Pre-surgical factors related to latent trajectories of 5-year weight loss for a diverse bariatric surgery population

BACKGROUND

Analyzing trajectories of weight loss may address how particular groups of patients respond to metabolic and bariatric surgery.

OBJECTIVES

The Bariatric Experience Long Term (BELONG) study was designed to use a theoretical model to examine determinants of weight loss and recurrence.

SETTING

Large integrated health system in Southern California with 11 surgical practices and 23 surgeons.

METHODS

A total of n = 1338 patients who had metabolic and bariatric surgery were surveyed before surgery to measure factors related to median percent total weight loss (%TWL) over 5 years. Longitudinal weight data were available for n = 1024 (76.5% of the sample). Data were analyzed using latent growth mixture models (GMM) to estimate trajectories of weight change separately for gastric sleeve and bypass operations. These trajectories were then described using relevant variables from the baseline survey.

RESULTS

For both gastric sleeve (n = 733) and bypass (n = 291) operations, 3 latent trajectories of median %TWL were found corresponding to most, moderate, and least %TWL. Sleeve trajectories were distinguished by body mass index at surgery and geocoded environmental factors. Bypass trajectories varied by self-reported and geocoded environmental factors, comorbidity burden, race, experiential avoidance, and weight control strategies.

CONCLUSIONS

Future research should examine the role of the built and perceived environment in surgical weight loss. Bariatric practices should focus less on the presurgical period for predictors of long-term weight loss and begin efforts to monitor real-time patient-reported outcomes to help tailor intervention strategies for patients who either do not lose an expected amount of weight or who begin to experience weight recurrence.

Air pollution and the sequelae of COVID-19 patients: A multistate analysis

IMPORTANCE

Recent evidence links air pollution to the severity COVID-19 symptoms and to death from the disease. To date, however, few studies have assessed whether air pollution affects the sequelae to more severe states or recovery from COVID-19 in a cohort with individual data.

OBJECTIVE

To assess how air pollution affects the transition to more severe COVID-19 states or to recovery from COVID-19 infection in a cohort with detailed patient information.

DESIGN AND OUTCOMES

We used a cohort design that followed patients admitted to hospital in the Kaiser Permanente Southern California (KPSC) Health System, which has 4.7 million members with characteristics similar to the general population. Enrollment began on 06/01/2020 and ran until 01/30/2021 for all patients admitted to hospital while ill with COVID-19. All possible states of sequelae were considered, including deterioration to intensive care, to death, discharge to recovery, or discharge to death. Transition risks were estimated with a multistate model. We assessed exposure using chemical transport model that predicted ambient concentrations of nitrogen dioxide, ozone, and fine particulate matter (PM2.5) at a 1 km scale.

RESULTS

Each increase in PM2.5 concentration equivalent to the interquartile range was associated with increased risk of deterioration to intensive care (HR of 1.16; 95% CI: 1.12-1.20) and deterioration to death (HR of 1.11; 95% CI: 1.04-1.17). Results for ozone were consistent with PM2.5 effects, but ozone also affected the transition from recovery to death: HR of 1.24 (95% CI: 1.01-1.51). NO2 had weaker effects but displayed some elevated risks.

CONCLUSIONS

PM2.5 and ozone were significantly associated with transitions to more severe states while in hospital and to death after discharge from hospital. Reducing air pollution could therefore lead to improved prognosis for COVID-19 patients and a sustainable means of reducing the health impacts of coronaviruses now and in the future.

Baseline Psychosocial, Environmental, Health, and Behavioral Correlates of 1- and 3-Year Weight Loss After Bariatric Surgery

PURPOSE

Weight loss surgery is an effective, long-term treatment for severe obesity but individual response to surgery varies widely. The purpose of this study was to test a comprehensive theoretical model of factors that may be correlated with the greatest surgical weight loss at 1-3 years following surgery. Such a model would help determine what predictive factors to measure when patients are preparing for surgery that may ensure the best weight outcomes.

MATERIALS AND METHODS

The Bariatric Experience Long Term (BELONG) study collected self-reported and medical record-based baseline information as correlates of 1- and 3-year % total weight loss (TWL) in n = 1341 patients. Multiple linear regression was used to determine the associations between 120 baseline variables and %TWL.

RESULTS

Participants were 43.4 ± 11.3 years old, Hispanic or Black (52%; n = 699), women (86%; n = 1149), and partnered (72%; n = 965) and had annual incomes of ≥ $51,000 (60%; n = 803). A total of 1006 (75%) had 3-year follow-up weight. Regression models accounted for 10.1% of the variance in %TWL at 1-year and 13.6% at 3 years. Only bariatric operation accounted for a clinically meaningful difference (~ 5%) in %TWL at 1-year. At 3 years after surgery, only bariatric operation, Black race, and BMI ≥ 50 kg/m2 were associated with clinically meaningful differences in %TWL.

CONCLUSIONS

Our findings combined with many others support a move away from extensive screening and selection of patients at the time of surgery to a focus on improving access to this treatment.

Effect of a Tobacco Cessation Intervention Incorporating Weight Management for Adults With Serious Mental Illness: A Randomized Clinical Trial

Importance

Tobacco smoking drives markedly elevated cardiovascular disease risk and preventable death in persons with serious mental illness, and these risks are compounded by the high prevalence of overweight/obesity that smoking cessation can exacerbate. Guideline-concordant combined pharmacotherapy and behavioral smoking cessation treatment improves abstinence but is not routinely offered in community settings, particularly to those not seeking to quit smoking immediately.

Objective

To determine the effectiveness of an 18-month pharmacotherapy and behavioral smoking cessation intervention incorporating weight management and support for physical activity in adults with serious mental illness interested in quitting smoking within 1 or 6 months.

Design, Setting, and Participants

This was a randomized clinical trial conducted from July 25, 2016, to March 20, 2020, at 4 community health programs. Adults with serious mental illness who smoked tobacco daily were included in the study. Participants were randomly assigned to intervention or control, stratified by willingness to try to quit immediately (within 1 month) or within 6 months. Assessors were masked to group assignment.

Interventions

Pharmacotherapy, primarily varenicline, dual-form nicotine replacement, or their combination; tailored individual and group counseling for motivational enhancement; smoking cessation and relapse prevention; weight management counseling; and support for physical activity. Controls received quitline referrals.

Main Outcome and Measures

The primary outcome was biochemically validated, 7-day point-prevalence tobacco abstinence at 18 months.

Results

Of the 298 individuals screened for study inclusion, 192 enrolled (mean [SD] age, 49.6 [11.7] years; 97 women [50.5%]) and were randomly assigned to intervention (97 [50.5%]) or control (95 [49.5%]) groups. Participants self-identified with the following race and ethnicity categories: 93 Black or African American (48.4%), 6 Hispanic or Latino (3.1%), 90 White (46.9%), and 9 other (4.7%). A total of 82 participants (42.7%) had a schizophrenia spectrum disorder, 62 (32.3%) had bipolar disorder, and 48 (25.0%) had major depressive disorder; 119 participants (62%) reported interest in quitting immediately (within 1 month). Primary outcome data were collected in 183 participants (95.3%). At 18 months, 26.4% of participants (observed count, 27 of 97 [27.8%]) in the intervention group and 5.7% of participants (observed count, 6 of 95 [6.3%]) in the control group achieved abstinence (adjusted odds ratio [OR], 5.9; 95% CI, 2.3-15.4; P < .001). Readiness to quit within 1 month did not statistically significantly modify the intervention's effect on abstinence. The intervention group did not have significantly greater weight gain than the control group (mean weight change difference, 1.6 kg; 95% CI, -1.5 to 4.7 kg).

Conclusions and Relevance

Findings of this randomized clinical trial showed that in persons with serious mental illness who are interested in quitting smoking within 6 months, an 18-month intervention with first-line pharmacotherapy and tailored behavioral support for smoking cessation and weight management increased tobacco abstinence without significant weight gain.

Trial Registration

ClinicalTrials.gov Identifier: NCT02424188.

Playground Location and Patterns of Use

Playgrounds have features that benefit visitors, including opportunities to engage in outdoor physical activity. We surveyed 1350 adults visiting 60 playgrounds across the USA in Summer 2021 to determine if distance to the playground from their residence was associated with weekly visit frequency, length of stay, and transportation mode to the site. About 2/3 of respondents living within ½ mile from the playground reported visiting it at least once per week compared with 14.1% of respondents living more than a mile away. Of respondents living within ¼ mile of playgrounds, 75.6% reported walking or biking there. After controlling for socio-demographics, respondents living within ½ mile of the playground had 5.1 times the odds (95% CI: 3.68, 7.04) of visiting the playground at least once per week compared with those living further away. Respondents walking or biking to the playground had 6.1 times the odds (95% CI: 4.23, 8.82) of visiting the playground at least once per week compared with respondents arriving via motorized transport. For public health purposes, city planners and designers should consider locating playgrounds ½ mile from all residences. Distance is likely the most important factor associated with playground use.

Playground Design: Contribution to Duration of Stay and Implications for Physical Activity

BACKGROUND

The study goal was to identify playground features associated with visitor length of stay and physical activity.

METHODS

We observed playground visitors over 4 days during summer 2021 in 60 playgrounds in 10 US cities, selected based on design, population density, and poverty levels. We observed 4278 visitors and documented their length of stay. We observed an additional 3713 visitors for 8 min, recording their playground location, activity level, and use of electronic media.

RESULTS

People stayed an average of 32 min (range 5 min-4 h). Stay time varied by group size, with larger groups staying longer. The presence of restrooms increased the likelihood of staying longer by 48%. Playground size, mature trees, swings, climbers, and spinners were associated with longer stays. When a teen was a part of the group observed, the group was 64% less likely to stay longer. The use of electronic media was associated with lower amounts of moderate-to-vigorous physical activity compared to non-media users.

CONCLUSIONS

To increase population-level physical activity and time spent outdoors, playground features associated with a longer stay should be considered when renovating or building new playgrounds.

Playground Design and Physical Activity

INTRODUCTION

This study compares traditional post-and-platform playgrounds with innovatively designed playgrounds to assess the degree to which design influences use and physical activity. Innovative playgrounds are defined as having (1) a variety of surface types; (2) naturalized and planted areas designed for play; (3) open-ended structures that do not dictate play sequences; (4) loose, movable equipment; and (5) not comprised solely of traditional post-and-platform structures. This study also examines how neighborhood contextual factors contribute to playground use and physical activity.

METHODS

The authors selected 30 traditional and 30 innovative playgrounds in 10 U.S. cities and used the System for Observing Play and Recreation in Communities to document the number and characteristics of users during 19 hourly observations over 1 week at each playground in the summer of 2021. Data were analyzed to identify the factors associated with the number of users and the amount of moderate-to-vigorous physical activity within each playground.

RESULTS

Innovative playgrounds attracted 2.5 times more users and generated almost 3 times as much moderate-to-vigorous physical activity. After controlling for playground size, population density, neighborhood poverty, and destination location, innovative playgrounds still attracted 43% more visitors than traditional playgrounds. Whereas playgrounds in high-poverty neighborhoods saw less overall use, innovatively designed playgrounds mitigated the difference by 60% compared with traditional playgrounds.

CONCLUSIONS

Playground characteristics that attract more users and are associated with more moderate-to-vigorous physical activity, such as design, size, and the number of unique features, should be integrated into future playground designs and renovations, with innovative designs prioritized for low-income neighborhoods.

Disparities in weight changes during the COVID-19 pandemic-related lockdown in youths

OBJECTIVE

This study evaluates whether changes in weight among school-aged youth in California due to the COVID-19 lockdown vary by social constructs of race/ethnicity and associated social factors.

METHODS

Including 160,472 youth aged 5 to 17 years enrolled at Kaiser Permanente Southern California, mixed effects models stratified by age group were fitted to estimate changes in distance from the median BMI-for-age from March 2020 to January 2021 (lockdown) compared with the same period before the pandemic.

RESULTS

Excess pandemic weight gain was higher among Black and Hispanic youth aged 5 to 17 years than among White and Asian youth; this difference was most pronounced in those aged 5 to 11 years. In youth aged 5 to 11 years, the distance from the median BMI-for-age increased by 1.72 kg/m2 (95% CI: 1.61-1.84) in Hispanic and 1.70 kg/m2 (95% CI: 1.47-1.94) in Black youth during the lockdown compared with 1.16 kg/m2 (95% CI: 1.02-1.29) in non-Hispanic White youth. The excess weight gain was also higher in youth with fewer neighborhood parks and those with state-subsidized health insurance.

CONCLUSIONS

The COVID-19 pandemic lockdown led to a gain of excess body weight, particularly for Black and Hispanic youth; this weight gain varied by social factors associated with race and ethnicity.

Abstract P510: Increase in Obesity Reduction Initiatives in San Francisco After Sugary Beverages Tax Implementation

A diet high in sugar sweetened beverages (SSB, has been shown to be associated with adverse health outcomes. Several cities across the US have implemented SSB taxes to decrease consumption and distribution of sugary drinks. Revenues generated from taxes were often allocated to fund public health programs and enhancements to reduce obesity. We examined efforts in San Francisco where the Sugary Drinks Distributor Tax (SDDT or “soda tax”) was implemented in 2018. SDDT legislation mandated the establishment of the Sugary Drinks Distributor Tax Advisory Committee (SDDTAC), responsible for making annual recommendations for the allocation of tax-generated revenues. We reviewed SDDTAC recommendations and funding for new and existing services that support public health through reduction and prevention of diet related diseases. We assessed if there was a significant increase in funding and number of health promotion programs implemented in San Francisco after the implementation of the SDDT. We documented obesity prevention initiatives resulting from increased tax revenue. We reviewed city government budget documents and press releases at least 1 year before tax implementation (2017) and 4 years post (2018-2022). We cataloged initiatives for adults and children including health education, nutrition and lifestyle, and community projects. The first full year of SDDT implementation (2018-19) saw the highest revenue generated at $16,097,908. Total revenue for the implementation period (2018-2021) was reported as $42,415,548. The revenue generated in the first six months of fiscal year (FY) 2018 was spent in FY2019-2020. During that period, the San Francisco Public Health Foundation awarded 26 one-year SDDT community grants - aligning with priority expenditure categories for SDDTAC - totaling $1,702,211. SDDTAC priority categories include decreasing consumption of sugary drinks, increasing water consumption, oral health, healthy food access, physical activity, and other (e.g. research/Community-Based Participatory Research, new innovations, etc.). [ACV1] In FY2019-2020 78% of SDDT revenues were spent on Healthy Communities, oral health, Healthy Food Purchasing Supplement grants and SF City Funded Agencies’ programming. The remaining 22% were spent on social media grants, infrastructure, and administrative costs. To address COVID-19, $1.65 million of unused funds from FY2019-20 supported food security and food distribution for vulnerable populations. Tax generated funding for 65 new or existing programs since implementation. New programs are funded each year: five new Policy Systems and Environmental Change programs were funded in FY2019-2020 and one new school-based program funded in FY2021-22. We observed a significant increase in number of health programs in San Francisco since SDDT implementation.

Neighborhood deprivation and residential property values do not affect weight loss at 1 or 3 years after bariatric surgery

OBJECTIVE

This study examined the association between individual- and neighborhood-level sociodemographic factors and surgical weight loss at 1 year (short term) and 3 years (long term).

METHODS

Data were obtained from the baseline survey of the BELONG (Bariatric Experience Long Term) prospective longitudinal cohort study. Individual-level self-reported data on sex, race and ethnicity, education, and household income were obtained by survey. Data from the 2010 US Census were used to calculate area Neighborhood Deprivation Index score and median value of owner-occupied housing units at the census tract level.

RESULTS

Patients (N = 1341) had a mean age of 43.4 (SD 11.3) years, were mostly female (86%), were mostly Black or Hispanic (52%), had some college education (83%), and had annual household incomes ≥$51,000 (55%). Percentage total weight loss was 25.8% (SD 9.0%) at year 1 and 22.2% (SD 10.5%) at year 3. Race and ethnicity and age were significant predictors of weight loss at 1 and 3 years with a small effect of self-reported household income at year 1. There were no significant associations between census tract-level Neighborhood Deprivation Index score or value of owner-occupied housing units and weight loss at either time point.

CONCLUSIONS

Health systems could improve the chances of weight-loss maintenance after surgery by addressing factors related to racial and ethnic disparities and to income disparities.

Air pollution and meteorology as risk factors for COVID-19 death in a cohort from Southern California

BACKGROUND

Recent evidence links ambient air pollution to COVID-19 incidence, severity, and death, but few studies have analyzed individual-level mortality data with high quality exposure models.

METHODS

We sought to assess whether higher air pollution exposures led to greater risk of death during or after hospitalization in confirmed COVID-19 cases among patients who were members of the Kaiser Permanente Southern California (KPSC) healthcare system (N=21,415 between 06-01-2020 and 01-31-2022 of whom 99.85 % were unvaccinated during the study period). We used 1 km resolution chemical transport models to estimate ambient concentrations of several common air pollutants, including ozone, nitrogen dioxide, and fine particle matter (PM_2.5). We also derived estimates of pollutant exposures from ultra-fine particulate matter (PM_0.1), PM chemical species, and PM sources. We employed Cox proportional hazards models to assess associations between air pollution exposures and death from COVID-19 among hospitalized patients.

FINDINGS

We found significant associations between COVID-19 death and several air pollution exposures, including: PM_2.5 mass, PM_0.1 mass, PM_2.5 nitrates, PM_2.5 elemental carbon, PM_2.5 on-road diesel, and PM_2.5 on-road gasoline. Based on the interquartile (IQR) exposure increment, effect sizes ranged from hazard ratios (HR) = 1.12 for PM_2.5 mass and PM_2.5 nitrate to HR ∼ 1.06-1.07 for other species or source markers. Humidity and temperature in the month of diagnosis were also significant negative predictors of COVID-19 death and negative modifiers of the air pollution effects.

INTERPRETATION

Air pollution exposures and meteorology were associated the risk of COVID-19 death in a cohort of patients from Southern California. These findings have implications for prevention of death from COVID-19 and for future pandemics.

Leveraging Implementation Science for Cardiovascular Health Equity: A Scientific Statement From the American Heart Association

Reducing cardiovascular disease disparities will require a concerted, focused effort to better adopt evidence-based interventions, in particular, those that address social determinants of health, in historically marginalized populations (ie, communities excluded on the basis of social identifiers like race, ethnicity, and social class and subject to inequitable distribution of social, economic, physical, and psychological resources). Implementation science is centered around stakeholder engagement and, by virtue of its reliance on theoretical frameworks, is custom built for addressing research-to-practice gaps. However, little guidance exists for how best to leverage implementation science to promote cardiovascular health equity. This American Heart Association scientific statement was commissioned to define implementation science with a cardiovascular health equity lens and to evaluate implementation research that targets cardiovascular inequities. We provide a 4-step roadmap and checklist with critical equity considerations for selecting/adapting evidence-based practices, assessing barriers and facilitators to implementation, selecting/using/adapting implementation strategies, and evaluating implementation success. Informed by our roadmap, we examine several organizational, community, policy, and multisetting interventions and implementation strategies developed to reduce cardiovascular disparities. We highlight gaps in implementation science research to date aimed at achieving cardiovascular health equity, including lack of stakeholder engagement, rigorous mixed methods, and equity-informed theoretical frameworks. We provide several key suggestions, including the need for improved conceptualization and inclusion of social and structural determinants of health in implementation science, and the use of adaptive, hybrid effectiveness designs. In addition, we call for more rigorous examination of multilevel interventions and implementation strategies with the greatest potential for reducing both primary and secondary cardiovascular disparities.

The association of 1-year weight loss from bariatric surgery and self-reported sleep: a prospective cohort

OBJECTIVE

This study examined the association of weight loss following bariatric surgery with self-reported sleep quality after accounting for other sleep-related factors.

METHODS

Participants were from the Bariatric Experience Long Term (BELONG) study. Participants completed a survey up to 6 months before surgery and approximately 1 year after surgery. The Pittsburgh Sleep Quality Index (PSQI) was used to measure sleep quality. One-year percentage total weight loss (%TWL) was determined from electronic medical records. Covariates included demographics, Charlson Comorbidity Index, geocoded variables to assess neighborhood quality, and physical activity. The authors assessed the association between %TWL at 1 year and PSQI component scores with separate cumulative logit models.

RESULTS

There were 997 participants in the analytic cohort. Participants were 86.2% women, 37.0% Hispanic, and 13.7% Black adults. Mean one-year %TWL was 26.3 (SD 8.7). Each 1% increase in %TWL was associated with a 3% better daytime dysfunction score (odds ratio = 1.03; 95% CI: 1.02-1.05) and a 2% better sleep quality score (odds ratio = 1.02; 95% CI: 1.00-1.03). No significant differences were found for the other PSQI components.

CONCLUSIONS

Weight loss from bariatric surgery was associated with better self-reported sleep at 1 year. For people undergoing bariatric surgery, there may be an added benefit of better sleep.

Cohort profile: The Bariatric Experience Long Term (BELONG): a long-term prospective study to understand the psychosocial, environmental, health and behavioural predictors of weight loss and regain in patients who have bariatric surgery

PURPOSE

The Bariatric Experience Long Term (BELONG) prospective study cohort was created to address limitations in the literature regarding the relationship between surgical weight loss and psychosocial, health, behaviour and environmental factors. The BELONG cohort is unique because it contains 70% gastric sleeve and 64% patients with non-white race/ethnicity and was developed with strong stakeholder engagement including patients and providers.

PARTICIPANTS

The BELONG cohort study included 1975 patients preparing to have bariatric surgery who completed a baseline survey in a large integrated health system in Southern California. Patients were primarily women (84%), either black or Hispanic (59%), with a body mass index (BMI) of 45.1±7.4 kg/m², age 43.3±11.5 years old, and 32% had at least one comorbidity.

FINDINGS TO DATE

A total of 5552 patients were approached before surgery between February 2016 and May 2017, and 1975 (42%) completed a baseline survey. A total of 1203 (73%) patients completed the year 1 and 1033 (74%) patients completed the year 3 postoperative survey. Of these survey respondents, 1341 at baseline, 999 at year 1, and 951 at year 3 were included in the analyses of all survey and weight outcome data. A total of 803 (60% of eligible patients) had survey data for all time points. Data collected were self-reported constructs to support the proposed theoretical model. Height, weight and BMI were abstracted from the electronic medical record to obtain the main outcomes of the study: weight loss and regain.

FUTURE PLANS

We will collect self-reported constructs and obtain height, weight and BMI from the electronic medical record 5 years after bariatric surgery between April 2022 and January 2023. We will also collect patient experiences using focus groups of 8-12 patients each throughout 2022.

Clustering of longitudinal physical activity trajectories among young females with selection of associated factors

We examined multi-level factors related to the longitudinal physical activity trajectories of adolescent girls to determine the important predictors for physical activity. The Trial of Activity in Adolescent Girls (TAAG) Maryland site recruited participants at age 14 (n = 566) and followed up with these girls at age 17 (n = 553) and age 23 (n = 442). Individual, social factors and perceived environmental factors were assessed by questionnaire; body mass index was measured at age 14 and age 17, and self-reported at age 23. Neighborhood factors were assessed by geographic information systems. The outcome, moderate-to-vigorous physical activity (MVPA) minutes in a day, was assessed from accelerometers. A mixture of linear mixed-effects models with double penalization on fixed effects and random effects was used to identify the intrinsic grouping of participants with similar physical activity trajectory patterns and the most relevant predictors within the groups simultaneously. Three clusters of participants were identified. Two hundred and forty participants were clustered as “maintainers” and had consistently low MVPA over time; 289 participants were clustered as “decreasers” who had decreasing MVPA over time; 39 participants were grouped as “increasers” and had increasing MVPA over time. Each of the three clusters has its own cluster-specific factors identified using the clustering method, indicating that each cluster has unique characteristics.

Association of masking policies with mask adherence and distancing during the SARS-COV-2 pandemic

BACKGROUND

Quantification of the impact of local masking policies may help guide future policy interventions to reduce SARS-COV-2 disease transmission. This study's objective was to identify factors associated with adherence to masking and social distancing guidelines.

METHODS

Faculty from 16 U.S. colleges and universities trained 231 students in systematic direct observation. They assessed correct mask use and distancing in public settings in 126 US cities from September 2020 through August 2021.

RESULTS

Of 109,999 individuals observed in 126 US cities, 48% wore masks correctly with highest adherence among females, teens and seniors and lowest among non-Hispanic whites, those in vigorous physical activity, and in larger groups (P < .0001). Having a local mask mandate increased the odds of wearing a mask by nearly 3-fold (OR = 2.99, P = .0003) compared to no recommendation. People observed in non-commercial areas were least likely to wear masks. Correct mask use was greatest in December 2020 and remained high until June 2021 (P < .0001). Masking policy requirements were not associated with distancing.

DISCUSSION

The strong association between mask mandates and correct mask use suggests that public policy has a powerful influence on individual behavior.

CONCLUSIONS

Mask mandates should be considered in future pandemics to increase adherence.

Transit Use and Health Care Costs: A Cross-sectional Analysis

INTRODUCTION

Greater transit use is associated with higher levels of physical activity, which is associated with lower health risks and better health outcomes. However, there is scant evidence about whether health care costs differ based on level of transit ridership.

METHODS

A sample (n=947) of members of Kaiser Permanente in the Portland, Oregon area were surveyed in 2015 about their typical use of various modes of travel including transit. Electronic medical record-derived health care costs were obtained among these members for the prior three years. Analysis examined proportional costs between High transit users (3+ days/week), Low transit users (1-2 days/week), and Non-users adjusting for age and sex, and then individually (base models) and together for demographic and health status variables.

RESULTS

In separate base models across individual covariates, High transit users had lower total health care costs (59-69% of Non-user's costs) and medication costs (31-37% of Non-users' costs) than Non-users. Low transit users also had lower total health care (69%-76% of Non-users' costs) and medication costs (43-57% transit of Non-user's costs) than Non-users. High transit users' outpatient costs were also lower (77-82% of Non-users). In fully-adjusted models, total health care and medication costs were lower among High transit users' (67% and 39%) and Low transit users' (75% and 48%) compared to Non-users, but outpatient costs did not differ by transit use.

CONCLUSIONS

Findings have implications for the potential cost benefit of encouraging and supporting more transit use, although controlled longitudinal and experimental evidence is needed to confirm findings and understand mechanisms.

Causal evaluation of the health effects of light rail line: A Natural Experiment

BACKGROUND AND OBJECTIVE

No research to date has causally linked built environment data with health care costs derived from clinically assessed health outcomes within the framework of longitudinal intervention design. This study examined the impact of light rail transit (LRT) line intervention on health care costs after controlling for mode-specific objectively assessed moderateto-vigorous physical activity (MVPA), participant-level neighborhood environmental measures, demographics, attitudinal predispositions, and residential choices.

DATA AND METHODS

Based on a natural experiment related to a new LRT line in Portland - 282 individuals divided into treatment and control groups were prospectively followed during the pre- and post-intervention periods. For each individual, we harness high-resolution data on Electronic Medical Record (EMR) based health care costs, mode-specific MVPA, survey-based travel behavior, attitudinal/perception information, and objectively assessed built environment measures. Simulation-assisted longitudinal grouped random parameter models are developed to gain more accurate insights into the effects of LRT line intervention.

RESULTS

Regarding the "average effect" of the LRT line intervention, no statistically significant reductions in health care costs were observed for the treated individuals over time. However, substantial heterogeneity was observed not only in the magnitude of effects but its direction as well after controlling for the within- and between-individual variations. For a subgroup of treated individuals, the LRT line opening decreased health care costs over time relative to the control group. Further comparative analysis based on the findings of heterogeneity-based models revealed that the effect of LRT intervention for the treated individuals differed by individual characteristics, attitudes/perceptions, and neighborhood level environmental features.

CONCLUSIONS

The study revealed the presence of significant effect modifiers and distinct subgroup structures in the data related to the effects of LRT line intervention on health care costs. Severe implications of ignoring unobserved heterogeneity are highlighted. Limitations and potential avenues for future research are discussed.

The Kaiser Permanente Research Bank Cancer Cohort: a collaborative resource to improve cancer care and survivorship

Background

The Kaiser Permanente Research Bank (KPRB) is collecting biospecimens and surveys linked to electronic health records (EHR) from approximately 400,000 adult KP members. Within the KPRB, we developed a Cancer Cohort to address issues related to cancer survival, and to understand how genetic, lifestyle and environmental factors impact cancer treatment, treatment sequelae, and prognosis. We describe the Cancer Cohort design and implementation, describe cohort characteristics after 5 years of enrollment, and discuss future directions.

Methods

Cancer cases are identified using rapid case ascertainment algorithms, linkage to regional or central tumor registries, and direct outreach to KP members with a history of cancer. Enrollment is primarily through email invitation. Participants complete a consent form, survey, and donate a blood or saliva sample. All cancer types are included.

Results

As of December 31, 2020, the cohort included 65,225 cases (56% female, 44% male) verified in tumor registries. The largest group was diagnosed between 60 and 69 years of age (31%) and are non-Hispanic White (83%); however, 10,076 (16%) were diagnosed at ages 18–49 years, 4208 (7%) are Hispanic, 3393 (5%) are Asian, and 2389 (4%) are Black. The median survival time is 14 years. Biospecimens are available on 98% of the cohort.

Conclusions

The KPRB Cancer Cohort is designed to improve our understanding of treatment efficacy and factors that contribute to long-term cancer survival. The cohort’s diversity - with respect to age, race/ethnicity and geographic location - will facilitate research on factors that contribute to cancer survival disparities.

Physical Activity Levels and Screen Time among Youth with Overweight/Obesity Using Mental Health Services

Youth with mental illness have higher levels of obesity than children in the general population. Both regular physical activity and limited screen time have been recommended to reduce and prevent childhood obesity. This study examines accelerometer-based moderate-vigorous physical activity (MVPA) and screen time among youth with overweight/obesity issues who are receiving mental health care. This study looked at a 12-month weight management randomized clinical trial for overweight/obese youth aged 8-18 years who are receiving mental health services. At baseline, MVPA was assessed using accelerometers, and screen time was self-reported. Among 100 youth, 43% were female, 44% were Black, and 48% were <13 years old. In an adjusted general linear model, higher levels of MVPA were associated with the younger age group (p = 0.012), male participants (p = 0.013), and lower BMI z-scores (p = 0.014). In a separate model, higher screen time was associated with participants who were Black (p = 0.007). Achieving optimal cardiovascular health at the population level requires an understanding of the groups that are most in need of additional assistance. These data reinforce that targeted lifestyle approaches to promote increased physical activity and decreased screen time among overweight/obese youth using mental health services may need additional tailoring for sex, age, and race subgroups.

Changes in Body Mass Index Among Children and Adolescents During the COVID-19 Pandemic

This study compares body mass index (BMI) of youths during the COVID-19 pandemic with BMI during the same period in 2019 to determine whether they experienced pandemic-related weight gain.

The Accuracy of Self-Reported Body Weight Is High but Dependent on Recent Weight Change and Negative Affect in Teenage Girls

BACKGROUND

Research studies often rely on self-reported weight to calculate body mass index. The present study investigated how the accuracy of self-reported body weight in adolescent girls is affected by overweight/obesity, race/ethnicity, and mental health factors.

METHODS

In a cohort of girls who participated in the Trial of Activity for Adolescent Girls at ages 11 and 17 (n = 588), self-reported and measured weight were compared, and linear regression models were fitted to model the over- or underreporting. The Center for Epidemiological Studies-Depression Scale (CES-D) was used to calculate depressive symptom subscales for negative affect, anhedonia and somatic symptoms.

RESULTS

Allowing 3% difference between self-reported and measured weight for the correct reporting of body weight, 59.2% of girls reported their weight correctly, 30.3% underreported (-5.8 ± 4.8 kg), and 10.5% overreported (4.3 ± 3.5 kg). The average difference between self-reported and measured body weight was -1.5 ± 4.3 kg (p < 0.001). Factors for misreporting body weight were overweight (β ± SE - 2.60 ± 0.66%), obesity (β ± SE - 2.41 ± 0.71%), weight change between ages 11 and 17 (β ± SE - 0.35 ± 0.04% for each kg), height change between ages 11 and 17 (β ± SE 0.29 ± 0.10% for each cm), and negative affect (β ± SE - 0.18 ± 0.08% for each score unit).

CONCLUSIONS

The difference between self-reported and measured body weight in adolescent girls is relatively small. However, the accuracy of self-reported body weight may be lower in girls with overweight or obesity, recent weight and height change, and higher negative affect.

Creating Built Environments That Expand Active Transportation and Active Living Across the United States: A Policy Statement From the American Heart Association

Physical activity is vital for the health and well-being of youth and adults, although the prevalence of physical activity continues to be low. Promoting active transportation or human-powered transportation through policy, systems, and environmental change is one of the leading evidence-based strategies to increase physical activity regardless of age, income, racial/ethnic background, ability, or disability. Initiatives often require coordination across federal, state, and local agencies. To maximize the effectiveness of all types of interventions, it is imperative to establish strong and broad partnerships across professional disciplines, community members, and advocacy groups. Health organizations can play important roles in facilitating these partnerships. This policy statement provides recommendations and resources that can improve transportation systems, enhance land use design, and provide education to support policies and environments to promote active travel. The American Heart Association supports safe, equitable active transportation policies in communities across the country that incorporate consistent implementation evaluation. Ultimately, to promote large increases in active transportation, policies need to be created, enforced, and funded across multiple sectors in a coordinated and equitable fashion. Active transportation policies should operate at 3 levels: the macroscale of land use, the mesoscale of pedestrian and bicycle networks and infrastructure such as Complete Streets policies and Safe Routes to School initiatives, and the microscale of design interventions and placemaking such as building orientation and access, street furnishings, and safety and traffic calming measures. Health professionals and organizations are encouraged to become involved in advocating for active transportation policies at all levels of government.

Behavioural and psychosocial factors associated with 5-year weight trajectories within the PORTAL Overweight/Obesity Cohort

Objective

The purpose of this study was to model weight trajectories over a 5‐year time period (2012–2016) and their association with behavioural and psychosocial characteristics and health care–related experiences using data from the Patient Outcomes Research to Advance Learning (PORTAL) overweight/obesity cohort.

Methods

Weight trajectories for each eligible patient in the PORTAL overweight/obesity cohort (n = 2864) were identified first using growth modelling; trajectories were then grouped using a hierarchical cluster analysis. Weight trajectory clusters that emerged were compared on demographics, and predictors of cluster membership were examined. Clusters were also compared on responses to a survey assessing health behaviours, quality of life, and health care experience completed in 2015 by 49% of the total sample (n = 1391).

Results

Seven distinct weight trajectory clusters were identified: (a) significant weight loss then maintenance; (b) higher stable weight; (c) moderate stable weight; (d) steady weight loss then relapse; (e) weight gain then weight loss; (f) steady weight gain then maintenance; and (g) lower stable weight. Age, sex, race/ethnicity, and body mass index at baseline predicted patient's weight trajectory (P < .001). Over two thirds of patients maintained their weight over the 5‐year period. Significant weight loss then maintenance, weight gain then weight loss, and higher stable weight patients were more likely to report receiving weight counselling from their provider. Patients in the significant weight loss then maintenance and lower stable weight clusters were more likely to be physically active than the other clusters.

Conclusion

Findings suggest variability in patterns of weight change among adults with overweight or obesity who have access to health care and that these patterns differ on demographic, behavioural and psychosocial factors, and health care experience.

Effect of a Comprehensive Cardiovascular Risk Reduction Intervention in Persons With Serious Mental Illness: A Randomized Clinical Trial

IMPORTANCE

Persons with serious mental illness have a cardiovascular disease mortality rate more than twice that of the overall population. Meaningful cardiovascular risk reduction requires targeted efforts in this population, who often have psychiatric symptoms and cognitive impairment.

OBJECTIVE

To determine the effectiveness of an 18-month multifaceted intervention incorporating behavioral counseling, care coordination, and care management for overall cardiovascular risk reduction in adults with serious mental illness.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted from December 2013 to November 2018 at 4 community mental health outpatient programs in Maryland. The study recruited adults with at least 1 cardiovascular disease risk factor (hypertension, diabetes, dyslipidemia, current tobacco smoking, and/or overweight or obesity) attending the mental health programs. Of 398 participants screened, 269 were randomized to intervention (132 participants) or control (137 participants). Data collection staff were blinded to group assignment. Data were analyzed on the principle of intention to treat, and data analysis was performed from November 2018 to March 2019.

INTERVENTIONS

A health coach and nurse provided individually tailored cardiovascular disease risk reduction behavioral counseling, collaborated with physicians to implement appropriate risk factor management, and coordinated with mental health staff to encourage attainment of health goals. Programs offered physical activity classes and received consultation on serving healthier meals; intervention and control participants were exposed to these environmental changes.

MAIN OUTCOMES AND MEASURES

The primary outcome was the change in the risk of cardiovascular disease from the global Framingham Risk Score (FRS), which estimates the 10-year probability of a cardiovascular disease event, from baseline to 18 months, expressed as percentage change for intervention compared with control.

RESULTS

Of 269 participants randomized (mean [SD] age, 48.8 [11.9] years; 128 men [47.6%]), 159 (59.1%) had a diagnosis of schizophrenia or schizoaffective disorder, 67 (24.9%) had bipolar disorder, and 38 (14.1%) had major depressive disorder. At 18 months, the primary outcome, FRS, was obtained for 256 participants (95.2%). The mean (SD) baseline FRS was 11.5% (11.5%) (median, 8.6%; interquartile range, 3.9%-16.0%) in the intervention group and 12.7% (12.7%) (median, 9.1%; interquartile range, 4.0%-16.7%) in the control group. At 18 months, the mean (SD) FRS was 9.9% (10.2%) (median, 7.7%; interquartile range, 3.1%-12.0%) in the intervention group and 12.3% (12.0%) (median, 9.7%; interquartile range, 4.0%-15.9%) in the control group. Compared with the control group, the intervention group experienced a 12.7% (95% CI, 2.5%-22.9%; P = .02) relative reduction in FRS at 18 months.

CONCLUSIONS AND RELEVANCE

An 18-month behavioral counseling, care coordination, and care management intervention statistically significantly reduced overall cardiovascular disease risk in adults with serious mental illness. This intervention provides the means to substantially reduce health disparities in this high-risk population.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02127671.

Antiobesity Medication Use in 2.2 Million Adults Across Eight Large Health Care Organizations: 2009-2015

OBJECTIVE

The aim of this study was to examine the prescribing patterns and use of antiobesity medications in a large cohort of patients using data from electronic health records.

METHODS

Pharmacy- and patient-level electronic health record data were obtained on 2,248,407 adults eligible for weight-loss medications from eight geographically dispersed health care organizations.

RESULTS

A total of 29,964 patients (1.3% of total cohort) filled at least one weight-loss medication prescription. This cohort was 82.3% female, with median age 44.9 years and median BMI 37.2 kg/m² . Phentermine accounted for 76.6% of all prescriptions, with 51.7% of prescriptions being filled for ≥ 120 days and 33.8% filled for ≥ 360 days. There was an increase of 32.9% in medication days for all medications in 2015 compared with 2009. Higher prescription rates were observed in women, black patients, and patients in higher BMI classes. Of 3,919 providers who wrote at least one filled prescription, 23.8% (n = 863) were "frequent prescribers" who wrote 89.6% of all filled prescriptions.

CONCLUSIONS

Weight-loss medications are rarely prescribed to eligible patients. Phentermine accounted for > 75% of all medication days, with a majority of patients filling it for more than 4 months. Less than one-quarter of prescribing providers accounted for approximately 90% of all prescriptions.

Racial/Ethnic Disparities in the Prevalence of Diabetes and Prediabetes by BMI: Patient Outcomes Research To Advance Learning (PORTAL) Multisite Cohort of Adults in the U.S

OBJECTIVE

To examine racial/ethnic disparities in the prevalence of diabetes and prediabetes by BMI category.

RESEARCH DESIGN AND METHODS

In a consortium of three U.S. integrated health care systems, 4,906,238 individuals aged ≥20 years during 2012-2013 were included. Diabetes and prediabetes were ascertained by diagnosis and laboratory results; antihyperglycemic medications were also included for diabetes ascertainment.

RESULTS

The age-standardized diabetes and prediabetes prevalence estimates were 15.9% and 33.4%, respectively. Diabetes but not prediabetes prevalence increased across BMI categories among all racial/ethnic groups (P for trend < 0.001). Racial/ethnic minorities reached a given diabetes prevalence at lower BMIs than whites; Hawaiians/Pacific Islanders and Asians had a diabetes prevalence of 24.6% (95% CI 24.1-25.2%) in overweight and 26.5% (26.3-26.8%) in obese class 1, whereas whites had a prevalence of 23.7% (23.5-23.8%) in obese class 2. The age-standardized prediabetes prevalence estimates in overweight among Hispanics (35.6% [35.4-35.7%]), Asians (38.1% [38.0-38.3%]), and Hawaiians/Pacific Islanders (37.5% [36.9-38.2%]) were similar to those in obese class 4 among whites (35.3% [34.5-36.0%]), blacks (36.8% [35.5-38.2%]), and American Indians/Alaskan Natives (34.2% [29.6-38.8%]). In adjusted models, the strength of association between BMI and diabetes was highest among whites (relative risk comparing obese class 4 with normal weight 7.64 [95% CI 7.50-7.79]) and lowest among blacks (3.16 [3.05-3.27]). The association between BMI and prediabetes was less pronounced.

CONCLUSIONS

Racial/ethnic minorities had a higher burden of diabetes and prediabetes at lower BMIs than whites, suggesting the role of factors other than obesity in racial/ethnic disparities in diabetes and prediabetes risk and highlighting the need for tailored screening and prevention strategies.

Health Status of Young Adults with Insurance Coverage Before and After Affordable Care Act Passage

INTRODUCTION

The purpose of this study was to assess changes in health status of California young adults with insurance coverage before and after passage of the Affordable Care Act (ACA).

METHODS

For this cross-sectional descriptive study, electronic health record information for young adults between ages 18 and 25 years enrolled in a large Southern California Health Plan in 2008, 2010, or 2015 was obtained (N = 665,686). Absolute changes and standardized annual differences in demographics and age-sex-race standardized prevalence of Elixhauser health conditions for pre-ACA (2008-2010) and post-ACA (2010-2015) periods were calculated.

RESULTS

The number of young adults enrolled in the Health Plan increased by 145,000 (65%) during the ACA transition with a shift toward low-income young adults. The increase in high-deductible insurance plans observed pre-ACA stabilized with a standardized annual difference of 0.22 pre-ACA vs 0.05 post-ACA. The prevalences of obesity and other health conditions between pre-ACA and post-ACA periods essentially were unaltered and comparable between young adults who became new members (< 1 year) and those with long-term memberships (≥ 3 years).

CONCLUSION

In this California health care system, the health status of new young adult members was comparable to that of long-term members. Future research should assess whether these young adults retain their health insurance coverage after turning age 26 years and being removed from their parents' insurance plans.

Safety and Effectiveness of Longer-Term Phentermine Use: Clinical Outcomes from an Electronic Health Record Cohort

OBJECTIVE

The aim of this work was to study weight loss and risk of cardiovascular disease (CVD) or death associated with longer-term phentermine use.

METHODS

Using electronic health record data, 13,972 adults were identified with a first phentermine fill in 2010 to 2015, creating exposure categories according to a patient's duration of use (referent: ≤ 3 months). Multivariable linear models were used to compare percent weight loss across categories at 6, 12, and 24 months, and Cox proportional hazards models were used to compare risk of composite CVD or death, up to 3 years after starting phentermine.

RESULTS

The cohort was 84% female and 45% white, with a mean (SD) baseline age 43.5 (10.7) years and BMI of 37.8 (7.2) kg/m² . In multivariable models, longer-term users of phentermine experienced more weight loss; patients using continuously for > 12 months lost 7.4% more than the referent group at 24 months (P < 0.001). The composite CVD or death outcome was rare (0.3%, 41 events), with no significant difference in hazard ratios between groups.

CONCLUSIONS

Greater weight loss without increased risk of incident CVD or death was observed in patients using phentermine monotherapy for longer than 3 months. Despite the limitations of the observational design, this study supports the effectiveness and safety of longer-term phentermine use for low-risk individuals.

Longitudinal Sedentary Time Among Females Aged 17 to 23 Years

INTRODUCTION

Time spent in sedentary behaviors is a newer risk factor for poor cardiometabolic health. This study examined longitudinal correlates of sedentary time among a cohort of females from about age 17 to age 23 years.

METHODS

The cohort included females originally participating in the Trial of Activity for Adolescent Girls Maryland site who had assessments in 2009 and 2015 (n=431). Percentage daily time in sedentary behaviors was determined from accelerometers. Sociodemographics, psychosocial factors, and health behaviors were assessed by questionnaire. Lasso variable selection identified potential variables included in linear mixed effects models. As a secondary analysis, a k-means algorithm for longitudinal data identified homogeneous clusters of individual sedentary time trajectories.

RESULTS

Percentage daily sedentary time did not change over time (67% to 68%). Not of black race (p=0.04), higher father's education (p<0.001), more weekday computer hours (p<0.001), more weekend TV hours (p=0.01), more physical activity barriers (p=0.003), fewer days per week driving (p=0.01), and more vehicles in the household (p=0.02) were associated with greater sedentary time. Cluster analysis resulted in two patterns: more (70%) versus less (60%) time being sedentary. The more sedentary individuals were more likely to be college graduates (p<0.001), have a higher income (p=0.03), and work fewer hours (p=0.009). They were also less likely to be married or in a common-law relationship (p=0.05) or in a parenting role (p=0.02).

CONCLUSIONS

Time spent in sedentary behaviors remained stable. Factors associated with sedentary time were significant across the socioecologic framework and included several factors indicating higher SES.

Effects of a behavioural weight loss intervention in people with serious mental illness: Subgroup analyses from the ACHIEVE trial

BACKGROUND

Persons with serious mental illnesses (SMI) such as schizophrenia and bipolar disorder have an increased risk of obesity and related chronic diseases and die 10-20years earlier than the overall population, primarily due to cardiovascular disease. In the ACHIEVE trial, a behavioural weight loss intervention led to clinically significant weight loss in persons with SMI. As the field turns its attention to intervention scale-up, it is important to understand whether the effectiveness of behavioural weight loss interventions for people with SMI, like ACHIEVE, differ for specific subgroups.

METHODS

This study examined whether the effectiveness of the ACHIEVE intervention differed by participant characteristics (e.g. age, sex, race, psychiatric diagnosis, body mass index) and/or their weight-related attitudes and behaviours (e.g. eating, food preparation, and shopping habits). We used likelihood-based mixed effects models to examine whether the baseline to 18 month effects of the ACHIEVE intervention differed across subgroups.

RESULTS

No statistically significant differences were found in the effectiveness of the ACHIEVE intervention across any of the subgroups examined.

CONCLUSIONS

These findings suggest that the ACHIEVE behavioural weight loss intervention is broadly applicable to the diverse population of individuals with SMI.

The Health and economic effects of light rail lines: design, methods, and protocol for a natural experiment

BACKGROUND

The health impacts of community design have been studied extensively over the past two decades. In particular, public transportation use is associated with more walking between transit stops and shops, work, home and other destinations. Change in transit access has been linked with physical activity and obesity but seldom to health outcomes and associated costs, especially within a causal framework. Health related fiscal impacts of transit investment should be a key consideration in major transit investment decisions.

METHODS

The Rails & Health study is a natural experiment evaluating changes in clinical measures, health care utilization and health care costs among Kaiser Permanente Northwest (KPNW) members following the opening of a new light rail transit (LRT) line in Portland, Oregon. The study is prospectively following 3036 adults exposed to the new LRT line and a similar cohort of 4386 adults who do not live close to the new line. Individual-level outcomes and covariates are extracted from the electronic medical record at KPNW, including member demographics and comorbidities, blood pressure, body mass index, lipids, glycosylated hemoglobin, and health care utilization and costs. In addition, participants are surveyed about additional demographics, travel patterns, physical activity (PA), and perceived neighborhood walkability. In a subsample of the study population, we are collecting direct measures of travel-related behavior-physical activity (accelerometry), global positioning system (GPS) tracking, and travel diaries-to document mechanisms responsible for observed changes in health outcomes and cost. Comprehensive measures of the built environment at baseline and after rail construction are also collected. Statistical analyses will (1) examine the effects of opening a new LRT line on chronic disease indicators, health care utilization, and health care costs and (2) evaluate the degree to which observed effects of the LRT line on health measures and costs are mediated by changes in total and transportation-associated PA.

DISCUSSION

The results of the Rails & Health study will provide urban planners, transportation engineers, health practitioners, developers, and decision makers with critical information needed to document how transit investments impact population health and related costs.

Need for Cardiovascular Risk Reduction in Persons With Serious Mental Illness: Design of a Comprehensive Intervention

Persons with serious mental illness (SMI) comprise a high-risk group for cardiovascular disease (CVD)-related mortality with rates at least twice those of the overall US. Potentially modifiable CVD risk behaviors (tobacco smoking, obesity, physical inactivity, unhealthy diet) and risk factors (hypertension, diabetes, dyslipidemia) are all markedly elevated in persons with SMI. Evaluations of programs implementing integrated medical care into specialty mental health settings have not shown meaningful effects on CVD risk factor reduction. Rigorously tested, innovative interventions are needed to address the large burden of CVD risk in populations with SMI. In this article, we describe the design of a comprehensive 18-month intervention to decrease CVD risk that we are studying in a randomized clinical trial in a community mental health organization with psychiatric rehabilitation programs. The individual-level intervention incorporated health behavior coaching and care coordination/care management to address all seven CVD risk behaviors and risk factors, and is delivered by a health coach and nurse. If successful, the intervention could be adopted within current integrated care models and significantly improve the physical health of persons with SMI.

Sociodemographic associations of 4-year overweight and obese incidence among a racially diverse cohort of healthy weight 18-year-olds

BACKGROUND

Emerging adulthood is a critical time for excess weight gain. Risk can be masked if recommended overweight and obesity cut-points for Asians are not employed.

OBJECTIVES

To determine the associations among sociodemographic factors and occurrence of overweight and obesity among normal weight 18-year olds.

METHODS

Normal weight (body mass index < 25 kg m^-2 ; <23 kg m^-2 for Asians) 18-year-old (9037 boys, 13 786 girls, 36% Hispanic, 34% non-Hispanic Whites, 10% Black, 5% Asian) members of a healthcare organization in 2008 were followed through 2012 to identify incidence of overweight and obesity. Hazard ratios (HR) and 95% confidence intervals (CI) were determined controlling for sex, race/ethnicity, neighbourhood education, neighbourhood income and smoking status.

RESULTS

After 3 years of follow-up, the HR for overweight was 1.28 (95% CI: 1.12, 1.45) in the lowest quartile of neighbourhood education compared with the highest. Asians and Pacific Islanders had greater risk of overweight (HR 2.89, 95% CI: 2.55, 3.28; HR 3.13, 95% CI 2.23, 4.38) than non-Hispanic Whites. Girls and Blacks were more likely to become obese than boys and non-Hispanic Whites, as were those living in the lowest neighbourhood education quartile and lower neighbourhood income quartiles.

CONCLUSIONS

Girls, Asians, Blacks and those living in low education and income neighbourhoods during adolescence are at risk for excessive weight gain trajectories.

Mental illness in bariatric surgery: A cohort study from the PORTAL network

OBJECTIVE

To compare bariatric surgery outcomes according to preoperative mental illness category.

METHODS

Electronic health record data from several US healthcare systems were used to compare outcomes of four groups of patients who underwent bariatric surgery in 2012 and 2013. These included the following: people with (1) no mental illness, (2) mild-to-moderate depression or anxiety, (3) severe depression or anxiety, and (4) bipolar, psychosis, or schizophrenia spectrum disorders. Groups were compared on weight loss trajectory using generalized estimating equations using B-spline bases and on all-cause emergency department visits and hospital days using zero-inflated Poisson and negative binomial regression up to 2 years after surgery. Models were adjusted for demographic and health covariates, including baseline healthcare use.

RESULTS

Among 8,192 patients, mean age was 44.3 (10.7) years, 79.9% were female, and 45.6% were white. Fifty-seven percent had preoperative mental illness. There were no differences between groups for weight loss, but patients with preoperative severe depression or anxiety or bipolar, psychosis, or schizophrenia spectrum disorders had higher follow-up levels of emergency department visits and hospital days compared to those with no mental illness.

CONCLUSIONS

In this multicenter study, mental illness was not associated with differential weight loss after bariatric surgery, but additional research could focus on reducing acute care use among these patients.

The Patient Outcomes Research To Advance Learning (PORTAL) Network Adult Overweight and Obesity Cohort: Development and Description

Background

The Patient-Centered Outcomes Research Institute (PCORI) created a new national network infrastructure to enable large-scale observational comparative effectiveness research across diverse clinical care settings. As part of testing the feasibility of this effort, each clinical data research network (CDRN) was required to construct cohorts of patients, including one of patients with overweight and obesity.

Objective

The aim of this paper is to report on the development of the Patient Outcomes Research to Advance Learning (PORTAL) overweight and obese cohort, which includes patients from 10 health plans located across the United States.

Methods

Information was gathered from each plan’s electronic health records (EHR). Eligibility included 18 years of age or older, a valid height and weight in 2012 or 2013, and body mass index (BMI) greater than 22.9 kg/m². Pre-diabetes and diabetes status was defined using the American Diabetes Association (ADA) criteria, using lab values of glycated hemoglobin (HbA1c) or fasting glucose available in the EHR. Hypertension was identified from the International Classification of Diseases (ICD) diagnosis codes. Individuals were classified into BMI categories: healthy weight (23.0-24.9 kg/m²), overweight (25.0-29.9 kg/m²), obese class 1 (30.0-34.9 kg/m²), obese class 2 (35.0-39.9 kg/m²), obese class 3 (40.0-49.0 kg/m²), and obese class 4 (>50.0 kg/m²).

Results

A cohort of 5,293,458 non-pregnant adults was created. Weight status was 20.39% (1,079,289/5,293,458) healthy weight, 40.40% (2,138,520/5,293,458) overweight, 22.78% (1,205,866/5,293,458) obese class 1, 9.86% (521,872/5,293,458) obese class 2, 5.59% (295,786/5,293,458) obese class 3, and 0.98% (52,125/5,293,458) obese class 4. Race/ethnicity was 49.02% (2,594,776/5,293,458) non-Hispanic white, 22.89% (1,211,677/5,293,458) Hispanic, 10.40% (550,608/5,293,458) Asian, 10.83% (573,506/5,293,458) black, and 6.59% (348,830/5,293,458) other. About 34.33% (1,817,438/5,293,458) met the definition of hypertension, 20.49% (1,660,940/5,293,458) of individuals met the criteria for pre-diabetes, and 14.98% (793,069/5,293,458) met criteria for diabetes. Prevalence of pre-diabetes and diabetes varied across health plans to a greater extent than expected based on hypertension prevalence and BMI status variability.

Conclusions

This large, race, ethnic, and geographically diverse cohort will be useful for future studies of rare exposures or outcomes and differences in health care practices.

Longitudinal study of body mass index in Asian men who immigrate to the US

BACKGROUND AND OBJECTIVES

Cross-sectional studies indicate that adaptation to Western norms, especially at a younger age, might explain the higher average body mass index (BMI) among Asians living in the United States (US) compared to Asians living in Asia. However, migrants differ from non-migrants in sociocultural factors that are difficult to measure and, thus, longitudinal studies on the same individuals prior to and after immigration are needed. The objective of this study was to determine differences in changes in BMI across age by residence (US or Asia) and age at immigration using longitudinal data on BMI prior to and after immigration.

METHODS AND STUDY DESIGN

The California Men's Health Study includes 1,549 foreign-born Asian men who were aged 44-71 at baseline in 2002-03. BMI at ages 30, 40, 50 and 60 was calculated using self-reported weight history and current height. Residence at each age decade and age at immigration were determined. Data were analyzed using generalized estimating equations.

RESULTS

Ten-year BMI increases were smaller among Asians who lived in Asia prior to migrating to the US compared to those who already lived in the US. This effect was most evident be-tween ages 30-40 when Asians in Asia had a 0.69 kg/m2 (95% CI: -1.08, -0.30) smaller increase in BMI. Immigrants who moved to the US before age 40 experienced greater increases in BMI than immigrants who moved to the US at an older age.

CONCLUSION

This study is the first to support the hypothesis that living in the US and younger age at immigration results in larger BMI increases in Asian men.

Secular Trends of Overweight and Obesity in Young Southern Californians 2008-2013

OBJECTIVE

To investigate secular trends in pediatric obesity in Southern California between 2008 and 2013.

STUDY DESIGN

In a population-based cohort study, measured weight and height were extracted from electronic health records of 1,331,931 patients aged 2-19 years who were enrolled in an integrated prepaid health plan between 2008 and 2013. Outcomes were the prevalence of overweight and obesity (body mass index-for-age ≥85th percentile).

RESULTS

The prevalence of obesity was 19.1% in 2008 and decreased by 1.6% (95% CI, 1.7%-1.5%) by 2013, corresponding to a relative decline of 8.4%. A significant decline was observed across all ages, sexes, races, and socioeconomic groups, but the magnitude of the decrease varied. The relative decline in obesity was stronger in boys (-9.3%) than in girls (-7.2%), in children aged 2-5 years (-15.4%) and 6-11 years (-11.8%) than in adolescents aged 12-19 years (-4.5%), and in whites (-12.6%) and Asians (-12.2%) than in Hispanics (-6.9%) and African Americans (-7.5%).

CONCLUSION

Secular trends from this large population-based cohort suggest that overweight and obesity in boys and girls are declining across age and racial/ethnic groups. However, the declines are less pronounced in adolescents compared with children, in girls, and in some minority groups. Programs addressing childhood obesity may need to be targeted.

Psychosocial predictors of weight loss by race and sex

This paper examined the psychosocial predictors of weight loss among race and sex subgroups. Analyses included overweight and obese participants from the PREMIER study, a previously published randomized trial that examined the effects of two multi-component lifestyle interventions on blood pressure among pre-hypertensive and stage 1 hypertensive adults. Both intervention conditions received behavioural recommendations for weight loss and group sessions. Weight and psychosocial measures of self-efficacy and social support for diet and exercise were assessed at baseline and at 6 months. There were 157 African-American (AA) women, 46 AA men, 203 non-AA women and 182 non-AA men with an average age of 50 years and average body mass index of 34 at baseline. Multiple predictor regression models were performed individually by race and sex subgroup. Among AA women, increases in diet self-efficacy were associated with weight loss. Among AA men, increases in diet-related social support and self-efficacy, along with increases in family support to exercise, were associated with weight loss (all Ps <0.05). Among non-AA women, increases in friends' support to exercise and exercise-related self-efficacy were associated with weight loss, and among non-AA men only increases in diet self-efficacy were associated with weight loss (all Ps <0.05). These results emphasize the need for targeted interventions based on race and sex to optimize the impact of lifestyle-based weight loss programmes.

Longitudinal study of acculturation and BMI change among Asian American men

BACKGROUND

Cross-sectional studies examining the association between Western acculturation and BMI in Asians have been inconsistent, and studies on BMI change are lacking.

OBJECTIVE

This study examined the associations between indicators of acculturation (generational status, length of US residence, and age at immigration) and overweight (BMI ≥25kg/m(2)) as well as 5-year BMI changes in 7,073 Chinese, Japanese, Korean, Filipino, and Vietnamese men who lived in the US and were 44-71years old at baseline of the California Men's Health Study (2002-2003).

METHODS

Indicators of acculturation were reported at baseline. Repeated clinical measures of BMI were extracted from electronic health records (2005-2012).

RESULTS

Using generalized estimating equations we found that lower generational status, shorter duration of US residence and older age at immigration were inversely associated with being overweight. However, analysis of BMI curves using linear mixed models showed that shorter length of US residence and older age at immigration were associated with larger 5-year increases in BMI.

CONCLUSIONS

Asian immigrants who were less acculturated had larger BMI increases as they became more acculturated but had not achieved overweight status. Healthy weight interventions among Asians immigrants may be most effective when targeting weight maintenance early in the process of acculturation.

Screening for High Blood Pressure in Adults During Ambulatory Nonprimary Care Visits: Opportunities to Improve Hypertension Recognition

Visits with nonprimary care providers such as optometrists may be missed opportunities for the detection of high blood pressure (BP). For this study, normotensive adults with at least 12 months of health plan membership on January 1, 2009 (n=1,075,522) were followed-up for high BP through March 14, 2011. Of 111,996 patients with a BP measurement ≥140/90 mm Hg, 82.7% were measured during primary care visits and 17.3% during nonprimary care visits. Individuals with a BP ≥140/90 mm Hg measured during nonprimary care visits were older and more likely to be male and non-Hispanic white. The proportion of patients with follow-up and false-positives were comparable between primary and nonprimary care. The main nonprimary care specialty to identify a first BP ≥140/90 mm Hg was ophthalmology/optometry with 24.5% of all patients. Results suggest that expanding screening for hypertension to nonprimary care settings may improve the detection of hypertension.

Childhood chronic health conditions and educational attainment: a social ecological approach

PURPOSE

This study examined the association between types of chronic health conditions reported during childhood and adolescence and their impact on educational attainment. School and neighborhood environments and potential mediating factors from academic and psychosocial variables were investigated.

METHODS

Using the National Longitudinal Survey of Youth-Cohort 1997, multivariate logistic regression models were fit to estimate the association between chronic health conditions and educational attainment, adjusting for confounders. Chronic health conditions were defined as a parental (1997) or participant (2002) report of a chronic health condition and classified into (1) asthma; (2) cancer, diabetes, and epilepsy; (3) heart conditions; and (4) other. Educational attainment was defined as receiving a high school diploma or Graduate Equivalency Degree by age 21, determined from self-report.

RESULTS

Youth who reported having a chronic health condition had higher odds of low educational attainment compared with youth who did not report a condition (n = 6,795; odds ratio [OR], 1.47; 95% confidence interval [CI], 1.22-1.76). Specifically, youth with asthma (OR, 1.63; 95% CI, 1.31-2.02) and those with cancer, diabetes, or epilepsy (OR, 1.96; 95% CI, 1.13-3.37) had higher odds of low attainment. For youth who reported cancer, diabetes, or epilepsy, the variables "school absences," "repeated a grade," and "depressive symptoms" attenuated the association and were considered mediators.

CONCLUSIONS

Youth with chronic health conditions had lower educational attainment. Students with cancer, diabetes, or epilepsy who had a high number of absences, had repeated a grade, or had a high-depressive symptoms score were particularly impacted.

Promoting physical activity through the shared use of school recreational spaces: a policy statement from the American Heart Association

Most Americans are not sufficiently physically active, even though regular physical activity improves health and reduces the risk of many chronic diseases. Those living in rural, non-White, and lower-income communities often have insufficient access to places to be active, which can contribute to their lower level of physical activity. The shared use of school recreational facilities can provide safe and affordable places for communities. Studies suggest that challenges to shared use include additional cost, liability protection, communication among constituencies interested in sharing space, and decision-making about scheduling and space allocation. This American Heart Association policy statement has provided recommendations for federal, state, and local decision-makers to support and expand opportunities for physical activity in communities through the shared use of school spaces.

A behavioral weight-loss intervention in persons with serious mental illness

BACKGROUND

Overweight and obesity are epidemic among persons with serious mental illness, yet weight-loss trials systematically exclude this vulnerable population. Lifestyle interventions require adaptation in this group because psychiatric symptoms and cognitive impairment are highly prevalent. Our objective was to determine the effectiveness of an 18-month tailored behavioral weight-loss intervention in adults with serious mental illness.

METHODS

We recruited overweight or obese adults from 10 community psychiatric rehabilitation outpatient programs and randomly assigned them to an intervention or a control group. Participants in the intervention group received tailored group and individual weight-management sessions and group exercise sessions. Weight change was assessed at 6, 12, and 18 months.

RESULTS

Of 291 participants who underwent randomization, 58.1% had schizophrenia or a schizoaffective disorder, 22.0% had bipolar disorder, and 12.0% had major depression. At baseline, the mean body-mass index (the weight in kilograms divided by the square of the height in meters) was 36.3, and the mean weight was 102.7 kg (225.9 lb). Data on weight at 18 months were obtained from 279 participants. Weight loss in the intervention group increased progressively over the 18-month study period and differed significantly from the control group at each follow-up visit. At 18 months, the mean between-group difference in weight (change in intervention group minus change in control group) was -3.2 kg (-7.0 lb, P=0.002); 37.8% of the participants in the intervention group lost 5% or more of their initial weight, as compared with 22.7% of those in the control group (P=0.009). There were no significant between-group differences in adverse events.

CONCLUSIONS

A behavioral weight-loss intervention significantly reduced weight over a period of 18 months in overweight and obese adults with serious mental illness. Given the epidemic of obesity and weight-related disease among persons with serious mental illness, our findings support implementation of targeted behavioral weight-loss interventions in this high-risk population. (Funded by the National Institute of Mental Health; ACHIEVE ClinicalTrials.gov number, NCT00902694.).

Glycemic index and glycemic load are associated with some cardiovascular risk factors among the PREMIER study participants

BACKGROUND

The clinical significance of glycemic index (GI) and glycemic load (GL) is inconclusive.

OBJECTIVE

This study was conducted to examine the association of GI and GL with clinical cardiovascular disease (CVD) risk factors including body weight, blood pressure (BP), serum lipids, fasting glucose, insulin and homocysteine over time among the PREMIER participants.

DESIGN

PREMIER was an 18-month randomized lifestyle intervention trial, conducted from 2000 to 2002, designed to help participants reduce BP by following the Dietary Approaches to Stop Hypertension (DASH) dietary pattern, losing weight, reducing sodium and increasing physical activity. GI and GL were estimated from 24 h diet recall data at baseline, 6 and 18 months after intervention. PROC MIXED model was used to examine the association of changes in GI or GL with changes in CVD risk factors.

RESULTS

A total of 756 randomized participants, 62% females and 34% African Americans and who averaged 50.0±0.3 years old and 95.3±0.7 kg, were included in this report. Neither GI nor GL changes was associated with changes in any risk factors at 6 months. At 18 months, however, the GI change was significantly and positively associated with total cholesterol (TC) change only (p<0.05, β=23.80±12.11 mg/dL or 0.62±0.31 mmol/L) with a significant age interaction. The GL change was significantly associated with TC (p=0.02, β=0.28±0.15 mg/dL or 0.01±0.00 mmol/L) positively and with low density lipoprotein cholesterol (LDL-C) changes negatively (p=0.03, β=-0.01±0.00 mg/dL or -0.00±0.00 mmol/L), and significant age interactions were observed for both.

CONCLUSIONS

GI and GL was associated with TC and LDL-C after controlling for energy, fat and fiber intake and other potential confounders and the associations were modified by age. Further investigation into this relationship is important because of its potential clinical impact.

The influence of body mass index on long-term fitness from physical education in adolescent girls

BACKGROUND

Physical education (PE) can improve physical fitness; however, little research has evaluated PE's long-term influence. The purpose is to determine PE's longitudinal effects on fitness in a group of adolescent girls and to determine whether body mass index (BMI) status influenced any potential effects.

METHODS

Participants were enrolled in daily PE throughout their ninth grade. Data were collected at baseline and at the end of 9th, 10th, and 11th grades. BMI (kg/m(2) ) was classified into Centers for Disease Control and Prevention percentiles. Fitness was estimated from a 3-stage step test (change in exercise heart rate (HR) indicated improved fitness) and analyzed using repeated measures general linear modeling with adjustments for baseline BMI, baseline age, ethnicity, intervention status, and moderate-to-vigorous physical activity outside PE.

RESULTS

Complete data were available for 131 girls (61% of sample) who were predominantly African American, 13.8 ± 0.4 years, mean BMI 24.7 ± 6.1 kg/m(2) at the ninth-grade baseline. Overall, stage 1 HR (bpm) decreased from baseline to 9th grade (-5.5 ± 1.3, p < 0.0001), baseline to 10th grade (-7.2 ± 1.4, p < 0.0001), and baseline to 11th grade (-7.0 ± 1.5, p < 0.0001). Change differed by BMI status; fitness improvement was significant for normal and overweight, but not obese girls. After 2 years, change in stage 1 HR (bpm) was significantly different between BMI categories: normal-weight girls versus obese girls (-10.0 ± 3.2, p = 0.002) and overweight girls versus obese girls (-9.3 ± 3.9, p = 0.02).

CONCLUSION

Fitness differences by BMI exist after a PE program in adolescent girls: fitness improved and was maintained in normal-weight and overweight girls, whereby obese girls had no improvement in fitness.