Goal-directed versus outcome-based financial incentives for weight loss among low-income patients with obesity: rationale and design of the Financial Incentives foR Weight Reduction (FIReWoRk) randomised controlled trial.

IntroductionObesity is a major public health challenge and exacerbates economic disparities through employment discrimination and increased personal health expenditures. Financial incentives for weight management may intensify individuals' utilisation of evidence-based behavioural strategies while addressing obesity-related economic disparities in low-income populations. Trials have focused on testing incentives contingent on achieving weight loss outcomes. However, based on social cognitive and self-determination theories, providing incentives for achieving intermediate behavioural goals may be more sustainable than incentivising outcomes if they enhance an individual's skills and self-efficacy for maintaining long-term weight loss. The objective of this paper is to describe the rationale and design of the Financial Incentives foR Weight Reduction study, a randomised controlled trial to test the comparative effectiveness and cost-effectiveness of two financial incentive strategies for weight loss (goal directed vs outcome based) among low-income adults with obesity, as well as compared with the provision of health behaviour change resources alone.Methods and analysisWe are recruiting 795 adults, aged 18-70 years with a body mass index ≥30 kg/m2, from three primary care clinics serving residents of socioeconomically disadvantaged neighbourhoods in New York City and Los Angeles. All participants receive a 1-year commercial weight loss programme membership, self-monitoring tools (bathroom scale, food journal and Fitbit Alta HR), health education and monthly check-in visits. In addition to these resources, those in the two intervention groups can earn up to $750 over 6 months for: (1) participating in an intensive weight management programme, self-monitoring weight and diet and meeting physical activity guidelines (goal-directed arm); or (2) a ≥1.5% to ≥5% reduction in baseline weight (outcome-based arm). To maximise incentive efficacy, we incorporate concepts from behavioural economics, including immediacy of payments and framing feedback to elicit regret aversion. We will use generalised mixed effect models for repeated measures to examine intervention effects on weight at 6, 9 and 12 months.Ethics and disseminationHuman research protection committees at New York University School of Medicine, University of California Los Angeles (UCLA) David Geffen School of Medicine and Olive-View-UCLA Medical Center granted ethics approval. We will disseminate the results of this research via peer-reviewed publications, conference presentations and meetings with stakeholders.Trial registration numberNCT03157713

Examining the moderating role of demographic factors and depressive symptoms in direct and indirect associations between the objective and perceived neighborhood environment and physical activity in three U.S. populations

Over the past twenty years, social ecological models have informed physical activity and public health research and practice. Social ecological models conceptualize individual, social, and environmental influences that operate in combination to affect health behaviors such as physical activity. Evidence is consistent that individual and interpersonal factors, as well as features of the neighborhood built environment (e.g., recreation facilities and trails) are associated with physical activity. Based on limited recent evidence, the perceived neighborhood environment appears to mediate associations between the objective built environment and physical activity. Multilevel correlates of physical activity can also interact across levels of influence within the social ecological framework (e.g., individual and environmental). For instance, psychosocial factors such as depressive symptoms may moderate associations between the objective and perceived neighborhood environment and physical activity. The purpose of this dissertation research was to examine associations between individual, social, and environmental factors and physical activity among three populations residing in the United States (U.S.), test whether the perceived neighborhood environment mediated associations between the objective built environment and physical activity, and assess the extent to which these direct and indirect associations were moderated by demographic factors and depressive symptoms. In Study 1, adults (N=1,195, mean age 44.9±12.5 years, 55.3% female, and 82.0% White) using one of five trails in Massachusetts responded to an intercept survey. Multiple linear and logistic regression were used to examine associations between individual, social, and environmental factors and trail use for recreation and transportation. Age (longer-term users only), trail use with others, travel time to the trail, and trail design were significantly associated with use for recreation (p<.05). Age, gender, trail safety (longer-term users only), travel time to the trail, trail design (younger users only), and trail beauty were associated with use for transportation (p<.05). (Abstract shortened by ProQuest.

Examining the moderating role of demographic factors and depressive symptoms in direct and indirect associations between the objective and perceived neighborhood environment and physical activity in three U.S. populations

Over the past twenty years, social ecological models have informed physical activity and public health research and practice. Social ecological models conceptualize individual, social, and environmental influences that operate in combination to affect health behaviors such as physical activity. Evidence is consistent that individual and interpersonal factors, as well as features of the neighborhood built environment (e.g., recreation facilities and trails) are associated with physical activity. Based on limited recent evidence, the perceived neighborhood environment appears to mediate associations between the objective built environment and physical activity. Multilevel correlates of physical activity can also interact across levels of influence within the social ecological framework (e.g., individual and environmental). For instance, psychosocial factors such as depressive symptoms may moderate associations between the objective and perceived neighborhood environment and physical activity. The purpose of this dissertation research was to examine associations between individual, social, and environmental factors and physical activity among three populations residing in the United States (U.S.), test whether the perceived neighborhood environment mediated associations between the objective built environment and physical activity, and assess the extent to which these direct and indirect associations were moderated by demographic factors and depressive symptoms. In Study 1, adults (N=1,195, mean age 44.9±12.5 years, 55.3% female, and 82.0% White) using one of five trails in Massachusetts responded to an intercept survey. Multiple linear and logistic regression were used to examine associations between individual, social, and environmental factors and trail use for recreation and transportation. Age (longer-term users only), trail use with others, travel time to the trail, and trail design were significantly associated with use for recreation (p\u3c.05). Age, gender, trail safety (longer-term users only), travel time to the trail, trail design (younger users only), and trail beauty were associated with use for transportation (p\u3c.05). (Abstract shortened by ProQuest.

Defining Valid Activity Monitor Data: A Multimethod Analysis of Weight-Loss Intervention Participants’ Barriers to Wear and First 100 Days of Physical Activity

Despite the popularity of commercially available wearable activity monitors (WAMs), there is a paucity of consistent methodology for analyzing large amounts of accelerometer data from these devices. This multimethod study aimed to inform appropriate Fitbit wear thresholds for physical activity (PA) outcomes assessment in a sample of 616 low-income, majority Latina patients with obesity enrolled in a behavioral weight-loss intervention. Secondly, this study aimed to understand intervention participants’ barriers to Fitbit use. We applied a heart rate (HR) criterion (≥10 h/day) and a step count (SC) criterion (≥1000 steps/day) to 100 days of continuous activity monitor data. We examined the prevalence of valid wear and PA outcomes between analytic subgroups of participants who met the HR criterion, SC criterion, or both. We undertook qualitative analysis of research staff notes and participant interviews to explore barriers to valid Fitbit data collection. Overall, one in three participants did not meet the SC criterion for valid wear in Weeks 1 and 13; however, we found the SC criterion to be more inclusive of participants who did not use a smartphone than the HR criterion. Older age, higher body mass index (BMI), barriers to smartphone use, device storage issues, and negative emotional responses to WAM-based self-monitoring may predict higher proportions of invalid WAM data in weight-loss intervention research

Associations between Procedural Fairness in Physician Communication and Lifestyle Behaviors in Patients with Obesity

Objective To investigate how patient perception of procedural fairness in primary care physician communication among diverse patients with obesity is associated with the patient’s willingness to follow recommendations, self-efficacy beliefs, and lifestyle behaviors. Methods We conducted a cross-sectional, secondary data analysis of 484 primary care patients (43.6% Black, 40.7% Hispanic/Latino, 56.4% Female, Mage=50 years) with a BMI ≥ 25 kg/m2 enrolled in a weight management study in two New York City healthcare systems. To evaluate direct and indirect associations between PF and outcome variables, we used ordinary least squares path analyses with bootstrapping procedures controlling for age and gender. Results Patients who perceived their primary care physician as fairer reported higher willingness to follow recommendations and higher dietary self-efficacy, which were associated with healthier dietary behaviors (willingness: indirect=.08, SE=.03; 95% CI[.04 to .14]; dietary self-efficacy: indirect=.03, SE=.01; 95% CI[.01 to .05]). Higher perceived PF was also associated with higher exercise self-efficacy, which was associated with increased physical activity (indirect=.03, SE=.01; 95% CI[.01 to .05]). Conclusion PF was associated with lifestyle behaviors via willingness to follow recommendations and self-efficacy beliefs. PF holds promise as a novel communication target to enhance patient-physician communication related to weight management in primary care

Procedural Fairness in Physician-Patient Communication: A Predictor of Health Outcomes in a Cohort of Adults with Overweight or Obesity

BACKGROUND: This study aimed to explore whether patients' perception of procedural fairness in physicians' communication was associated with willingness to follow doctor's recommendations, self-efficacy beliefs, dietary behaviors, and body mass index. METHODS: This was a secondary analysis of baseline data from 489 primary care patients with a BMI ≥ 25 kg/m$^{2}$ (43.6% Black, 40.7% Hispanic/Latino, 55.8% female, mean age = 50 years), who enrolled in a weight management study in two New York City healthcare institutions. We conducted ordinary least squares path analyses with bootstrapping to explore direct and indirect associations among procedural fairness, willingness to follow recommendations, self-efficacy, dietary behaviors, and body mass index, while controlling for age and gender. RESULTS: Serial, multiple mediator models indicated that higher procedural fairness was associated with an increased willingness to follow recommendations which, in turn, was associated with healthier dietary behaviors and a lower BMI (indirect effect =  - .02, SE = .01; 95% CI [- .04 to - .01]). Additionally, higher procedural fairness was associated with elevated dietary self-efficacy, which was, in turn, was associated with healthier dietary behaviors and lower BMI (indirect effect =  - .01, SE = .003; 95% CI [- .02 to - .002]). CONCLUSIONS: These findings highlight the importance of incorporating procedural fairness in physician-patient communication concerning weight management in diverse primary care patients

Disparities in routine healthcare utilization disruptions during COVID-19 pandemic among veterans with type 2 diabetes

Abstract Background While emerging studies suggest that the COVID-19 pandemic caused disruptions in routine healthcare utilization, the full impact of the pandemic on healthcare utilization among diverse group of patients with type 2 diabetes is unclear. The purpose of this study is to examine trends in healthcare utilization, including in-person and telehealth visits, among U.S. veterans with type 2 diabetes before, during and after the onset of the COVID-19 pandemic, by demographics, pre-pandemic glycemic control, and geographic region. Methods We longitudinally examined healthcare utilization in a large national cohort of veterans with new diabetes diagnoses between January 1, 2008 and December 31, 2018. The analytic sample was 733,006 veterans with recently-diagnosed diabetes, at least 1 encounter with veterans administration between March 2018–2020, and followed through March 2021. Monthly rates of glycohemoglobin (HbA1c) measurements, in-person and telehealth outpatient visits, and prescription fills for diabetes and hypertension medications were compared before and after March 2020 using interrupted time-series design. Log-linear regression model was used for statistical analysis. Secular trends were modeled with penalized cubic splines. Results In the initial 3 months after the pandemic onset, we observed large reductions in monthly rates of HbA1c measurements, from 130 (95%CI,110–140) to 50 (95%CI,30–80) per 1000 veterans, and in-person outpatient visits, from 1830 (95%CI,1640–2040) to 810 (95%CI,710–930) per 1000 veterans. However, monthly rates of telehealth visits doubled between March 2020–2021 from 330 (95%CI,310–350) to 770 (95%CI,720–820) per 1000 veterans. This pattern of increases in telehealth utilization varied by community type, with lowest increase in rural areas, and by race/ethnicity, with highest increase among non-hispanic Black veterans. Combined in-person and telehealth outpatient visits rebounded to pre-pandemic levels after 3 months. Despite notable changes in HbA1c measurements and visits during that initial window, we observed no changes in prescription fills rates. Conclusions Healthcare utilization among veterans with diabetes was substantially disrupted at the onset of the pandemic, but rebounded after 3 months. There was disparity in uptake of telehealth visits by geography and race/ethnicity

Peer-Assisted Lifestyle (PAL) intervention: a protocol of a cluster-randomised controlled trial of a health-coaching intervention delivered by veteran peers to improve obesity treatment in primary care

Introduction Among US veterans, more than 78% have a body mass index (BMI) in the overweight (≥25 kg/m2) or obese range (≥30 kg/m2). Clinical guidelines recommend multicomponent lifestyle programmes to promote modest, clinically significant body mass (BM) loss. Primary care providers (PCPs) often lack time to counsel and refer patients to intensive programmes (≥6 sessions over 3 months). Using peer coaches to deliver obesity counselling in primary care may increase patient motivation, promote behavioural change and address the specific needs of veterans. We describe the rationale and design of a cluster-randomised controlled trial to test the efficacy of the Peer-Assisted Lifestyle (PAL) intervention compared with enhanced usual care (EUC) to improve BM loss, clinical and behavioural outcomes (aim 1); identify BM-loss predictors (aim 2); and increase PCP counselling (aim 3).Methods and analysis We are recruiting 461 veterans aged 18–69 years with obesity or overweight with an obesity-associated condition under the care of a PCP at the Brooklyn campus of the Veterans Affairs NY Harbor Healthcare System. To deliver counselling, PAL uses in-person and telephone-based peer support, a tablet-delivered goal-setting tool and PCP training. Patients in the EUC arm receive non-tailored healthy living handouts. In-person data collection occurs at baseline, month 6 and month 12 for patients in both arms. Repeated measures modelling based on mixed models will compare mean BM loss (primary outcome) between study arms.Ethics and dissemination The protocol has been approved by the Institutional Review Board and the Research and Development Committee at the VA NY Harbor Health Systems (#01607). We will disseminate the results via peer-reviewed publications, conference presentations and meetings with stakeholders.Trial registration number NCT03163264; Pre-results