Long-Term Results of a Digital Hypertension Self-Management Program: Retrospective Cohort Study.

BACKGROUND: Digital health programs that incorporate frequent blood pressure (BP) self-monitoring and support for behavior change offer a scalable solution for hypertension management. OBJECTIVE: We examined the impact of a digital hypertension self-management and lifestyle change support program on BP over 12 months. METHODS: Data were analyzed from a retrospective observational cohort of commercially insured members (n=1117) that started the Omada for Hypertension program between January 1, 2019, and September 30, 2021. Paired t tests and linear regression were used to measure the changes in systolic blood pressure (SBP) over 12 months overall and by SBP control status at baseline (≥130 mm Hg vs <130 mm Hg). RESULTS: Members were on average 50.9 years old, 50.8% (n=567) of them were female, 60.5% (n=675) of them were White, and 70.5% (n=788) of them had uncontrolled SBP at baseline (≥130 mm Hg). At 12 months, all members (including members with controlled and uncontrolled BP at baseline) and those with uncontrolled SBP at baseline experienced significant mean reductions in SBP (mean -4.8 mm Hg, 95% CI -5.6 to -4.0; -8.1 mm Hg, 95% CI -9.0 to -7.1, respectively; both P<.001). Members with uncontrolled SBP at baseline also had significant reductions in diastolic blood pressure (-4.7 mm Hg; 95% CI -5.3 to -4.1), weight (-6.5 lbs, 95% CI -7.7 to -5.3; 2.7% weight loss), and BMI (-1.1 kg/m2; 95% CI -1.3 to -0.9; all P<.001). Those with controlled SBP at baseline maintained within BP goal range. Additionally, 48% (418/860) of members with uncontrolled BP at baseline experienced enough change in BP to improve their BP category. CONCLUSIONS: This study provides real-world evidence that a comprehensive digital health program involving hypertension education, at-home BP monitoring, and behavior change coaching support was effective for self-managing hypertension over 12 months.

Cost Savings and Reduced Health Care Utilization Associated with Participation in a Digital Diabetes Prevention Program in an Adult Workforce Population.

BACKGROUND: Though in-person delivery of the Diabetes Prevention Program (DPP) has demonstrated medical cost savings, the economic impact of digital programs is not as well understood. OBJECTIVE: This study examines the impact of a digital DPP program on reducing all-cause health care costs and utilization among 2027 adult participants at 12 months. METHODS: A longitudinal, observational analysis of health care claims data was conducted on a workforce population who participated in a digital diabetes prevention program. Differences in utilization and costs from the year prior to program delivery through 1 year after enrollment were calculated using medical claims data for digital DPP participants compared to a propensity matched cohort in a differences-in-differences model. RESULTS: At 1 year, the digital DPP population had a reduction in all-cause health care spend of US$1169 per participant relative to the comparison group (P = 0.01), with US$699 of that savings coming from reduced inpatient spend (P = 0.001). Cost savings were driven by fewer hospital admissions and shorter length of stay (P < 0.001). No other significant results in cost differences were detected. There was a trend toward savings extending into the second year, but the savings did not reach statistical significance. CONCLUSIONS: These results demonstrated significant short-term health care cost savings at 1 year associated with digital DPP program delivery.

Practical Tips for Implementing the Diabetes Prevention Program in Clinical Practice.

PURPOSE OF REVIEW: The Diabetes Prevention Program (DPP) is an evidence-based lifestyle change program for prediabetes that is associated with a 58% reduction in 3-year diabetes incidence, and it has been supported by the American Medical Association and the Centers for Disease Control and Prevention. However, 9 in 10 patients are unaware they have the condition. RECENT FINDINGS: With the passage of the Affordable Care Act (ACA) and broadened coverage for preventive services, the DPP has emerged as an accessible intervention in patients at risk. In 2018, Medicare began to cover the DPP, making it widely available for the first time to any patient over the age of 65 meeting eligibility criteria. The DPP is an evidence-based, widely available, frequently covered benefit, for lifestyle change for patients with prediabetes. To take advantage of this intervention, providers need to develop prediabetes screening and DPP referral workflows.

Teen Preferences for Clinic-Based Behavior Screens: Who, Where, When, and How?

PURPOSE: Previous research examining computer-based adolescent risk behavior screening was done before widespread adoption of smartphones and merits updating. METHODS: This is a cross-sectional survey among 115 adolescents seeking primary care age 12-18 years. It is a diverse sample with 59% female, 51% white, 18% African-American, and 27% Latino. Respondents were asked level of comfort and honesty (1 = strongly disagree, 5 = strongly agree) when answering health behavior questions by paper, interview, or electronic device. Differences in the level of agreement were tested using a Wilcoxon signed rank test. RESULTS: Adolescents reported a higher level of comfort and honesty for screening conducted via electronic device versus paper (90% vs. 57%, p < .001; 89% vs. 61%, p < .001). Sixty-two percent adolescents prefer waiting room electronic screening versus at home (4.7%) or by provider in the examination room (11.2%). CONCLUSIONS: Electronic same-day risk behavior screening is the preferred method for adolescents and should be incorporated into preventive services.

Use of theory in computer-based interventions to reduce alcohol use among adolescents and young adults: a systematic review.

BACKGROUND: Alcohol use and binge drinking among adolescents and young adults remain frequent causes of preventable injuries, disease, and death, and there has been growing attention to computer-based modes of intervention delivery to prevent/reduce alcohol use. Research suggests that health interventions grounded in established theory are more effective than those with no theoretical basis. The goal of this study was to conduct a literature review of computer-based interventions (CBIs) designed to address alcohol use among adolescents and young adults (aged 12-21 years) and examine the extent to which CBIs use theories of behavior change in their development and evaluations. This study also provides an update on extant CBIs addressing alcohol use among youth and their effectiveness. METHODS: Between November and December of 2014, a literature review of CBIs aimed at preventing or reducing alcohol in PsychINFO, PubMed, and Google Scholar was conducted. The use of theory in each CBI was examined using a modified version of the classification system developed by Painter et al. (Ann Behav Med 35:358-362, 2008). RESULTS: The search yielded 600 unique articles, 500 were excluded because they did not meet the inclusion criteria. The 100 remaining articles were retained for analyses. Many articles were written about a single intervention; thus, the search revealed a total of 42 unique CBIs. In examining the use of theory, 22 CBIs (52 %) explicitly named one or more theoretical frameworks. Primary theories mentioned were social cognitive theory, transtheoretical model, theory of planned behavior and reasoned action, and health belief model. Less than half (48 %), did not use theory, but mentioned either use of a theoretical construct (such as self-efficacy) or an intervention technique (e.g., manipulating social norms). Only a few articles provided detailed information about how the theory was applied to the CBI; the vast majority included little to no information. CONCLUSIONS: Given the importance of theory in guiding interventions, greater emphasis on the selection and application of theory is needed. The classification system used in this review offers a guiding framework for reporting how theory based principles can be applied to computer based interventions.

Characteristics of Youth Presenting for Weight Management: Retrospective National Data from the POWER Study Group.

BACKGROUND: There are no existing multisite national data on obese youth presenting for pediatric weight management. The primary aim was to describe BMI status and comorbidities among youth with obesity presenting for pediatric weight management (PWM) at programs within the Pediatric Obesity Weight Evaluation Registry (POWER). METHODS: Data were collected from 2009-2010 among 6737 obese patients ages 2-17. Patients were classified in three groups by BMI (kg/m(2)) cutoffs and percent of the 95th percentile for BMI: (1) obesity; (2) severe obesity class 2; and (3) severe obesity class 3. Weighted percentages are presented for baseline laboratory tests, blood pressure, and demographics. Generalized logistic regression with clustering was used to examine the relationships between BMI status and comorbidities. RESULTS: Study youth were 11.6 ± 3.4 years of age, 56% female, 31% black, 17% Hispanic, and 53% publicly insured. Twenty-five percent of patients had obesity (n = 1674), 34% (2337) had severe obesity class 2, and 41% (2726) had severe obesity class 3. Logistic regression revealed that males (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.5-2.0), blacks (OR, 1.7; 95% CI, 1.5-2.0), age <6 years (OR, 2.0; 95% CI, 1.5-2.6), and public insurance (OR, 1.8; 95% CI, 1.5-2.0) had a higher odds of severe obesity class 3. Severe obesity class 3 was associated with higher odds of laboratory abnormalities for hemoglobin A1c (OR, 1.7; 95% CI, 1.3-2.2), alanine aminotransferase ≥40 U/L (OR, 1.9; 95% CI, 1.3-2.6), and elevated systolic blood pressure (OR, 2.5; 95% CI, 2.0-3.0). CONCLUSIONS: Youth with obesity need earlier access to PWM given that they are presenting when they have severe obesity with significant comorbidities.

Body image and health: eating disorders and obesity.

Eating behavior in adolescents can be as high risk as other behaviors that arise during this period and can have serious health consequences. This article presents a framework for screening and treatment of abnormal adolescent eating behavior by the primary care provider. A review of the types of disordered eating is presented along with suggested ways to screen. Indications for subspecialty eating disorder referrals and key aspects of screening and intervention in adolescent obesity and eating disorders are also reviewed. Specific attention is paid to the aspects of care that can be provided in primary care and multidisciplinary care.

Gender differences in prediabetes and insulin resistance among 1356 obese children in Northern California.

AIMS: While it has been shown that there are gender differences in prediabetes and insulin resistance among adults, less is known about whether these differences exist in children. Obese children have elevated risk for developing metabolic dysfunction, and this analysis was conducted to compare obese boys and girls. METHODS: Biomarkers of prediabetes (IFG and HbA1c) and insulin resistance (HOMA-IR), were examined for 1356 obese children (2-19 years) who presented to a pediatric weight management clinic between 2008 and 2012. Gender differences were analyzed with multivariate logistic regression. RESULTS: Boys were more likely than girls to have IFG (adjusted OR: 1.68; CI: 1.06-2.65), but less likely to have elevated HOMA-IR (adjusted OR 0.71; CI: 0.52 -0.97). The female predominance of insulin resistance was present at younger ages than the male predominance of IFG. There were no gender differences with respect to HbA1c. Elevated HbA1c identified 20.7% of the sample as prediabetic whereas IFG identified 7.8%. CONCLUSIONS: Similar to findings in adults, obese children appear to exhibit more impaired fasting glucose among boys and a higher predominance of insulin resistance among girls. However, HbA1c identified a larger proportion of these high-risk, obese youth as prediabetic than IFG.

The association of BMI status with adolescent preventive screening.

OBJECTIVE: To examine the relationship between BMI status (normal, overweight, and obese) and preventive screening among adolescents at their last checkup. METHODS: We used population-based data from the 2003-2007 California Health Interview Surveys, telephone interviews of adolescents aged 12 to 17 years with a checkup in the past 12 months (n = 9220). Respondents were asked whether they received screening for nutrition, physical activity, and emotional distress. BMI was calculated from self-reported height and weight: (1) normal weight or underweight (<85th percentile); (2) overweight (85th-94th percentile); and (3) obese (>95th percentile). Multivariate logistic regression models tested how screening by topic differed according to BMI status, adjusting for age, gender, income, race/ethnicity, and survey year. RESULTS: Screening percentages in the pooled sample (all 3 years) were higher for obese, but not overweight, adolescents for physical activity (odds ratio: 1.4; P < .01) and nutrition (odds ratio: 1.6; screening did not differ P < .01). Stratified analysis by year revealed higher screening for obese (versus normal-weight) adolescents for nutrition and physical activity in 2003 and for all 3 topics in 2005. However, by 2007, screening did not differ according to BMI status. Overall screening between 2003 and 2007 declined for nutrition (75%-59%; P < .01), physical activity (74%-60%; P < .01), and emotional distress (31%-24%; P < .01). CONCLUSIONS: Obese adolescents receive more preventive screening versus their normal-weight peers. Overweight adolescents do not report more screening, but standards of care dictate increased attention for this group. These results are discouraging amid a rise in pediatric obesity and new guidelines that recommend screening by BMI status.

Adolescent obesity and puberty: the "perfect storm".

Obesity is the most serious long-term health risk currently facing America's adolescents. Weight gain during adolescence carries a higher risk for adult obesity and the metabolic syndrome. This review highlights early adolescence as a particularly high-risk time for weight gain due to the synergy of naturally occurring metabolic changes along with increasing behavioral risk factors. One of the first potential health effects of abnormal weight gain during this period is earlier puberty, usually manifested as thelarche. The obesity epidemic is clearly implicated in the national trend toward earlier thelarche, although the data are not as strong in relation to menarche. Leptin activation of the hypothalamic-pituitary axis, combined with insulin resistance, and increased adiposity may result in the higher estrogen levels that are linked to breast development. Young adolescents also experience a sharp decline in their level of physical activity, worsening nutritional habits, and other important psychosocial and developmental risk factors that may contribute to obesity and estrogen-dependent disease in later life, including polycystic ovary syndrome and breast cancer. Unfortunately, the very psychosocial factors that contribute to abnormal weight gain during early adolescence make prevention and treatment in this population particularly challenging. Therefore, intervening prior to pubertal onset becomes even more important given the risk factors present once puberty begins.

Public savings from the prevention of unintended pregnancy: a cost analysis of family planning services in California.

OBJECTIVE: To assess the short-term economic savings associated with the prevention of unintended pregnancies through California's Medicaid family planning demonstration project. DATA SOURCES: Secondary data from health and social service programs available to pregnant or parenting women at or below 200 percent of the federal poverty level in California in 2002 and data on the quantity and type of contraceptives dispensed to clients of California's 1115 Federal Medicaid demonstration project. STUDY DESIGN: The cost of providing publicly funded family planning services was compared with an estimate of public savings resulting from the prevention of unintended pregnancies. DATA COLLECTION: To estimate costs and participation rates in each health and social service program, we examined published program reports, government budgetary data, analyses conducted by federal and state level program managers, and calculations from national datasets. FINDINGS: The unintended pregnancies averted by California's family planning demonstration project in 2002 would have incurred $1.1 billion in public expenditures within 2 years and $2.2 billion within 5 years, significantly more than the $403.8 million spent on the project. Each dollar spent generated savings of $2.76 within 2 years and $5.33 within 5 years. CONCLUSIONS: The California 1115 Medicaid family planning demonstration project resulted in significant public cost savings. The cost of the project was substantially less than the public sector health and social service costs which would have occurred in its absence.