Engaging patients and caregivers to establish priorities for the management of diabetic foot ulcers.

OBJECTIVE: Effective diabetic foot ulcer (DFU) care has been stymied by a lack of input from patients and caregivers, reducing treatment adherence and overall quality of care. Our objectives were to capture the patient and caregiver perspectives on experiencing a DFU and to improve prioritization of patient-centered outcomes. METHODS: A DFU-related stakeholder group was formed at an urban tertiary care center. Seven group meetings were held across 4 months, each lasting ∼1 hour. The meeting facilitator used semistructured questions to guide each discussion. The topics assessed the challenges of the current DFU care system and identified the outcomes most important to stakeholders. The meetings were audio recorded and transcribed. Directed and conventional content analyses were used to identify key themes. RESULTS: Six patients with diabetes (five with an active DFU), 3 family caregivers, and 1 Wound Clinic staff member participated in the stakeholder group meetings. The mean patient age was 61 years, four (67%) were women, five (83%) were either African American or Hispanic, and the mean hemoglobin A1c was 8.3%. Of the five patients with a DFU, three had previously required lower extremity endovascular treatment and four had undergone at least one minor foot amputation. Overall, stakeholders described how poor communication between medical personnel and patients made the DFU experience difficult. They felt overwhelmed by the complexity of DFU care and were persistently frustrated by inconsistent medical recommendations. Limited resources further exacerbated their frustrations and barriers to care. To improve DFU management, the stakeholders suggested a centralized healthcare delivery pathway with timely access to a coordinated, multidisciplinary DFU team. The clinical outcomes most valued by stakeholders were (1) avoiding amputation and (2) maintaining or improving health-related quality of life, which included independent mobility, pain control, and mental health. From these themes, we developed a conceptual model to inform DFU care pathways. CONCLUSIONS: Current DFU management lacks adequate care coordination. Multidisciplinary approaches tailored to the self-identified needs of patients and caregivers could improve adherence. Future DFU-related comparative effectiveness studies will benefit from direct stakeholder engagement and are required to evaluate the efficacy of incorporating patient-centered goals into the design of a multidisciplinary DFU care delivery system.

State of the art conference on weight management in VA: Policy and research recommendations for advancing behavioral interventions.

This article summarizes outcomes of the behavioral interventions work group for the Veterans Health Administration (VHA) State of the Art Conference (SOTA) for Weight Management. Sixteen VHA and non-VHA subject matter experts, representing clinical care delivery, research, and policy arenas, participated. The work group reviewed current evidence of efficacy, effectiveness, and implementation of behavioral interventions for weight management, participated in phone- and online-based consensus processes, generated key questions to address gaps, and attended an in-person conference in March 2016. The work group agreed that there is strong evidence for efficacy and effectiveness of core behavioral intervention components and processes, but insufficient evidence to determine the comparative effectiveness of multiple clinician-delivered weight management modalities, as well as technologies that may or may not supplement clinician-delivered treatments. Effective strategies for implementation of weight management services in VHA were identified. The SOTA work group's foremost policy recommendations are to establish a system-wide culture for weight management and to identify a population-level health metric to measure the impact of weight management interventions that can be tracked and clearly communicated throughout VHA. The work group's top research recommendation is to determine how to deploy and scale the most effective behavioral weight management interventions for Veterans.

Predictors of Outcomes for Older Adults Participating in Calmer Life, a Culturally Tailored Intervention for Anxiety.

OBJECTIVE: Determine predictors of reduced worry and anxiety for older adults participating in the pilot phase of Calmer Life, a modular, personalized cognitive-behavioral treatment for worry. METHODS: Underserved adults (N = 54) over age 50 participated. Therapists were either experts (Ph.D. or Master's) or nonexpert providers (case managers, community health workers, and bachelor's level). Participants completed the Penn State Worry Questionnaire-Abbreviated (PSWQ-A) and the Geriatric Anxiety Inventory-Short Form (GAI-SF) before treatment and at 3 months. RESULTS: Demographic and clinical variables were individually entered into separate regression equations, controlling for pretreatment scores, to determine their associations with post-treatment 1) PSWQ-A and 2) GAI-SF scores. Only younger age and African American race were significant (p < .05) univariate predictors of higher post-treatment PSWQ-A scores. African American race was also a significant predictor of higher post-treatment GAI-SF scores. CONCLUSIONS: African American participants had higher post-treatment PSWQ-A and GAI-SF scores than White and Hispanic participants. Younger age was also associated with more severe PSWQ-A post-treatment scores. CLINICAL IMPLICATIONS: Younger participants may experience additional stressors (e.g., caregiving, working) compared with older participants. Smaller decreases in anxiety in African Americans point to the need for continued focus and additional modification of interventions.

Calmer Life: A Culturally Tailored Intervention for Anxiety in Underserved Older Adults.

OBJECTIVES: To evaluate the feasibility of the Calmer Life and Enhanced Community Care interventions delivered by community and expert providers and test their preliminary effectiveness on worry, generalized anxiety disorder (GAD) severity, anxiety, depression, sleep, health-related quality of life, and satisfaction. DESIGN: Small randomized trial, with measurements at baseline and 3 months. SETTING: Underserved, low-income, mostly minority communities in Houston, TX. PARTICIPANTS: Forty underserved adults 50 years and older, with significant worry and principal or coprincipal GAD or anxiety disorder not otherwise specified. INTERVENTION: Combination of person-centered, flexible skills training to reduce worry; resource counseling to target unmet basic needs; and facilitation of communication with primary care providers developed through a community-academic partnership with social service and faith-based organizations. Religion/spirituality may be incorporated. PRIMARY OUTCOMES: worry (Penn State Worry Questionnaire-Abbreviated), GAD severity (GAD-7), anxiety (Geriatric Anxiety Inventory-Short Form). SECONDARY OUTCOMES: depression (Patient Health Questionnaire-8 and Geriatric Depression Scale-Short Form), sleep (Insomnia Severity Index), health-related quality of life (12-item Medical Outcomes Study Short Form), satisfaction (Client Satisfaction Questionnaire and exit interviews). RESULTS: Provider training was valid; mean ratings for community providers were well above average, with none less than adequate. Reach was excellent. Participants receiving the Calmer Life intervention had greater improvement in GAD severity and depression than those receiving Enhanced Community Care. Satisfaction with both treatments was equivalent. CONCLUSIONS: A larger comparative-effectiveness trial needs to examine outcomes following the Calmer Life intervention relative to standard community-based care and to evaluate more fully issues of implementation potential.

Sedentary behavior, body mass index, and weight loss maintenance among African American women.

OBJECTIVES: Relationships among sedentary behavior, weight gain, and weight loss and regain are understudied particularly for African Americans, a high risk group for obesity. The hypotheses were: sedentary behavior is positively associated with current body mass and % of weight loss maintained after initial weight loss; these associations differ by physical activity status. DESIGN: Cross-sectional. SETTING: National survey. PATIENTS OR PARTICIPANTS: 1,110 African American women. INTERVENTIONS: Observational study. MAIN OUTCOME MEASURES: A cross-sectional survey was administered to African Americans who had intentionally lost 10% of their body weight. Those who lost weight and maintained at least a 10% weight loss for a year were classified as weight loss maintainers; all others were classified as weight loss re-gainers. Participants were classified into one of four categories based on low and high levels of sedentary behavior and physical activity. The high physical activity, low sedentary behavior category was the reference group. Sociodemographic characteristics and health conditions were covariates. Data were collected in 2009 and analyzed in 2013. RESULTS: Each additional daily hour of sedentary time was associated with an increase in BMI (P<.001) and poorer weight loss maintenance (P<.01). Regardless of sedentary behavior, low physically active participants had BMIs that were greater (P<.001) compared to the reference group. Sedentary behavior had an independent effect on BMI and % of weight loss maintained for high but not low physically active participants. CONCLUSIONS: High levels of sedentary behavior were associated with poorer weight-loss maintenance among African American women even for those with high levels of physical activity. The implications of this study are that physical activity and sedentary behavior, independently and combined, are associated with BMI and weight-loss maintenance.

Improving secondary stroke self-care among underserved ethnic minority individuals: a randomized clinical trial of a pilot intervention.

The overall purpose of this study was to pilot a multibehavioral, brief, stroke self-care treatment adapted for implementation with underserved racial/ethnic minority groups and to test the moderating effects of anxiety and depression on engagement in secondary stroke-prevention behaviors. Fifty-two participants were randomized to the secondary stroke prevention (STOP) (N = 27) or usual care (N = 25) group. The STOP program consisted of 3 culturally tailored information sessions and goal-setting activities that were delivered in person by a research assistant. Participants were assessed at baseline and 4-week follow-up for stroke knowledge, exercise, fruit and vegetable consumption, tobacco and alcohol use, and medication adherence (primary outcomes) and anxiety and depression (moderator variables). Between-groups analysis of covariance and logistic multiple regressions revealed significant between-group differences for stroke knowledge, tobacco use and moderating effects between tobacco and anxiety, and improved alcohol use. The STOP program decreased secondary stroke risk factors among underserved racial/ethnic minorities and should be tested in large-scale trials.

Booster Breaks in the workplace: participants' perspectives on health-promoting work breaks.

Increasing sedentary work has been associated with greater cardiovascular and metabolic risk, as well as premature mortality. Interrupting the sedentary workday with health-promoting work breaks can counter these negative health effects. To examine the potential sustainability of work-break programs, we assessed the acceptance of these breaks among participants in a Booster Break program. We analyzed qualitative responses from 35 participants across five worksites where one 15-min physical activity break was taken each workday. Two worksites completed a 1-year intervention and three worksites completed a 6-month intervention. Responses to two open-ended questions about the acceptance and feasibility of Booster Breaks were obtained from a survey administered after the intervention. Three themes for benefits and two themes for barriers were identified. The benefit themes were (i) reduced stress and promoted enjoyment, (ii) increased health awareness and facilitated behavior change, and (iii) enhanced workplace social interaction. The barrier themes were the need for (iv) greater variety in Booster Break routines and (v) greater management support. This study provides empirical support for the acceptance and feasibility of Booster Breaks during the workday. Emphasizing the benefits and minimizing the barriers are strategies that can be used to implement Booster Breaks in other workplaces.

Using an Adjunctive Treatment to Address Psychological Distress in a National Weight Management Program: Results of an Integrated Pilot Study.

INTRODUCTION: Obesity is highly comorbid with psychological symptoms in veterans, particularly post-traumatic stress disorder (PTSD), depression, and anxiety. Obese veterans with comorbid psychological symptoms often display suboptimal weight loss and poor physical functioning when participating in weight management programs. The MOVE! program aims to increase healthy eating and physical activity to promote weight loss in obese veterans. Adequately addressing psychological barriers is necessary to maximize outcomes in MOVE! for veterans with PTSD, depression, and anxiety. We examined the preliminary outcomes of administering the Healthy Emotions and Improving Health BehavioR Outcomes (HERO) intervention. HERO is adjunctive cognitive-behavioral therapy to MOVE! that addresses PTSD, depression, and anxiety symptom barriers to engagement in physical activity. MATERIALS AND METHODS: All recruitment and study procedures were approved by the institutional review board and research and development committees of the Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine in Houston, Texas. Participants gave written informed consent before enrollment. Thirty-four obese veterans with a diagnosis of PTSD, depression, and/or anxiety who were attending MOVE! were assigned to the 8-session HERO group or the usual care (UC) group. Veterans completed assessments of PTSD, depression and anxiety symptoms, physical activity, physical functioning, and weight at baseline, 8 and 16 weeks post treatment. Changes from baseline to 8- and 16-week follow-up on the self-report and clinician-rated measures were assessed, using independent samples t-tests and analyses of covariance. RESULTS: At 8 weeks post treatment, participants in the HERO group had significantly higher step counts per day than participants in the UC group. Similarly, at 16 weeks post-treatment, participants in the HERO group continued to experience a significant increase in daily steps taken per day, as well as statistically and clinically significantly lower scores on the depression symptom and PTSD symptom severity. Participants in the HERO group also demonstrated significantly higher scores on the physical functioning inventory than participants in the UC group (44.1 ± 12.1 vs. 35.7 ± 10.7, P = 0.04) at 16 weeks post treatment. CONCLUSIONS: Findings of this small trial have important implications pending replication in a more rigorously designed large-scale study. Providing an adjunctive treatment to MOVE! that addresses psychological distress has potential benefits for psychological symptom reduction, engagement in healthy dietary habits, and greater physical activity for individuals who traditionally experience barriers to making positive weight management changes.

Iraq and Afghanistan veterans with PTSD participate less in VA's weight loss program than those without PTSD.

BACKGROUND: Three-quarters of Iraq and Afghanistan veterans enrolled in Veterans Health Administration (VHA) care are overweight or obese. The VHA MOVE!® weight management program can mitigate the risks of obesity-related morbidity. However, many Iraq and Afghanistan veterans experience barriers to VHA services, which may affect participation, especially among those with posttraumatic stress disorder (PTSD) and/or depression. Little is known about MOVE! engagement among recent veterans. We describe a retrospective evaluation of MOVE! participation among Iraq and Afghanistan veterans with and without mental health problems. METHODS: As part of a national VHA mental health evaluation study, we accessed VHA patient care databases to identify Iraq and Afghanistan veterans receiving care from 2008-2013 who had ≥1 MOVE! visit(s) and ≥1 weight measurements (N=24,899). We used logistic regression to determine whether mental health conditions were associated with having 12 visits/year (desirable dose of care), adjusting for demographic, health, and utilization factors. RESULTS: Among Iraq and Afghanistan veterans enrolled in MOVE!, 4% had a desirable dose of participation. In adjusted models, desirable MOVE! participation was more likely among those without PTSD; those who were older, female, and unmarried; and those who had higher baseline weight, more medical comorbidities, no pain, psychotropic medication use, higher disability ratings, and more mental health visits. LIMITATIONS: We used administrative ICD-9 codes. Sample only included veterans in VHA care. CONCLUSIONS: Iraq and Afghanistan veterans, particularly those with PTSD, had low participation in VHA weight management programming. Correlates of MOVE! participation were identified, highlighting opportunities to tailor MOVE! to improve participation for these veterans.

Veterans Health Administration's MOVE! Weight Management Program: Primary Care Clinicians' Perceptions of Program Implementation.

The Veterans Health Administration's MOVE! Program is the largest health care-delivered weight loss intervention in the United States. As a referring clinician's perceptions and knowledge of health programs may impact implementation, examining perceptions of MOVE! may inform improvements to this and other programs. This study investigated primary care clinician perceptions of MOVE! (n = 754, 50% nurses). Perceived effectiveness ratings were highest for groups with 11 to 25 group members (p < 0.01) and for a combined lecture and support group format (p = 0.026), though session length and several other aspects of delivery were not associated with perceptions of effectiveness. MOVE! staff also rated the program as more effective than did other clinicians (p < 0.01). Many respondents lacked knowledge about program specifics, especially those not involved with MOVE! delivery (vs. those directly involved; p < 0.01). These findings indicate that variety in group size and format is related to perceptions of MOVE! effectiveness. Also, clinicians not involved with MOVE! may lack knowledge about the program and underestimate its effectiveness, which could negatively affect referral likelihood or enthusiasm expressed to referred patients. Findings highlight opportunities for clarifying perceptions of a weight control program among clinicians in a large health care system.

Provider and staff perceptions of veterans' attrition from a national primary care weight management program.

BACKGROUND: Overweight and obesity are growing problems for primary care. Although effective weight management programs exist, these programs experience significant attrition, which limits effectiveness. OBJECTIVES: This study examined provider and staff perceptions of attrition from the Veterans Health Administration MOVE!(®) Weight Management Program as an initial step toward understanding attrition from primary care-based programs. PARTICIPANTS: MOVE!(®) clinicians, primary care providers, and other staff members who interacted with patients about participating in MOVE!(®) (n=754) from Department of Veterans Affairs medical centers throughout the United States. Respondents were predominantly female (80.8%), Caucasian (79.2%), and trained as nurses (L.P.N., R.N., or N.P.; 50%). MEASURE: Participants completed a web-mediated survey; items assessed agreement with personal and programmatic reasons for dropout, and allowed respondents to indicate the number one reason for dropout in an open-ended format. This survey was adapted from an existing tool designed to capture patient perceptions. RESULTS: Respondents indicated that veterans experienced practical barriers to attendance (eg, transportation and scheduling difficulties) and desire for additions to the program (eg, a live exercise component). Low motivation was the primary factor identified by respondents as associated with dropout, particularly as noted by MOVE!(®) clinicians (versus other providers/staff; P<0.01). CONCLUSIONS: These findings suggest that programmatic changes, such as adding additional meeting times or in-session exercise time, may be of benefit to MOVE!(®). In addition, increasing the use of techniques such as Motivational Interviewing among providers who refer patients to MOVE!(®) may improve participant engagement in MOVE!(®) and other primary care-based weight management programs. Further research is needed to effectively identify those likely to withdraw from weight management programs before achieving their goals, and the reasons for withdrawal.

Variation in Utilization of Health Care Services for Rural VA Enrollees With Mental Health-Related Diagnoses.

PURPOSE: Rural-dwelling Department of Veterans Affairs (VA) enrollees are at high risk for a wide variety of mental health-related disorders. The objective of this study is to examine the variation in the types of mental and nonmental health services received by rural VA enrollees who have a mental health-related diagnosis. METHODS: The Andersen and Aday behavioral model of health services use and the Agency for Healthcare Research and Quality Medical Expenditure Panel Survey (MEPS) data were used to examine how VA enrollees with mental health-related diagnoses accessed places of care from 1999 to 2009. Population survey weights were applied to the MEPS data, and logit regression was conducted to model how predisposing, enabling, and need factors influence rural veteran health services use (measured by visits to different places of care). Analyses were performed on the subpopulations: rural VA, rural non-VA, urban VA, and urban non-VA enrollees. FINDINGS: For all types of care, both rural and urban VA enrollees received care from inpatient, outpatient, office-based, and emergency room settings at higher odds than urban non-VA enrollees. Rural VA enrollees also received all types of care from inpatient, office-based, and emergency room settings at higher odds than urban VA enrollees. Rural VA enrollees had higher odds of a mental health visit of any kind compared to urban VA and non-VA enrollees. CONCLUSIONS: Based on these variations, the VA may want to develop strategies to increase screening efforts in inpatient settings and emergency rooms to further capture rural VA enrollees who have undiagnosed mental health conditions.

Evaluation of early weight loss thresholds for identifying nonresponders to an intensive lifestyle intervention.

OBJECTIVE: Weight losses in lifestyle interventions are variable, yet prediction of long-term success is difficult. The utility of using various weight loss thresholds in the first 2 months of treatment for predicting 1-year outcomes was examined. METHODS: Participants included 2327 adults with type 2 diabetes (BMI:35.8 ± 6.0) randomized to the intensive lifestyle intervention (ILI) of the Look AHEAD trial. ILI included weekly behavioral sessions designed to increase physical activity and reduce caloric intake. 1-month, 2-month, and 1-year weight changes were calculated. RESULTS: Participants failing to achieve a ≥2% weight loss at Month 1 were 5.6 (95% CI:4.5, 7.0) times more likely to also not achieve a ≥10% weight loss at Year 1, compared to those losing ≥2% initially. These odds were increased to 11.6 (95% CI:8.6, 15.6) when using a 3% weight loss threshold at Month 2. Only 15.2% and 8.2% of individuals failing to achieve the ≥2% and ≥3% thresholds at Months 1 and 2, respectively, go on to achieve a ≥10% weight loss at Year 1. CONCLUSIONS: Given the association between initial and 1-year weight loss, the first few months of treatment may be an opportune time to identify those who are unsuccessful and utilize rescue efforts. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00017953.

Self-Care Self-Efficacy, Religious Participation and Depression as Predictors of Poststroke Self-Care Among Underserved Ethnic Minorities.

Underserved ethnic minorities have multiple chronic disease risk factors, including tobacco, alcohol and substance use, which contribute to increased incidence of stroke. Self-efficacy (self-care self-efficacy), religious participation and depression may directly and indirectly influence engagement in post stroke self-care behaviors. The primary aim of the present study was to investigate the effects of self-care self-efficacy, religious participation and depression, on tobacco, alcohol and substance use in a sample of largely ethnic minority, underserved stroke survivors (n=52). Participants previously recruited for a culturally tailored secondary stroke prevention self-care intervention were included. The treatment group received three stroke self-care sessions. The usual care group completed assessments only. Both groups were included in these analyses. Main outcome measures included tobacco, alcohol and substance use. Self-care self-efficacy, religious participation and depression were also assessed. Logistic regression analyses, using self-efficacy, religious practice and depression as the referents, were used to predict binary outcomes of tobacco, alcohol and substance use at 4-weeks poststroke. Higher depression and self-care self-efficacy were associated with reduced odds of smoking and substance use. Greater participation in religious activities was associated with lower odds of alcohol use. We can conclude that incorporating depression treatment and techniques to increase self-care self-efficacy, and encouraging religious participation may help to improve stroke self-care behaviors for underserved and low socioeconomic status individuals. Results are discussed in the context of stroke self-management.

Four-year analysis of cardiovascular disease risk factors, depression symptoms, and antidepressant medicine use in the Look AHEAD (Action for Health in Diabetes) clinical trial of weight loss in diabetes.

OBJECTIVE: To study the association of depressive symptoms or antidepressant medicine (ADM) use with subsequent cardiovascular disease (CVD) risk factor status in the Look AHEAD (Action for Health in Diabetes) trial of weight loss in type 2 diabetes. RESEARCH DESIGN AND METHODS: Participants (n = 5,145; age [mean ± SD] 58.7 ± 6.8 years; BMI 35.8 ± 5.8 kg/m(2)) in two study arms (intensive lifestyle [ILI], diabetes support and education [DSE]) completed the Beck Depression Inventory (BDI), reported ADM use, and were assessed for CVD risk factors at baseline and annually for 4 years. Risk factor-positive status was defined as current smoking, obesity, HbA1c >7.0% or insulin use, and blood pressure or cholesterol not at levels recommended by expert consensus panel or medicine to achieve recommended levels. Generalized estimating equations assessed within-study arm relationships of elevated BDI score (≥11) or ADM use with subsequent year CVD risk status, controlled for demographic variables, CVD history, diabetes duration, and prior CVD risk status. RESULTS: Prior year elevated BDI was associated with subsequent CVD risk factor-positive status for the DSE arm (A1C [odds ratio 1.30 (95% CI 1.09-1.56)]; total cholesterol [0.80 (0.65-1.00)]; i.e., protective from high total cholesterol) and the ILI arm (HDL [1.40 (1.12-1.75)], triglyceride [1.28 (1.00-1.64)]). Prior year ADM use predicted subsequent elevated CVD risk status for the DSE arm (HDL [1.24 (1.03-1.50)], total cholesterol [1.28 (1.05-1.57)], current smoking [1.73 (1.04-2.88)]) and for the ILI arm (A1C [1.25 (1.08-1.46)], HDL [1.32 (1.11-1.58)], triglycerides [1.75 (1.43-2.14)], systolic blood pressure [1.39 (1.11-1.74)], and obesity [1.46 (1.22-2.18)]). CONCLUSIONS: Aggressive monitoring of CVD risk in diabetic patients with depressive symptoms or who are treated with ADM may be warranted.

Ill Effects of Smoking: Baseline Knowledge among School Children and Implementation of the "AntE Tobacco" Project.

Introduction. Cigarette smoking contributes to the deaths of more than 400,000 Americans annually. Each day >3,000 children and adolescents become regular smokers. This paper details a new antitobacco educational program titled "AntE Tobacco" Method. Children in grades 1-3 were administered a 10-item questionnaire to ascertain their baseline knowledge about the ill effects of smoking, shown an educational cartoon video depicting the ill effects of tobacco, and given a story book based on the video. At the end of video, children were administered a questionnaire to determine short-term recall of the antitobacco educational objectives of the program. Four to 6 weeks later, the children were then administered a follow-up survey to determine long-term retention of the anti tobacco educational program. Result. Eighty two percent of the children answered the outcome questions correctly immediately following the video. At follow-up, 4-6 weeks later, 83% of children answered all questions correctly. Conclusion. The anti tobacco education program used in this study effectively conveyed most of the educational objectives. The results of this study indicate that a multimedia (i.e., video and book) educational program can be used to educate and reinforce anti tobacco messages. This program may be very useful as a part of a comprehensive anti tobacco curriculum in school systems.