Is glycemia control in Canadians with diabetes individualized? A cross-sectional observational study.

OBJECTIVE: Diabetes guidelines recommend individualized glycemic targets: tighter control in younger, healthier patients and consideration of more moderate control in the elderly and those with coexisting illnesses. Our objective was to examine whether glycemic control varied by age and comorbidities in Canadian primary care. RESEARCH DESIGN AND METHODS: Cross-sectional study using data from the electronic medical records of 537 primary care providers across Canada; 30 416 patients with diabetes, aged 40 or above, with at least one encounter and one hemoglobin A1c (HbA1c) measurement between 1 January 2012 and 31 December 2013. The outcome was the most recent HbA1c, categorized into three levels of control: tight (<7.0% or <53 mmol/mol), moderate (7.0%-8.5%, 53 mmol/mol-69.5 mmol/mol) and uncontrolled (>8.5% or >69.5 mmol/mol). We adjusted for several factors associated with glycemic control including treatment intensity. RESULTS: Younger patients (aged 40-49) were more likely to have moderate as opposed to tight control than the older patients (aged 80+) (OR 1.28; 95% CI 1.11 to 1.49, p=0.001). The youngest were also more likely to have uncontrolled as opposed to moderately controlled glycemia (OR 3.39; 95% CI 2.75 to 4.17, p<0.0001). Patients with no or only one comorbidity were more likely to have moderate as opposed to tight control than those with three or more comorbidities (OR 1.66;95% CI 1.46 to 1.90, p<0.0001). CONCLUSIONS: Levels of glycemic control, given age and comorbidities appear to differ from guideline recommendations. Research is needed to understand these discrepancies and develop methods to assist providers in personalizing glycemic targets.

Mechanisms of Change in Diet and Activity in the Make Better Choices 1 Trial.

OBJECTIVE: The Make Better Choices 1 trial demonstrated that participants with unhealthy diet and activity behaviors who were randomized to increase fruits/vegetables and decrease sedentary leisure achieved greater diet and activity improvement than those randomized to change other pairs of eating and activity behaviors. Participants randomized to decrease saturated fat and increase physical activity achieved the least diet-activity improvement. This study examined which psychological mechanisms mediated the effects of the study treatments on healthy behavior change. METHODS: Participants (n = 204) were randomized to 1 of 4 treatments: increase fruits/vegetables and physical activity; decrease saturated fat and sedentary leisure; decrease saturated fat and increase physical activity; increase fruits/vegetables and decrease sedentary leisure. Treatments provided 3 weeks of remote coaching supported by mobile decision support technology and financial incentives. Mediational analyses were performed to examine whether changes in positive and negative affect, and self-efficacy, stages of readiness to change, liking, craving and attentional bias for fruit/vegetable intake, saturated fat intake, physical activity, and sedentary leisure explained the impact of the treatments on diet-activity improvement. RESULTS: Greater diet-activity improvement in those randomized to increase fruits/vegetables and decrease sedentary leisure was mediated by increased self-efficacy (indirect effect estimate = 0.04; 95% bias corrected CI, 0.003-0.11). All treatments improved craving, stage of change and positive affect. CONCLUSION: Accomplishing healthy lifestyle changes for 3 weeks improves positive affect, increases cravings for healthy foods and activities, and enhances readiness to make healthy behavior changes. Maximal diet and activity improvement occurs when interventions enhance self-efficacy to make multiple healthy behavior changes. (PsycINFO Database Record

Social embeddedness in an online weight management programme is linked to greater weight loss.

The obesity epidemic is heightening chronic disease risk globally. Online weight management (OWM) communities could potentially promote weight loss among large numbers of people at low cost. Because little is known about the impact of these online communities, we examined the relationship between individual and social network variables, and weight loss in a large, international OWM programme. We studied the online activity and weight change of 22,419 members of an OWM system during a six-month period, focusing especially on the 2033 members with at least one friend within the community. Using Heckman's sample-selection procedure to account for potential selection bias and data censoring, we found that initial body mass index, adherence to self-monitoring and social networking were significantly correlated with weight loss. Remarkably, greater embeddedness in the network was the variable with the highest statistical significance in our model for weight loss. Average per cent weight loss at six months increased in a graded manner from 4.1% for non-networked members, to 5.2% for those with a few (two to nine) friends, to 6.8% for those connected to the giant component of the network, to 8.3% for those with high social embeddedness. Social networking within an OWM community, and particularly when highly embedded, may offer a potent, scalable way to curb the obesity epidemic and other disorders that could benefit from behavioural changes.

Technology Interventions to Curb Obesity: A Systematic Review of the Current Literature.

Obesity is a public health crisis that has reached epidemic proportions. Although intensive behavioral interventions can produce clinically significant weight loss, their cost to implement, coupled with resource limitations, pose significant barriers to scalability. To overcome these challenges, researchers have made attempts to shift intervention content to the Internet and other mobile devices. This article systematically reviews the recent literature examining technology-supported interventions for weight loss and maintenance among overweight and obese adults. Thirteen studies were identified that satisfied our inclusion criteria (12 weight loss trials, 1 weight maintenance trial). Our findings suggest that technology interventions may be efficacious at producing weight loss. However, several studies are limited by methodologic shortcomings. There are insufficient data to evaluate their efficacy for weight maintenance. Further research is needed that employs state-of-the-art methodology, with careful attention being paid to adherence and fidelity to intervention protocols.

Multiple health behaviours: overview and implications.

BACKGROUND: More remains unknown than known about how to optimize multiple health behaviour change. METHODS: After reviewing the prevalence and comorbidities among major chronic disease risk behaviours for adults and youth, we consider the origins and applicability of high-risk and population strategies to foster multiple health behaviour change. RESULTS: Findings indicate that health risk behaviours are prevalent, increase with age and co-occur as risk behaviour clusters or bundles. CONCLUSIONS: We conclude that both population and high-risk strategies for health behaviour intervention are warranted, potentially synergistic and need intervention design that accounts for substitute and complementary relationships among bundled health behaviours. To maximize positive public health impact, a pressing need exists for bodies of basic and translational science that explain health behaviour bundling. Also needed is applied science that elucidates the following: (1) the optimal number of behaviours to intervene upon; (2) how target behaviours are best selected (e.g. greatest health impact; patient preference or positive effect on bundled behaviours); (3) whether to increase healthy or decrease unhealthy behaviours; (4) whether to intervene on health behaviours simultaneously or sequentially and (5) how to achieve positive synergies across individual-, group- and population-level intervention approaches.

The potential of virtual reality technologies to improve adherence to weight loss behaviors.

A significant proportion of the global population is obese, foreshadowing an epidemic of chronic disease. Self-monitoring (of diet, exercise, and body weight), decreasing energy intake, and increasing energy expenditure are robust predictors of successful weight loss. However, few individuals consistently practice these behaviors, making long-term weight loss and maintenance unlikely. Technologies afford unique opportunities to overcome barriers and increase the reach of traditional obesity interventions. In this article, we introduce ENGAGED, a technology-enhanced modification of the Diabetes Prevention Program designed to improve adherence to weight loss behaviors. Using a treatment implementation framework, we suggest how virtual reality technologies might further improve the delivery, receipt, and enactment of ENGAGED to maximize patient impact.

Exercise and pharmacotherapy in patients with major depression: one-year follow-up of the SMILE study.

OBJECTIVE: To examine a 1-year follow-up of a 4-month, controlled clinical trial of exercise and antidepressant medication in patients with major depressive disorder (MDD). METHODS: In the original study, 202 sedentary adults with MDD were randomized to: a) supervised exercise; b) home-based exercise; c) sertraline; or d) placebo pill. We examined two outcomes measured at 1-year follow-up (i.e., 16 months post randomization): 1) continuous Hamilton Depression Rating Scale score; and 2) MDD status (depressed; partial remission; full remission) in 172 available participants (85% of the original cohort). Regression analyses were performed to examine the effects of treatment group assignment, as well as follow-up antidepressant medication use and self-reported exercise (Godin Leisure-Time Exercise Questionnaire), on the two outcomes. RESULTS: In the original study, patients receiving exercise achieved similar benefits compared with those receiving sertraline. At the time of the 1-year follow-up, rates of MDD remission increased from 46% at post treatment to 66% for participants available for follow-up. Neither initial treatment group assignment nor antidepressant medication use during the follow-up period were significant predictors of MDD remission at 1 year. However, regular exercise during the follow-up period predicted both Hamilton Depression Rating Scale scores and MDD diagnosis at 1 year. This relationship was curvilinear, with the association concentrated between 0 minute and 180 minutes of weekly exercise. CONCLUSION: The effects of aerobic exercise on MDD remission seem to be similar to sertraline after 4 months of treatment; exercise during the follow-up period seems to extend the short-term benefits of exercise and may augment the benefits of antidepressant use. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00331305.

Personality differences between surgery residents, nonsurgery residents, and medical students.

BACKGROUND: The Five-Factor Model (FFM) of personality may provide a useful framework to understand performance-related issues in academic medical settings. We examined the distribution of FFM personality traits among surgery residents compared with medicine residents, medical students, and community norms. METHODS: Two hundred and seventy-four residents in surgery, medicine, pediatrics, and anesthesiology and 207 medical students at a large tertiary care teaching hospital completed the Big Five Inventory, a well-validated 44-item measure of the FFM. Analysis of covariance was used to examine specialty group differences in personality traits, controlling for desirable response bias. RESULTS: Surgery residents obtained greater scores for Conscientiousness, Extraversion, and Emotional Stability, but lower scores for Openness compared with community norms (all P < .05). Controlling for desirable responding, surgery residents also obtained greater Conscientiousness scores compared with medical students (P < .0001) and pediatric residents (P < .05), greater Extraversion scores compared with first-year medical students (P < .05), and lesser Openness scores compared with first-year medical students (P < .05). CONCLUSION: Greater levels of Conscientiousness, which has been associated with academic and job success in previous studies, were observed among surgery residents compared with community norms, medical students, and some residents. We conclude that (1) surgery residents continue to exhibit desirable professional characteristics; and (2) further study into the utility of the FFM as a screening tool for future surgery trainees is warranted.

Anxious temperament and disease progression at diagnosis: the case of type 2 diabetes.

OBJECTIVE: To examine the association between anxious temperament and disease progression at diagnosis for individuals with Type 2 diabetes mellitus (T2DM). METHODS: A sample of 204 individuals, newly diagnosed with T2DM, completed the Behavioral Inhibition and Activation Scales (BIS/BAS) and provided an A1C reading. Regression analyses were used to predict A1C levels from individual differences in BIS and BAS. RESULTS: Individual differences in BIS were inversely related to A1C at diagnosis in the sample as a whole, and this association remained strong after controlling for demographic variables and body mass index. Most importantly, temperamentally anxious individuals had low A1C levels at diagnosis in all age groups, in contrast to their nonanxious counterparts who showed increasing A1C at diagnosis as a function of decreasing age. BAS scores were unrelated to A1C. CONCLUSIONS: Although older age is generally associated with lower disease progression at diagnosis, high BIS individuals show uniformly lower disease progression across all age groups. High levels of temperamental anxiety may facilitate early diagnosis of T2DM, particularly among younger individuals who are not subject to routine screening.

Psychometric properties of the social phobia inventory: further evaluation.

This study investigated the psychometric properties of the Social Phobia Inventory [SPIN; Connor, K. M., Davidson, J. R. T., Churchill, L. E., Sherwood, A., Foa, E., Wesler, R.H., 2000. Psychometric properties of the Social Phobia Inventory (SPIN). British Journal of Psychiatry, 176, 379-386], a measure of severity in social phobia (social anxiety disorder). Participants included 132 participants with social phobia, 57 participants with panic disorder and agoraphobia (PDA), and 62 participants with obsessive-compulsive disorder (OCD). Confirming findings from an initial validation study, the SPIN was found to have excellent internal consistency and good test-retest reliability. It also distinguished well between those with social phobia and those with either PDA or OCD. Good convergent and discriminant validity were established by examining correlations with other conceptually related and unrelated scales. Finally, the SPIN was sensitive to changes in social phobia severity following cognitive behavioral group treatment. In conclusion, the SPIN is both reliable and valid for the measurement of social phobia severity and outcome following psychological treatment.

Factor structure and psychometric properties of the Pain Anxiety Symptoms Scale-20 in a community physiotherapy clinic sample.

The PASS-20 was developed to assess pain-related anxiety among a variety of pain populations. This measure was constructed by extracting 20 items from its 40-item parent measure (PASS). Initial studies of the PASS-20 suggest that the psychometric properties have been preserved. The purpose of the present study extended this research and explored the factor structure of the PASS-20, and its reliability and validity in a sample of pain patients receiving treatment in a community physiotherapy clinic. Patients with current pain (n = 201) were asked to complete a battery of self-report measures related to the experience of pain on two separate occasions (3-month interval). Results of principal components analyses suggested that a 4-factor solution representing fear of pain, escape-avoidance, physiological symptoms, and cognitive symptoms of anxiety provided the best fit to these data. Results also showed that the total and subscale scores of the PASS-20 have good reliability (internal consistency, test-retest) and validity (construct) correlating greater with other conceptually similar measures than distinct constructs. These results suggest that this measure has good utility for both clinical and research applications. Directions for future evaluation are also discussed.

PTSD and the experience of pain: research and clinical implications of shared vulnerability and mutual maintenance models.

It is common for individuals with symptoms of posttraumatic stress disorder (PTSD) to present with co-occurring pain problems, and vice versa. However, the relation between these conditions often goes unrecognized in clinical settings. In this paper, we describe potential relations between PTSD and chronic pain and their implications for assessment and treatment. To accomplish this, we discuss phenomenological similarities of these conditions, the prevalence of chronic pain in patients with PTSD, and the prevalence of PTSD in patients with chronic pain. We also present several possible explanations for the co-occurrence of these disorders, based primarily on the notions of shared vulnerability and mutual maintenance. The paper concludes with an overview of future research directions, as well as practical recommendations for assessing and treating patients who present with co-occurring PTSD or chronic pain symptoms.