Faculty Bibliography

BACKGROUND:This study aimed to explore whether patients' perception of procedural fairness in physicians' communication was associated with willingness to follow doctor's recommendations, self-efficacy beliefs, dietary behaviors, and body mass index. METHODS:(43.6% Black, 40.7% Hispanic/Latino, 55.8% female, mean age = 50 years), who enrolled in a weight management study in two New York City healthcare institutions. We conducted ordinary least squares path analyses with bootstrapping to explore direct and indirect associations among procedural fairness, willingness to follow recommendations, self-efficacy, dietary behaviors, and body mass index, while controlling for age and gender. RESULTS:Serial, multiple mediator models indicated that higher procedural fairness was associated with an increased willingness to follow recommendations which, in turn, was associated with healthier dietary behaviors and a lower BMI (indirect effect =  - .02, SE = .01; 95% CI [- .04 to - .01]). Additionally, higher procedural fairness was associated with elevated dietary self-efficacy, which was, in turn, was associated with healthier dietary behaviors and lower BMI (indirect effect =  - .01, SE = .003; 95% CI [- .02 to - .002]). CONCLUSIONS:These findings highlight the importance of incorporating procedural fairness in physician-patient communication concerning weight management in diverse primary care patients.

OBJECTIVES:This study examined COVID-19's impact in the 2020 compared to 2019 survey years on preventive medical care utilization. RESEARCH DESIGN:Using a cross-sectional sample of adults aged 18 years and over (2019; n = 31,997; 2020; n = 31,568), from the National Health Interview Survey, multivariable models compared 2020 to 2019 survey years for receiving diabetes screening blood tests, well-care visits, and physical therapy. An additional multivariable model predicted not having medical care due to the COVID-19 pandemic in the 2020 2020 survey year. RESULTS:In the 2020 versus 2019 survey years, the likelihood lowered for receiving a blood test for diabetes screening (aOR .83 CI = .76, .90). There was a lowered likelihood for a well care visits (aOR = .98 CI = .84, 1.1) and physical therapy (aOR = .97 CI = .89, 1.0). Black (aOR = .62 CI = .51, .75), Hispanic (aOR = .62 CI = .51, .75) and Asian (aOR .67 CI = .53, .86) adults had a lowered likelihood of having physical therapy compared to White adults. Having no insurance coverage lowered the likelihood of getting all three indicators of preventive medical care. There was a higher likelihood of not getting medical care due to COVID-19 in the 2020 survey year (aOR = 1.7 CI = 1.3, 2.1) with Medicaid compared to private coverage. CONCLUSIONS:Use of preventive medical care lowered in the pandemic. Race and ethnicity and not having any coverage contributed to not receiving preventive care. Medicaid appeared to increase utilization of preventive medical care but not acute medical care.

Objective: HbA1c is an insensitive marker for assessing real-time dysglycemia in obesity. This study investigated whether 1-h plasma glucose level (1-h PG) ≥155 mg/dL (8.6 mmol/L) during an oral glucose tolerance test (OGTT) and continuous glucose monitoring (CGM) measurement of glucose variability (GV) better reflected dysglycemia than HbA1c after weight loss from metabolic and bariatric surgery. Methods: This was a prospective cohort study of 10 participants with type 2 diabetes compared with 11 participants with non-diabetes undergoing sleeve gastrectomy (SG). At each research visit; before SG, and 6 weeks and 6 months post-SG, body weight, fasting lipid levels, and PG and insulin concentrations during an OGTT were analyzed. Mean amplitude of glycemic excursions (MAGE), a CGM-derived GV index, was analyzed. Results: The 1-h PG correlated with insulin resistance markers, triglyceride/HDL ratio and triglyceride glucose index in both groups before surgery. At 6 months, SG caused 22% weight loss in both groups. Despite a reduction in HbA1c by 3.0 ± 1.3% in the diabetes group (p < 0.01), 1-h PG, and MAGE remained elevated, and the oral disposition index, which represents pancreatic β-cell function, remained reduced in the diabetes group when compared to the non-diabetes group. Conclusions: Elevation of GV markers and reduced disposition index following SG-induced weight loss in the diabetes group underscores persistent β-cell dysfunction and the potential residual risk of diabetes complications.

BACKGROUND:The Financial Incentives for Weight Reduction (FIReWoRk) clinical trial showed that financial incentive weight-loss strategies designed using behavioral economics were more effective than provision of weight-management resources only. We now evaluate cost-effectiveness. METHODS:Cost-effectiveness analysis of a multisite randomized trial enrolling 668 participants with obesity living in low-income neighborhoods. Participants were randomized to (1) goal-directed incentives (targeting behavioral goals), (2) outcome-based incentives (targeting weight-loss), and (3) resources only, which were provided to all participants and included a 1-year commercial weight-loss program membership, wearable activity monitor, food journal, and digital scale. We assessed program costs, time costs, quality of life, weight, and incremental cost-effectiveness in dollars-per-kilogram lost. RESULTS:Mean program costs at 12 months, based on weight loss program attendance, physical activity participation, food diary use, self-monitoring of weight, and incentive payments was $1271 in the goal-directed group, $1194 in the outcome-based group, and $834 in the resources-only group (difference, $437 [95% CI, 398 to 462] and $360 [95% CI, 341-363] for goal-directed or outcome-based vs resources-only, respectively; difference, $77 [95% CI, 58-130] for goal-directed vs outcome-based group). Quality of life did not differ significantly between the groups, but weight loss was substantially greater in the incentive groups (difference, 2.34 kg [95% CI, 0.53-4.14] and 1.79 kg [95% CI, -0.14 to 3.72] for goal-directed or outcome-based vs resources only, respectively; difference, 0.54 kg [95% CI, -1.29 to 2.38] for goal-directed vs outcome-based). Cost-effectiveness of incentive strategies based on program costs was $189/kg lost in the goal-directed group (95% CI, $124/kg to $383/kg) and $186/kg lost in the outcome-based group (95% CI, $113/kg to $530/kg). CONCLUSIONS:Goal-directed and outcome-based financial incentives were cost-effective strategies for helping low-income individuals with obesity lose weight. Their incremental cost per kilogram lost were comparable to other weight loss interventions.

OBJECTIVE/UNASSIGNED:HbA1c is an insensitive marker for assessing real-time dysglycemia in obesity. This study investigated whether 1-h plasma glucose level (1-h PG) ≥155 mg/dL (8.6 mmol/L) during an oral glucose tolerance test (OGTT) and continuous glucose monitoring (CGM) measurement of glucose variability (GV) better reflected dysglycemia than HbA1c after weight loss from metabolic and bariatric surgery. METHODS/UNASSIGNED:This was a prospective cohort study of 10 participants with type 2 diabetes compared with 11 participants with non-diabetes undergoing sleeve gastrectomy (SG). At each research visit; before SG, and 6 weeks and 6 months post-SG, body weight, fasting lipid levels, and PG and insulin concentrations during an OGTT were analyzed. Mean amplitude of glycemic excursions (MAGE), a CGM-derived GV index, was analyzed. RESULTS/UNASSIGNED:-cell function, remained reduced in the diabetes group when compared to the non-diabetes group. CONCLUSIONS/UNASSIGNED:-cell dysfunction and the potential residual risk of diabetes complications.

PURPOSE/OBJECTIVE:We undertook a trial to test the efficacy of a technology-assisted health coaching intervention for weight management, called Goals for Eating and Moving (GEM), within primary care. METHODS:). The primary outcome (weight change at 12 months) and exploratory outcomes (eg, program attendance, diet, physical activity) were analyzed according to intention to treat. RESULTS:= .48). There were no statistically significant differences in secondary outcomes. Exploratory analyses showed that the GEM arm had a greater change than the EUC arm in mean number of weekly minutes of moderate to vigorous physical activity other than walking, a finding that may warrant further exploration. CONCLUSIONS:The GEM intervention did not achieve clinically important weight loss in primary care. Although this was a negative study possibly affected by health system resource limitations and disruptions, its findings can guide the development of similar interventions. Future studies could explore the efficacy of higher-intensity interventions and interventions that include medication and bariatric surgery options, in addition to lifestyle modification.

IMPORTANCE:Obesity affects approximately 42% of US adults and is associated with increased rates of type 2 diabetes, hypertension, cardiovascular disease, sleep disorders, osteoarthritis, and premature death. OBSERVATIONS:A body mass index (BMI) of 25 or greater is commonly used to define overweight, and a BMI of 30 or greater to define obesity, with lower thresholds for Asian populations (BMI ≥25-27.5), although use of BMI alone is not recommended to determine individual risk. Individuals with obesity have higher rates of incident cardiovascular disease. In men with a BMI of 30 to 39, cardiovascular event rates are 20.21 per 1000 person-years compared with 13.72 per 1000 person-years in men with a normal BMI. In women with a BMI of 30 to 39.9, cardiovascular event rates are 9.97 per 1000 person-years compared with 6.37 per 1000 person-years in women with a normal BMI. Among people with obesity, 5% to 10% weight loss improves systolic blood pressure by about 3 mm Hg for those with hypertension, and may decrease hemoglobin A1c by 0.6% to 1% for those with type 2 diabetes. Evidence-based obesity treatment includes interventions addressing 5 major categories: behavioral interventions, nutrition, physical activity, pharmacotherapy, and metabolic/bariatric procedures. Comprehensive obesity care plans combine appropriate interventions for individual patients. Multicomponent behavioral interventions, ideally consisting of at least 14 sessions in 6 months to promote lifestyle changes, including components such as weight self-monitoring, dietary and physical activity counseling, and problem solving, often produce 5% to 10% weight loss, although weight regain occurs in 25% or more of participants at 2-year follow-up. Effective nutritional approaches focus on reducing total caloric intake and dietary strategies based on patient preferences. Physical activity without calorie reduction typically causes less weight loss (2-3 kg) but is important for weight-loss maintenance. Commonly prescribed medications such as antidepressants (eg, mirtazapine, amitriptyline) and antihyperglycemics such as glyburide or insulin cause weight gain, and clinicians should review and consider alternatives. Antiobesity medications are recommended for nonpregnant patients with obesity or overweight and weight-related comorbidities in conjunction with lifestyle modifications. Six medications are currently approved by the US Food and Drug Administration for long-term use: glucagon-like peptide receptor 1 (GLP-1) agonists (semaglutide and liraglutide only), tirzepatide (a glucose-dependent insulinotropic polypeptide/GLP-1 agonist), phentermine-topiramate, naltrexone-bupropion, and orlistat. Of these, tirzepatide has the greatest effect, with mean weight loss of 21% at 72 weeks. Endoscopic procedures (ie, intragastric balloon and endoscopic sleeve gastroplasty) can attain 10% to 13% weight loss at 6 months. Weight loss from metabolic and bariatric surgeries (ie, laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass) ranges from 25% to 30% at 12 months. Maintaining long-term weight loss is difficult, and clinical guidelines support the use of long-term antiobesity medications when weight maintenance is inadequate with lifestyle interventions alone. CONCLUSION AND RELEVANCE:Obesity affects approximately 42% of adults in the US. Behavioral interventions can attain approximately 5% to 10% weight loss, GLP-1 agonists and glucose-dependent insulinotropic polypeptide/GLP-1 receptor agonists can attain approximately 8% to 21% weight loss, and bariatric surgery can attain approximately 25% to 30% weight loss. Comprehensive, evidence-based obesity treatment combines behavioral interventions, nutrition, physical activity, pharmacotherapy, and metabolic/bariatric procedures as appropriate for individual patients.

BACKGROUND:Prediabetes affects 26.4 million people aged 65 years or older (48.8%) in the United States. Although older adults respond well to the evidence-based Diabetes Prevention Program, they are a heterogeneous group with differing physiological, biomedical, and psychosocial needs who can benefit from additional support to accommodate age-related changes in sensory and motor function. OBJECTIVE:The purpose of this paper is to describe adaptations of the Centers for Disease Control and Prevention's Diabetes Prevention Program aimed at preventing diabetes among older adults (ages ≥65 years) and findings from a pilot of 2 virtual sessions of the adapted program that evaluated the acceptability of the content. METHODS:The research team adapted the program by incorporating additional resources necessary for older adults. A certified lifestyle coach delivered 2 sessions of the adapted content via videoconference to 189 older adults. RESULTS:The first session had a 34.9% (38/109) response rate to the survey, and the second had a 34% (30/88) response rate. Over three-quarters (50/59, 85%) of respondents agreed that they liked the virtual program, with 82% (45/55) agreeing that they would recommend it to a family member or a friend. CONCLUSIONS:This data will be used to inform intervention delivery in a randomized controlled trial comparing in-person versus virtual delivery of the adapted program.

BACKGROUND/UNASSIGNED:The transition to telehealth during the COVID-19 pandemic revealed a lack of preexisting telehealth training for clinicians. As a workplace-based simulation methodology designed to improve virtual clinical skills, announced standardized patients (ASPs) may help meet evolving educational needs to sustain quality telehealth care. OBJECTIVE/UNASSIGNED:We describe the development and implementation of an ASP program to assess and provide feedback to resident and faculty clinicians in virtual practice, and report on performance, feasibility, and acceptability. METHODS/UNASSIGNED:From June 2021 to April 2022, resident and faculty clinicians at a VA primary care clinic participated in a video visit in which an ASP portrayed either a 70-year-old man with hearing loss and hypertension or a 60-year-old man with hypertension and financial stress. Following the visit, ASPs provided verbal feedback and completed a behaviorally anchored checklist to rate telehealth and communication skills, chronic disease management, and use of resources. Domain summary scores were calculated as the mean percentage of "well done" items. Participants completed a feedback survey on their experience. RESULTS/UNASSIGNED:Seventy-six televisits (60 primary care residents [postgraduate year 1-3], 16 internal medicine faculty) were conducted from August 2021 to April 2022. Clinicians performed well in communication skills: information gathering (79%, 60 of 76, well done), relationship development (67%, 51 of 76), education and counseling (71%, 54 of 76), and patient satisfaction (86%, 65 of 76). They performed less well in telemedicine skills (38%, 29 of 76). Participants agreed that the experience was a good use of their time (88%, 67 of 76). CONCLUSIONS/UNASSIGNED:An ASP-facilitated training for resident and faculty clinicians assessed telehealth skills and clinical practice and identified areas for intervention. Clinicians responded well to the training and feedback.