Emotional Eating is Associated with Intake of Energy-dense Foods in Latinos

Background: Latinos experience profound health disparities in diet-related chronic conditions. Emotional eating (EE) has been positively associated with such conditions, however, little is known about the relationship between EE and energy-dense food intake that may influence risk for developing these conditions. Objective: To examine associations between EE and energy-dense food intake in Latino men and women. Methods: Latino individuals were recruited from a community health center in Lawrence, MA. Participants completed standardized assessments. EE was measured with the Three Factor Eating Behavior Questionnaire R18-V2. Dietary intake was measured with a culturally tailored Food Frequency Questionnaire. Energy-dense food groups defined as food groups exceeding 225calories per 100 grams were identified. Covariates considered in this analysis included: age, sex, education, employment status and BMI. Statistical analysis consisted of multivariable logistic regression. Results: A total of 201 participants were included in this analysis (53.7% female, 68.1% Dominicans). After adjusting for covariates, EE was significantly associated with high intake of sweet and/or fatty foods, namely dairy desserts (i.e., ice-cream, sherbet and frozen yogurt) (OR=1.55; 95%CI=1.08, 2.21; p=0.017), oleaginous fruits (i.e., nuts and seeds) (OR=1.44; 95%CI=1.01, 2.05; p=0.046) and baked goods (i.e., cakes, cookies, pies, doughnuts and muffins) (OR=1.54; 95%CI=1.07, 2.20; p=0.020). Conclusion: EE was positively associated with consumption of energy-dense foods in this Latino sample. Future studies should examine longitudinal associations between EE, intake of energy-dense foods and risk of chronic health conditions. Understanding these associations can unveil potential intervention targets for Latinos at high risk of diet-related chronic health conditions. Also presented at the Experimental Biology 2017 Annual Conference, Chicago, IL

Association of dysfunctional eating with metabolic risk factors for cardiovascular disease in Latinos

Background: Latinos bear high burden of nutrition related cardiovascular disease (CVD) risk factors. Dysfunctional eating behaviors (emotional eating, uncontrolled eating and cognitive restraint of eating) may influence metabolic CVD risk factors but little is known about this relationship in Latinos. Objective: To examine associations between dysfunctional eating behaviors and metabolic risk factors for CVD in Latinos. Methods: Latino individuals were recruited from a community health center. Participants completed standardized interviews (i.e., demographics, Three Factor Eating Questionnaire-TFEQ-R18V2, Perceived Stress Scale-10) and anthropometric measurements. Data on diagnosis of type 2 diabetes, hypertension and hyperlipidemia were abstracted from medical records. Statistical analysis included multivariable logistic and Poisson regression models. Results: A total of 578 participants (51% female, 67% Dominican), ages 21-84, were included in this analysis. Controlling for age, sex, education and perceived stress high emotional eating (hEE) was associated with greater odds of obesity (OR=2.25 (1.47, 3.24)) and diabetes (OR=1.80 (1.07, 3.01)). High uncontrolled eating (hUE) was associated with obesity (OR=2.16 (1.34, 3.47)) and high cognitive restraint (hCR) was associated with greater odds of obesity (OR=2.55 (1.64, 3.98)), diabetes (OR=2.39 (1.40, 4.04) and hyperlipidemia (OR=1.92 (1.17, 3.14)). Lastly, hEE, hUE and hCR were significantly associated increased odds of having a greater number of the metabolic CVD risk factors (IRR=1.39 (1.20, 1.59), IRR=1.21 (1.04, 1.42), IRR=1.45 (1.24, 1.69); respectively). Conclusion: Interventions that target eating behaviors may facilitate reduction of metabolic CVD risk factors and health disparities in CVD among Latinos

Healthy Eating and Physical Activity Policy, Systems, and Environmental Strategies: A Content Analysis of Community Health Improvement Plans

Background: Policy, systems, and environmental (PSE) approaches can sustainably improve healthy eating (HE) and physical activity (PA) but are challenging to implement. Community health improvement plans (CHIPs) represent a strategic opportunity to advance PSEs but have not been adequately researched. The objective of this study was to describe types of HE and PA strategies included in CHIPs and assess strategies designed to facilitate successful PSE-change using an established framework that identifies six key activities to catalyze change. Methods: A content analysis was conducted of 75 CHIP documents containing HE and/or PA PSE strategies, which represented communities that were identified from responses to a national probability sample of US local health departments ( \u3c 500,000 residents). Each HE/PA PSE strategy was assessed for alignment with six key activities that facilitate PSE-change (identifying and framing the problem, engaging and educating key people, identifying PSE solutions, utilizing available evidence, assessing social and political environment, and building support and political will). Multilevel latent class analyses were conducted to identify classes of CHIPs based on HE/PA PSE strategy alignment with key activities. Analyses were conducted separately for CHIPs containing HE and PA PSE strategies. Results: Two classes of CHIPs with PSE strategies emerged from the HE (n = 40 CHIPs) and PA (n = 43 CHIPs) multilevel latent class analyses. More CHIPs were grouped in Class A (HE: 75%; PA: 79%), which were characterized by PSE strategies that simply identified a PSE solution. Fewer CHIPs were grouped in Class B (HE: 25%; PA: 21%), and these mostly included PSE strategies that comprehensively addressed multiple key activities for PSE-change. Conclusions: Few CHIPs containing PSE strategies addressed multiple key activities for PSE-change. Efforts to enhance collaborations with important decision-makers and community capacity to engage in a range of key activities are warranted

Healthy Eating Policy Strategies in Community Health Improvement Plans: A Cross-Sectional Survey of US Local Health Departments

CONTEXT: Policies (eg, regulations, taxes, and zoning ordinances) can increase opportunities for healthy eating. Community Health Improvement Plans (CHIP) may foster collaboration and local health department (LHD) engagement in policy decision making to improve local food environments. Limited research describes what policies supportive of healthy food environments are included in CHIPs nationally and relationships between LHD characteristics and participation in plans including such policies. OBJECTIVES: To determine the proportion of US LHDs who participated in development of a CHIP containing healthy eating policy strategies and assess the association between LHD characteristics and inclusion of any healthy eating policy strategy in a CHIP. DESIGN: A cross-sectional national probability survey. PARTICIPANTS: Of the 209 US LHDs (serving populations \u3c 500 000) (response rate: 30.2%), 176 LHDs with complete data on CHIP status, outcomes, and covariates were eligible for analysis. MAIN OUTCOME MEASURES: Thirteen healthy eating policy strategies were organized into 3 categories: increasing availability/identification of healthy foods, reducing access to unhealthy foods, and improving school food environments. Strategies and categories were identified from literature and public health recommendations. RESULTS: In total, 32.2% of LHDs reported inclusion of 1 or more healthy eating policy strategies in a CHIP. The proportion of departments reporting specific strategies ranged from 20.8% for school district policies to 1.1% for sugar-sweetened beverage taxes. Local health departments serving 25 000 to 49 999 residents (odds ratio [OR]: 5.00; 95% confidence interval [CI]: 1.71-14.63), 100 000 to 499 999 residents (OR: 3.66; 95% CI: 1.12-11.95), pursuing national accreditation (OR: 4.46; 95% CI: 1.83-10.83), or accredited (OR: 3.22; 95% CI: 1.08-9.63) were more likely to include 1 or more healthy eating policy strategies in a CHIP than smaller LHDs ( \u3c 25 000) and LHDs not seeking accreditation, respectively, after adjusting for covariates. CONCLUSIONS: Few LHDs serving less than 500 000 residents reported CHIPs that included a policy-based approach to improve food environments, indicating room for improvement. Population size served and accreditation may affect LHD policy engagement to enhance local food environments

Marginal structural models for the estimation of the risk of Diabetes Mellitus in the presence of elevated depressive symptoms and antidepressant medication use in the Women\u27s Health Initiative observational and clinical trial cohorts

BACKGROUND: We evaluate the combined effect of the presence of elevated depressive symptoms and antidepressant medication use with respect to risk of type 2 diabetes among approximately 120,000 women enrolled in the Women\u27s Health Initiative (WHI), and compare several different statistical models appropriate for causal inference in non-randomized settings. METHODS: Data were analyzed for 52,326 women in the Women\u27s Health Initiative Clinical Trials (CT) Cohort and 68,169 women in the Observational Study (OS) Cohort after exclusions. We included follow-up to 2005, resulting in a median duration of 7.6 years of follow up after enrollment. Results from three multivariable Cox models were compared to those from marginal structural models that included time varying measures of antidepressant medication use, presence of elevated depressive symptoms and BMI, while adjusting for potential confounders including age, ethnicity, education, minutes of recreational physical activity per week, total energy intake, hormone therapy use, family history of diabetes and smoking status. RESULTS: Our results are consistent with previous studies examining the relationship of antidepressant medication use and risk of type 2 diabetes. All models showed a significant increase in diabetes risk for those taking antidepressants. The Cox Proportional Hazards models using baseline covariates showed the lowest increase in risk , with hazard ratios of 1.19 (95 % CI 1.06 - 1.35) and 1.14 (95 % CI 1.01 - 1.30) in the OS and CT, respectively. Hazard ratios from marginal structural models comparing antidepressant users to non-users were 1.35 (95 % CI 1.21 - 1.51) and 1.27 (95 % CI 1.13 - 1.43) in the WHI OS and CT, respectively - however, differences among estimates from traditional Cox models and marginal structural models were not statistically significant in both cohorts. One explanation suggests that time-dependent confounding was not a substantial factor in these data, however other explanations exist. Unadjusted Cox Proportional Hazards models showed that women with elevated depressive symptoms had a significant increase in diabetes risk that remained after adjustment for confounders. However, this association missed the threshold for statistical significance in propensity score adjusted and marginal structural models. CONCLUSIONS: Results from the multiple approaches provide further evidence of an increase in risk of type 2 diabetes for those on antidepressants

Gender Differences in Indoor Tanning Habits and Location

To the Editor, In 2013, 1.9 million US men reported tanning indoors. Existing research largely target teen and young adult female tanners, and less is known about male tanning behavior. Using Survey Sampling International, we recruited a nationally representative sample of 773 adults who intend to use or used an indoor tanning bed. Participants reporting a lifetime history of tanning indoors (n=636; 33.5% male) were included...

Racial/ethnic representation in lifestyle weight loss intervention studies in the United States: A systematic review

Obesity remains a persistent public health and health disparity concern in the United States. Eliminating health disparities, particularly among racial/ethnic minority groups, is a major health priority in the US. The primary aim of this review was to evaluate representation of racial/ethnic sub-group members in behavioral weight loss interventions conducted among adults in the United States. The secondary aims were to assess recruitment and study design approaches to include racial/ethnic groups and the extent of racial/ethnic sub-group analyses conducted in these studies. PubMed, PsycInfo, Medline, and CINAHL were searched for behavioral weight loss intervention trials conducted in 2009-2015 using keywords: weight, loss, overweight, obese, intervention and trial. Most of the 94 studies included a majority of White participants compared to any other racial/ethnic group. Across the included studies, 58.9% of participants were White, 18.2% were African American, 8.7% were Hispanic/Latino, 5.0% were Asian and 1.0% were Native Americans. An additional 8.2% were categorized as Other . Nine of the 94 studies exclusively included minority samples. Lack of adequate representation of racial and ethnic minority populations in behavioral trials limits the generalizability and potential public health impact of these interventions to groups that might most benefit from weight loss. Given racial/ethnic disparities in obesity rates and the burden of obesity and obesity-related diseases among minority groups in the United States, greater inclusion in weight loss intervention studies is warranted

Exposure to Weight Management Counseling Among Students at 8 U.S. Medical Schools

INTRODUCTION: Clinical guidelines support physician intervention consistent with the Ask, Advise, Assess, Assist, Arrange framework for adults who have obesity. However, weight management counseling curricula vary across medical schools. It is unknown how frequently students receive experiences in weight management counseling, such as instruction, observation, and direct experience. METHODS: A cross-sectional survey, conducted in 2017, of 730 third-year medical students in 8 U.S. medical schools assessed the frequency of direct patient, observational, and instructional weight management counseling experiences that were reported as summed scores with a range of 018. Analysis was completed in 2017. RESULTS: Students reported the least experience with receiving instruction (6.5, SD=3.9), followed by direct patient experience (8.6, SD=4.8) and observational experiences (10.3, SD=5.0). During the preclinical years, 79% of students reported a total of \u3c /=3 hours of combined weight management counseling instruction in the classroom, clinic, doctor\u27s office, or hospital. The majority of the students (59%-76%) reported never receiving skills-based instruction for weight management counseling. Of the Ask, Advise, Assess, Assist, Arrange framework, scores were lowest for assisting the patient to achieve their agreed-upon goals (31%) and arranging follow-up contact (22%). CONCLUSIONS: Overall exposure to weight management counseling was less than optimal. Medical school educators can work toward developing a more coordinated approach to weight management counseling. Inc

Teaching Medical Students to Help Patients Manage Their Weight: Outcomes of an Eight-School Randomized Controlled Trial

BACKGROUND: Given the rising rates of obesity there is a pressing need for medical schools to better prepare students for intervening with patients who have overweight or obesity and for prevention efforts. OBJECTIVE: To assess the effect of a multi-modal weight management curriculum on counseling skills for health behavior change. DESIGN: A pair-matched, group-randomized controlled trial (2015-2020) included students enrolled in eight U.S. medical schools randomized to receive either multi-modal weight management education (MME) or traditional weight management education (TE). SETTING/PARTICIPANTS: Students from the class of 2020 (N=1305) were asked to participate in an objective structured clinical examination (OSCE) focused on weight management counseling and complete pre and post surveys. A total of 70.1% of eligible students (N=915) completed the OSCE and 69.3% (N=904) completed both surveys. INTERVENTIONS: The MME implemented over three years included a web-based course, a role-play classroom exercise, a web-patient encounter with feedback, and an enhanced clerkship experience with preceptors trained in weight management counseling (WMC). Counseling focused on the 5As (Ask, Advise, Assess, Assist, Arrange) and patient-centeredness. MEASUREMENTS: The outcome was student 5As WMC skills assessed using an objective measure, an OSCE, scored using a behavior checklist, and a subjective measure, student self-reported skills for performing the 5As. RESULTS: Among MME students who completed two of three WMC components compared to those who completed none, exposure was significantly associated with higher OSCE scores and self-reported 5A skills. LIMITATIONS: Variability in medical schools requiring participation in the WMC curriculum. CONCLUSIONS: This trial revealed that medical students struggle with delivering weight management counseling to their patients who have overweight or obesity. Medical schools, though restrained in adding curricula, should incorporate should incorporate multiple WMC curricula components early in medical student education to provide knowledge and build confidence for supporting patients in developing individualized plans for weight management. NIH TRIAL REGISTRY NUMBER: R01-194787

Evaluation of a Train-the-trainer Program to Build Capacity for Training Tobacco Treatment Specialists

Introduction: Tobacco treatment specialists (TTSs) and high quality TTS training programs are needed to improve access to evidence-based tobacco dependence treatment. To meet this demand, the University of Massachusetts (UMass) Medical School developed the Train the Trainer in Tobacco Treatment (T4) program to build a cadre of trainers to deliver the accredited UMass TTS training programs. This paper reports on the feasibility and quality of TTS trainings led by Certified UMass TTS Trainers (Trainer-led) compared with trainings led by UMass staff (On-site). Methods: Data were collected between September 2014 and June 2017. Feasibility included the number of Trainers, Trainer-led programs and participants. Quality compared participant exam results and evaluations of the two training program types. Results: Fifty-three Trainers were certified during 2014-2017, and conducted 26 TTS trainings with 351 participants. There were no significant differences in participant mean exam scores [On-site=86.33 (SD=7.83); Trainer-led=86.15 (SD=8.47)], and a similar percentage of participants obtained a passing score on the exam (On-site 94.4%, Trainer-led 94.0%). There were no significant differences in increased self-efficacy in delivering effective tobacco treatment services [On-site=2.92, Trainer-led=2.93; p=0.52 (3-point Likert scale, 1=not at all, 3=a great deal)] or in overall satisfaction with the training [On-site=3.84; Trainer-led=3.81; p=.072 (4-point Likert scale, 1=very dissatisfied, 4=very satisfied)]. Conclusions: The Trainer-led model expanded the number of UMass-trained TTSs with equivalent participant knowledge and perceived improvement in ability to deliver effective tobacco dependence treatment compared to the gold-standard training model. It offers a potentially more accessible option for training TTSs compared to the On-site model. Implications: Train the Trainer in Tobacco Treatment (T4) has increased the capacity to deliver high quality training to healthcare providers who might not otherwise have access to an accredited Tobacco Treatment Specialist training program. Certified Trainers effectively identified potential participants and delivered training that was equivalent in quality to the standard UMass TTS Core Training program. There were no significant differences between the training models in two critical measures: 1) participant exam scores, and 2) participants\u27 rating of improvement in their ability to deliver effective tobacco dependence treatment. Organizations can now choose from two equally effective models for delivering TTS training based on their unique needs and training populations