Issues in evaluating the costs and cost-effectiveness of Cognitive Behavioural Therapy for overweight/obese adolescents, CHERE Working Paper 2009/1

Economic evaluation is the systematic assessment of the costs and consequences of alternative courses of action. In health and healthcare, the results can be used to inform clinicians and policy makers about the relative cost-effectiveness of options under consideration [1]. Many economic evaluations are undertaken alongside randomised controlled trials (RCTs); the advantages of this approach are that i) prospective, accurate data can be collected on costs and effects and ii) appropriate outcome measures for use in economic evaluation can be chosen. The outcome of an economic evaluation is usually described as a ratio of the costs and effects ? often called the incremental cost-effectiveness ratio (ICER). The ICER is determined by calculating the differences in the costs and effects of both intervention and control groups and dividing the former by the latter. In designing an economic evaluation, the important questions to resolve are: which costs should be included and which outcome measures are most appropriate for estimating the cost-effectiveness ratio? In 2005, the Australian Technology Network of Universities funded the Centre for Metabolic Fitness (CMF) through a competitive, peer-reviewed process. The aims of the centre are to develop and evaluate diet and exercise interventions to counteract metabolic syndrome and assess their acceptability by target community groups. Metabolic syndrome is a cluster of metabolically determined risk factors associated with obesity (e.g. hypertension, impaired blood glucose etc). A number of collaborative projects have been developed within the centre, one of which is the CHOOSE HEALTH project. As part of this project, the effectiveness of cognitive behavioural therapy (CBT) as an intervention for overweight or obese adolescents has been trialled at the University of RMIT by Leah Brennan and the University of South Australia by Margarita Tsiros, as part of their post-graduate studies1. Subsequently, it has been decided to add an economic component to this work. Trials of the effectiveness and cost-effectiveness of different means of delivering cognitive behaviourally based weight management programs are planned2. This paper reports the results of investigations into the two questions which need to be addressed prior to undertaking a formal economic evaluation of the CHOOSE HEALTH program: i) what costs should be included and ii) which measures of outcome are suitable for estimating an ICER in this context. The paper is organised in four sections. Following the introduction (section 1) and brief descriptions of the background to and context in which the program was planned (section 2), details of the RMIT trial design and results are provided in section 3. In the final section (section 4), a cost model is presented and the implications of the outcomes used in the initial trials of the effectiveness are discussed in relation to designing a prospective economic evaluation of the CHOOSE HEALTH program.costs, economic evaluation, cognitive behavioural therapy (CBT), adolescent obesity, Australia

Psychometric evaluation of disordered eating measures in bariatric surgery candidates

Introduction: Assessment of disordered eating is common in bariatric surgery candidates, yet psychometric properties of disordered eating measures in this population are largely unknown. Methods: Measures were completed by 405 adult bariatric surgery candidates at pre-surgical consultation. Fit of the original scale structures was tested using confirmatory factor analysis (CFA) and alternative factor solutions were generated using exploratory factor analysis (EFA). Reliability (internal consistency), construct validity (convergent and divergent) and criterion validity (with the EDE as criterion) were assessed. Materials: The measures prioritised for evaluation are the following: Eating Disorder Examination Questionnaire (EDE-Q; n = 405), Three-Factor EatingQuestionnaire (TFEQ; n = 405), Questionnaire of Eating and Weight Patterns Revised (QEWP-R; n = 204), Clinical Impairment Assessment (CIA; n = 204) and the Eating Disorder Examination clinical interview (EDE; n = 131). Results: CFA revealed adequate fit for only the CIA in its current form (CFI = 0.925, RMSEA = 0.096). EFA produced revised scales with improved reliability for the EDE, EDE-Q and TFEQ. Reliability of revised subscales was improved (original scales α = 0.43–0.82; revised scales α = 0.67–0.93). Correlational analyses of the CIA and revised versions of remaining scales with measures of psychological wellbeing and impairment revealed adequate convergent validity. All measures differentiated an EDE-classified disordered eating group from a non-disordered eating group (criterion validity). Diagnostic concordance between the EDE, EDE-Q and QEWP-R was low, and identification of disordered eating behaviours was inconsistent across measures. Conclusions: Findings highlight the limitations of existing disordered eating questionnaires in bariatric surgery candidates. Results suggest revised assessments are required to overcome these limitations and ensure that measures informing clinical recommendations regarding patient care are reliable and valid

Internalised weight stigma mediates relationships between perceived weight stigma and psychosocial correlates in individuals seeking bariatric surgery : A cross-sectional study

Purpose Research suggests that internalised weight stigma may explain the relationship between perceived weight stigma and adverse psychological correlates (e.g. depression, disordered eating, body image disturbances). However, few studies have assessed this mechanism in individuals seeking bariatric surgery, even though depression and disordered eating are more common in this group than the general population. Materials and Methods We used data from a cross-sectional study with individuals seeking bariatric surgery (n = 217; 73.6% female) from Melbourne, Australia. Participants (Mage = 44.1 years, SD = 11.9; MBMI = 43.1, SD = 7.9) completed a battery of self-report measures on weight stigma and biopsychosocial variables, prior to their procedures. Bias-corrected bootstrapped mediations were used to test the mediating role of internalised weight stigma. Significance thresholds were statistically corrected to reduce the risk of Type I error due to the large number of mediation tests conducted. Results Controlling for BMI, internalised weight stigma mediated the relationship between perceived weight stigma and psychological quality of life, symptoms of depression and anxiety, stress, adverse coping behaviours, self-esteem, exercise avoidance, some disordered eating measures and body image subscales, but not physical quality of life or pain. Conclusion Although the findings are cross-sectional, they are mostly consistent with previous research in other cohorts and provide partial support for theoretical models of weight stigma. Interventions addressing internalised weight stigma may be a useful tool for clinicians to reduce the negative correlates associated with weight stigma

Sea anemone model has a single Toll-like receptor that can function in pathogen detection, NF-κB signal transduction, and development

In organisms from insects to vertebrates, Toll-like receptors (TLRs) are primary pathogen detectors that activate downstream pathways, specifically those that direct expression of innate immune effector genes. TLRs also have roles in development in many species. The sea anemone Nematostella vectensis is a useful cnidarian model to study the origins of TLR signaling because its genome encodes a single TLR and homologs of many downstream signaling components, including the NF-κB pathway. We have characterized the single N. vectensis TLR (Nv-TLR) and demonstrated that it can activate canonical NF-κB signaling in human cells. Furthermore, we show that the intracellular Toll/IL-1 receptor (TIR) domain of Nv-TLR can interact with the human TLR adapter proteins MAL and MYD88. We demonstrate that the coral pathogen Vibrio coralliilyticus causes a rapidly lethal disease in N. vectensis and that heat-inactivated V. coralliilyticus and bacterial flagellin can activate a reconstituted Nv-TLR–to–NF-κB pathway in human cells. By immunostaining of anemones, we show that Nv-TLR is expressed in a subset of cnidocytes and that many of these Nv-TLR–expressing cells also express Nv-NF-κB. Additionally, the nematosome, which is a Nematostella-specific multicellular structure, expresses Nv-TLR and many innate immune pathway homologs and can engulf V. coralliilyticus. Morpholino knockdown indicates that Nv-TLR also has an essential role during early embryonic development. Our characterization of this primitive TLR and identification of a bacterial pathogen for N. vectensis reveal ancient TLR functions and provide a model for studying the molecular basis of cnidarian disease and immunity.IOS-1354935 - National Science Foundation (NSF); GRFP - National Science Foundation (NSF); GRFP - National Science Foundation (NSF); 1262934 - National Science Foundation (NSF); 2014-BSP - Arnold and Mabel Beckman Foundatio

A cluster randomised controlled trial of a telephone-based intervention targeting the home food environment of preschoolers (The Healthy Habits Trial): the effect on parent fruit and vegetable consumption

AbstractBackground: The home food environment is an important setting for the development of dietary patterns in childhood. Interventions that support parents to modify the home food environment for their children, however, may also improve parent diet. The purpose of this study was to assess the impact of a telephone-based intervention targeting the home food environment of preschool children on the fruit and vegetable consumption of parents.Methods: In 2010, 394 parents of 3 &ndash; 5 year &ndash; old children from 30 preschools in the Hunter region of Australia were recruited to this cluster randomised controlled trial and were randomly assigned to an intervention or control group. Intervention group parents received four weekly 30-minute telephone calls and written resources. The scripted calls focused on; fruit and vegetable availability and accessibility, parental role-modelling, and supportive home food routines. Two items from the Australian National Nutrition Survey were used to assess the average number of serves of fruit and vegetables consumed each day by parents at baseline, and 2-, 6-, 12-, and 18-months later, using generalised estimating equations (adjusted for baseline values and clustering by preschool) and an intention-to-treat-approach.Results: At each follow-up, vegetable consumption among intervention parents significantly exceeded that of controls. At 2-months the difference was 0.71 serves (95% CI: 0.58-0.85, p &lt; 0.0001), and at 18-months the difference was 0.36 serves (95% CI: 0.10-0.61, p = 0.0067). Fruit consumption among intervention parents was found to significantly exceed consumption of control parents at the 2-,12- and 18-month follow-up, with the difference at 2-months being 0.26 serves (95% CI: 0.12-0.40, p = 0.0003), and 0.26 serves maintained at 18-months, (95% CI: 0.10-0.43, p = 0.0015).Conclusions: A four-contact telephone-based intervention that focuses on changing characteristics of preschoolers&rsquo; home food environment can increase parents&rsquo; fruit and vegetable consumption.(ANZCTR12609000820202)<br /

Development of a measure of barriers to laparoscopic adjustable gastric banding (LAGB) aftercare attendance

Background: Regular aftercare attendance following laparoscopic adjustable gastric banding (LAGB) is associated with greater weight loss and fewer post-surgical complications. Despite high reported rates of attrition from LAGB aftercare, the reasons for non-attendance have not been thoroughly explored. The aim of the current study was to describe the scale development, explore the factor structure and evaluate the psychometric properties of the Gastric Banding Aftercare Attendance Questionnaire (GBAAQ)—a tool that measures barriers to aftercare attendance in LAGB patients. Methods: One hundred and eighty-three participants completed the GBAAQ; 107 regular attendees and 76 non-attendees. Results: A factor analysis identified four factors (Treatment Approach, Time Constraints, Stress and Pressures, Uncomfortable Participating) that demonstrated good known-groups validity and internal consistency. Conclusions: Although further validation is needed, the results of the present study provide preliminary support for the validity of the GBAAQ. Knowledge about the barriers to LAGB aftercare attendance can be used to identify those most at risk of non-attendance and can inform strategies aimed at reducing non-attendance

A Systematic Review of Ecological Momentary Assessment Studies on Weight Stigma and a Call for a Large Scale Collaboration

Background Weight stigma is associated with poor mental health correlates in cross-sectional research. Researchers are increasingly using Ecological Momentary Assessment (EMA) methods, collecting comprehensive within-person data to understand the temporal nature of weight stigma and its biopsychosocial correlates. Aim To systematically review EMA studies on the effect of weight stigma on biopsychosocial correlates and integrate the findings. Method PsycINFO, CINAHL, Embase, Medline Complete, and Web of Science were searched and studies were doubled screened (H.B. and X.P.G.). Results Twelve studies (N = 615) met our inclusion criteria. For both between- and within-subject effects, experienced and internalized weight stigmas were associated with negative correlates/outcomes (e.g., higher disordered eating and lower positive mood). However, studies differed in the correlate measures assessed, EMA methods used, and participant instructions provided. Given these inconsistencies, comparison across studies was difficult, and findings could not be reliably integrated. Conclusions Consistent with previous research, studies from this review suggest weight stigma leads to adverse outcomes. EMA has the potential to overcome many of the limitations present in cross-sectional research on weight stigma and provide more ecologically valid and reliable results. We argue for a collaborative data-sharing consortium with standardized EMA methodologies, so researchers worldwide can contribute to and make use of a large, collective dataset on weight stigma and health correlates (see osf.io/s5ru6/)

Patient and parent perspectives of adolescent Laparoscopic Adjustable Gastric Banding (LAGB)

Introduction Adolescent obesity is a significant global health challenge and severely obese adolescents commonly experience serious medical and psychosocial challenges. Consequently, severe adolescent obesity is increasingly being treated surgically. The limited available research examining the effectiveness of adolescent bariatric surgery focuses primarily on bio-medical outcomes. There is a need for a more comprehensive understanding of the behavioural, emotional and social factors which affect adolescents’ and parents’ experience of weight-loss surgery. Materials/Methods Patient and parents’ perspectives of adolescent LAGB were examined using a qualitative research methodology. Individual, semi-structured interviews were conducted with eight adolescent patients and five parents. Thematic analysis was used to identify key themes in the qualitative data. Results Patients and parents generally considered adolescent LAGB to be a life-changing experience, resulting in physical and mental health benefits. Factors considered to facilitate weight-loss following surgery included parental support and adherence to treatment guidelines. Many adolescents reported experiencing surgical weight-loss stigma and challenging interpersonal outcomes after weight-loss for which they felt unprepared. Conclusion Patients and parents perceived LAGB positively. There are opportunities to improve both the experience and outcomes of adolescent LAGB through parental education and enhancements to surgical aftercare programs

Pupil Cycle Time Distinguishes Migraineurs From Subjects Without Headache

Migraine is a neurological disorder characterized by paroxysms of head pain accompanied by trigeminovascular system activation and autonomic dysfunction. Diagnosis is currently based on clinical diagnostic criteria. Though physiological differences exist between migraineurs and non-headache controls, true physiological biomarkers have been elusive, especially for the full clinical spectrum of migraine, inclusive of chronic, episodic, and probable migraine. We used edge-light pupil cycle time (PCT) as a probe of the pupillary light circuit in migraine, paired with clinical assessment of migraine characteristics, and compared these to non-headache controls. We found significantly increased PCT in probable, episodic, and chronic migraine, compared to controls. Additionally, increased PCT correlated with the presence of craniofacial autonomic symptoms, linking pupillary circuit dysfunction to peripheral trigeminal sensitization. The sensitivity of PCT, especially for all severities of disease, distinguishes it from other physiological phenotypes, which may make it useful as a potential biomarker

Psychiatric and medical comorbidities of eating disorders : findings from a rapid review of the literature

Background: Eating disorders (EDs) are potentially severe, complex, and life-threatening illnesses. The mortality rate of EDs is signifcantly elevated compared to other psychiatric conditions, primarily due to medical complications and suicide. The current rapid review aimed to summarise the literature and identify gaps in knowledge relating to any psychiatric and medical comorbidities of eating disorders. Methods: This paper forms part of a rapid review) series scoping the evidence base for the feld of EDs, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021–2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for English-language studies focused on the psychiatric and medical comorbidities of EDs, published between 2009 and 2021. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised. Results: A total of 202 studies were included in this review, with 58% pertaining to psychiatric comorbidities and 42% to medical comorbidities. For EDs in general, the most prevalent psychiatric comorbidities were anxiety (up to 62%), mood (up to 54%) and substance use and post-traumatic stress disorders (similar comorbidity rates up to 27%). The review also noted associations between specifc EDs and non-suicidal self-injury, personality disorders, and neurodevelopmental disorders. EDs were complicated by medical comorbidities across the neuroendocrine, skeletal, nutritional, gastrointestinal, dental, and reproductive systems. Medical comorbidities can precede, occur alongside or emerge as a complication of the ED. Conclusions: This review provides a thorough overview of the comorbid psychiatric and medical conditions cooccurring with EDs. High psychiatric and medical comorbidity rates were observed in people with EDs, with comorbidities contributing to increased ED symptom severity, maintenance of some ED behaviours, and poorer functioning as well as treatment outcomes. Early identifcation and management of psychiatric and medical comorbidities in people with an ED may improve response to treatment and overall outcomes