Faculty Bibliography

Background/UNASSIGNED:Worry is a common problem among older adults. Cognitive-behavioral therapy is the most studied nonpharmacological intervention and it has demonstrated efficacy in reducing late-life worry and anxiety. Although the evidence-base is smaller, yoga has been shown to reduce anxiety and stress. However, little is known about the relative effectiveness of these two nonpharmacological interventions. Further, the impact of patient preference on outcomes is unknown.Purpose: The purpose to this study is to compare the effectiveness of cognitive-behavioral therapy (CBT) with yoga for improving late-life worry, anxiety, and sleep. We will also examine the effects of preference and selection on outcomes, adherence, and attrition. Methods/UNASSIGNED:We are conducting a two-stage randomized preference trial comparing CBT and yoga for the reduction of worry in a sample of anxious older adults. Five hundred participants will be randomized to either the preference trial (participants choose the intervention; N = 250) or to the randomized trial (participants are randomized to one of the two interventions; N = 250) with equal probability. CBT consists of 10 telephone-based sessions with an accompanying workbook. Yoga consists of 10 weeks of group yoga classes (twice a week) that is modified for use with older adults. Conclusions/UNASSIGNED:The study design is based on feedback from anxious older adults who wanted more nonpharmacological options for intervention as well as more input into the intervention they receive. It is the first head-to-head comparison of CBT and yoga for reducing late-life worry and anxiety. It will also provide information about how intervention preference affects outcomes. Trial registration/UNASSIGNED:ClinicalTrials.gov NCT02968238.

AIM:Recent studies revealed a correlation between skeletal muscle mass index and density with longevity; these studies largely evaluated appendicular skeletal muscles in older Caucasians. This retrospective cohort study assessed the association between axial skeletal muscles size and density with survival in African Americans with type 2 diabetes mellitus. METHODS:) and radiographic density (in Hounsfield Units) were measured using computed tomography in African American-Diabetes Heart Study participants, 314 women and 256 men, with median (25th, 75th quartile) age 55.0(48.0, 62.0) and 57.0(50.0, 64.0) years, respectively. Covariates in fully-adjusted model included age, sex, BMI, smoking, hormone replacement therapy (women), cardiovascular disease, hypertension, coronary artery calcified plaque mass, carotid artery calcified plaque mass, and African ancestry proportion. RESULTS:After median of 7.1(5.9, 8.2) years follow-up, 30(9.6%) of women and 49(19.1%) of men were deceased. In fully-adjusted models, psoas muscle mass index and paraspinous muscle mass index were inversely associated with mortality in men (psoas muscle mass index, hazard ratio [HR] = 0.61, P = 0.004; paraspinous muscle mass index, HR = 0.64, P = 0.004), but not in women. Psoas and paraspinous muscle densities did not associate with all-cause mortality. A penalized Cox regression that involved all covariates and predictors associated with mortality showed that only paraspinous muscle mass index remained a significant predictor of mortality (HR = 0.65, P = 0.02). CONCLUSION:Independent from established risk factors for mortality, higher psoas and paraspinous muscle index associate with reduced all-cause mortality in middle-aged African American men with type 2 diabetes mellitus.

AIMS:To estimate short-term mortality rates for individuals with type 1 or type 2 diabetes diagnosed before age 20 years from the SEARCH for Diabetes in Youth study. METHODS:We included 8358 individuals newly-diagnosed with type 1 (n = 6840) or type 2 (n = 1518) diabetes from 1/1/2002-12/31/2008. We searched the National Death Index through 12/31/2010. We calculated standardized mortality ratios (SMRs) based on age, sex, and race for the comparable US population in the geographic areas of the SEARCH study. RESULTS:During 44,893 person-years (PY) of observation (median follow-up = 5.3 years), 41 individuals died (91.3 deaths/100,000 PY); 26 with type 1 (70.6 deaths/100,000 PY) and 15 with type 2 (185.6 deaths/100,000 PY) diabetes. The expected mortality rate was 70.9 deaths/100,000 PY. The overall SMR (95% CI) was 1.3 (1.0, 1.8) and was high among individuals with type 2 diabetes 2.4 (1.3, 3.9), females 2.2 (1.3, 3.3), 15-19 year olds 2.7 (1.7,4.0), and non-Hispanic blacks 2.1 (1.2, 3.4). CONCLUSIONS:Compared to the state populations of similar age, sex, and race, our results show excess mortality in individuals with type 2 diabetes, females, older youth, and non-Hispanic blacks. We did not observe excess short-term mortality in individuals with type 1 diabetes.

OBJECTIVE:To estimate the prevalence of and risk factors for cardiovascular autonomic neuropathy (CAN) in adolescents and young adults with type 1 and type 2 diabetes enrolled in the SEARCH for Diabetes in Youth Study. METHODS:The study included 1646 subjects with type 1 diabetes (age 18 ± 4 years, diabetes duration 8 ± 2 years, HbA1c 9.1 ± 1.9%, 76% non-Hispanic Whites) and 252 with type 2 diabetes (age 22 ± 4 years, diabetes duration 8 ± 2 years, HbA1c 9.2 ± 3.0%, 45% non-Hispanic Blacks). Cross-sectional and longitudinal risk factors were assessed at baseline and follow-up visits. Area under the curve (AUC) was used to assess the longitudinal glycemic exposure and cardiovascular risk factors. CAN was assessed by time and frequency domain indices of heart rate variability (HRV). CAN was defined as the presence of ≥3 of 5 abnormal HRV indices. RESULTS:The prevalence of CAN was 12% in adolescents and young adults with type 1 diabetes and 17% in those with type 2 diabetes. Poor long-term glycemic control (AUC HbA1c), high blood pressure, and elevated triglyceride levels were correlates of CAN in subjects with type 1 diabetes. In those with type 2 diabetes, CAN was associated with elevated triglycerides and increased urinary albumin excretion. CONCLUSIONS:The prevalence of CAN in this multiethnic cohort of adolescents and young adults with type 1 and type 2 diabetes are comparable to those reported in adults with diabetes. Suboptimal glycemic control and elevated triglycerides were the modifiable risk factors associated with CAN.

Brazil has a sizable alcohol and substance use disorder (ASUD) population, yet there are considerable gaps in treatment access and retention. ASUD, a chronic medical condition, is highly comorbid with medical and behavioral health disorders. This indicates a need for more targeted interventions in order to achieve health care integration (a major goal of Brazil's health care system). Care management - that is, the organization of patient care by an institution - is a viable strategy to engage individuals with ASUD who might benefit from treatment but are not aware of or do not use the available resources, as well as to help maintain patients in treatment. Care management is considered an essential supplement to the treatment of chronic disease. The objective of this article is to discuss the applicability of care management for the treatment of ASUD within the public health care system in Brazil. We describe models of care management that have been adopted internationally and identify the feasibility and advantages for its adoption in Brazil.

BACKGROUND:Local and national policies to encourage supermarket opening or expansion are popular strategies for improving access to healthy food for residents in neighborhoods lacking these types of stores, yet few evaluations of such initiatives exist. OBJECTIVE:Our aim was to test whether a newly opened supermarket in the Bronx, NY, changed household availability of healthy and unhealthy food items and reported daily consumption of these items among respondents residing in close proximity (≤0.5 mile) to the new supermarket. DESIGN/METHODS:This quasi-experimental study evaluated changes in purchasing and consumption habits of residents within 0.5 mile of the new supermarket as compared to residents living more than 0.5 mile from the supermarket. Data were collected through street intercept surveys at three different times: once before the store opened (March to August 2011) and in two follow-up periods (1 to 5 months and 13 to 17 months after the store opened). This study analyzed a subset of successfully geocoded resident intersections from the larger study. PARTICIPANTS/SETTING/METHODS:We surveyed 3,998 residents older than the age of 18 years in two Bronx neighborhoods about their food-purchasing behaviors before the store opened and in two follow-up periods. Responses from residents whose intersections were successfully geocoded (N=3,378) were analyzed to examine the consumption and purchasing behaviors of those in close proximity to the new store. INTERVENTION/METHODS:A new supermarket opened in a low-access neighborhood in the Bronx with the help of financial incentives through New York City's Food Retail Expansion to Support Health (FRESH) program. MAIN OUTCOME MEASURES/METHODS:The primary outcome evaluated was the change in percent of respondents reporting that the following food items were "always available" in the home: milk, fruit juice, soda, pastries, packaged snacks, fruits, and vegetables. As a secondary outcome, we explored changes in self-reported daily servings of these items. STATISTICAL ANALYSIS PERFORMED/METHODS:A difference-in-difference analysis was performed, controlling for age, education, marital status, income, sex, race, and ethnicity. RESULTS:Residents within 0.5 mile of the store had increased household availability of both healthy and unhealthy foods. After the introduction of the supermarket, the percent of residents in close proximity to the store who reported always having produce available in the home increased by 8.8% compared to those living >0.5 mile from the store in the first post-period and by 10.6% compared to those living >0.5 mile from the store in the second post-period. A similar positive increase in household availability of salty snacks and pastries was observed. Residents living in close proximity also reported greater consumption of healthy foods like produce and water, and lower intake of soft drinks and pastries. CONCLUSIONS:Given the financial support at the national and local levels to encourage supermarket development and expansion in high-need communities, it is imperative to evaluate the impact of such initiatives. Although the findings have so far been equivocal, our findings give weight to the argument that, at a micro-level, the siting of a new supermarket can indeed impact local purchasing and consumption behavior. Although purchasing for both healthy and unhealthy food items increased, reported consumption showed an increase in servings of healthy items (water, vegetables, and fruit) and a decrease in servings of unhealthy foods (soft drinks, salty snacks, and pastries).

Background: There are limited data on the adherence of migraine patients to recommendations for evidence-based behavioral treatments. Among patients seen by a headache specialist, we sought to determine rates of adherence to recommended behavioral treatments and barriers to adherence. We also sought to determine whether psychosocial factors such as migraine related disability, locus of control and self-efficacy were associated with adherence to migraine behavioral treatment recommendations. Methods: We conducted a prospective study of consecutive patients presenting to four headache specialists who were diagnosed with migraine at our Headache Center from 2016-2017 to examine whether they adhered to the recommendation to receive behavioral treatment. The primary outcome was whether patients had scheduled at least one visit for behavioral treatment. Descriptive statistics were reported. Patients who made an appointment for behavioral treatment were compared to those who did not across multiple categories including demographics, migraine characteristics, and personal beliefs with ANOVA and chi-square tests. Qualitative analyses were also done for open ended survey questions. Results: Of the 234 eligible patients, 69 (29.5%) were referred for behavioral treatment. Fifty-three (76.8%) patients referred for behavioral treatment were successfully reached by phone. Mean duration from time of referral to follow-up was 76 days (median 76, SD5 45). Just over half of patients (56.6%, N530) adhered to the recommendation for behavioral treatment. Patients who had previously seen a psychologist for their migraines were more likely to adhere to the behavioral treatment recommendation than patients who had not. Time constraints were the most common barrier cited for not scheduling a behavioral treatment appointment. Conclusion: Less than one third of eligible patients were referred for behavioral treatment and only about half adhered to the recommendation to schedule an appointment for behavioral treatment. More research should assess factors which might play a role in adherence to migraine behavioral treatment recommendations

Background: Level A evidence supports behavioral treatments for migraine. However, such treatments are underutilized due to the lack of 1) time, 2) insurance payment, and 3) patients'; therapeutic education on the behavioral options. Health message framing is a promising way to help guide patients with treatment decisions. Methods: Eight message frames about behavioral treatment for migraine were developed: six specific messages and two nonspecific messages, with half being gain-framed and the other half loss-framed. Message frames were assessed via a survey distributed on Turk Prime to people with migraine. Results: Fifty-six people completed the survey, with seven participants per message frame. Specific gain of frame was the most understood (90% of participants understood) and motivated participants to pursue behavioral therapy (57% willing to try in person behavioral therapy and 76% willing to try smartphone based behavioral treatment options). In this most motivated group, 14% reported that they would pay out of pocket for behavioral treatment. The least understood and least likely to motivate participants were the specific loss of frame messages; 52% were willing to try in person behavioral therapy and 38% were willing to try smartphone behavioral treatment options. 5% would pay out of pocket Conclusion: In this pilot study, the most easily understood and successful message frame was specific gain frame message. Larger studies may help determine best message framing for discussing behavioral treatments for migraine patients