Behavior change techniques in digital physical activity interventions for breast cancer survivors: a systematic review.

Given the broad benefits of physical activity (PA) but low PA levels among breast cancer survivors (i.e., women who have received a breast cancer diagnosis), innovative and evidence-based techniques are needed to motivate and support exercise. This study systematically reviews the use of behavior change techniques (BCTs) in digital PA interventions for breast cancer survivors. Studies were retrieved from five electronic databases and were included if they (i) sampled exclusively female breast cancer survivors aged >18 years, (ii) involved a digital intervention with the primary purpose of increasing PA, (iii) included a BCT component, (iv) used a randomized or quasi-randomized design, and (v) were published from January 2000 to May 2022. Two coders independently extracted data. Twenty primary studies met the inclusion criteria and were included in this review. All interventions used at least one BCT (mean 4 ± 1, range 2-13); self-monitoring (85%) and goal setting (79%) were the most common BCTs. Twelve of 20 (60%) studies reported improvements in PA behavior in the intervention vs. control group, and self-monitoring and goal setting were the most commonly used BCTs in these studies. Of the 93 total BCTs, 66 were not used in any interventions in the review, including critical constructs for PA behavior change (e.g., biofeedback). BCTs, important facilitators of PA behavior change, are being underutilized in digital PA interventions for breast cancer survivors. Future research should incorporate more diverse BCTs to explore if they can add to the effectiveness of digital interventions for this population.

Physical activity (PA) has many benefits, yet PA levels are low among breast cancer survivors (i.e., women who have received a breast cancer diagnosis). This study reviews the use of behavior change techniques (BCTs) in digital PA interventions for breast cancer survivors. BCTs are evidence-based and are important for encouraging changes in health behaviors, such as PA. Twenty studies were included in this review. All interventions used at least one BCT (mean 4 ± 1, range 2­13); self-monitoring (85%) and goal setting (79%) were the most common BCTs. Twelve of 20 (60%) studies reported improvements in PA, and self-monitoring and goal setting were the most commonly used BCTs in these studies. Of the 93 total BCTs, 66 were not used in any interventions in the review. This finding reveals that many BCTs, which are important influencers of behavior change, are often not being used in digital PA interventions for breast cancer survivors. BCTs such as biofeedback (e.g., providing information on heart rate during exercise) and practical social support (e.g., virtual exercise coaching), could be helpful. Future research should include more diverse BCTs to explore if they can add to the usefulness of digital interventions for this population.

Volunteer-Based Social Support Structures and Program Exposure Outcomes in an Adolescent Young Adult Palliative Care Peer Support Program.

Objective: To conduct a social network analysis (SNA) of patient-volunteer networks and assess the impact of patient characteristics on network measures. Background: Volunteers play a critical role in providing peer support to adolescent and young adult (AYA) palliative care patients. Streetlight at UF Health is a peer support palliative care program for hospitalized AYAs that aims at forming positive peer relationships through volunteer visits, events, and a virtual online health community. Methods: Data were collected on patient characteristics, hospitalizations, average length of stays (LOS), and volunteer visitation records. Egocentric SNAs were conducted on each patient to calculate network outcomes. Study participants were AYA patients (N = 69), enrolled in the US-based Streetlight program at UF Health Shands Hospital. Results: The LOS was significantly associated with network size (B = 0.583; 95% confidence interval; CI [0.463 to 0.702]). Autoimmune patients had smaller network sizes when controlling for LOS. Total hospital admissions predicted - 0.172 ([- 0.263 to - 0.080]) lower average repeat visits. Higher average repeat visits were predicted for patients who had cancer (B = 0.246 [0.046 to 0.447]) and awaiting organ transplantation (B = 0.370 [0.082 to 0.658]). Although cystic fibrosis patients received more visits (B = 0.364 [0.003 to 0.724]) compared with other illness populations, the network density was lower (B = - 0.580 [1.01 to - 0.155]). Cancer patients had networks with a higher diversity in volunteer repeat visits (B = 0.714 [0.312 to 0.920]). Conclusions: Significant relationships between patient characteristics and network outcomes highlight the differences in social support service delivery among diverse populations. These analyses can be utilized in practice to guide program delivery for high-need patients.

Early-phase study of a telephone-based intervention to reduce weight regain among bariatric surgery patients.

OBJECTIVE: This study describes early-phase development of a behavioral intervention to reduce weight regain following bariatric surgery. We utilized the Obesity-Related Behavioral Intervention Trials model to guide intervention development and evaluation. We sought to establish recruitment, retention, and fidelity monitoring procedures; evaluate feasibility of utilizing weight from the electronic medical record (EMR) as an outcome; observe improvement in behavioral risk factors; and evaluate treatment acceptability. METHOD: The intervention comprised 4 weekly telephone calls addressing behavior change strategies for diet, physical activity, and nutrition supplement adherence and 5 biweekly calls addressing weight loss maintenance constructs. Veterans (N = 33) who received bariatric surgery 9-15 months prior consented to a 16-week, pre-post study. Self-reported outcomes were obtained by telephone at baseline and 16 weeks. Clinic weights were obtained from the EMR 6 months pre- and postconsent. Qualitative interviews were conducted at 16 weeks to evaluate treatment acceptability. We aimed to achieve a recruitment rate of ≥ 25% and retention rate of ≥ 80%, and have ≥ 50% of participants regain < 3% of their baseline weight. RESULTS: Results supported the feasibility of recruiting (48%) and retaining participants (93% provided survey data; 100% had EMR weight). Pre-post changes in weight (73% with < 3% weight regain) and physical activity (Cohen's ds 0.38 to 0.52) supported the potential for the intervention to yield clinically significant results. Intervention adherence (mean 7.8 calls of 9 received) and positive feedback from interviews supported treatment acceptability. CONCLUSIONS: The intervention should be evaluated in an adequately powered randomized controlled trial. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Patient predictors of weight loss following a behavioral weight management intervention among US Veterans with severe obesity.

PURPOSE: Identification of patient characteristics that are associated with behavioral weight loss success among bariatric surgery candidates could inform selection of optimal bariatric surgery candidates. We examined the associations between psychosocial characteristics and weight loss in a group of Veterans with severe obesity who participated in a behavioral weight loss intervention. METHODS: The MAINTAIN trial involved a 16-week weight loss program followed by randomization among participants losing at least 4 kg to a maintenance intervention or usual care. This secondary analysis was performed on Veterans who participated in the 16-week weight loss program and met NIH criteria for bariatric surgery (body mass index [BMI] 35.0-39.9 with at least 1 obesity-related comorbidity or BMI ≥ 40). Unadjusted and adjusted associations between baseline patient characteristics and weight loss during the 16-week induction phase were evaluated with linear regression. Missing weight measurements were multiply imputed, and results combined across ten imputations. RESULTS: Among the 206 patients who met inclusion criteria, mean initial BMI was 40.8 kg/m2 (SD 6.0), and mean age was 59.2 years (SD 9.4). Approximately 20% of participants were female, 51.5% were Black, and 44.7% were White. Estimated mean 16-week weight loss was 5.16 kg (SD 4.31). In adjusted analyses, greater social support and older age were associated with greater weight loss (p < 0.05). None of the nine psychosocial characteristics we examined were associated with greater weight loss. CONCLUSIONS: Understanding and strengthening the level of social support for bariatric surgery candidates may be important given that it appears to be strongly correlated with behavioral weight loss success. LEVEL OF EVIDENCE: Level II, Evidence obtained from well-designed controlled trials without randomization. TRIAL REGISTRATION: ClinicalTrials.gov NCT01357551 http://clinicaltrials.gov/show/NCT01357551 .

Bariatric surgery in patients with bipolar spectrum disorders: Selection factors, postoperative visit attendance, and weight outcomes.

BACKGROUND: As many as 3% of bariatric surgery candidates are diagnosed with a bipolar spectrum disorder. OBJECTIVES: 1) To describe differences between patients with bipolar spectrum disorders who are approved and not approved for surgery by the mental health evaluator and 2) to examine surgical outcomes of patients with bipolar spectrum disorders. SETTING: Academic medical center, United States. METHODS: A retrospective record review was conducted of consecutive patients who applied for bariatric surgery between 2004 and 2009. Patients diagnosed with bipolar spectrum disorders who were approved for surgery (n = 42) were compared with patients with a bipolar spectrum disorder who were not approved (n = 31) and to matched control surgical patients without a bipolar spectrum diagnosis (n = 29) on a variety of characteristics and surgical outcomes. RESULTS: Of bariatric surgery candidates diagnosed with a bipolar spectrum disorder who applied for surgery, 57% were approved by the psychologist and 48% ultimately had surgery. Patients with a bipolar spectrum disorder who were approved for surgery were less likely to have had a previous psychiatric hospitalization than those who were not approved for surgery. Bariatric surgery patients diagnosed with a bipolar spectrum disorder were less likely to attend follow-up care appointments 2 or more years postsurgery compared to matched patients without bipolar disorder. Among patients with available data, those with a bipolar spectrum disorder and matched patients had similar weight loss at 12 months (n = 21 for bipolar; n = 24 for matched controls) and at 2 or more years (mean = 51 mo; n = 11 for bipolar; n = 20 for matched controls). CONCLUSION: Patients diagnosed with a bipolar spectrum disorder have a high rate of delay/denial for bariatric surgery based on the psychosocial evaluation and are less likely to attend medical follow-up care 2 or more years postsurgery. Carefully screened patients with bipolar disorder who engage in long-term follow-up care may benefit from bariatric surgery.

Primary care physician decision making regarding severe obesity treatment and bariatric surgery: a qualitative study.

BACKGROUND: Less than 1% of severely obese US adults undergo bariatric surgery annually. It is critical to understand the factors that contribute to its utilization. OBJECTIVES: To understand how primary care physicians (PCPs) make decisions regarding severe obesity treatment and bariatric surgery referral. SETTING: Focus groups with PCPs practicing in small, medium, and large cities in Wisconsin. METHODS: PCPs were asked to discuss prioritization of treatment for a severely obese patient with multiple co-morbidities and considerations regarding bariatric surgery referral. Focus group sessions were analyzed by using a directed approach to content analysis. A taxonomy of consensus codes was developed. Code summaries were created and representative quotes identified. RESULTS: Sixteen PCPs participated in 3 focus groups. Four treatment prioritization approaches were identified: (1) treat the disease that is easiest to address; (2) treat the disease that is perceived as the most dangerous; (3) let the patient set the agenda; and (4) address obesity first because it is the common denominator underlying other co-morbid conditions. Only the latter approach placed emphasis on obesity treatment. Five factors made PCPs hesitate to refer patients for bariatric surgery: (1) wanting to "do no harm"; (2) questioning the long-term effectiveness of bariatric surgery; (3) limited knowledge about bariatric surgery; (4) not wanting to recommend bariatric surgery too early; and (5) not knowing if insurance would cover bariatric surgery. CONCLUSION: Decision making by PCPs for severely obese patients seems to underprioritize obesity treatment and overestimate bariatric surgery risks. This could be addressed with PCP education and improvements in communication between PCPs and bariatric surgeons.

Fear of fatness and drive for thinness in predicting smoking status in college women.

Recent research has identified fear of fatness (FF) as a related yet distinct construct from drive for thinness (DT). Whereas DT may be associated with need for approval and an "approach" tendency, FF may be more strongly related to avoidance of disapproval and an avoidant problem-solving style. Although no research has directly compared the influence of FF vs. DT with regard to smoking behavior, FF and DT might represent distinct motivations for smoking. We predicted that both FF and DT would be significantly associated with cigarette smoking, but that FF would be a stronger predictor of smoking behavior, even after controlling for variables such as body mass index (BMI) and nicotine dependence. Participants (N=289) were female college undergraduate students. Daily smokers had the highest scores on measures of DT and FF, followed sequentially by infrequent smokers, "triers," and never smokers. More frequent smokers also reported greater levels of body dissatisfaction and eating pathology than less frequent and never-smokers. Hierarchical regression analyses showed that greater DT predicted higher likelihood of smoking on a daily basis; however, higher FF predicted fewer cigarettes smoked per day. FF and DT may each play a role in the relationship between eating pathology and smoking, but they might be differentially related to specific smoking patterns. Both FF and DT and their coinciding coping styles should be further researched in the role of smoking initiation and maintenance.

Smoking relapse and weight gain prevention program for postmenopausal weight-concerned women: A pilot study.

OBJECTIVE: Postmenopausal women have substantial concerns about weight gain when quitting smoking, which may contribute smoking relapse. There is a need for smoking cessation and weight gain prevention programs effective in this population. METHODS: Two formats of a smoking cessation/weight gain prevention follow-up intervention in postmenopausal weight concerned women were compared: a minimally-tailored group format and a highly tailored, multidisciplinary individual format. Effects on sustained abstinence and postcessation weight gain were assessed. Postmenopausal smokers received 6 sessions of behavioral counseling over a 2-week period, 8weeks of the nicotine transdermal patch, and subsequent random assignment to receive follow-up relapse prevention sessions at 1, 3, 8, and 16weeks postcessation in either group or individual format. RESULTS: The sample (N=98) was 67% Caucasian and 33% African-American. Age: m=52.3 (7.8) years, follicle stimulating hormone: m=42.6 (25.7), body mass index (BMI): m=27.4 (6.2), daily smoking rate: m=20.3 (11.5), for m=29.4 (10.7) years, Fagerström Test for Nicotine Dependence (FTND): m=6.4 (2.1), and carbon monoxide: m=23.8 (13.0) ppm. Abstinence rates in the group condition were significantly higher at 8weeks posttreatment. Group format significantly predicted abstinence rates at 8 and 16weeks posttreatment, even while controlling for age, race, BMI, CPD, years smoking, FTND, and weight concern. Weight concern predicted postcessation weight gain at 8 and 16weeks posttreatment. CONCLUSIONS: Results indicate that smoking cessation programs for postmenopausal women may best be delivered in a group format and that postcessation weight concerns be dealt with prior to a quit date.

Mechanisms of patient health behavior change in a randomized controlled trial of a spouse-assisted intervention.

Spouse-assisted interventions can improve health behaviors, but mechanisms of action are unknown. This study evaluated mediators of dietary and physical activity outcomes during a spouse-assisted intervention to improve low-density lipoprotein cholesterol. This is a secondary analysis of data from a randomized controlled trial comparing usual care (n = 128) to a spouse-assisted lifestyle change intervention (n = 127) comprising nine monthly goal setting telephone calls to participants and support planning calls to spouses over 11 months. Structural equation modeling was used to examine if the intervention influenced the putative mediators of participant self-efficacy and perceived spousal support at 6 months (i.e. action test); if changes in putative mediators at 6 months were associated with changes in diet and physical activity outcomes at 11 months (i.e. conceptual test); and if treatment condition effects on outcomes at 11 months were mediated by its effects on the 6-month putative mediators (i.e. indirect effects test). Participants were 94.9% male, 64.9% white and were 61.3 years old on average. The action test showed that the intervention increased dietary self-efficacy (p < .001) and perceived spousal support for diet (p < .001) and physical activity (p < .01) at 6 months. The conceptual test showed that increases in participant physical activity self-efficacy at 6 months were associated with increases in physical activity frequency (p = .01) and duration (p = .04) at 11 months; other putative mediators were not associated with changes in outcomes at 11 months. The indirect effects tests did not support a mediating role for self-efficacy or perceived spousal support. Intervention-induced changes in spousal support and dietary self-efficacy did not translate into behavior change. Other mechanisms may be driving behavior change.

Spouse health behavior outcomes from a randomized controlled trial of a spouse-assisted lifestyle change intervention to improve patient low-density lipoprotein cholesterol.

This study evaluated spouse health behavior outcomes from a randomized controlled trial of a spouse-assisted lifestyle intervention to reduce patient low-density lipoprotein cholesterol and improve patient health behaviors. Participants were 251 spouses of patients from the Durham Veterans Affairs Medical Center randomized to intervention or usual care. The intervention comprised 9 monthly telephone calls to patients and spouses. Outcomes were assessed at baseline, 6 and 11 months. At 11 months, there were no differences in spouse outcomes between intervention and usual care groups for moderate intensity physical activity (i.e., frequency, duration) or dietary intake (i.e., total calories, total fat, percentage of calories from total fat, saturated fat, percentage of calories from saturated fat, cholesterol, fiber). To improve spouse outcomes, couple interventions may need to include spouse behavior change goals and reciprocal support between patients and spouses and consider the need for improvement in spouse outcomes.

Patient predictors of follow-up care attendance in Roux-en-Y gastric bypass patients.

BACKGROUND: Multidisciplinary care after bariatric surgery is important for long-term safety and optimal weight loss, yet many patients do not attend follow-up appointments. We sought to identify demographic, psychosocial, and weight-related variables that were associated with medical and behavioral health appointment attendance after bariatric surgery. METHODS: A retrospective chart review was conducted with consecutive patients (n=538) obtaining first-time Roux-en-Y gastric bypass surgery between August 2009 and August 2010. Demographic and psychosocial data were compared between high (>50%) and low (≤50%) medical appointment attendees and high (>50%) and low (≤50%) behavioral health group attendees in their first postoperative year. Percentage excess weight loss at 6 months after surgery was evaluated as a predictor of 12-month appointment attendance. RESULTS: High medical appointment attendees were more likely to be older, be Caucasian, and have lower phobic anxiety than low medical appointment attendees. High behavioral health attendees had shorter travel distance to the clinic and lower levels of hostility, anxiety, and phobic anxiety compared with low attendees. In multivariate analyses, race/ethnicity and phobic anxiety remained significant predictors of medical attendance, while travel distance to clinic predicted behavioral health attendance. Six-month percent excess weight loss predicted medical appointment attendance at 12 months. CONCLUSION: The identified predictors of poor attendance at medical and behavioral bariatric surgery follow-up appointments should inform efforts to increase follow-up and improve surgical outcomes.

Actual medical and pharmacy costs for bariatric surgery: 6-year follow-up.

OBJECTIVE: To determine the change in total medical expenditures, total pharmacy expenditures, and subcategories of medical and pharmacy expenditures in obese individuals following weight loss surgery (WLS), and to compare these costs with expenditures in obese individuals not receiving WLS. METHODS: Louisiana Office of Group Benefits (OGB), the state-managed health insurer, invited members to be evaluated for insurance-covered WLS. Of 951 obese members who provided written consent to begin the WLS screening process, 40 were selected for surgery. Medical and pharmaceutical claims cost data of the 911 patients who did not have surgery and the 39 individuals who completed surgery were compared over a 2-year presurgical and 6-year postsurgical period. RESULTS: Total nonpharmacy medical costs were lower for WLS patients compared with non-WLS patients beginning 4 years postsurgery and lasting through 6 years postsurgery. No differences were found between WLS and non-WLS patients in expenditures for most medical subcategories examined, including emergency department, physical and occupational therapy, office visits, and laboratory/pathology; whereas sleep facility and all remaining medical expenditures not represented by a subcategory were lower for WLS patients during some postsurgery years. Total pharmacy costs were lower for WLS participants at 2 and 3 years postsurgery, but these lower costs were not maintained; however, costs remained lower for antidiabetic agents, antihypertensive agents, and dyslipidemic agents through all 6 postsurgery years under study. CONCLUSIONS: The cost of WLS may begin to be recouped within the first 4 years postsurgery with continued effects 6 years postsurgery.

Smoking cessation in peri- and postmenopausal women: a review.

A substantial portion of smokers are peri- or postmenopausal women. Cigarette smoking and menopause have overlapping negative health consequences and may act synergistically to contribute to worse health outcomes in this population. Little is known about issues specific to peri- and postmenopausal women attempting to quit smoking; however, it can be hypothesized that they face unique challenges in quitting smoking. Particularly, negative affect and vasomotor menopausal symptoms may make smoking cessation particularly challenging in this group of women. Peri- and postmenopausal women are also more prone to weight gain following smoking cessation, and concerns about postcessation weight gain may contribute to reduced motivation to quit smoking or to relapse to smoking. Recent evidence suggests that estrogen level may be positively associated with nicotine reward, which may aid in the smoking cessation efforts of postmenopausal women while possibly contributing to worse outcomes in perimenopausal women. Unfortunately, no known studies have compared premenopausal women with peri- or postmenopausal women on smoking cessation outcome variables. Studies in postmenopausal women indicate that hormone therapy (HT) use does not affect nicotine withdrawal, smoking cessation outcomes, or weight gain following smoking cessation; however, a lack of randomized trials limits the strength of these conclusions. Evidence of the effects of HT on mood following smoking cessation is conflicting. Further research is needed to identify the unique factors influencing smoking cessation in peri- and postmenopausal women and to develop and test interventions that target these variables in a way that improves cessation rates among this population.

A comparison of delay discounting among smokers, substance abusers, and non-dependent controls.

Previous studies have shown that smokers and substance-dependent individuals discount rewards that are available after a delay more than individuals without a history of substance dependence. However, it is not clear whether delay discounting is similar among smokers and substance-dependent individuals. Further, the influence of the combination of smoking and other substance dependence on delay discounting remains unknown. The present study compared the performance of four groups of individuals on a delay discounting task. The groups were (a) heavy smokers with comorbid substance dependence, (b) heavy smokers with no history of substance dependence, (c) never smokers with comorbid substance dependence, and (d) never smokers with no history of substance dependence. Analysis revealed that individuals who smoked and/or were dependent on another substance discounted delayed rewards more than individuals with no history of smoking or other substance dependence. No differences in the task performance of heavy smokers and substance-dependent individuals were found. Notably, participants who were dependent on multiple substances did not discount delayed rewards more than those dependent on only one substance. Overall, findings indicate that smoking and other substance dependence are similarly related to delay discounting.