Publications by authors named "Matthew M Clark"

174 Publications

Identifying Opportunities to Promote Physical Activity in a Diverse Low-Income Population: A Mixed-Method Study at a Boys & Girls Club Site.

Child Youth Care Forum 2020 Apr 12;49(2):171-200. Epub 2019 Sep 12.

Mayo Clinic.

Background: Prevalence and consequences of obesity and sedentary lifestyle are well-documented public health concerns for youth in the United State of America (U.S.A) that disproportionally affect children from low income and minority families.

Objective: This mixed-method study focused on estimating levels of physical activity and sedentary behavior and prevalence of overweight and obesity among the child members served in one Boys and Girls Club in the Midwest U.S.A. We aimed to better understand opportunities for improving children's engagement in physical activity through focus groups with members, staff, and parents/caregivers of members.

Methods: Social cognitive learning theory, the ecological model of health behavior, and community based participatory research principles provided the study framework. Members completed assessments of physical activity, sedentary activity, height, and weight. Focus groups with members, staff, and parents/caregivers identified barriers, facilitators, and opportunities for promoting physical activity. RESULTS: Nearly 50% of members were overweight or obese. Most (87%) participants reported at least 60 minutes physical activity every day across the 3-day recall. Fewer than half (41%) reported 2 hours or less of sedentary screen time every day across the 3 day recall. Focus group themes identified opportunities for addressing needs associated with health disparities in physical activity and pediatric obesity.

Conclusions: Findings suggest stakeholder interest in physical activity promotion through afterschool programs. We discuss study implications regarding needs specific to individuals from diverse, low-income households that may not be adequately addressed with existing empirically-supported treatments and opportunities to address health disparities in physical activity and pediatric obesity through afterschool programs.
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http://dx.doi.org/10.1007/s10566-019-09521-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8025775PMC
April 2020

Selection of Antiobesity Medications Based on Phenotypes Enhances Weight Loss: A Pragmatic Trial in an Obesity Clinic.

Obesity (Silver Spring) 2021 Apr;29(4):662-671

Department of Psychology and Psychiatry, Mayo Clinic, Rochester, Minnesota, USA.

Objective: Little is known about the predictors of response to obesity interventions.

Methods: In 450 participants with obesity, body composition, resting energy expenditure, satiety, satiation, eating behavior, affect, and physical activity were measured by validated studies and questionnaires. These variables were used to classify obesity phenotypes. Subsequently, in a 12-month, pragmatic, real-world trial performed in a weight management center, 312 patients were randomly assigned to phenotype-guided treatment or non-phenotype-guided treatment with antiobesity medications: phentermine, phentermine/topiramate, bupropion/naltrexone, lorcaserin, and liraglutide. The primary outcome was weight loss at 12 months.

Results: Four phenotypes of obesity were identified in 383 of 450 participants (85%): hungry brain (abnormal satiation), emotional hunger (hedonic eating), hungry gut (abnormal satiety), and slow burn (decreased metabolic rate). In 15% of participants, no phenotype was identified. Two or more phenotypes were identified in 27% of patients. In the pragmatic clinical trial, the phenotype-guided approach was associated with 1.75-fold greater weight loss after 12 months with mean weight loss of 15.9% compared with 9.0% in the non-phenotype-guided group (difference -6.9% [95% CI -9.4% to -4.5%], P < 0.001), and the proportion of patients who lost >10% at 12 months was 79% in the phenotype-guided group compared with 34% with non-phenotype-guided treatment group.

Conclusions: Biological and behavioral phenotypes elucidate human obesity heterogeneity and can be targeted pharmacologically to enhance weight loss.
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http://dx.doi.org/10.1002/oby.23120DOI Listing
April 2021

Mental Health and Chemical Dependency Services at US Cancer Centers.

J Natl Compr Canc Netw 2021 Mar 4:1-10. Epub 2021 Mar 4.

1Department of Psychiatry & Psychology.

Background: It is standard of care and an accreditation requirement to screen for and address distress and psychosocial needs in patients with cancer. This study assessed the availability of mental health (MH) and chemical dependency (CD) services at US cancer centers.

Methods: The 2017-2018 American Hospital Association (AHA) survey, Area Health Resource File, and Centers for Medicare & Medicaid Services Hospital Compare databases were used to assess availability of services and associations with hospital-level and health services area (HSA)-level characteristics.

Results: Of 1,144 cancer centers surveyed, 85.4% offered MH services and 45.5% offered CD services; only 44.1% provided both. Factors associated with increased adjusted odds of offering MH services were teaching status (odds ratio [OR], 1.76; 95% CI, 1.18-2.62), being a member of a hospital system (OR, 2.00; 95% CI, 1.31-3.07), and having more beds (OR, 1.04 per 10-bed increase; 95% CI, 1.02-1.05). Higher population estimate (OR, 0.98; 95% CI, 0.97-0.99), higher percentage uninsured (OR, 0.90; 95% CI, 0.86-0.95), and higher Mental Health Professional Shortage Area level in the HSA (OR, 0.99; 95% CI, 0.98-1.00) were associated with decreased odds of offering MH services. Government-run (OR, 2.85; 95% CI, 1.30-6.22) and nonprofit centers (OR, 3.48; 95% CI, 1.78-6.79) showed increased odds of offering CD services compared with for-profit centers. Those that were members of hospital systems (OR, 1.61; 95% CI, 1.14-2.29) and had more beds (OR, 1.02; 95% CI, 1.01-1.03) also showed increased odds of offering these services. A higher percentage of uninsured patients in the HSA (OR, 0.92; 95% CI, 0.88-0.97) was associated with decreased odds of offering CD services.

Conclusions: Patients' ability to pay, membership in a hospital system, and organization size may be drivers of decisions to co-locate services within cancer centers. Larger organizations may be better able to financially support offering these services despite poor reimbursement rates. Innovations in specialty payment models highlight opportunities to drive transformation in delivering MH and CD services for high-need patients with cancer.
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http://dx.doi.org/10.6004/jnccn.2020.7657DOI Listing
March 2021

Lay health worker as interventionist training: reflective writing in US family health promotion practice.

Health Promot Int 2021 Feb 23. Epub 2021 Feb 23.

Division of Infectious Diseases, Mayo Clinic, Rochester, MN 55905, USA.

Lay health worker-led health promotion interventions are well received within racial and ethnic minority communities. Increasing numbers of trained lay health workers will be needed to meet global health goals. The purpose of this process evaluation was to gain insights about how lay health worker as interventionists used theory-based approaches within a nutrition and physical activity health behavior change intervention in a clinical trial enrolling immigrant and refugee families. Data were comprised of ongoing reflective writing statements from four health workers about their implementation of the intervention. Using content analysis three themes emerged: (i) encouraging setting of small, family focused and relevant goals, (ii) being flexible in content delivery and (iii) being personally transformed (i.e. gained a sense of meaning from their experience). Lay health worker interventionist reflections on practice revealed they delivered the intervention within the primacy of the family partnering relationship by attending to unique family needs, and adjusting educational content and goal setting accordingly. Our results provide guidance for training and process evaluation of lay health worker intervention delivery in ethnically and racially diverse populations. Incorporating real-time reflection upon what was learned about skills of facilitating family motivation and family confidence enhanced affective learning and may be useful in future research studies and health promotion practice. The processes identified including setting small goals, flexibility and personal transformation could be considered in future lay health worker-delivered health promotion interventions.
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http://dx.doi.org/10.1093/heapro/daaa143DOI Listing
February 2021

Clinician Satisfaction with Rapid Adoption and Implementation of Telehealth Services During the COVID-19 Pandemic.

Telemed J E Health 2021 Feb 19. Epub 2021 Feb 19.

VA Northern California Health Care System, Mather, California, USA.

To examine clinician perspectives on the acceptability, appropriateness/suitability, and feasibility of video telehealth as a way to deliver mental health services during the COVID-19 pandemic. Mental health clinicians were surveyed with 27 Likert questions, using previously validated measures, on satisfaction and implementation experience with video telehealth visits between March and June 2020. A total of 112 of 193 clinicians completed the survey (58.0%), including psychiatrists, psychologists, trainees (i.e., residents and fellows), advanced practice providers, and licensed mental health counselors. Clinicians reported high levels of acceptability, feasibility, and appropriateness of video telehealth; they also reported high levels of satisfaction with video telehealth visits. Seventy-nine and a half (79.5%) reported that their patients seemed highly satisfied with video telehealth visits, and 107 (95.5%) of clinicians responded that they would like video telehealth visits to represent at least 25% of their practice in the future. Mental health clinicians showed positive attitudes toward the implementation of video telehealth visits, high levels of satisfaction with this care, and indicated strong interest in continuing this modality as a significant portion of clinical practice. This study demonstrates the ability of mental health clinicians to embrace new technology to expand access to care during the COVID-19 pandemic. Results indicate that telemental health is likely to be an integral part of clinic practice in the future.
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http://dx.doi.org/10.1089/tmj.2020.0575DOI Listing
February 2021

Cannabis use and bariatric surgery psychology practice: survey and insights.

Surg Obes Relat Dis 2021 Apr 16;17(4):701-710. Epub 2020 Dec 16.

Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota; Department of Internal Medicine, Division of Endocrinology, Mayo Clinic, Rochester, Minnesota.

Background: Cannabis is second only to alcohol as a substance of abuse and dependence in the United States. While there is extensive research examining alcohol use and bariatric surgery, there is currently little research and there are no published guidelines specific to cannabis use and bariatric surgery.

Objectives: To identify major themes and general guidelines applied by bariatric surgery psychology clinicians.

Setting: This practice survey was disseminated to bariatric surgery psychologists at various U.S. academic medical centers, hospitals, and private practices.

Methods: An electronic, 35-question survey was sent to 47 bariatric surgery psychologists to collect information on current clinical practice guidelines regarding cannabis use before and after bariatric surgery.

Results: The survey questionnaire was completed by 34 (72.34%) bariatric surgery psychologists. The major identified themes included: (1) the lack of a standardized assessment of cannabis use; (2) a requirement for 3 months of abstinence from cannabis before bariatric surgery; (3) recommended lifetime abstinence from cannabis after bariatric surgery; and (4) discussion of cannabis use risks following bariatric surgery, including appetite stimulation, addiction potential, and possible negative impacts on judgment.

Conclusion: Cannabis use will likely further increase in the United States. This survey highlighted common bariatric surgery psychology practices in the absence of extensive research and published guidelines. These findings suggest a preliminary framework with which to address cannabis use in patients seeking bariatric surgery. It is recommended that professional organizations and societies build on these initial survey findings to develop guidelines for more consistent, evidence-based practice regarding cannabis use and bariatric surgery.
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http://dx.doi.org/10.1016/j.soard.2020.12.004DOI Listing
April 2021

Associations Between Experience of Early Childhood Trauma and Impact on Obesity Status, Health, as Well as Perceptions of Obesity-Related Health Care.

Mayo Clin Proc 2021 02;96(2):408-419

Division of General Internal Medicine, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center of Science and Health Care Delivery, Mayo Clinic, Rochester, MN; Division of Community Internal Medicine, Mayo Clinic, Rochester, MN; Division of Epidemiology, Department of Health Science Research, Mayo Clinic, Rochester, MN.

Objective: To evaluate the association between obesity and history of childhood trauma in an effort to define implications for the provider-patient relationship and possible causes of failure of obesity treatment.

Methods: Multisite survey developed by the Patient-Centered Outcomes Research Institute Learning Health Systems Obesity Cohort Workgroup consisting of 49 questions with 2 questions focusing on history of being a victim of childhood physical and/or sexual abuse was mailed to 19,964 overweight or obese patients. Data collection for this survey occurred from October 27, 2017, through March 1, 2018.

Results: Among the 2211 surveys included in analysis, respondents reporting being a victim of childhood abuse increased significantly with obesity (23.6%, 26.0%, 29.1%, and 36.8% for overweight, class I, class II, and class III obesity, respectively; P<.001). A higher percentage of those who reported being a victim of childhood abuse noted that their weight issues began at an earlier age (P=.002) and were more likely to have weight-related comorbidities (P<.001), even after controlling for body mass index. Impacting physician counseling on weight loss, patients who were childhood victims of abuse reported lower self-esteem (P<.001), were more likely to feel judged by their health care providers (P=.009), and less likely to feel being treated with respect (P=.045).

Conclusion: Overall, being a victim of childhood abuse was significantly associated with obesity, lower self-esteem and negative experiences interacting with health care providers. Health care providers should receive training to ensure open and nonjudgmental visits with obese patients and consider the role of trauma survivorship issues in patients' development of obesity and health care experiences.
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http://dx.doi.org/10.1016/j.mayocp.2020.05.049DOI Listing
February 2021

Feasibility and acceptability of a technology-based, rural weight management intervention in older adults with obesity.

BMC Geriatr 2021 Jan 12;21(1):44. Epub 2021 Jan 12.

Dartmouth College, Hanover, NH, USA.

Background: Older adults with obesity residing in rural areas have reduced access to weight management programs. We determined the feasibility, acceptability and preliminary outcomes of an integrated technology-based health promotion intervention in rural-living, older adults using remote monitoring and synchronous video-based technology.

Methods: A 6-month, non-randomized, non-blinded, single-arm study was conducted from October 2018 to May 2020 at a community-based aging center of adults aged ≥65 years with a body mass index (BMI) ≥30 kg/m. Weekly dietitian visits focusing on behavior therapy and caloric restriction and twice-weekly physical therapist-led group strength, flexibility and balance training classes were delivered using video-conferencing to participants in their homes. Participants used a Fitbit Alta HR for remote monitoring with data feedback provided by the interventionists. An aerobic activity prescription was provided and monitored.

Results: Mean age was 72.9±3.9 years (82% female). Baseline anthropometric measures of weight, BMI, and waist circumference were 97.8±16.3 kg, 36.5±5.2 kg/m, and 115.5±13.0 cm, respectively. A total of 142 participants were screened (n=27 ineligible), and 53 consented. There were nine dropouts (17%). Overall satisfaction with the trial (4.7+ 0.6, scale: 1 (low) to 5 (high)) and with Fitbit (4.2+ 0.9) were high. Fitbit was worn an average of 81.7±19.3% of intervention days. In completers, mean weight loss was 4.6±3.5 kg or 4.7±3.5% (p< 0.001). Physical function measures of 30-s sit-to-stand repetitions increased from 13.5±5.7 to 16.7±5.9 (p< 0.001), 6-min walk improved by 42.0±77.3 m (p=0.005) but no differences were observed in gait speed or grip strength. Subjective measures of late-life function improved (3.4±4.7 points, p< 0.001).

Conclusions: A technology-based obesity intervention is feasible and acceptable to older adults with obesity and may lead to weight loss and improved physical function.

Clinical Trial Registration: Registered on Clinicaltrials.gov # NCT03104205 . Registered on April 7, 2017. First participant enrolled on October 1st, 2018.
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http://dx.doi.org/10.1186/s12877-020-01978-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7801868PMC
January 2021

Exercise, Yoga, and Tai Chi for Treatment of Major Depressive Disorder in Outpatient Settings: A Systematic Review and Meta-Analysis.

Prim Care Companion CNS Disord 2020 Dec 31;23(1). Epub 2020 Dec 31.

School of Psychology, Deakin University, Geelong, Australia.

Objective: Exercise, yoga, and tai chi are commonly used complementary approaches for health and wellness. This review aims to synthesize the evidence for exercise, yoga, and tai chi in the outpatient treatment of major depressive disorder.

Study Selection: A systematic search of the Ovid MEDLINE, EMBASE, PsycINFO, and Cochrane databases was conducted for randomized controlled trials of exercise, yoga, and tai chi for major depressive disorder.

Data Extraction: Standardized mean differences were calculated and meta-analyzed using a random effects multilevel modeling framework. Heterogeneity and subgroup analysis was conducted.

Results: Twenty-five studies were included for final analysis (exercise: 15, yoga: 7, tai chi: 3). Overall, meta-analysis showed a moderate significant clinical effect. However, when only studies (6 studies) with the lowest risk of bias were included, the overall effect size was reduced to low to moderate efficacy. Overall quality of evidence was low. Heterogeneity and publication bias were high.

Conclusions: The current meta-analysis of outpatient exercise, yoga, and tai chi for treatment of major depressive disorder suggests that adjunctive exercise and yoga may have small additive clinical effects in comparison to control for reducing depressive symptoms. The evidence for tai chi is insufficient to draw conclusions. The concerns with quality of studies, high heterogeneity, and evidence of publication bias preclude making firm conclusions.
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http://dx.doi.org/10.4088/PCC.20r02722DOI Listing
December 2020

Symptoms of bipolar disorder are associated with lower bariatric surgery completion rates and higher food addiction.

Eat Behav 2021 Jan 22;40:101462. Epub 2020 Nov 22.

Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN 55905, USA. Electronic address:

Background: Bipolar disorder (BP) is highly comorbid with obesity, however, little is known about how BP might be associated with bariatric surgery outcomes.

Methods: In this retrospective clinical cohort study, 1034 patients completed a psychological evaluation, and screening positive for possible BP was defined as a score ≥7 and moderate disability on the Mood Disorders Questionnaire. Food addiction (FA), subthreshold binge eating disorder (BED), and illegal drug use were also assessed using standardized questionnaires.

Results: The 54 (5.2%) patients screening positive for BP were less likely to have bariatric surgery compared to 980 (94.8%) patients who screened negative for BP (5 patients or 9.3% vs 273 patients, or 27.9%). Patients with possible BP also had significantly higher prevalence of FA (37% vs 13.2%), subthreshold BED (29.6% vs 8.3%) and illegal drug use (7.4% vs 2.1%).

Conclusions: In this retrospective clinical cohort study, patients who screened positive for BP had a higher prevalence of food addiction, subthreshold binge eating disorder and recent illegal drug use. They also demonstrated lower completion rates for having bariatric surgery. Clearly, more needs to be learned about how to help patients with symptoms of bipolar disorder manage their obesity and behavioral challenges.
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http://dx.doi.org/10.1016/j.eatbeh.2020.101462DOI Listing
January 2021

Identifying Persuasive Design Principles and Behavior Change Techniques Supporting End User Values and Needs in eHealth Interventions for Long-Term Weight Loss Maintenance: Qualitative Study.

J Med Internet Res 2020 11 30;22(11):e22598. Epub 2020 Nov 30.

Centre for eHealth and Wellbeing Research, Department of Psychology, Health and Technology, University of Twente, Enschede, Netherlands.

Background: An increasing number of eHealth interventions aim to support healthy behaviors that facilitate weight loss. However, there is limited evidence of the effectiveness of the interventions and little focus on weight loss maintenance. Knowledge about end user values and needs is essential to create meaningful and effective eHealth interventions, and to identify persuasive system design (PSD) principles and behavior change techniques (BCTs) that may contribute to the behavior change required for successful long-term weight loss maintenance.

Objective: This study aimed to provide insight into the design of eHealth interventions supporting behavior change for long-term weight maintenance. The study sought to identify the values and needs of people with obesity aiming to maintain weight after weight loss, and to identify PSD principles, BCTs, and design requirements that potentially enable an eHealth intervention to meet end user values and needs.

Methods: This study presents the concept of integrating PSD principles and BCTs into the design process of eHealth interventions to meet user values and needs. In this study, individual interviews and focus groups were conducted with people with obesity (n=23) and other key stakeholders (n=27) to explore end user values and needs related to weight loss maintenance. Design thinking methods were applied during the focus group sessions to identify design elements and to explore how eHealth solutions can support the needs to achieve sustainable weight loss maintenance. The PSD model and behavior change taxonomy by Michie were used to identify PSD principles and BCT clusters to meet end user values and needs.

Results: A total of 8 key end user values were identified, reflecting user needs for weight loss maintenance support: self-management, personalized care, autonomy, feel supported, positive self-image, motivation, happiness, and health. Goals and planning, feedback and monitoring, repetition and substitution, shaping knowledge, social support, identity, and self-belief were some of the BCT clusters identified to address these concepts, together with PSD principles such as personalization, tailoring, self-monitoring, praise, and suggestions.

Conclusions: The process of translating end user values and needs into design elements or features of eHealth technologies is an important part of the design process. To our knowledge, this is the first study to explore how PSD principles and BCTs can be integrated when designing eHealth self-management interventions for long-term weight loss maintenance. End users and other key stakeholders highlighted important factors to be considered in the design of eHealth interventions supporting sustained behavior change. The PSD principles and BCTs identified provide insights and suggestions about design elements and features to include for supporting weight loss maintenance. The findings indicate that a combination of BCTs and PSD principles may be needed in evidence-based eHealth interventions to stimulate motivation and adherence to support healthy behaviors and sustained weight loss maintenance.

Trial Registration: ClinicalTrials.gov NCT04537988; https://clinicaltrials.gov/ct2/show/NCT04537988.
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http://dx.doi.org/10.2196/22598DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7735908PMC
November 2020

Mindfulness-Based Cognitive Therapy, Acceptance and Commitment Therapy, and Positive Psychotherapy for Major Depression.

Am J Psychother 2021 Mar 28;74(1):4-12. Epub 2020 Sep 28.

Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota (Seshadri, Adaji, Singh, Clark, Frye); Department of Psychiatry and Psychology, Mayo Clinic Health System, Austin, Minnesota (Seshadri, Orth); Department of Psychiatry, Olmsted Medical Center, Rochester, Minnesota (Orth); Department of Psychiatry, Monash Health-Casey Hospital, Berwick, Australia (Adaji); School of Psychology, Deakin University, Geelong, Australia (McGillivray, Fuller-Tyszkiewicz).

Objective: In the past two decades, newer psychotherapy treatments have emerged for the treatment of major depression. This review aimed to comprehensively synthesize the evidence for mindfulness-based cognitive therapy (MBCT), acceptance and commitment therapy (ACT), and positive psychotherapy (PPT) in treating a current episode of major depression.

Methods: A systematic search of the Ovid MEDLINE, Embase, PsycINFO, and Cochrane databases was conducted for randomized controlled trials of MBCT, ACT, and PPT for major depression. Standardized mean differences were calculated with Hedges' g to complete random-effects meta-analysis. Heterogeneity was assessed with the Cochran Q statistic and I statistic. Subgroup analysis was conducted to further investigate heterogeneity.

Results: A random-effects meta-analysis of 15 studies (MBCT, N=7; ACT, N=4; PPT, N=4) revealed that all three therapies showed efficacy in reducing symptoms of depression with a small favorable effect, compared with all control conditions (N=946; Hedges' g=0.34; 95% confidence interval=0.14, 0.54; p<0.001). Cochrane's Q statistic (Q=32, df=15, p=0.007) suggested significant heterogeneity (I=53%). A mixed-effects model test for subgroup differences showed significant differences between active controls and treatment-as-usual controls (χ=15.3, df=1, p<0.001). Overall quality of evidence and publication bias were low.

Conclusions: Meta-analysis shows that MBCT and ACT may be superior to inactive or treatment-as-usual controls and that PPT may be comparable to active controls for reducing symptoms of major depression after an acute course of therapy. However, the quality of the evidence was low. High-quality studies are needed to confirm the efficacy of these interventions.
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http://dx.doi.org/10.1176/appi.psychotherapy.20200006DOI Listing
March 2021

Feasibility of a Behavioral Intervention to Reduce Psychological Distress in Mechanically Ventilated Patients.

Int J Clin Exp Hypn 2020 Oct-Dec;68(4):419-432. Epub 2020 Jul 30.

Division of Pulmonary and Critical Care Medicine, Mayo Clinic , Rochester, Minnesota, USA.

Many survivors of acute respiratory failure suffer from mood disorders following discharge from the hospital. We investigated the feasibility of intensivists delivering psychological support based on positive suggestion (PSBPS) to 20 intubated patients to reduce their psychological distress. Thirteen patients completed follow-up surveys. Of those, 9 remembered the intensive care unit physician talking to them, and 7 described it as comforting. Five patients (38%) met criteria for anxiety, depression, and acute stress. In comparison to historical controls, intervention may be associated with lower estimated odds of anxiety. PSBPS can be performed with patients in parallel with medical treatment to potentially reduce psychological morbidity and to humanize critical care. A larger randomized study is warranted to assess the efficacy of PSBPS.
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http://dx.doi.org/10.1080/00207144.2020.1795663DOI Listing
July 2020

Associations of gastric volumes, ingestive behavior, calorie and volume intake, and fullness in obesity.

Am J Physiol Gastrointest Liver Physiol 2020 08 6;319(2):G238-G244. Epub 2020 Jul 6.

Clinical Enteric Neuroscience Translational and Epidemiological Research, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.

Whereas gastric emptying significantly predicts calorie intake, the association between gastric capacity and satiation and satiety is unclear. To study the associations between gastric volumes and ingestive behaviors with satiation and satiety in obesity, 62 healthy adult obese patients (57 female) with no eating disorders underwent measurements of satiety, as determined by kilocalories of ingestion at a buffet meal, and satiation by volume to comfortable fullness (VTF) and maximum tolerated volume (MTV), while drinking Ensure (30 mL/min). Fasting and postprandial gastric volumes were measured by validated single-photon emission computed tomography. We also measured eating [Weight Efficacy Life-Style Questionnaire score (WEL)] and exercise behaviors associated with obesity. Spearman correlation-assessed relationships of measured traits and linear regression analysis to identify predictors of satiation or satiety. The participants were aged 38 ± 10.1 yr and the body mass index (BMI) 36.8 ± 4.8 kg/m. Fasting gastric volume was significantly correlated with VTF ( = 0.3, = 0.03), but not with MTV or buffet meal kilocalorie ingestion. Regression analysis identified sex ( = 0.02, with males having significantly higher fasting gastric volume) and fasting gastric volume (0.04) as predictors of higher VTF. An increase in fasting gastric volume of 50 mL resulted in a 6-mL increase in VTF. Buffet meal intake was inversely related to the ability to resist the urge to eat; factors associated with ingestive behavior (increase in total WEL score) significantly correlated with satiety and gastric accommodation ( < 0.05). Gastric capacity during fasting is associated with calorie intake to the point of comfortable fullness; factors associated with ingestive behavior are associated with satiety and gastric accommodation. Buffet meal intake was inversely related to the ability to resist the urge to overeat. Factors associated with ingestive behavior significantly correlated with satiety and gastric accommodation. Gastric capacity during fasting is associated with calorie intake to the point of comfortable fullness; factors associated with ingestive behavior are associated with satiety and gastric accommodation.
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http://dx.doi.org/10.1152/ajpgi.00140.2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7500268PMC
August 2020

Barriers to accepting mental health care in cancer patients with depression.

Soc Work Health Care 2020 07 14;59(6):351-364. Epub 2020 Jun 14.

Department of Psychiatry & Psychology, Mayo Clinic , Jacksonville, FL, USA.

This study aimed to determine barriers to accepting mental health care among depressed cancer patients. Cancer patients who screened positive for depression were referred for mental health treatment and sent a validated questionnaire designed to assess barriers to receiving mental health care. Responses were compared between patients who accepted their referral and those who did not. Among 75 patients who agreed to participate, 51 (68%) completed the questionnaire. Reported barriers to accessing mental healthcare were not significantly different between the two groups but patients residing within 50 miles of the clinic had increased odds of attending their appointment.
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http://dx.doi.org/10.1080/00981389.2020.1769248DOI Listing
July 2020

Wellness Coaching: An Intervention to Increase Healthy Behavior in Breast Cancer Survivors.

Clin J Oncol Nurs 2020 06;24(3):305-315

Mayo Clinic.

Background: Regular physical activity after breast cancer diagnosis improves survival rates and quality of life (QOL). However, breast cancer survivors rarely meet guidelines for recommended levels of physical activity. Wellness coaching interventions (WCIs) have improved exercise and health behaviors in other patient populations.

Objectives: This study assessed the feasibility and effectiveness of WCIs for increasing physical activity in breast cancer survivors; secondary measures included changes in dietary habits, weight, and QOL.

Methods: 20 obese or overweight breast cancer survivors who recently completed active breast cancer treatment were recruited into a single-arm, 12-week WCI pilot feasibility study. The intervention was comprised of one in-person wellness coaching visit followed by four telephone calls over 12 weeks and 12 weekly emails containing wellness recommendations.

Findings: Significant improvements from pre- to postintervention were seen in physical activity level, dietary habits, and in some aspects of QOL. Forty percent of participants achieved the 3% postintervention weight-loss goal, but this was not sustained at 30 weeks.
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http://dx.doi.org/10.1188/20.CJON.305-315DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7486982PMC
June 2020

A Weight Loss Intervention Augmented by a Wearable Device in Rural Older Adults With Obesity: A Feasibility Study.

J Gerontol A Biol Sci Med Sci 2021 Jan;76(1):95-100

Massachusetts General Hospital, Boston.

Background: Older persons with obesity aged 65+ residing in rural areas have reduced access to weight management programs due to geographic isolation. The ability to integrate technology into health promotion interventions shows a potential to reach this underserved population.

Methods: A 12-week pilot in 28 older rural adults with obesity (body mass index [BMI] ≥ 30 kg/m2) was conducted at a community aging center. The intervention consisted of individualized, weekly dietitian visits focusing on behavior therapy and caloric restriction with twice weekly physical therapist-led group strengthening training classes in a community-based aging center. All participants were provided a Fitbit Flex 2. An aerobic activity prescription outside the strength training classes was provided.

Results: Mean age was 72.9 ± 5.3 years (82% female). Baseline BMI was 37.1 kg/m2, and waist circumference was 120.0 ± 33.0 cm. Mean weight loss (pre/post) was 4.6 ± 3.2 kg (4.9 ± 3.4%; p < .001). Of the 40 eligible participants, 33 (75%) enrolled, and the completion rate was high (84.8%). Objective measures of physical function improved at follow-up: 6-minute walk test improved: 35.7 ± 41.2 m (p < .001); gait speed improved: 0.10 ± 0.24 m/s (p = .04); and five-times sit-to-stand improved by 2.1 seconds (p < .001). Subjective measures of late-life function improved (5.2 ± 7.1 points, p = .003), as did Patient-Reported Outcome Measurement Information Systems mental and physical health scores (5.0 ± 5.7 and 4.4 ± 5.0, both p < .001). Participants wore their Fitbit 93.9% of all intervention days, and were overall satisfied with the trial (4.5/5.0, 1-5 low-high) and with Fitbit (4.0/5.0).

Conclusions: A multicomponent obesity intervention incorporating a wearable device is feasible and acceptable to older adults with obesity, and potentially holds promise in enhancing health.
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http://dx.doi.org/10.1093/gerona/glaa115DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7756700PMC
January 2021

Feasibility Study of Stress Management and Resiliency Training (SMART) in Patients With Major Depressive Disorder.

Prim Care Companion CNS Disord 2020 Apr 30;22(3). Epub 2020 Apr 30.

Departments of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA.

Objective: Stress is associated with the onset, maintenance, and recurrence of depression. This study investigated the feasibility of stress management and resiliency training (SMART) for enhancing resiliency in a group of patients with major depressive disorder.

Methods: In an open-label study, patients with major depressive disorder were invited to participate in an adjunctive 8-week group therapy of SMART (from June 2017 to June 2018) that encompassed attention training and practice of gratitude, compassion, higher meaning, acceptance, and forgiveness. The primary outcome measure was baseline-to-endpoint change in resilience as measured by the Connor Davidson Resilience Scale (CD-RISC). Secondary outcome measures included baseline-to-endpoint change in stress using the Perceived Stress Scale (PSS) and in depression using the 17-item Hamilton Depression Rating Scale (HDRS-17) and 9-item Patient Health Questionnaire (PHQ-9).

Results: Twenty-three participants enrolled in the study (mean ± SD age = 46 ± 13 years, female = 91%). Baseline ratings of mood were of mild-to-moderate symptom severity (mean HDRS-17 score = 14.5 and PHQ-9 score = 12), resilience (mean CD-RISC score = 53.8), and perceived stress (mean PSS score = 23.5). Of the participants, 74% were study completers (attended ≥ 6 sessions). In an intention-to-treat analysis, at study endpoint there was a significant improvement in resilience (mean CD-RISC score = 61.1, P = .03), reduction in perceived stress (mean PSS score = 19.4, P = .002), and improvement in depression (mean HDRS-17 score = 9.1 and PHQ-9 score = 7.6, both P < .001).

Conclusions: A resilience training program focused on wellness is feasible for patients who are currently symptomatic with major depressive disorder. A larger randomized controlled trial is needed to establish efficacy of this intervention and explore the long-term impact of stress management and resilience training in depression.

Trial Registration: ClinicalTrials.gov identifier: NCT03275961.
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http://dx.doi.org/10.4088/PCC.19m02556DOI Listing
April 2020

Results from a randomized controlled trial testing StressProffen; an application-based stress-management intervention for cancer survivors.

Cancer Med 2020 06 3;9(11):3775-3785. Epub 2020 Apr 3.

Department of Digital Health Research, Division of Medicine, Oslo University Hospital, Oslo, Norway.

Background: In-person cognitive-behavioral stress-management interventions are consistently associated with reduced cancer distress. However, face-to-face delivery is an access barrier for many patients, and there is a need to develop remote-delivered interventions. The current study evaluated the preliminary efficacy of an application (app)-based cancer stress-management intervention, StressProffen, in a randomized controlled trial.

Methods: Cancer survivors, maximum 1-year posttreatment (N = 172), were randomized to StressProffen (n = 84) or a usual care control group (n = 88). Participants received a blended delivery care model: (a) one face-to-face introduction session, (b) 10 app-based cognitive-behavioral stress-management modules, and (c) follow-up phone calls at weeks 2-3 and 6-7. Outcome measures included stress (Perceived Stress Scale), anxiety and depression (Hospital Anxiety Depression Scale), and health-related quality of life (HRQoL; Short-Form Health Surveys [SF-36]) at 3-months post-intervention, analyzed with change scores as dependent variables in linear regression models.

Results: Participants were primarily women (82%), aged 20-78 years (mean 52, SD 11.2), with mixed cancer types (majority breast cancer; 48%). Analysis of 149 participants completing questionnaires at baseline and 3 months revealed significant intervention effects: decreased stress (mean difference [MD] -2.8; 95% confidence interval [CI], [-5.2 to -0.4]; P = .022) and improved HRQoL (Role Physical MD = 17.7, [CI 3.7-31.3], P = .013; Social Functioning MD = 8.5, [CI 0.7-16.2], P = .034; Role Emotional MD = 19.5, [CI 3.7-35.2], P = .016; Mental Health MD = 6.7, [CI 1.7-11.6], P = .009). No significant changes were observed for anxiety or depression.

Conclusions: Digital-based cancer stress-management interventions, such as StressProffen, have the potential to provide easily accessible, effective psychosocial support for cancer survivors.
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http://dx.doi.org/10.1002/cam4.3000DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7286452PMC
June 2020

Rethinking Patient and Medical Professional Perspectives on Bariatric Surgery as a Medically Necessary Treatment.

Mayo Clin Proc 2020 03;95(3):527-540

Division of General Surgery, Mayo Clinic, Jacksonville, FL.

The prevalence of class 3 obesity (body mass index ≥40 kg/m) is 7.7% of the United States adult population; thus, more than 25 million people may be medically appropriate for consideration of bariatric surgery as therapy for severe obesity. Although bariatric surgery is the most effective therapy for patients with severe obesity, the surgery is performed in less than 1% of patients annually for whom it may be appropriate. Patients' and medical professionals' misperceptions about obesity and bariatric surgery create barriers to accessing bariatric surgery that are not given adequate attention and clinical consideration. Commonly cited patient barriers are lack of knowledge about the severity of obesity, the perception that obesity is a lifestyle problem rather than a chronic disease, and fear that bariatric surgery is dangerous. Medical professional barriers include failing to recognize causes of obesity and weight gain, providing recommendations that are inconsistent with current obesity treatment guidelines, and being uncomfortable counseling patients about treatment options for severe obesity. Previous research has revealed that medical professional counseling and accurate perception of the health risks associated with severe obesity are strong predictors of patients' willingness to consider bariatric surgery. This article reviews patient and medical professional barriers to acceptance of bariatric surgery as a treatment of medical necessity and offers practical advice for medical professionals to rethink perspectives about bariatric surgery when it is medically and psychologically appropriate.
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http://dx.doi.org/10.1016/j.mayocp.2019.09.019DOI Listing
March 2020

Club Fit: Development of a Physical Activity and Healthy Eating Intervention at a Boys & Girls Club After School Program.

J Prim Prev 2020 04;41(2):153-170

Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55901, USA.

Children and adolescents from minority and low income backgrounds face social and environmental challenges to engaging in physical activity and healthy eating to maintain a healthy weight. In this study, we present pilot work to develop and implement a multi-component physical activity and healthy eating intervention at a Boys & Girls Club (BGC) afterschool program. Using a community-based participatory approach, BGC staff and academic researchers developed intervention components informed by formative studies and based on a Social Ecological Theory framework. Components included healthy eating and physical activity policy implementation, staff training, a challenge and self-monitoring program for healthy behaviors, a peer-coaching program for healthy behaviors, and a social marketing campaign. We assessed pilot feasibility through a single group, pre-post study design with measures collected at baseline and 6 months. The sample included 61 children with a mean age of 10.4 years. Mean (SD) body mass index (BMI) percentile was 72.8 (28.9); 47.5% were in the healthy weight range for their age. We found statistically significant improvements of self-efficacy and motivation for physical activity. Self-efficacy and motivation for fruit and vegetable consumption, sugary beverage consumption, and screen time improved but were not statistically different from baseline. We found no improvements of perceived social support, objectively measured physical activity, or self-reported dietary quality. Though BMI did not improve overall, a dose effect was observed such that attendance in Club Fit specific programming was significantly correlated with decreased BMI z scores. Processes and products from this study may be helpful to other communities aiming to address childhood obesity prevention through afterschool programs.
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http://dx.doi.org/10.1007/s10935-020-00582-4DOI Listing
April 2020

The Use and Meaning of the Term Obesity in Rural Older Adults: A Qualitative Study.

J Appl Gerontol 2021 Apr 15;40(4):423-432. Epub 2020 Feb 15.

Dartmouth College, Hanover, NH, USA.

The term "obesity" is associated with societal stigma and discrimination. Eight individual semi-structured interviews and five focus groups with 29 community-dwelling, rural older adults with obesity, seven primary care clinicians, and four rural community leaders were completed using purposive and snowball sampling. Clinicians perceived that older adults are less affected by obesity stigma than younger adults, yet this was not observed by community leaders; however, older participants with obesity reported that they often felt ashamed and/or stigmatized because of their weight. There was also a disconnect between clinician and older adult understanding of obesity. For older adults with obesity, the word "obesity" was associated with negative connotations. Just as physiological aspects of obesity persist into older adulthood, so do psychological aspects, such as perceptions of stigma. The use of the word "obesity" in medical settings may hinder communication between clinician and older participants. Heightened awareness may change the dialogue around obesity.
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http://dx.doi.org/10.1177/0733464820903253DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7429325PMC
April 2021

Dementia palliative care in the acute psychiatric hospital: A feasibility study.

Perspect Psychiatr Care 2020 Jul 14;56(3):593-597. Epub 2020 Jan 14.

Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota.

Purpose: We explored the feasibility of a clinical pathway to identify hospitalized patients with dementia who would benefit from a palliative intervention.

Design And Methods: Consecutive geropsychiatric admissions were screened for terminal dementia to be randomized to a palliative consultation vs usual care.

Findings: A total of 43 of the 188 patients (23%) had dementia; however, dementia stages were severe but not terminal. The pathway was not feasible because of the lack of the target population in the inpatient setting for the intervention.

Practice Implications: New clinical pathways are needed to identify patients with dementia who would benefit from palliative care.
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http://dx.doi.org/10.1111/ppc.12473DOI Listing
July 2020

Impact of Psychiatric Comorbidities on Health Care Costs Among Patients With Cancer.

Psychosomatics 2020 Mar - Apr;61(2):145-153. Epub 2019 Nov 6.

Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, FL; Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN.

Background: Psychiatric disorders are common in cancer patients and impact outcomes. Impact on cancer care cost needs study to develop business case for psychosocial interventions.

Objective: To evaluate the impact of preexisting psychiatric comorbidities on total cost of care during 6 months after cancer diagnosis.

Methods: This retrospective cohort study examined patients diagnosed with cancer between January 1, 2009, and December 31, 2014, at one National Cancer Institute-designated cancer center. Patients who received all cancer treatment at the study site (6598 of 11,035 patients) were included. Patients were divided into 2 groups, with or without psychiatric comorbidity, based on International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes. Total costs of care during the first 6 months of treatment were based on standardized costs adjusted to 2014 dollars, determined by assigning Medicare reimbursement rates to professional billed services and applying appropriate cost-to-charge ratios. Quantile regression models with covariate adjustments were developed to assess the effect of psychiatric comorbidity across the distribution of costs.

Results: Six hundred ninety-eight (10.6%) of 6598 eligible patients had at least one psychiatric comorbidity. These patients had more nonpsychiatric Elixhauser comorbidities (mean 4 vs. 3). Unadjusted total cancer care costs were higher for patients with psychiatric comorbidity (mean [standard deviation]: $51,798 [$74,549] vs. $32,186 [$45,240]; median [quartiles]: $23,871 [$10,705-$57,338] vs. $19,073 [$8120-$38,230]). Quantile regression models demonstrated that psychiatric comorbidity had significant incremental effects at higher levels of cost: 75th percentile $8629 (95% confidence interval: $3617-13,642) and 90th percentile $42,586 (95% confidence interval: $25,843-59,330).

Conclusions: Psychiatric comorbidities are associated with increased total cancer costs, especially in patients with very high cancer care costs, representing an opportunity to develop mitigation strategies.
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http://dx.doi.org/10.1016/j.psym.2019.10.010DOI Listing
February 2021

A Randomized Controlled Trial in the Evaluation of a Novel Stress Management Tool: A Lounge Chair Experience.

Glob Adv Health Med 2019 29;8:2164956119892597. Epub 2019 Nov 29.

Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota.

Objectives: The aim of this study was to compare the stress reduction effects of spending 25 minutes reclining in a SolTec™ Lounge between 2 intervention groups. Group 1 experienced the Lounge with multilayered music on an external speaker, while group 2 experienced the Lounge with multilayered music and synchronous vibration and magnetic stimulation from within the chair.

Subjects: In total, 110 participants with a self-reported stress level of 4 or higher on a 0- to 10-point scale were recruited from the local community including employees. Participants were randomized into receiving 1 of the 2 interventions. There were no significant differences between the group's average stress levels prior to the interventions.

Interventions: Both groups received a 25-minute session in a dimly lit, quiet area on the Lounge with multilayered music. The second group also received vibration and magnetic stimulation that were synchronized with the music.

Design: Current stress level as well as ratings or feelings of anxiety, tenseness, energy, focus, happiness, relaxation, nervousness, creativeness, and being rested were recorded before and after the session.

Results: Both groups of participants reported equivalent decreased feelings of stress after using the Lounge. Participants receiving the synchronous multilayered music, vibration, and magnetic stimulation did report significantly reduced feelings of tenseness, feeling more relaxed, and feeling more creative when compared with the group that received music only.

Conclusion: Spending 25 minutes in the SolTec™ Lounge with multilayered music is an effective way to reduce self-reported stress in individuals who self-report having a high stress level. If confirmed by future studies, including synchronous vibration and magnetic stimulation with the multilayered music might be an effective stress reduction strategy.
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http://dx.doi.org/10.1177/2164956119892597DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6886274PMC
November 2019

A primary care modification of family-based treatment for adolescent restrictive eating disorders.

Eat Disord 2019 Nov 1:1-14. Epub 2019 Nov 1.

Department of Psychiatry and Psychology, Mayo Clinic School of Medicine, Rochester, MN, USA.

Although eating disorders pose a significant threat to the health and well-being of children and adolescents, due to a profound scarcity of specialty providers, only a small percentage of patients receives evidence-based treatment. To improve access to care for restrictive eating disorders, we developed a modified version of Family-Based Treatment to be delivered by primary care providers (PCPs) and conducted a pilot study to evaluate the feasibility and preliminary outcomes of this intervention. Fifteen adolescents (mean age = 15.5 years) with restrictive eating disorders and their caregiver(s) were enrolled in Family-Based Treatment for Primary Care (FBT-PC), delivered by three trained PCPs. Retention for the intervention was high (n = 13, 86.7%). Over the course of 3 months, participants attended an average of 9.2 (SD = 2.8) sessions and experienced a significant increase in BMI percentile from 39.1 to 54.8 ( (13) = -6.71, < .001; = .61). FBT-PC appears to be feasible for implementation in the primary care setting and has the potential to improve access to treatment and yield positive outcomes for young patients with restrictive eating disorders.
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http://dx.doi.org/10.1080/10640266.2019.1656468DOI Listing
November 2019

GLP-1 Analog Modulates Appetite, Taste Preference, Gut Hormones, and Regional Body Fat Stores in Adults with Obesity.

J Clin Endocrinol Metab 2020 05;105(5)

Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, MN, US.

Purpose: Obesity is associated with alterations in appetite, gastrointestinal hormone levels and excessive fat mass. We previously published a double-blind, placebo-controlled, randomized, 16-week trial on effects of once-daily glucagon-like peptide-1 (GLP-1) analog, liraglutide on weight, satiation, and gastric functions in obese volunteers. The aim of this substudy is to compare to placebo the effects of liraglutide on appetite, taste preference, regional body fat stores, and anthropometric measurements.

Methods: Forty obese adults received standard instruction for weight management, monthly behavioral intervention utilizing motivational interviews, and 16-week treatment of once-daily liraglutide (escalated to 3 mg SQ daily). At baseline and 16 weeks, the following were measured: appetite and taste preferences rated every 30 min for 5 h after ingesting 300 mL Ensure®; maximal tolerated volume (MTV) with a nutrient drink test; fasting and postprandial bioactive GLP-1 (7-36) and peptide YY (PYY) levels; total and regional body fat with dual-energy X-ray absorptiometry, and waist and hip circumference.

Results: Thirty-five participants (17 liraglutide; 18 placebo) completed the trial. Compared to placebo group, liraglutide group had significant reductions in MTV; prospective food consumption score; desire to eat something sweet, salty, savory or fatty; and an increase in perceived fullness. Postprandial plasma levels of GLP-1 decreased and PYY levels increased with liraglutide relative to baseline. Significant reductions in total body, trunk, and upper and lower body fat without reduction in lean body mass were observed.

Conclusion: Liraglutide 3 mg SQ modulates appetite, taste preference, gut hormones, and regional body fat stores in adults with obesity without reduction in lean body mass.
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http://dx.doi.org/10.1210/clinem/dgz140DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7105351PMC
May 2020

Gender Differences in Self-perception of Health at a Wellness Center.

Am J Health Behav 2019 11;43(6):1129-1135

Matthew M. Clark, Mayo Clinic, Department of Psychiatry and Psychology, Rochester, MN.

Understanding gender differences in self-perception of health (SPH) and self-efficacy can inform the design of tailored programs to improve health behaviors. We aimed to assess gender-specific differences in SPH and self-efficacy for maintaining wellness habits at a work-place wellness center. A workplace wellness center member survey was conducted in 2016. Information about SPH and self-efficacy to maintain wellness habits was assessed. Data were analyzed to assess gender differences in SPH and self-efficacy. The survey was completed by 2784 members (mean age, 49.2 years; 68.2% women). SPH was similar between genders despite more men reporting health problems such as hypertension, diabetes, high cholesterol, and cigarette smoking. Women had higher self-efficacy about maintaining healthy diet, but the difference was not clinically meaningful. Women had lower self-efficacy in their ability to maintain physical activity. In this large cohort of worksite wellness center members, men and women had similar self-perception of health despite higher disease burden among men. Women had lower self-efficacy in their ability to maintain physical activity level but similar self-efficacy for maintaining healthy diet. These differences may inform the design of tailored wellness programs to meet the needs of both genders.
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http://dx.doi.org/10.5993/AJHB.43.6.10DOI Listing
November 2019