Faculty Bibliography

BACKGROUND:Weight stigma is a fundamental cause of health inequality. Body positivity may be a counterbalance to weight stigma. Social media is replete with weight-stigmatizing content and is a driver of poor mental health outcomes; however, there remains a gap in understanding its potential to mitigate the prevalence and impact of harmful messaging and to promote positive effects on a large scale. OBJECTIVE:We selected musical artist Lizzo, whose brand emphasizes body positivity and empowerment, for an instrumental case study on the discourse on social media and specifically Instagram. We focused on 3 domains, including body positivity, physical health, and emotional well-being. These domains challenge social norms around weight and body size and have the potential to positively affect the physical and psychological health of people with diverse body sizes. METHODS:We evaluated posts by Lizzo, comments from Instagram users, and replies to comments over a 2-month period (October 11 to December 12, 2019). Two coders rated Lizzo's posts and Instagram users' comments for their sentiments on the 3 domains. Replies to Instagram users' comments were assessed for their reactions to comments (ie, did they oppose or argue against the comment or did they support or bolster the comment). Engagement metrics, including the number of "likes," were also collected. RESULTS:The final sample included 50 original posts by Lizzo, 250 comments from Instagram users, and 1099 replies to comments. A proportion of Lizzo's content included body positive sentiments (34%) and emotional well-being (18%); no posts dealt explicitly with physical health. A substantial amount Instagram users' comments and replies contained stigmatizing content including the use of nauseated and vomiting emojis, implications that Lizzo's body was shameful and should be hidden away, accusations that she was promoting obesity, and impeachments of Lizzo's health. In spite of the stigmatizing content, we also discovered content highlighting the beneficial nature of having positive representation of a Black woman living in a larger body who is thriving. Moreover, analysis of the discourse between users illustrated that stigmatizing expressions are being combated online, at least to some degree. CONCLUSIONS:This study demonstrates that Lizzo has exposed millions of social media users to messages about body positivity and provided more visibility for conversations about weight and shape. Future research should examine the extent to which body positive messages can lead to greater acceptance of individuals living in larger bodies. Instagram and other social media platforms should consider ways to reduce body-shaming content while finding ways to promote content that features diverse bodies. Shifting the landscape of social media could decrease stereotypes about weight and shape while increasing dialog about the need for greater acceptance and inclusion of people with diverse bodies.

The number and complexity of obesity treatments has increased rapidly in recent years. This is driven by the approval of new anti-obesity medications (AOMs) that produce larger degrees of weight loss than previously approved AOMs. Unfortunately, access to these highly effective therapies and to integrated team-based obesity care is limited by intra-/interpersonal patient, institutional/practitioner, community, and policy factors. We contextualized these complexities and the impact of patients' social drivers of health (SDOH) by adapting the social ecological model for obesity. Without multi-level intervention, these barriers to care will deepen the existing inequities in obesity prevalence and treatment outcomes among historically underserved communities. As General Internal Medicine (GIM) physicians, we can help our patients navigate the complexities of evidence-based obesity treatments. As care team leaders, GIM physicians are well-positioned to (1) improve education for trainees and practitioners, (2) address healthcare-associated weight stigma, (3) advocate for equity in treatment accessibility, and (4) coordinate interdisciplinary teams around non-traditional models of care focused on upstream (e.g., policy changes, insurance coverage, health system culture change, medical education requirements) and downstream (e.g., evidence-based weight management didactics for trainees, using non-stigmatizing language with patients, developing interdisciplinary weight management clinics) strategies to promote optimal obesity care for all patients.

In 2022, 1 in 8 people in the world were living with obesity, and lifestyle interventions that include diet, exercise, and behavioral modification have been the foundation for management of obesity. Recently, pharmacologic therapies have been developed for management of obesity, the newest of these being glucagon-like peptide 1 receptor agonists. With the development of new pharmacologic options, the American Gastroenterological Association developed a guideline in 2022 to provide evidence-based recommendations for the pharmacologic management of obesity in adults and recommended, for adults with obesity or overweight with weight-related complications who have had an inadequate response to lifestyle interventions, adding pharmacologic agents to lifestyle interventions over continuing lifestyle interventions alone. In this article, 2 experts review the available evidence to answer the following questions: How effective are lifestyle interventions for the treatment of obesity? How effective are pharmacologic interventions for the treatment of obesity? Given these options, how do you engage in a shared decision-making discussion to develop a mutually agreed-on treatment plan?

The study objective was to examine the mental health of children during a time period that included the COVID-19 Lockdown. The sample included a cross-section of children aged 2 to 17 years (2019; n = 4, 194; 2020; n = 5,172), from the National Health Interview Survey. In multivariate models, survey years 2020 and 2019 were compared for significant changes in anxiety, depression, and social behaviors in children after adjustment for sociodemographic variables. Bivariate analysis also examined sociodemographic characteristics, health care utilization by anxiety, depression, and social behaviors, and examined differences in anxiety and depression from 2019 to 2020. In multivariate models, there was an increased risk of anxiety ((AOR = 1.3(1.0, 1.6)), depression ((AOR = 1.2 (1.0, 1.4)) and difficult social behaviors (AOR = 1.2 (1.0, 1.4) in children from 2019 to 2020. Girls were at increased risk compared to boys for anxiety and depression ((anxiety; AOR = 1.4 (1.2, 1.8), depression; AOR = 1.2 (1.0, 1.3)), however, girls were at decreased risk compared to boys for uncontrolled social behaviors (AOR = 0.51 (0.43, 0.61)). White children were at increased risk for anxiety and depression compared to all other race and ethnic groups. High rates of anxiety, depression and difficult social behaviors that preexisted the Covid-19 Lock Down, continued or increased during the Lockdown. Effective public health interventions could prevent further declines in mental health, and a potential trajectory into adulthood of poor physical and mental health.

The study objective was to examine the mental health of children during a time period that included the COVID-19 Lockdown. The sample included a cross-section of children aged 2 to 17 years (2019; n = 4, 194; 2020; n = 5,172), from the National Health Interview Survey. In multivariate models, survey years 2020 and 2019 were compared for significant changes in anxiety, depression, and social behaviors in children after adjustment for sociodemographic variables. Bivariate analysis also examined sociodemographic characteristics, health care utilization by anxiety, depression, and social behaviors, and examined differences in anxiety and depression from 2019 to 2020. In multivariate models, there was an increased risk of anxiety ((AOR = 1.3(1.0, 1.6)), depression ((AOR = 1.2 (1.0, 1.4)) and difficult social behaviors (AOR = 1.2 (1.0, 1.4) in children from 2019 to 2020. Girls were at increased risk compared to boys for anxiety and depression ((anxiety; AOR = 1.4 (1.2, 1.8), depression; AOR = 1.2 (1.0, 1.3)), however, girls were at decreased risk compared to boys for uncontrolled social behaviors (AOR = 0.51 (0.43, 0.61)). White children were at increased risk for anxiety and depression compared to all other race and ethnic groups. High rates of anxiety, depression and difficult social behaviors that preexisted the Covid-19 Lock Down, continued or increased during the Lockdown. Effective public health interventions could prevent further declines in mental health, and a potential trajectory into adulthood of poor physical and mental health.

PURPOSE/OBJECTIVE:We developed a comprehensive sleeve gastrectomy (SG) weight loss study cohort and biorepository to uncover mechanisms, biomarkers and predictive factors of weight loss, weight maintenance and amelioration of obesity-related comorbidities. For this purpose, we collected psychosocial, anthropometric, clinical data and a variety of samples pre-surgery, intraoperatively and 1.5, 3, 12 and 24 months post-surgery. For longer-term assessment, the collection of psychosocial and anthropometric data was extended to 10 years. Here, we present in-depth characterisation of the cohort and detailed overview of study procedures as a foundation for future analyses. PARTICIPANTS/METHODS:We consented 647 participants between June 2017 and March 2020 from two bariatric surgery clinics in New York City-one major urban hospital and one private hospital. Of 355 participants who provided baseline data, 300 underwent SG. Of these, 79% are females with an average age of 38 years, 68% are Hispanic, 20% are non-Hispanic Black and 11% are non-Hispanic White. FINDINGS TO DATE/RESULTS:We collected intraoperative adipose and stomach tissues from 282 patients and biosamples (blood, urine, saliva, stool) from 245 patients at 1.5 months, 238 at 3 month, 218 at 12 months and 180 at 24 months post-surgery. We are currently collecting anthropometric and psychosocial data annually until 10 years post-surgery. Data analysis is currently underway. FUTURE PLANS/UNASSIGNED:Our future research will explore the variability in weight loss outcomes observed in our cohort, particularly among Black and Hispanic patients in comparison to their White counterparts. We will identify social determinants of health, metabolic factors and other variables that may predict weight loss success, weight maintenance and remission of obesity-related comorbidities. Additionally, we plan to leverage our biorepository for collaborative research studies. We will complete long-term follow-up data by December 2031. We plan to apply for funding to expand biosample collection through year 10 to provide insights into the mechanisms of long-term weight maintenance.

Widespread pain (WP) is associated with reduced function and disability. Importantly, three-fourths of the approximately 42% of U.S. adults with obesity have WP. Moreover, rates of adult obesity are higher, and WP outcomes are worse in racialized non-Hispanic Black and Hispanic/Latino/a/X groups, potentially exacerbating existing pain disparities. Bariatric surgery significantly reduces weight and improves pain. However, recurrent or unresolved pain after bariatric surgery can hinder weight loss or facilitate weight regain. The current study conducted a secondary analysis of a longitudinal study of predictors and mechanisms of weight loss after bariatric surgery to examine the point prevalence of WP and pain trajectories 24 months post surgery. Our secondary aim was to examine the association between weight loss and pain characteristics. Our exploratory aim was to longitudinally examine racial differences in pain trajectories after bariatric surgery. Our results showed that point prevalence decreased after bariatric surgery. Additionally, significant improvements in pain trajectories occurred within the first 3 months post surgery with a pattern of pain reemergence beginning at 12 months post surgery. Hispanic/Latino/a/X participants reported a higher number of painful anatomical sites before bariatric surgery, and the rate of change in this domain for this group was faster compared with the racialized non-Hispanic Black participants. These findings suggest that pain improvements are most evident during the early stages of surgical weight loss in racialized populations of adults with WP. Thus, clinicians should routinely monitor patients' weight changes after bariatric surgery as they are likely to correspond to changes in their pain experiences. PERSPECTIVE: This article presents the prevalence and pain trajectories of racialized adults with WP after surgical weight loss. Clinicians should evaluate changes in the magnitude and spatial distribution of pain after significant weight change in these populations so that pain interventions can be prescribed with greater precision.

INTRODUCTION:Intensive weight management programs are effective but often have low enrollment and high attrition. Lack of motivation is a key psychological barrier to enrollment, engagement, and weight loss. Mental Contrasting with Implementation Intentions (MCII) is a unique imagery technique that increases motivation for behavior change. We describe our study protocol to assess the efficacy and implementation of MCII to enhance the effectiveness of VA's MOVE! or TeleMOVE! weight management programs using a procedure called "WOOP" (Wish, Outcome, Obstacle, Plan) for Veterans. We hypothesize that WOOP+MOVE! or TeleMOVE! (intervention) will lead to greater MOVE!/TeleMOVE! program engagment and consequently weight loss than MOVE!/TeleMOVE! alone (control). METHOD:Veterans are randomized to either the intervention or control. Both arms receive the either MOVE! or TeleMOVE! weight management programs. The intervention group receives an hour long WOOP training while the control group receives patient education. Both groups receive telephone follow up calls at 3 days, 4 weeks, and 2 months post-baseline. Eligible participants are Veterans (ages 18-70 years) with either obesity (BMI ≥ 30 kg/m2) or overweight (BMI ≥ 25 kg/m2) and an obesity-associated co-morbidity. At baseline, 6 and 12 months, we assess weight, diet, physical activity in both groups. The primary outcome is mean percent weight change at 6 months. Secondary outcomes include changes in waist circumference, diet, physical activity, and dieting self-efficacy and engagement in regular physical activity. We assess implementation using the RE-AIM framework. CONCLUSION:If WOOP VA is found to be efficacious, it will be an important tool to facilitate weight management and improve weight outcomes. CLINICAL TRIAL REGISTRATION:NCT05014984.

PURPOSE/OBJECTIVE:Examine associations between whether participants' were matched to their preferred financial incentive design and behavioral goal adherence in a weight management intervention. DESIGN/METHODS:Secondary quantitative analysis incorporating qualitative survey data. SETTING/METHODS:Primary care clinics in socioeconomically disadvantaged communities in New York City and Los Angeles. SUBJECTS/METHODS:668 participants (mean age 47.7 years, 81.0% female, 72.6% Hispanic) with obesity were enrolled in the Financial Incentives foR Weight Reduction (FIReWoRk) intervention. MEASURES/METHODS:We explored qualitatively participant's reasons for hypothetically choosing a behavioral goal-directed vs a weight loss outcome-based financial incentive program. Additionally, behavioral adherence to different goals was collected at the 6-month timepoint, categorized by match to preferred financial incentive design. ANALYSIS/METHODS:Logistic regression was used to examine if participants with certain demographic and higher psychosocial factors were more likely to choose goal-directed over outcome-based incentives. Additionally, logistic regression was used to test for associations between preference and behavioral adherence, using incentive type as an interaction term. RESULTS:= .025). Moderation analysis revealed that participants who preferred goal-directed and were matched to goal-directed had greater rates of behavioral adherence for program attendance and self-weighing, but not dietary tracking and physical activity tracking, compared to those who preferred outcome-based and were matched to outcome-based. CONCLUSION/CONCLUSIONS:Receiving one's preferred incentive design may not play a strong role in behavioral goal adherence during financially incentivized weight loss interventions.