Sourcebook: Women Veterans in the Veterans Health Administration. Volume 2: Sociodemographics and Use of VHA and Non-VA Care (Fee)
Describes sociodemographic characteristics and health care utilization patterns of women Veteran patients in the VHA. Its primary purpose is to present data to inform policy and program planning as VHA implements and evaluates new ways of providing care to women Veterans. Provides data about women residing in rural versus urban areas and by examining use of health care through VHA’s “Non-VA Care (Fee)” system, which is comprised of services provided to Veterans by non-VHA providers but reimbursed through VHA.
Produced by the Women’s Health Evaluation Initiative, Women’s Health Services, Veterans Health Administration, Department of Veterans Affairs, Washington DC.
Objective: To determine if self-reported cynical hostility predicted incident diabetes or increase in number of symptoms associated with metabolic syndrome in postmenopausal women.
Design: Prospective study of a subsample of women (n = 3,658) participating in the Women's Health Initiative Clinical Trial.
Methods: Subjects: Postmenopausal women aged 50 to 79 years at baseline who were enrolled in the Women's Health Initiative Dietary Modification Trial, Hormone Trial or both. Measures: The Cynicism subscale of the Cook-Medley Hostility Questionnaire was used to assess cynical hostility at baseline. Incident diabetes was ascertained by self-report of treatment with insulin or oral hypoglycemic medication at one year. Metabolic syndrome was defined based on number of Adult Treatment Panel (ATP) III criteria met at one year.Statistical Analysis: The relationship between baseline cynical hostility and incident diabetes and worsening of metabolic syndrome was assessed from baseline to one year using multivariable Cox proportional hazards models and multivariable logistic regression models, respectively.
Results: Incident diabetes was 36% higher among women in the upper tertile for baseline cynical hostility compared to the lowest tertile (p-trend = 0.05). The odds of a worsening of metabolic syndrome was 27% greater in the highest cynical hostility tertile compared to the lowest tertile (p-trend = 0.04).
Conclusions: Cynical hostility may increase the risk for developing diabetes and worsening of the metabolic syndrome in postmenopausal women.
Summarizes the rationale and scientific evidence for providing health promotion programs at worksites.
Collaborative Connection to the Past and Future: Introducing an Archival Program and Creating a History and Image Web Exhibit
Objectives: Establishing an archival program and creating a digital exhibit highlighting the history of an institution provides invaluable outreach and support. There are opportunities for significant collaboration between affiliated organizations by building relationships and sharing expertise. This paper provides a project description and product evaluation of the collaboration between a large academic medical library and archives and an affiliated vaccine manufacturer. The planning, implementation, and outcomes are discussed, with generally applicable components of this project detailed. Finally, recommendations for similar project implementations are given.
Methods and Results: In collaboration with a medical library and archives, an affiliated, historic vaccine manufacturer developed a project to preserve and publicize its long, rich history. While initially there were many goals for the project, an archivist was hired for only 900 hours. Priorities, a timeline, and deliverables had to be negotiated. The result was the development of an institutional archival program and an online history and image exhibit, both serving as powerful outreach and marketing tools. The project had 2 notable components: the establishment of traditional archival procedures and activities, including supporting documentation for future work; and the research, selection, and implementation of an appropriate web platform supporting an image exhibit, comprehensive timeline, and narrative history. By developing a web exhibit, the vaccine manufacturer now has a visible product used for outreach and promotion. The creative manipulation of an open source, simple web service served the needs of the archivist, the institution, and the budget. Collaboration between the manufacturer and the medical school has increased general communication and connection between the two. Finally, by providing very clear guidelines, education, and documentation for the project and all aspects of archival work, invested parties could make more appropriate planning decisions and be better prepared to continue the project in the future. Collaboration, communication, and creativity by all parties grounded and guided this project and are crucial to any success in projects of this type.
Conclusions: The creative use of resources and the creation of clear foundational policies and procedures--while also providing education about the nature, importance, and work expectations of archives--led to valued deliverables and a successful project. While not all initial goals were able to be addressed, by creating realistic expectations and timelines, and producing an appreciated, visible product, the project was ultimately extended with additional funding and labor.
The Society of Behavioral Medicine position statement on the CMS decision memo on intensive behavior therapy for obesity
In 2011, the Centers for Medicare and Medicaid Services (CMS) issued a decision to cover intensive behavior therapy for obesity in the primary care setting. The Society of Behavioral Medicine (SBM) Public Policy Leadership Group reviewed the CMS decision and has issued a position statement. SBM is in support of the CMS decision to cover intensive behavior therapy for obesity but expresses significant concern that aspects of the decision will severely limit the impact of the decision. Concerns focus on the degree to which this care can be feasibly implemented in its current form given the limitations in providers who are covered and the short length of counseling visits relative to evidence-based protocols. SBM is in strong support of modifications that would include providers who have expertise in weight control (e.g., psychologists and dietitians) and to expand the treatment time to better match protocols with confirmed efficacy.
Comment on A behavioral weight-loss intervention in persons with serious mental illness. [N Engl J Med. 2013]
Evidence for community-based approaches to weight loss: a case for revising the Centers for Medicaid and Medicare Services reimbursement structures
Comment on The Healthy Living Partnerships to Prevent Diabetes study: 2-year outcomes of a randomized controlled trial. [Am J Prev Med. 2013]
The present study examined whether trait anxiety and trait anger are associated with vulnerability to emotional eating, particularly among obese individuals. Lean (n = 37) and obese (n = 24) participants engaged in a laboratory study where they completed measures of trait anxiety and trait anger at screening and then completed 3 counterbalanced experimental sessions involving different mood inductions (neutral, anxiety, anger). Following each mood induction, participants were provided with snack foods in a sham taste test. Models predicting snack intake revealed a significant trait anxietyxbody mass index group interaction, such that high trait anxiety was positively associated with food intake for obese individuals, but not their lean counterparts. Contrary to the hypothesis, trait anger was not associated with food intake for obese or lean participants. Results suggest that trait anxiety may be a risk factor for emotional eating among obese individuals.
Emotional eating appears to contribute to weight gain, but the characteristics that make one vulnerable to emotional eating remain unclear. The present study examined whether two negative affect response styles, rumination and distraction, influenced palatable food intake following an anger mood induction in normal weight and obese adults. We hypothesized that higher rumination and lower distraction would be associated with greater vulnerability to anger-induced eating, particularly among obese individuals. Sixty-one participants (74% female, mean age=34.6) underwent neutral and anger mood inductions in counterbalanced order. Directly following each mood induction, participants were provided with 2400 kcal of highly palatable snack foods in the context of a laboratory taste test. Results revealed that distraction influenced energy intake following the mood induction for obese but not normal weight individuals. Obese participants who reported greater use of distraction strategies consumed fewer calories than those reporting less use of distraction strategies. These findings were independent of subjective hunger levels, individual differences in mood responses and trait anger, and other factors. Rumination did not account for changes in energy intake among obese or normal weight participants. Among obese individuals, the tendency to utilize fewer negative affect distraction strategies appears to be associated with vulnerability to eating in response to anger. Future research should determine whether coping skills training can reduce emotional eating tendencies.
De-emphasizing the role of personal choice in dietary counseling for obesity would reduce stigma, but doing so carries the risk of undermining patients' perceived control over their weight loss success. The goal of this commentary is to help dietetics practitioners negotiate this dilemma by presenting a scientifically informed framework that views the personal choices relevant to obesity counseling in terms of three neurobehavioral processes. We argue that applying this framework in dietary counseling can both minimize patient stigma and preserve patients' sense of empowerment.
Intensive lifestyle interventions are being adopted throughout the nation, and a growing body of research is identifying the settings, circumstances, and processes by which sustainable adoption occurs. Sustainability remains a challenge, although studies are providing important insights into the barriers as well as the playbook to overcoming them... The increasing magnitude of national initiatives and grassroot efforts to implement and disseminate lifestyle interventions over the past 10 years suggests forward movement toward widespread implementation.
Translation of the diabetes prevention program into a community mental health organization for individuals with severe mental illness: a case study
Individuals with severe mental illness (SMI) have significant health disparities. Wellness services embedded in community mental health organizations could lessen these disparities. This case study illustrates the integration of the Diabetes Prevention Program (DPP) lifestyle intervention into a community mental health organization. The Diffusion of Innovations Theory was used as a model for integration, which included a collaboration between researchers and the organization and qualitative work, culminating in a small pilot of the DPP led by peer specialists to test the feasibility of the DPP in this setting. Fourteen individuals with SMI participated in the 19-week intervention. Three dropped out, but the remaining 11 demonstrated 92% attendance. Weight loss was minimal, but the participants reported benefit and showed continued interest in the intervention. The use of a peer-led DPP in a community mental health organization is feasible and warrants further investigation to demonstrate efficacy.
Can familial factors account for the association of body mass index with poor mental health in men or women
OBJECTIVE: This study examined if associations between body mass index (BMI) and mental and physical health were independent of genetic and familial factors.
METHOD: Data from 2831 twins (66% female) were used in an epidemiological co-twin control design with measures of BMI and mental and physical health outcomes. Generalized estimating equation regressions assessed relationships between BMI and health outcomes controlling for interdependency among twins and demographics. Within-pair regression analyses examined the association of BMI with health outcomes controlling for genetic and familial influences.
RESULTS: Adjusted analyses with individual twins found associations in women between BMI and perceived stress (P=.01) and depression (P=.002), and the link between BMI and depression (P=.03) was significant in men. All physical health outcomes were significantly related to BMI. Once genetic and familial factors were taken into account, mental health outcomes were no longer significantly associated with BMI. BMI in women remained related to ratings of physical health (P=.01) and body pain (P=.004), independent of genetic and familial influences.
CONCLUSION: These findings suggest that genetic and familial factors may account for the relationship between increased weight and poor mental health.
Individuals who have had basal cell carcinoma (BCC) are at high risk of subsequent BCCs and melanoma. Indoor tanning is an established risk factor for BCC, squamous cell carcinoma, and melanoma. As such, continuing to tan indoors after a BCC diagnosis may elevate one’s risk for future skin cancers. Skin cancer survivors have sun protection behaviors that are similar to those of the general population, but little is known about their indoor tanning behavior. Notably, research suggests that some individuals develop tanning dependence, analogous to substance dependence,which could be related to continued indoor tanning. To understand better the patterns of and reasons for indoor tanning after BCC diagnosis, we assessed indoor tanning and symptoms of tanning dependence in people who had received at least 1 BCC diagnosis before age 40 years.
Comment on Translating the Diabetes Prevention Program lifestyle intervention for weight loss into primary care: a randomized trial. [JAMA Intern Med. 2013]
The field of behavioral science has produced myriad data on health behavior change strategies and leveraged such data into effective human-delivered interventions to improve health. Unfortunately, the impact of traditional health behavior change interventions has been heavily constrained by patient and provider burden, limited ability to measure and intervene upon behavior in real time, variable adherence, low rates of implementation, and poor third-party coverage. Digital health technologies, including mobile phones, sensors, and online social networks, by being available in real time, are being explored as tools to increase our understanding of health behavior and to enhance the impact of behavioral interventions. The recent explosion of industry attention to the development of novel health technologies is exciting but has far outpaced research. This Special Section of Translational Behavioral Medicine, Smartphones, Sensors, and Social Networks: A New Age of Health Behavior Change features a collection of studies that leverage health technologies to measure, change, and/or understand health behavior. We propose five key areas in which behavioral science can improve the impact of digital health technologies on public health. First, research is needed to identify which health technologies actually impact behavior and health outcomes. Second, we need to understand how online social networks can be leveraged to impact health behavior on a large scale. Third, a team science approach is needed in the developmental process of health technologies. Fourth, behavioral scientists should identify how a balance can be struck between the fast pace of innovation and the much slower pace of research. Fifth, behavioral scientists have an integral role in informing the development of health technologies and facilitating the movement of health technologies into the healthcare system.
BACKGROUND: Physicians have limited time for weight-loss counseling, and there is a lack of resources to which they can refer patients for assistance with weight loss. Weight-loss mobile applications (apps) have the potential to be a helpful tool, but the extent to which they include the behavioral strategies included in evidence-based interventions is unknown.
PURPOSE: The primary aims of the study were to determine the degree to which commercial weight-loss mobile apps include the behavioral strategies included in evidence-based weight-loss interventions, and to identify features that enhance behavioral strategies via technology.
METHODS: Thirty weight-loss mobile apps, available on iPhone and/or Android platforms, were coded for whether they included any of 20 behavioral strategies derived from an evidence-based weight-loss program (i.e., Diabetes Prevention Program). Data on available apps were collected in January 2012; data were analyzed in June 2012.
RESULTS: The apps included on average 18.83% (SD=13.24; range=0%-65%) of the 20 strategies. Seven of the strategies were not found in any app. The most common technology-enhanced features were barcode scanners (56.7%) and a social network (46.7%).
CONCLUSIONS: Weight-loss mobile apps typically included only a minority of the behavioral strategies found in evidence-based weight-loss interventions. Behavioral strategies that help improve motivation, reduce stress, and assist with problem solving were missing across apps. Inclusion of additional strategies could make apps more helpful to users who have motivational challenges.
Education, income, and incident heart failure in post-menopausal women: the Women's Health Initiative Hormone Therapy Trials
OBJECTIVES: The purpose of this study is to estimate the effect of education and income on incident heart failure (HF) hospitalization among post-menopausal women.
BACKGROUND: Investigations of socioeconomic status have focused on outcomes after HF diagnosis, not associations with incident HF. We used data from the Women's Health Initiative Hormone Trials to examine the association between socioeconomic status levels and incident HF hospitalization.
METHODS: We included 26,160 healthy, post-menopausal women. Education and income were self-reported. Analysis of variance, chi-square tests, and proportional hazards models were used for statistical analysis, with adjustment for demographics, comorbid conditions, behavioral factors, and hormone and dietary modification assignments.
RESULTS: Women with household incomes $50,000 a year (16.7/10,000 person-years; p < 0.01). Women with less than a high school education had higher HF hospitalization incidence (51.2/10,000 person-years) than college graduates and above (25.5/10,000 person-years; p < 0.01). In multivariable analyses, women with the lowest income levels had 56% higher risk (hazard ratio: 1.56, 95% confidence interval: 1.19 to 2.04) than the highest income women; women with the least amount of education had 21% higher risk for incident HF hospitalization (hazard ratio: 1.21, 95% confidence interval: 0.90 to 1.62) than the most educated women.
CONCLUSIONS: Lower income is associated with an increased incidence of HF hospitalization among healthy, post-menopausal women, whereas multivariable adjustment attenuated the association of education with incident HF. Elsevier Inc. All rights reserved.
Antidepressant use and risk of incident cardiovascular morbidity and mortality among postmenopausal women in the Women's Health Initiative study
BACKGROUND: Antidepressants are commonly prescribed medications, but their effect on cardiovascular morbidity and mortality remains unclear.
METHODS: Prospective cohort study of 136 293 community-dwelling postmenopausal women in the Women's Health Initiative (WHI). Women taking no antidepressants at study entry and who had at least 1 follow-up visit were included. Cardiovascular morbidity and all-cause mortality for women with new antidepressant use at follow-up (n = 5496) were compared with those characteristics for women taking no antidepressants at follow-up (mean follow-up, 5.9 years).
RESULTS: Antidepressant use was not associated with coronary heart disease (CHD). Selective serotonin reuptake inhibitor (SSRI) use was associated with increased stroke risk (hazard ratio [HR],1.45, [95% CI, 1.08-1.97]) and all-cause mortality (HR,1.32 [95% CI, 1.10-1.59]). Annualized rates per 1000 person-years of stroke with no antidepressant use and SSRI use were 2.99 and 4.16, respectively, and death rates were 7.79 and 12.77. Tricyclic antidepressant (TCA) use was associated with increased risk of all-cause mortality (HR,1.67 [95% CI, 1.33-2.09]; annualized rate, 14.14 deaths per 1000 person-years). There were no significant differences between SSRI and TCA use in risk of any outcomes. In analyses by stroke type, SSRI use was associated with incident hemorrhagic stroke (HR, 2.12 [95% CI, 1.10-4.07]) and fatal stroke (HR, 2.10 [95% CI, 1.15-3.81]).
CONCLUSIONS: In postmenopausal women, there were no significant differences between SSRI and TCA use in risk of CHD, stroke, or mortality. Antidepressants were not associated with risk of CHD. Tricyclic antidepressants and SSRIs may be associated with increased risk of mortality, and SSRIs with increased risk of hemorrhagic and fatal stroke, although absolute event risks are low. These findings must be weighed against quality of life and established risks of cardiovascular disease and mortality associated with untreated depression.
OBJECTIVE: To describe the development of measures of worksite descriptive social norms for weight loss, physical activity, and eating behaviors.
METHODS: Three surveys were tested in 844 public high school employees. Factor analysis, Cronbach alpha, and tests of association with other worksite social contextual measures and behaviors were performed.
RESULTS: Each survey demonstrated high internal consistency and was associated with measures of social support and behaviors. Confirmatory factor analysis supported the reliability of the weight-loss and eating-behavior norms surveys, but not the physical-activity norms survey.
CONCLUSIONS: The weight-loss and eating norms surveys are reliable, valid measures.