavior during behavioral weight loss programs exists. This study evaluated the magnitude of changes in total and prolonged sedentary behavior and how these changes related to changes in weight and cardiovascular outcomes during a behavioral weight loss program. Participants (n = 450) in two lifestyle modification programs underwent assessments of sedentary behavior (by accelerometry), weight, waist circumference, blood pressure, and resting heart rate at baseline and after 6 months of treatment. Sedentary behavior was defined as both total and prolonged (≥30 continuous minutes) sedentary minutes/day. Reductions in total and prolonged sedentary time were significant and were accounted for by increases in moderate-to-vigorous physical activity (MVPA). Only changes in MVPA significantly predicted change in weight when entered into a model simultaneously with changes in sedentary behavior. Changes in total and prolonged sedentary time were not associated with changes in waist circumference, heart rate, or blood pressure. Change in sedentary time was not independently associated with change in health outcomes during a behavioral weight loss treatment. High variability in changes in sedentary time indicate that individual differences may be important to examine. Reducing sedentary time may not be powerful enough to impact these health outcomes above the effects of other changes made during these programs; alternatively, it may be that increasing focus in treatment on reducing sedentary time may engender greater decreases in sedentariness, which could lead to better health outcomes.

Effects of Calorie Restriction in Obese Older Adults: The CROSSROADS Randomized Controlled Trial

Background

We lack a comprehensive assessment of the risks and benefits of calorie restriction in older adults at high risk for cardiometabolic disease. Calorie restriction may reduce visceral adipose tissue (VAT) but also have negative effects on lean mass and quality of life.

Methods

We conducted a 52-week, randomized controlled trial involving 164 older adults with obesity taking at least one medication for hyperlipidemia, hypertension, or diabetes. Interventions included an exercise intervention alone (Exercise), or with diet modification and body weight maintenance (Maintenance), or with diet modification and energy restriction (Weight Loss). The primary outcome was change in VAT at 12 months. Secondary outcomes included cardiometabolic risk factors, functional status, and quality of life.

Results

A total of 148 participants had measured weight at 12 months. Despite loss of -1.6% ± 0.3% body fat and 4.1% ± 0.7% initial body weight, Weight Loss did not have statistically greater loss of VAT (-192.6 ± 185.2 cm3) or lean mass (-0.4 ± 0.3 kg) compared with Exercise (VAT = -21.9 ± 173.7 cm3; lean mass = 0.3 ± 0.3 kg). Quality of life improved in all groups with no differences between groups. No significant changes in physical function were observed. Weight Loss had significantly greater improvements in blood glucose (-8.3 ± 3.6 mg/dL, p < .05) and HDL-cholesterol (5.3 ± 1.9, p < .01) compared with Exercise. There were no group differences in the frequency of adverse events.

Conclusions

While moderate calorie restriction did not significantly decrease VAT in older adults at high risk for cardiometabolic disease, it did reduce total body fat and cardiometabolic risk factors without significantly more adverse events and lean mass loss.

Randomized trial comparing group size of periodic in-person sessions in a remotely delivered weight loss intervention

BACKGROUND

Few randomized studies have examined differential effects of group size in behavioral weight control, especially in hybrid programs that include Internet treatment approaches.

METHODS

Randomized controlled trial (n = 195) comparing a 4 month hybrid internet weight loss program coupled with monthly face to face groups of 100 persons (Large Group, LG; 1 group) or to the same approach with monthly groups of 20 persons (Small Group, SG; 4 groups). Repeated-measures mixed-model analysis with age and race as covariates were used to estimate primary (weight) and secondary outcomes, and to test group differences in change over time.

RESULTS

The sample was 46.3 years old ±10.4, 90.3% female, and 51.9% non-white, with BMI 37.9 ± 8.4 kg/m2. Participants in the LG were more likely to return for the 4-month assessment visit than those in the SG (p = 0.04). Participants randomized to both the LG and SG conditions experienced significant WL over time (no between group difference: -4.1 kg and -3.7 kg, respectively) and weight loss was positively associated with attendance at monthly meetings and logins to the website. Satisfaction with the program was high and similar in both groups (94.4% reported that they were "satisfied" or "very satisfied").

CONCLUSIONS

Using a hybrid approach of in-person and online weight loss interventions may be an effective way to reach larger and more diverse populations. Delivering the face to face component of the intervention in groups larger than those traditionally delivered (20-25 people) could increase the cost-effectiveness of group-based behavioral weight loss interventions.

CLINICAL TRIALS REGISTRATION NUMBER

NCT01615471 . Registered June 6, 2012. Registered retrospectively.

The association between previous success with weight loss through dietary change and success in a lifestyle modification program

Prior work has yielded mixed results regarding the association between previous weight loss and success in a current weight loss attempt. The present study evaluated differences in baseline psychosocial processes, changes in these over time, and weight loss during a yearlong behavioral weight loss program between individuals who have and have not previously been successful losing weight through self-regulating dietary intake. Individuals with prior success had greater weight losses over time than those without. Differences in baseline and change over time in some facets of motivation and self-efficacy were observed, but only differences in attendance accounted for differential weight loss. Prior success with dietary self-regulation may predict better adherence to and success in behavioral weight control programs. Evaluating the type of weight control efforts that have previously helped induce weight losses may help to better match individuals to treatments likely to yield success.

A systematic survey of the methods literature on the reporting quality and optimal methods of handling participants with missing outcome data for continuous outcomes in randomized controlled trials

OBJECTIVE

To conduct (1) a systematic survey of the reporting quality of simulation studies dealing with how to handle missing participant data (MPD) in randomized control trials and (2) summarize the findings of these studies.

STUDY DESIGN AND SETTING

We included simulation studies comparing statistical methods dealing with continuous MPD in randomized controlled trials addressing bias, precision, coverage, accuracy, power, type-I error, and overall ranking. For the reporting of simulation studies, we adapted previously developed criteria for reporting quality and applied them to eligible studies.

RESULTS

Of 16,446 identified citations, the 60 eligible generally had important limitations in reporting, particularly in reporting simulation procedures. Of the 60 studies, 47 addressed ignorable and 32 addressed nonignorable data. For ignorable missing data, mixed model was most frequently the best on overall ranking (9 times best, 34.6% of times tested) and bias (10, 55.6%). Multiple imputation was also performed well. For nonignorable data, mixed model was most frequently the best on overall ranking (7, 46.7%) and bias (8, 57.1%). Mixed model performance varied on other criteria. Last observation carried forward (LOCF) was very seldom the best performing, and for nonignorable MPD frequently the worst.

CONCLUSION

Simulation studies addressing methods to deal with MPD suffered from serious limitations. The mixed model approach was superior to other methods in terms of overall performance and bias. LOCF performed worst.

The use of support people to improve the weight-related and psychological outcomes of adults with obesity: A randomised controlled trial

OBJECTIVES

To investigate whether training individuals from the personal networks of adults with obesity in the skills of motivational interviewing enhances the anthropometric and psychological outcomes of a cognitive-behavioural weight loss intervention.

METHODS

Adults with obesity (N = 201) were randomised to participate in 26 sessions of cognitive behaviour therapy (CBT) for weight loss either alone (CBT-A) or with the addition of a support person (CBT-SP). Outcomes were assessed at the end of the 12-month intervention and at a follow-up one year later.

RESULTS

Analyses indicated negligible additive effect for the CBT-SP versus the CBT-A condition, although the quality of the patient's relationship with their support person predicted the anthropometric outcomes. Across conditions, significant improvements were observed for all anthropometric (weight, body mass index, and waist circumference) and psychological (self efficacy, weight-related quality of life, weight satisfaction, and binge eating) variables between baseline and post-treatment, and baseline and the follow-up.

CONCLUSIONS

The benefits of the cognitive-behavioural weight loss program were found to extend to psychological variables. Yet the lack of evidence for the additive benefits of including support people in treatment suggests a need to develop more effective training programs for support people in weight management.

TRIAL REGISTRATION

anzctr.org.au Trial ID: ACTRN12611000509965.

Liraglutide Improves Water Maze Learning and Memory Performance While Reduces Hyperphosphorylation of Tau and Neurofilaments in APP/PS1/Tau Triple Transgenic Mice

The purpose of this study was to explore how liraglutide affects AD-like pathology and cognitive function in APP/PS1/Tau triple transgenic (3 × Tg) Alzheimer disease (AD) model mice. Male 3 × Tg mice and C57BL/6 J mice were treated for 8 weeks with liraglutide (300 μg/kg/day, subcutaneous injection) or saline. Levels of phosphorylated tau, neurofilaments (NFs), extracellular signal-regulated kinase (ERK), and c-Jun N-terminal kinase (JNK) in brain tissues were assessed with western blots. Fluoro-Jade-B labeling were applied to detect pathological changes. The Morris water maze (MWM) was used to assess the spatial learning and memory. Liraglutide decreased levels of hyperphosphorylated tau and NFs in 3 × Tg liraglutide-treated (Tg + LIR) mice, increased ERK phosphorylation, and decreased JNK phosphorylation. Liraglutide also decreased the number of degenerative neurons in the hippocampus and cortex of Tg + LIR mice, and shortened their escape latencies and increased their hidden platform crossings in the MWM task. Liraglutide did not significantly affect the animals' body weight (BW) or fasting blood glucose. Liraglutide can reduce hyperphosphorylation of tau and NFs and reduce neuronal degeneration, apparently through alterations in JNK and ERK signaling, which may be related to its positive effects on AD-like learning and memory impairment.

Reduced Sufentanil Doses are Effective for Postoperative Analgesia After Ductal Closure in Extremely Premature Infants: A 10 Years Retrospective Cohort Study

OBJECTIVES

The objective of the study was to assess the efficacy of reduced sufentanil doses for postoperative analgesia following surgical ductal closure in extremely premature infants.

METHODS

This was a retrospective, single-center, cohort study comparing 2 sufentanil dosing regimens used between 2001 and 2010 and included all infants born at <28 weeks of gestation with surgical ductal closure. Sufentanil doses were reduced in 2007 as a standard of care. Time was divided into 3 epochs to distinguish the effects of practice changes over time from the effects of sufentanil dose change: epoch 1 (2001 to 2004), epoch 2 (May 2005 to 2007), and epoch 3 (June 2007 to 2010).

RESULTS

A total of 109 of 114 eligible infants were analyzed (mean [±SD], gestational age: 25.1 [±1.1] wk; mean [±SD], birth weight: 756 [±144] g). Median sufentanil doses were significantly higher during epochs 1 and 2 (0.1 to 0.2 µg/kg/h) than during epoch 3 (0.03 to 0.04 µg/kg/h) (P<0.0001). EDIN (Echelle de Douleur et d'Inconfort du Nouveau-né) pain scores were mostly ≤4 throughout the study period and their changes over time were not contemporaneous with the reduction in sufentanil doses; they were lower during epoch 1 versus epochs 2 and 3 (P<0.0001) and comparable between epochs 2 and 3. Midazolam doses and paracetamol use were not higher during epoch 3 as compared with epochs 1 and 2. No difference in opioid-related adverse events was observed between the 3 epochs.

CONCLUSION

Our study supports the use of low continuous intravenous sufentanil doses, consistent with morphine doses currently recommended in this population.

The effect of three different ad libitum diets for weight loss maintenance: a randomized 18-month trial

PURPOSE

To test the effect of three diets in their ability to sustain weight loss and improve type 2 diabetes (T2D) and cardiovascular disease (CVD) risk markers after 18-month intervention.

METHODS

Following a ≥8 % weight loss, 131 healthy, overweight/obese (BMI ± SD 31.5 ± 2.6 kg/m2) men (n = 55) and women (n = 76) aged 28.2 ± 4.8 years were randomized to either 1. Moderate fat (40 E%) with 20 E% MUFA and low in glycemic index (GI) (MUFA, n = 54), 2. Low fat (25 E%) and medium in GI (LF, n = 51) or 3. Control (35 E% fat) and high in GI (CTR, n = 26) all with similar protein content, and all provided ad libitum. First 6-month intervention with 100 % food provision (previously reported) following 12 months of moderately intensive intervention with 20 % food provision now reported.

RESULTS

Attrition rate was higher in MUFA (63 %) than in LF (37 %, P = 0.019) and CTR (42 %, P = 0.09) group. Weight regain in completers was not different between groups (mean ± SEM), MUFA 7.1 ± 2.1 % versus LF 5.6 ± 1.3 % versus CTR 7.2 ± 1.5 %, nor was body fat regain, MUFA 4.8 ± 1.0 % versus LF 4.7 ± 0.8 % versus CTR 5.7 ± 0.6 %. The MUFA group reduced LDL/HDL ratio by -0.47 ± 0.09 compared with -0.23 ± 0.11 in LF (P < 0.05) and 0.06 ± 0.14 (P < 0.005) in CTR groups.

CONCLUSIONS

Weight regain or body composition did not differ between diets over 18 months. No effects on risk markers for T2D or CVD were found, with the exception of an improvement in the LDL/HDL ratio by the MUFA diet compared to the CTR diet. The LF diet was generally more satisfactory and the MUFA diet seemed more difficult to follow.

Best (but oft-forgotten) practices: intention-to-treat, treatment adherence, and missing participant outcome data in the nutrition literature

Among clinical trials of adequate size, randomization balances both known and unknown prognostic factors between trial arms, thus allowing an unbiased comparison of intervention and control. To preserve this benefit, all randomly assigned participants should be followed to study termination and analyzed in the arm to which they were allocated. There are 2 potential limitations in study implementation: 1) patients are nonadherent and continue with follow-up visits, or 2) patients are lost to follow-up and their outcome data are missing. Herein, we address these issues with an emphasis on binary outcomes, and discuss how authors of randomized trials should address issues of both noncompliance and missing data.

Long-term effects of very low-carbohydrate and high-carbohydrate weight-loss diets on psychological health in obese adults with type 2 diabetes: randomized controlled trial

BACKGROUND/OBJECTIVE

Very low-carbohydrate, high-fat (LC) diets are used for type 2 diabetes (T2DM) management, but their effects on psychological health remain largely unknown. This study examined the long-term effects of an LC diet on psychological health.

METHODS

One hundred and fifteen obese adults [age: 58.5 ± 7.1 years; body mass index: 34.6 ± 4.3 kg m(-2) ; HbA1c : 7.3 ± 1.1%] with T2DM were randomized to consume either an energy-restricted (~6 to 7 MJ), planned isocaloric LC or high-carbohydrate, low-fat (HC) diet, combined with a supervised exercise programme (3 days week(-1) ) for 1 year. Body weight, psychological mood state and well-being [Profile of Mood States (POMS), Beck Depression Inventory (BDI) and Spielberger State Anxiety Inventory (SAI)] and diabetes-specific emotional distress [Problem Areas in Diabetes (PAID) Questionnaire] and quality of life [QoL Diabetes-39 (D-39)] were assessed.

RESULTS

Overall weight loss was 9.5 ± 0.5 kg (mean ± SE), with no difference between groups (P = 0.91 time × diet). Significant improvements occurred in BDI, POMS (total mood disturbance and the six subscales of anger-hostility, confusion-bewilderment, depression-dejection, fatigue-inertia, vigour-activity and tension-anxiety), PAID (total score) and the D-39 dimensions of diabetes control, anxiety and worry, sexual functioning and energy and mobility, P < 0.05 time. SAI and the D-39 dimension of social burden remained unchanged (P ≥ 0.08 time). Diet composition had no effect on the responses for the outcomes assessed (P ≥ 0.22 time × diet).

CONCLUSION

In obese adults with T2DM, both diets achieved substantial weight loss and comparable improvements in QoL, mood state and affect. These results suggest that either an LC or HC diet within a lifestyle modification programme that includes exercise training improves psychological well-being.

Randomized Controlled Trial of Exercise for ADHD and Disruptive Behavior Disorders

PURPOSE

The objective of this study is to test the feasibility and impact of a 10-wk after-school exercise program for children with attention deficit hyperactivity disorder and/or disruptive behavior disorders living in an urban poor community.

METHODS

Children were randomized to an exercise program (n = 19) or a comparable but sedentary attention control program (n = 16). Cognitive and behavioral outcomes were collected pre-/posttest. Intent-to-treat mixed models tested group-time and group-time-attendance interactions. Effect sizes were calculated within and between groups.

RESULTS

Feasibility was evidenced by 86% retention, 60% attendance, and average 75% maximum HR. Group-time results were null on the primary outcome, parent-reported executive function. Among secondary outcomes, between-group effect sizes favored exercise on hyperactive symptoms (d = 0.47) and verbal working memory (d = 0.26), and controls on visuospatial working memory (d = -0.21) and oppositional defiant symptoms (d = -0.37). In each group, within-group effect sizes were moderate to large on most outcomes (d = 0.67 to 1.60). A group-time-attendance interaction emerged on visuospatial working memory (F[1,33] = 7.42, P < 0.05), such that attendance to the control program was related to greater improvements (r = 0.72, P < 0.01), whereas attendance to the exercise program was not (r = 0.25, P = 0.34).

CONCLUSIONS

Although between-group findings on the primary outcome, parent-reported executive function, were null, between-group effect sizes on hyperactivity and visuospatial working memory may reflect adaptations to the specific challenges presented by distinct formats. Both groups demonstrated substantial within-group improvements on clinically relevant outcomes. Findings underscore the importance of programmatic features, such as routines, engaging activities, behavior management strategies, and adult attention, and highlight the potential for after-school programs to benefit children with attention deficit hyperactivity disorder and disruptive behavior disorder living in urban poverty where health needs are high and services resources few.

Imputation strategies for blood pressure data nonignorably missing due to medication use

Background Underlying or untreated blood pressure (BP) is often an outcome of interest, but is unobservable when study participants are on anti-hypertensive medications. Untreated levels are not missing at random but would be higher among those on such medication. In such cases, standard methods of analysis may lead to bias.

Purpose BPs obtained at the private physician's office (out-of-study BPs) at the time of prescription of anti-hypertensive medications were available from Phase II of the Trials of Hypertension Prevention (TOHP) and were used to adjust for the potential bias.

Methods Observed out-of-study BPs were used to estimate the conditional expectation and variance of the unobserved unmedicated study BPs. For those with no physician data, imputation from bootstrap samples of out-of-study BPs was used. An iterative method based on the EM algorithm was used to estimate the unknown study parameters in a random-effects model using multiple imputations. This was compared to an alternative model for the out-of-study BPs based on a theoretical truncated normal distribution, and to standard analyses, including both multivariate repeated measures and last-observation-carried-forward (LOCF) analyses, using data from Phase II of TOHP.

Results Differences between methods were seen in the decline in BP over time in the reference group, where the changes from baseline to 36 months were 3.0 in univariate analyses, 2.4 using LOCF, and 2.6 in the multivariate analysis, compared to 2.0 or 1.7 in the imputation analyses, depending on the number of physician visits. Estimated intervention effects tended to be slightly larger using the imputation methods. Limitations out-of-study measures may not be available for other studies.

Conclusions Because the proposed strategy was based on an empirically observed distribution for out-of-study BP, fewer assumptions about the missing data were made. These data may be useful in suggesting imputation strategies for other studies.

Effects of Variety Support on Exercise-Related Well-Being

BACKGROUND

The purpose of this study was to experimentally examine the extent to which variety support in a resistance exercise program influences exercise-related well-being among inactive adults.

METHODS

A sample of 121 inactive university students were randomly assigned and participated in either a high or low variety support 6-week exercise program. Measures of exercise-related perceived variety, positive affect, negative affect, and subjective vitality were completed at baseline, after 3 weeks, and after 6 weeks (i.e. post-test).

RESULTS

Through use of structural equation modelling, the results showed that for those who completed measures at post-test (i.e. n = 55), and for all participants who received variety support (i.e. a modified intention-to-treat analysis; N = 121), exercise-related variety support indirectly explained higher levels of exercise-related positive affect, and subjective vitality, and lower levels of negative affect, through the mediating role of perceived variety.

CONCLUSIONS

The provision of variety support in a resistance exercise program influences exercise-related well-being through perceptions of variety. Results are discussed in relation to the potential utility of providing variety support to promote exercise-related well-being in people who are physically inactive.

From last supper to self-initiated weight loss: Pretreatment weight change may be more important than previously thought

OBJECTIVE

Evaluate the association between pretreatment and during-treatment weight change, as well as differences in self-regulation between those who gain weight, remain weight stable, and lose weight pretreatment.

METHODS

Data from the first 6 months of a behavioral weight loss study were used. Participants (n = 283) were weighed at two assessment points (screening visit and baseline) prior to the start of treatment and at every treatment session. Participants were divided into those who gained weight, remained weight stable, or lost weight between the screening visit and the first treatment session.

RESULTS

Pretreatment weight change was not significantly associated with during-treatment change. Weight change from the screening visit to month 6 was significantly different by category, with losses of 11% and 7% for those who lost and gained weight pretreatment, respectively. Weight change from first treatment session to month 6 was not different by category. Poorer self-regulation was associated with pretreatment weight gain and better self-regulation with pretreatment weight loss.

CONCLUSIONS

Pretreatment weight change may not relate to success during behavioral weight loss treatment. Researchers should carefully consider when the "baseline" assessment takes place to reduce bias introduced by pretreatment weight change. Poorer self-regulation may place individuals at risk for weight gain prior to treatment.

Elearning approaches to prevent weight gain in young adults: A randomized controlled study

OBJECTIVE

Preventing obesity among young adults should be a preferred public health approach given the limited efficacy of treatment interventions. This study examined whether weight gain can be prevented by online approaches using two different behavioral models, one overtly directed at obesity and the other covertly.

METHODS

A three-group parallel randomized controlled intervention was conducted in 2012-2013; 20,975 young adults were allocated a priori to one control and two "treatment" groups. Two treatment groups were offered online courses over 19 weeks on (1) personal weight control ("Not the Ice Cream Van," NTICV) and, (2) political, environmental, and social issues around food ("Goddess Demetra," "GD"). Control group received no contact. The primary outcome was weight change over 40 weeks.

RESULTS

Within-group 40-week weight changes were different between groups (P < 0.001): Control (n = 2,134): +2.0 kg (95% CI = 1.5, 2.3 kg); NTICV (n = 1,810): -1.0 kg (95% CI = -1.3, -0.5); and GD (n = 2,057): -1.35 kg (95% CI = -1.4 to -0.7). Relative risks for weight gain vs.

CONTROL

NTICV = 0.13 kg (95% CI = 0.10, 0.15), P < 0.0001; GD = 0.07 kg (95% CI = 0.05, 0.10), P < 0.0001.

CONCLUSIONS

Both interventions were associated with prevention of the weight gain observed among control subjects. This low-cost intervention could be widely transferable as one tool against the obesity epidemic. Outside the randomized controlled trial setting, it could be enhanced using supporting advertising and social media.

Effects of carbohydrate quantity and glycemic index on resting metabolic rate and body composition during weight loss

OBJECTIVE

To examine the effects of diets varying in carbohydrate and glycemic index (GI) on changes in body composition, resting metabolic rate (RMR), and metabolic adaptation during and after weight loss.

METHODS

Adults with obesity (n = 91) were randomized to one of four provided-food diets for 17 weeks. Diets differed in percentage energy from carbohydrate (55% or 70%) and GI (low or high) but were matched for protein, fiber, and energy. Body weight, body composition, RMR, and metabolic adaptation (measured RMR-predicted RMR) were measured during weight loss and subsequent weight stability.

RESULTS

No effect of dietary carbohydrate content or GI on body weight loss or percentage of weight lost as fat mass (FM) was observed. Measured RMR was significantly lower (-226 kJ/day [95% CI: -314 to -138 kJ/day], P < 0.001) than predicted RMR following weight loss, but this difference was attenuated after 5 weeks of weight stability. Metabolic adaptation did not differ by dietary carbohydrate content or GI and was not associated with weight regain 12 months later.

CONCLUSIONS

Moderate-carbohydrate and low-GI diets did not preferentially reduce FM, preserve lean mass, or attenuate metabolic adaptation during weight loss compared to high-carbohydrate and high-GI diets.

Best (but oft-forgotten) practices: designing, analyzing, and reporting cluster randomized controlled trials

Cluster randomized controlled trials (cRCTs; also known as group randomized trials and community-randomized trials) are multilevel experiments in which units that are randomly assigned to experimental conditions are sets of grouped individuals, whereas outcomes are recorded at the individual level. In human cRCTs, clusters that are randomly assigned are typically families, classrooms, schools, worksites, or counties. With growing interest in community-based, public health, and policy interventions to reduce obesity or improve nutrition, the use of cRCTs has increased. Errors in the design, analysis, and interpretation of cRCTs are unfortunately all too common. This situation seems to stem in part from investigator confusion about how the unit of randomization affects causal inferences and the statistical procedures required for the valid estimation and testing of effects. In this article, we provide a brief introduction and overview of the importance of cRCTs and highlight and explain important considerations for the design, analysis, and reporting of cRCTs by using published examples.

Levator hiatal area as a risk factor for cystocele recurrence after surgery: a prospective study

OBJECTIVE

To investigate whether increased levator hiatal area, measured preoperatively, was independently associated with anatom-ical cystocele recurrence 12 months after anterior colporrhaphy.

DESIGN

Multicentre prospective cohort study.

SETTING

Nine teaching hospitals in the Netherlands.

POPULATION

Women planned for conventional anterior colporrhaphy without mesh.

METHODS

Women underwent physical examination, translabial three-dimensional (3D) ultrasound and magnetic resonance imaging (MRI) prior to surgery. At 12 months after surgery the physical examination was repeated.

MAIN OUTCOME MEASURES

Women with and without anatomical cystocele recurrence were compared to assess the association with levator hiatal area on 3D ultrasound, levator hiatal area on MRI, and potential confounding factors. The receiver operating characteristic (ROC) curve was created to quantify the discriminative ability of using levator hiatal area to predict anatomical cystocele recurrence.

RESULTS

Of 139 included women, 76 (54.7%) had anatomical cystocele recurrence. Preoperative stage 3 or 4 and increased levator hiatal area during Valsalva on ultrasound were significantly associated with cystocele recurrence, with odds ratios of 3.47 (95% confidence interval, 95% CI 1.66-7.28) and 1.06 (95% CI 1.01-1.11) respectively. The area under the ROC curve was 0.60 (95% CI 0.51-0.70) for levator hiatal area during Valsalva on ultrasound, and 0.65 (95% CI 0.55-0.71) for preoperative Pelvic Organ Prolapse Quantification (POP-Q) stage.

CONCLUSIONS

Increased levator hiatal area during Valsalva on ultrasound prior to surgery and preoperative stage 3 or 4 are independent risk factors for anatomical cystocele recurrence after anterior colporrhaphy; however, increased levator hiatal area as the sole factor for predicting anatomical cystocele recurrence after surgery shows poor test characteristics.

The steps to health randomized trial for arthritis: a self-directed exercise versus nutrition control program

BACKGROUND

Despite the established benefits of exercise for adults with arthritis, participation is low. Safe, evidence-based, self-directed programs, which have the potential for high reach at a low cost, are needed.

PURPOSE

To test a 12-week, self-directed, multicomponent exercise program for adults with arthritis.

DESIGN

Randomized controlled trial. Data were collected from 2010 to 2012. Data were analyzed in 2013 and 2014.

SETTING/PARTICIPANTS

Adults with arthritis (N=401, aged 56.3 [10.7] years, 85.8% women, 63.8% white, 35.2% African American, BMI of 33.0 [8.2]) completed measures at a university research center and participated in a self-directed exercise intervention (First Step to Active Health(®)) or nutrition control program (Steps to Healthy Eating).

INTERVENTION

Intervention participants received a self-directed multicomponent exercise program and returned self-monitoring logs for 12 weeks.

MAIN OUTCOME MEASURES

Self-reported physical activity, functional performance measures, and disease-specific outcomes (arthritis symptoms and self-efficacy) assessed at baseline, 12 weeks, and 9 months.

RESULTS

Participants in the exercise condition showed greater increases in physical activity than those in the nutrition control group (p=0.01). Significant improvements, irrespective of condition, were seen in lower body strength, functional exercise capacity, lower body flexibility, pain, fatigue, stiffness, and arthritis management self-efficacy (p values<0.0001). More adverse events occurred in the exercise than nutrition control condition, but only one was severe and most were expected with increased physical activity.

CONCLUSIONS

The exercise program improves physical activity, and both programs improve functional and psychosocial outcomes. Potential reasons for improvements in the nutrition control condition are discussed. These interventions have the potential for large-scale dissemination. This study is registered at Clinicaltrials.gov NCT01172327.

Intra-articular injection of mesenchymal stem cells for the treatment of osteoarthritis of the knee: a proof-of-concept clinical trial

Mesenchymal stem cells (MSCs) are known to have a potential for articular cartilage regeneration. However, most studies focused on focal cartilage defect through surgical implantation. For the treatment of generalized cartilage loss in osteoarthritis, an alternative delivery strategy would be more appropriate. The purpose of this study was to assess the safety and efficacy of intra-articular injection of autologous adipose tissue derived MSCs (AD-MSCs) for knee osteoarthritis. We enrolled 18 patients with osteoarthritis of the knee and injected AD MSCs into the knee. The phase I study consists of three dose-escalation cohorts; the low-dose (1.0 × 10(7) cells), mid-dose (5.0 × 10(7)), and high-dose (1.0 × 10(8)) group with three patients each. The phase II included nine patients receiving the high-dose. The primary outcomes were the safety and the Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) at 6 months. Secondary outcomes included clinical, radiological, arthroscopic, and histological evaluations. There was no treatment-related adverse event. The WOMAC score improved at 6 months after injection in the high-dose group. The size of cartilage defect decreased while the volume of cartilage increased in the medial femoral and tibial condyles of the high-dose group. Arthroscopy showed that the size of cartilage defect decreased in the medial femoral and medial tibial condyles of the high-dose group. Histology demonstrated thick, hyaline-like cartilage regeneration. These results showed that intra-articular injection of 1.0 × 10(8) AD MSCs into the osteoarthritic knee improved function and pain of the knee joint without causing adverse events, and reduced cartilage defects by regeneration of hyaline-like articular cartilage.

Comparison of results from different imputation techniques for missing data from an anti-obesity drug trial

Background

In randomised trials of medical interventions, the most reliable analysis follows the intention-to-treat (ITT) principle. However, the ITT analysis requires that missing outcome data have to be imputed. Different imputation techniques may give different results and some may lead to bias. In anti-obesity drug trials, many data are usually missing, and the most used imputation method is last observation carried forward (LOCF). LOCF is generally considered conservative, but there are more reliable methods such as multiple imputation (MI).

Objectives

To compare four different methods of handling missing data in a 60-week placebo controlled anti-obesity drug trial on topiramate.

Methods

We compared an analysis of complete cases with datasets where missing body weight measurements had been replaced using three different imputation methods: LOCF, baseline carried forward (BOCF) and MI.

Results

561 participants were randomised. Compared to placebo, there was a significantly greater weight loss with topiramate in all analyses: 9.5 kg (SE 1.17) in the complete case analysis (N = 86), 6.8 kg (SE 0.66) using LOCF (N = 561), 6.4 kg (SE 0.90) using MI (N = 561) and 1.5 kg (SE 0.28) using BOCF (N = 561).

Conclusions

The different imputation methods gave very different results. Contrary to widely stated claims, LOCF did not produce a conservative (i.e., lower) efficacy estimate compared to MI. Also, LOCF had a lower SE than MI.

Efficacy of Constraint-Induced Movement Therapy in Early Stroke Rehabilitation: A Randomized Controlled Multisite Trial

BACKGROUND

There is limited evidence for the effects of constraint-induced movement therapy (CIMT) in the early stages of stroke recovery.

OBJECTIVE

To evaluate the effect of a modified CIMT within 4 weeks poststroke.

METHODS

This single-blinded randomized multisite trial investigated the effects of CIMT in 47 individuals who had experienced a stroke in the preceding 26 days. Patients were allocated to a CIMT or a usual care (control) group. The CIMT program was 3 h/d over 10 consecutive working days, with mitt use on the unaffected arm for up to 90% of waking hours. The follow-up time was 6 months. The primary outcome was the Wolf Motor Function test (WMFT) score. Secondary outcomes were the Fugl-Meyer upper-extremity motor score, Nine-Hole Peg test (NHPT) score, the arm use ratio, and the Stroke Impact Scale. Analyses of covariance with adjustment for baseline values were used to assess differences between the groups.

RESULTS

After treatment, the mean timed WMFT score was significantly better in the CIMT group compared with the control group. Moreover, posttreatment dexterity, as tested with the NHPT, was significantly better in the CIMT group, whereas the other test results were similar in both the groups. At the 6-month follow-up, the 2 groups showed no significant difference in arm impairment, function, or use in daily activities.

CONCLUSIONS

Despite a favorable effect of CIMT on timed movement measures immediately after treatment, significant effects were not found after 6 months.

Long-term effects of 4 popular diets on weight loss and cardiovascular risk factors: a systematic review of randomized controlled trials

BACKGROUND

We conducted a systematic review to examine the efficacy of the Atkins, South Beach, Weight Watchers (WW), and Zone diets, with a particular focus on sustained weight loss at ≥12 months.

METHODS AND RESULTS

We systematically searched MEDLINE, EMBASE, and the Cochrane Library of Clinical Trials to identify randomized controlled trials (RCTs) published in English with follow-up ≥4 weeks that examined the effects of these 4 popular diets on weight loss and cardiovascular risk factors. We identified 12 RCTs (n=2559) with follow-up ≥12 months: 10 versus usual care (5 Atkins, 4 WW, and 1 South Beach) and 2 head-to-head (1 of Atkins, WW, and Zone, and 1 of Atkins, Zone, and control). At 12 months, the 10 RCTs comparing popular diets to usual care revealed that only WW was consistently more efficacious at reducing weight (range of mean changes: -3.5 to -6.0 kg versus -0.8 to -5.4 kg; P<0.05 for 3/4 RCTs). However, the 2 head-to-head RCTs suggest that Atkins (range: -2.1 to -4.7 kg), WW (-3.0 kg), Zone (-1.6 to -3.2 kg), and control (-2.2 kg) all achieved modest long-term weight loss. Twenty-four-month data suggest that weight lost with Atkins or WW is partially regained over time.

CONCLUSIONS

Head-to-head RCTs, providing the most robust evidence available, demonstrated that Atkins, WW, and Zone achieved modest and similar long-term weight loss. Despite millions of dollars spent on popular commercial diets, data are conflicting and insufficient to identify one popular diet as being more beneficial than the others.

Current pharmacotherapy for obesity: extrapolation of clinical trials data to practice

INTRODUCTION

When used prudently and in combination with lifestyle modification, pharmacotherapy has an important role in the management of obesity.

AREAS COVERED

This review covers targets for antiobesity drugs, challenges and limitations, failed translation of basic science to clinical practice, methodological and regulatory issues in clinical trials of pharmacotherapy, efficacy and risks of drugs currently approved for obesity, and clinical practice issues when using antiobesity drugs with emphasis on recently approved drugs.

EXPERT OPINION

Drugs currently approved for long-term therapy of obesity offer modest benefits for most patients, substantial benefits for some and no benefits for others. Numerous methodological problems including exclusion of the type of patients who are most often seen in clinical practices, inadequate enrollment of men and minorities, exclusion of patients taking antidepressants, high dropout rates, lack of follow-up after treatment discontinuation, and less than ideal imputation methods in data analysis limit the interpretation of clinical trials data and generalizability. Single-drug therapies offer small to moderate weight-loss benefits, but are generally better tolerated. Efficacy is enhanced with combination drug therapies, but so are the hazards. Clinicians should base their decisions on the expected and observed benefit-to-risk balance.

Health effect of the New Nordic Diet in adults with increased waist circumference: a 6-mo randomized controlled trial

BACKGROUND

The regional Mediterranean Diet has been associated with lower risk of disease.

OBJECTIVE

We tested the health effects of the New Nordic Diet (NND), which is a gastronomically driven regional, organic, and environmentally friendly diet, in a carefully controlled but free-living setting.

DESIGN

A total of 181 centrally obese men and women, with a mean (range) age of 42 y (20-66 y), body mass index (in kg/m(2)) of 30.2 (22.6-47.3), and waist circumference of 100 cm (80-138 cm) were randomly assigned to receive either the NND (high in fruit, vegetables, whole grains, and fish) or an average Danish diet (ADD) for 26 wk. Participants received cookbooks and all foods ad libitum and free of charge by using a shop model. The primary endpoint was the weight change analyzed by both completer and intention-to-treat analyses.

RESULTS

A total of 147 subjects [81% (NND 81%; ADD 82%)] completed the intervention. A high dietary compliance was achieved, with significant differences in dietary intakes between groups. The mean (±SEM) weight change was -4.7 ± 0.5 kg for the NND compared with -1.5 ± 0.5 kg for the ADD (adjusted difference: -3.2 kg; 95% CI: -4.6, -1.8 kg; P < 0.001) for the completer analysis, and the difference was -3.0 kg (95% CI: -4.0, -2.1 kg) for the intention-to-treat analysis. The NND produced greater reductions in systolic blood pressure (adjusted difference: -5.1 mm Hg; 95% CI: -8.2, -2.1 mm Hg) and diastolic blood pressure (adjusted difference: -3.2 mm Hg; 95% CI: -5.7, -0.8 mm Hg) than did the ADD.

CONCLUSION

An ad libitum NND produces weight loss and blood pressure reduction in centrally obese individuals. This trial was registered at www.clinicaltrials.gov as NCT01195610.