Faculty Bibliography

BACKGROUND: Food insecurity (FI) occurs when individuals or households have limited or uncertain access to adequate food. People with FI may find it particularly difficult to eat a balanced diet and manage weight. Individuals who report FI are 1.4 times more likely to have obesity. U.S. Veterans have a greater prevalence of FI compared with the general population (24% vs. 19%). As part of a pilot randomized controlled trial to test the impact of an obesity intervention for Veterans, we explored the prevalence of FI in our sample and assessed the impact of FI on weight outcomes. METHODS: Veterans with a Body Mass Index of greater than or equal to 30 or between 25 and 29.99 with at least one comorbidity were recruited by phone for a pilot study. Participants randomized to the intervention received a technology-assisted health coaching session and follow-up coaching calls; control participants received a VA "healthy living messages" pamphlet. At baseline and 3 months, participants had weight measurements and completed surveys. To measure FI, we used a 6-item Household Food Security Scale (FI = 2 or more affirmative responses). We assessed the impact of FI on variables independent of arm assignment in participants who returned for a 3-month measurement visit (Wilcoxon rank sum tests and Fisher's Exact Test). We also analyzed the role of FI as a moderator between arm and study variables using ANOVA. RESULTS: Out of 31 Veterans who enrolled in the study (Mean age = 53.48, 63% male, mean BMI = 31.72), 10 demonstrated FI at baseline and 25 participants completed 3 month measurements. Independent of the intervention, those with FI (n = 10) lost .01 kg of weight and those without FI (n = 15) lost 1.69 kg at 3-months but the difference was not significant (p = 0.2). Similarly, 0/10 Veterans with FI achieved 2.5% weight loss, compared to 4/15 of those without FI (p = 0.12). Those with FI in the control group gained weight when compared to those without FI (1.04 kg, SD = 1.41 vs. -1.75, SD = 3.96) and those with FI in the intervention lost the same amount of weight as those without FI (-1.59 kg, SD = 0.83, vs. -1.59, SD = 2.27; p = 0.24 for the interaction (not significant)). CONCLUSIONS: FI in Veterans enrolled in a weight management study is high. Participants with FI in the control arm may have gained weight when compared to non-FI participants, while intervention arm participants with FI lost similar amounts of weight to those without FI. This suggests that the intervention may reduce the negative impact of FI. While this pilot study was not powered to show a significant difference, we have amended health coaching protocols to better address FI in our intervention (e.g. screening for FI and linking participants with Supplemental Nutrition Assistance Program (SNAP) benefits and similar resources) hoping to maximize its effectiveness

There is a dearth of evidence on the relative efficacy of intervention modalities to improve and maintain patient adherence to antiretroviral medications. Although empiric findings from research on HIV/AIDS, other diseases, and chronic medical conditions consistently demonstrate that social support plays an important role in facilitating adherence, few HIV/AIDS interventions have directly targeted this factor. Ewart's social action theory emphasizes the role of social relationships in behavior change and provides a comprehensive and useful guide to the development of interventions for adherence. We describe the development, content, and testing of SMART Couples, an effective antiretroviral adherence intervention that is grounded in social action theory and designed to enhance social support for ART adherence. Finally, we discuss some of the challenges of translating findings from the randomized clinical trial of this intervention into clinical practice and offer recommendations for integration of lessons learned into ongoing clinical care.

OBJECTIVE: To assess the efficacy of a couple-based intervention to improve medication-taking behavior in a clinic population with demonstrated adherence problems. DESIGN: A randomized controlled trial (SMART Couples Study) conducted between August 2000 and January 2004. SETTING: Two HIV/AIDS outpatient clinics in New York City. PARTICIPANTS: Heterosexual and homosexual HIV-serodiscordant couples (n = 215) in which the HIV-seropositive partner had < 80% adherence at baseline. The sample was predominantly lower-income racial/ethnic minorities. INTERVENTION: Participants were randomly assigned to a four-session couple-focused adherence intervention or usual care. The intervention consisted of education about treatment and adherence, identifying adherence barriers, developing communication and problem-solving strategies, optimizing partner support, and building confidence for optimal adherence. OUTCOME MEASURES: Medication adherence at week 8 (2 weeks after the intervention) compared with baseline, assessed with a Medication Event Monitoring System cap. RESULTS: Intervention participants showed higher mean medication adherence at post-intervention when compared with controls whether adherence was defined as proportion of prescribed doses taken (76% versus 60%) or doses taken within specified time parameters (58% versus 35%). Also, participants in the intervention arm were significantly more likely to achieve high levels of adherence (> 80%, > 90%, or > 95%) when compared with controls. However, in most cases, effects diminished with time, as seen at follow-up at 3 and 6 months. CONCLUSION: The SMART Couples program significantly improved medication adherence over usual care, although the level of improved adherence, for many participants, was still suboptimal and the effect was attenuated over time.