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This study aimed to evaluate whether coaching features were successfully transmitted via electronic health record (EHR) communication and to evaluate their relationship with weight change in a previously tested EHR-based coaching intervention.A secondary analysis from the Maintaining Activity and Nutrition through Technology-Assisted Innovation in Primary Care (MAINTAIN-pc) study randomized clinical trial was conducted in nine primary care practices and one specialty practice (endocrinology) affiliated with the University of Pittsburgh Medical Center. Eligibility included age 18 to 75 years, intentional 5% weight loss in the previous 2 years, access to an internet-connected computer, and receipt of care from a University of Pittsburgh Medical Center primary care provider. Survey data were collected during the randomized clinical trial.Participants content with intervention delivery via the EHR and those who felt a strong connection to their coach had significantly less weight regain (p = 0.013 and p 0.01, respectively). Participants who had needs unmet by the intervention (e.g., "in-person" support in a group setting or individual settings) regained more weight (p 0.01).The data suggest heterogeneity in the patient population regarding preference for in-person versus EHR-based coaching formats. Such heterogeneity might result in the differential success of EHR-based interventions.

Introduction: Self-monitoring (SM) is the core of behavioral weight loss. Efficacy evidence for mHealth to improve SM adherence and impact weight loss outcomes is limited. Purpose: Examine associations among diet, weight, and physical activity (PA) SM and adherence to diet, fat and PA goals on weight loss at 12 mos in adults with overweight or obesity. Methods: SMARTER was a single-site, 2-arm weight loss trial. We randomized adults with (BMI) 27-43 kg/m 2 to diet, weight, and PA SM plus tailored feedback messages (SM+FB, n=251) or SM alone (n=251). The SM+FB group received feedback messages via the SMARTER app on diet daily, PA every other day and weight weekly. The study provided Fitbit Charge 2™ for PA, smart scales for weight and Fitbit app for diet. Participants received individualized daily calorie/fat goals (based on sex & weight) and incremental weekly PA goals to reach ≥300 min/wk of moderate- and vigorous-intensity PA. Staff measured weight at baseline, 6 and 12 mos. Diet SM was the % of days with ≥50% of calorie goal recorded. Weight SM was the % of days with weight recorded. PA SM was % of days with ≥500 steps. Calorie goal adherence was % of days with ≥85% and Results: The sample (N=502) was 82% white (n=414), 79% female (n=399), on average 45.0±14.4 years of age with a mean BMI of 33.7±4.0 kg/m 2 . Treatment arms were similar on % days of weight and PA SM and % days adherent to calorie, fat and PA goals (p≥.05); however, the SM+FB group had greater % days of SM diet than the SM group (58.9 [24.7, 84.9] vs. 41.1 [14.0, 81.9]; P=.01). Weight loss at 12 mos was significantly associated (reported as b [95% CI]) with higher % of days of SM diet (-0.10 [-0.13, -0.08]), weight (-0.12 [-0.14, -0.09]) and PA (-0.10 [-0.13, -0.07]) and % days adherent to calorie (-0.06 [-0.11, -0.01]) and fat goals (-0.11 [-0.20, -0.02]) and average % days adherent to PA goals (-0.04 [-0.06, -0.02]). The effect of treatment assignment and its interactions with SM of diet, weight and PA and adherence to calorie, fat and PA goals on weight loss at 12 mos were not significant. Conclusions: In this study, SM of lifestyle behaviors and adherence to diet and PA goals were associated with better weight loss at 12 months and did not depend on treatment group assignment, suggesting that the mHealth intervention did not enhance adherence sufficiently to affect weight loss outcomes.

This study aimed to test the efficacy of self-monitoring and feedback (SM+FB) versus SM without FB (SM) in a behavioral weight-loss intervention at 6 months.This was a randomized clinical trial. Eligibility criteria included the following: ≥18 years of age, BMI ≥ 27 and ≤43, smartphone user, and ability to engage in moderate physical activity. All participants received a 90-minute 1:1 counseling session, a Fitbit Charge 2, and a digital scale for SM. SM+FB participants were provided access to a customized smartphone application that provided three daily FB messages. The primary outcome was percentage of weight change from 0 to 6 months.The sample (N = 502) was 45 (SD 14.4) years old, BMI was 33.7 (SD 4.00) kg/mThere was no significant between-group difference in weight loss at 6 months.

PURPOSE This study aimed to determine if energy intake and appetite regulation differ in response to an acute bout of resistance exercise (REx) versus aerobic exercise (AEx). METHODS Physically inactive adults (n = 24, 35% ± 2% body fat, 50% female) completed three conditions: AEx (walking at 65%-70% heart rate max for 45 min), REx (1 set to failure of 12 exercises), and sedentary control (SED). Each condition was initiated in the postprandial state (35 min after breakfast). Appetite (visual analog scale for hunger, satiety, and prospective food consumption) and hormones (ghrelin, peptide YY (PYY), and glucagon-like peptide-1 (GLP-1)) were measured before and 30, 90, 120, 150, and 180 min after a standardized breakfast. Area under the curve was calculated using the trapezoid method. Ad libitum energy intake was evaluated at a lunch meal after the 180-min measurements. RESULTS No differences in ad libitum energy intake (REx, 991 ± 68; AEx, 937 ± 65; SED, 944 ± 76 kcal; P = 0.50) or appetite ratings (all, P > 0.05) were detected. The area under the curve for ghrelin, PYY, and GLP-1 were all lower after REx versus AEx (ghrelin: 130,737 ± 4928 for REx; 143,708 ± 7500 for AEx (P = 0.006); PYY: 20,540 ± 1177 for REx, 23,812 ± 1592 for AEx (P = 0.001); and GLP-1: 1314 ± 93 for REx, 1615 ± 110 for AEx (P = 0.013)). Neither exercise condition significantly differed from SED. CONCLUSIONS Acute REx lowers both orexigenic (ghrelin) and anorectic (PYY and GLP-1) gut peptides compared with acute AEx. Ad libitum energy intake did not increase compared with SED in either exercise condition, indicating both exercise modalities have appetite and energy intake suppressing effects. Future work is needed to determine if exercise of differing modalities influences chronic appetite regulation.

BACKGROUND Self-monitoring (SM) is the centerpiece of behavioral weight loss treatment, but the efficacy of smartphone-delivered SM feedback (FB) has not been tested in large, long-term, randomized trials. OBJECTIVE The aim of this study was to establish the efficacy of providing remote FB to diet, physical activity (PA), and weight SM on improving weight loss outcomes when comparing the SM plus FB (SM+FB) condition to the SM-only condition in a 12-month randomized controlled trial. The study was a single-site, population-based trial that took place in southwestern Pennsylvania, USA, conducted between 2018 and 2021. Participants were smartphone users age ≥18 years, able to engage in moderate PA, with a mean BMI between 27 and 43 kg/m2. METHODS All participants received a 90-minute, one-to-one, in-person behavioral weight loss counseling session addressing behavioral strategies, establishing participants’ dietary and PA goals, and instructing on use of the PA tracker (Fitbit Charge 2), smart scale, and diet SM app. Only SM+FB participants had access to an investigator-developed smartphone app that read SM data, in which an algorithm selected tailored messages sent to the smartphone up to 3 times daily. The SM-only participants did not receive any tailored FB based on SM data. The primary outcome was percent weight change from baseline to 12 months. Secondary outcomes included engagement with digital tools (eg, monthly percentage of FB messages opened and monthly percentage of days adherent to the calorie goal). RESULTS Participants (N=502) were on average 45.0 (SD 14.4) years old with a mean BMI of 33.7 (SD 4.0) kg/m2. The sample was 79.5% female (n=399/502) and 82.5% White (n=414/502). At 12 months, retention was 78.5% (n=394/502) and similar by group (SM+FB: 202/251, 80.5%; SM: 192/251, 76.5%; P=.28). There was significant percent weight loss from baseline in both groups (SM+FB: –2.12%, 95% CI –3.04% to –1.21%, PPt =–0.41; P=.68). Similarly, 26.3% (66/251) of the SM+FB group and 29.1% (73/251) of the SM group achieved ≥5% weight loss (chi-square value=0.49; P=.49). A 1% increase in FB messages opened was associated with a 0.10 greater percent weight loss at 12 months (b=–0.10; 95% CI –0.13 to –0.07; t =–5.90; PF=22.19; P CONCLUSIONS There were no significant between-group differences in weight loss; however, the findings suggested that the use of commercially available digital SM tools with or without FB resulted in a clinically significant weight loss in over 25% of participants. Future studies need to test additional strategies that will promote greater engagement with digital tools. CLINICALTRIAL Clinicaltrials.gov NCT03367936; https://clinicaltrials.gov/ct2/show/NCT03367936

Introduction To improve the management of overweight and obesity in the primary care setting, an analysis of patient perceptions of weight status and predictors of weight loss attempts for those with overweight and obesity is needed. Methods Primary care patients (n=949) across 5 health systems in the Mid-Atlantic region of the U.S. were surveyed in 2015; data analysis was performed in 2018. Survey data was combined with data via the electronic health record to understand patients’ perceptions of weight, factors associated with weight loss efforts, and provider counseling practices. Results Most participants with overweight or obesity perceived themselves as weighing too much and reported trying to lose weight. Furthermore, most participants with obesity reported receiving advice to lose weight by a provider in the past 12 months. However, less than half of patients with overweight reported receiving advice to lose weight, maintain weight, or develop healthy eating and physical activity patterns from a health professional in the past 12 months. Among participants with overweight and obesity, multivariable logistic regression analysis demonstrated that the perception of being overweight and receiving healthcare advice to lose weight had the highest odds of reporting attempted weight loss (OR=5.5, 95% CI=2.7, 11.2 and OR=3.9, 95% CI=1.9, 7.9, respectively). Conclusions The findings emphasize the importance of provider attention to weight management counseling and identifies patients with overweight as needing increased attention by providers.

BACKGROUND: Though long-term weight loss maintenance is the treatment goal for obesity, weight regain is typical and few studies have evaluated lifestyle habits associated with weight regain. OBJECTIVE: To identify dietary and physical activity habits associated with 6- and 24-month weight regain among participants in a weight loss maintenance clinical trial. DESIGN: Secondary analysis of randomized clinical trial data. PARTICIPANTS: Adult primary care patients with recent, intentional weight loss of at least 5%. MAIN MEASURES: Lifestyle habits included consumption of low-fat foods, fish, desserts, sugary beverages, fruits, and vegetables and eating at restaurants from the Connor Diet Habit Survey; moderate-vigorous physical activity by self-report; steps recorded by a pedometer; and sedentary behavior by self-report. The outcome variable was weight change at 6 and 24 months. Linear regression models estimated adjusted associations between changes in weight and changes in dietary and physical activity habits. KEY RESULTS: Overall, participants (mean (SD): 53.4 (12.2) years old; 26% male; 88% white) maintained weight loss at 6 months (n = 178, mean (SD): − 0.02 (5.70)% change) but began to regain weight by 24 months (n = 157, mean (SD): 4.22 (9.15)% increase). When considered all together, more eating at restaurants, reduced fish consumption, and less physical activity were most consistently associated with weight regain in fully adjusted models at both 6 and 24 months of follow-up. In addition, more sedentary behavior was associated with weight regain at 6 months while reduced consumption of low-fat foods, and more desserts and sugary beverages were associated with weight regain at 24 months. CONCLUSIONS: Consuming less fish, fewer steps per day, and more frequent restaurant eating were most consistently associated with weight regain in primary care patients. Primary care providers may consider addressing specific lifestyle behaviors when counseling patients after successful weight loss. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01946191 ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-020-06056-x) contains supplementary material, which is available to authorized users.

Measuring adherence to the 2015 U.S. Preventive Services Task Force (USPSTF) diabetes prevention guidelines can inform implementation efforts to prevent or delay Type 2 diabetes. A retrospective cohort was used to study patients without a diagnosis of diabetes attributed to primary care clinics within two large healthcare systems in our state to study adherence to the following: (1) screening at-risk patients and (2) referring individuals with confirmed prediabetes to participate in an intensive behavioral counseling intervention, defined as a Center for Disease Control and Prevention (CDC)-recognized Diabetes Prevention Program (DPP). Among 461,866 adults attributed to 79 primary care clinics, 45.7% of patients were screened, yet variability at the level of the clinic ranged from 14.5% to 83.2%. Very few patients participated in a CDC-recognized DPP (0.52%; range 0%-3.53%). These findings support the importance of a systematic implementation strategy to specifically target barriers to diabetes prevention screening and referral to treatment.

Unattended automated office blood pressure (BP) measurement (u‐AOBP) improves office BP measurement accuracy and reduces white‐coat BP elevation, but there are reservations about its time efficiency in primary care. We used time‐stamp methodology to measure u‐AOBP procedure times performed without a rest period in 130 patients during routine clinic visits to three primary care clinics with 2.5‐4.9 years u‐AOBP experience. We documented the clinical activities of 30 medical assistants during the u‐AOBP procedures. We also assessed MA and clinician satisfaction and knowledge about u‐AOBP performance and interpretation. Median u‐AOBP procedure time was

The work of physician-investigators has historically led to key discoveries and developments in modern medicine, but recent decades have seen significant declines in the number of U.S. physician-investigators. One of the barriers to physicians participating in research is the lack of mentored research opportunities during clinical training, especially during residency training. In response to this identified barrier and to expand the physician-investigator workforce, the National Institutes of Health initiated the R38 program, known as Stimulating Access to Research in Residency, to support mentored research opportunities for residents. This article reports on the early outcomes of the recipients of the initial round of R38 awards, granted in 2018. Early positive outcomes include increases in the reported likelihood of resident-investigators pursuing physician-investigator careers, greater reported clarity in resident-investigators' research directions, the commitment of additional institutional resources to support the R38-awarded programs, and the approval of resident-investigators as having met training requirements for certification by multiple medical boards.

Introduction: Obesity is a significant health problem in the US. Sustainable interventions are needed to support longer-term maintenance after weight loss. We designed and tested a successful electronic health record (EHR)-based weight maintenance intervention with coaching delivered by research staff. Our next step is to determine whether coaching can be done by primary care staff during routine clinical work. We address 3 feasibility questions for using staff as coaches: coach recruitment, efficiency and effectiveness of coach training, and workflow integration and burden. Methods: MAINTAIN PRIME is an RCT comparing EHR-based coaching plus tracking vs tracking alone for primary care patients with recent weight loss. Implementation in 2 pilot clinics included: 1) approval of clinic leaders; 2) advertising to clinic staff for volunteers; 3) development and delivery of a self-paced coach training program; 4) coaching pilot patients for one month. Training (with a $400 one-time stipend) consisted of: 1) in-person orientation; 2) six core interactive online learning modules; 3) in-person review session; and 4) hands-on EHR tool training. Topics included weight management and behavior change, online communication, and structure of coaching messages. We obtained quantitative and qualitative feedback for both training and pilot coaching experience. Results: Recruitment: All clinical leaders (n=9) agreed to staff participation. Thirteen (10 medical assistants (MAs), 2 nurses, and 1 care manager) volunteered, out of 96 total clinical staff. Training : Six (46%) staff completed training. Reported confidence was very high (4.6/5) after training and the likelihood of recommending training to others was moderate (6.8/10). A common theme to improve training was to consolidate; we eliminated in-person review and added case studies to online modules. Staff found hands-on EHR tool training and research team support most valuable components of training. Coaching Experience: Integration of coaching into routine clinic work varied extensively, with some coaching throughout the day, and others saving it for end of day or once a week. All reported that coaching was easy to do with tools provided and took between 10-20 minutes/day. Most believed that they could coach between 10 to 20 patients at a time. Confidence levels were high (5.8/7) while coaching and belief in usefulness of coaching was very high (6.4/7). Of the 6 coaches trained, 3 elected to continue coaching after pilot conclusion. Conclusions: Coaching by primary care staff appears to be feasible with clinical leaders supporting staff engagement and staff coaching during routine clinical work. The training program was well received and reported to be effective by coaches both right after the training and during coaching. The relatively low volunteer levels and coach attrition may be barriers and further incentives may need to be considered.

ImportanceBariatric surgery is the most effective treatment for severe obesity; yet it is unclear whether the long-term safety and comparative effectiveness of these operations differ across racial and ethnic groups.ObjectiveTo compare outcomes of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) across racial and ethnic groups in the National Patient-Centered Clinical Research Network (PCORnet) Bariatric Study.Design, Setting, and ParticipantsThis was a retrospective, observational, comparative effectiveness cohort study that comprised 25 health care systems in the PCORnet Bariatric Study. Patients were adults and adolescents aged 12 to 79 years who underwent a primary (first nonrevisional) RYGB or SG operation between January 1, 2005, and September 30, 2015, at participating health systems. Patient race and ethnicity included Black, Hispanic, White, other, and unrecorded. Data were analyzed from July 1, 2021, to January 17, 2022.ExposureRYGB or SG.OutcomesPercentage total weight loss (%TWL); type 2 diabetes remission, relapse, and change in hemoglobin A1c (HbA1c) level; and postsurgical safety and utilization outcomes (operations, interventions, revisions/conversions, endoscopy, hospitalizations, mortality, 30-day major adverse events) at 1, 3, and 5 years after surgery.ResultsA total of 36 871 patients (mean [SE] age, 45.0 [11.7] years; 29 746 female patients [81%]) were included in the weight analysis. Patients identified with the following race and ethnic categories: 6891 Black (19%), 8756 Hispanic (24%), 19 645 White (53%), 826 other (2%), and 783 unrecorded (2%). Weight loss and mean reductions in HbA1c level were larger for RYGB than SG in all years for Black, Hispanic, and White patients (difference in 5-year weight loss: Black, −7.6%; 95% CI, −8.0 to −7.1; P < .001; Hispanic, −6.2%; 95% CI, −6.6 to −5.9; P < .001; White, −5.9%; 95% CI, −6.3 to −5.7; P < .001; difference in change in year 5 HbA1c level: Black, −0.29; 95% CI, −0.51 to −0.08; P = .009; Hispanic, −0.45; 95% CI, −0.61 to −0.29; P < .001; and White, −0.25; 95% CI, −0.40 to −0.11; P = .001.) The magnitude of these differences was small among racial and ethnic groups (1%-3% of %TWL). Black and Hispanic patients had higher risk of hospitalization when they had RYGB compared with SG (hazard ratio [HR], 1.45; 95% CI, 1.17-1.79; P = .001 and 1.48; 95% CI, 1.22-1.79; P < .001, respectively). Hispanic patients had greater risk of all-cause mortality (HR, 2.41; 95% CI, 1.24-4.70; P = .01) and higher odds of a 30-day major adverse event (odds ratio, 1.92; 95% CI, 1.38-2.68; P < .001) for RYGB compared with SG. There was no interaction between race and ethnicity and operation type for diabetes remission and relapse.Conclusions and RelevanceVariability of the comparative effectiveness of operations for %TWL and HbA1c level across race and ethnicity was clinically small; however, differences in safety and utilization outcomes were clinically and statistically significant for Black and Hispanic patients who had RYGB compared with SG. These findings can inform shared decision-making regarding bariatric operation choice for different racial and ethnic groups of patients.

BACKGROUND: Greater than 60% of adults have overweight or obesity. Self-weighing is an effective weight loss and weight maintenance tool. However, little is known about self-weighing habits among the primary care patient population. Our objective was to examine the frequency of patient-reported self-weighing, and to evaluate the associations of self-weighing with demographic characteristics and self-monitoring behaviors. METHODS: We conducted an analysis of survey data collected as part of the PaTH Clinical Data Research Network, which recruited a cohort of 1,021 primary care patients at 4 academic medical centers. Patients of all body mass index (BMI) categories were included. RESULTS: Response rate of 6-month survey was 727 (71%). The mean age was 56 years, and most were female (68%), White (78%), college graduates (66%), and employed/retired (85%). The mean BMI was 30.2 kg/m(2), 80% of participants had a BMI ≧ 25 kg/m(2). Of patients with BMI ≧ 25 kg/m(2), 35% of participants self-weighed weekly and 23% daily. Participants who reported self-weighing at least weekly were more likely to be older (59 vs 54 years, p

Purpose of Review While obesity-related comorbidities are frequently addressed and treated in primary care (PC), obesity itself is undertreated. We review the current treatments for obesity and provide potential provider and system-level strategies for integrating weight management and improving longer term obesity care within PC settings. Recent Findings We now understand that the body develops multiple mechanisms to resist weight loss and promote weight regain, making both weight loss and weight loss maintenance challenging. Therefore, weight management often requires medically supervised interventions and should be treated on a long-term basis. However, there are multiple barriers to improving obesity care within PC settings. Summary Clinically, utilizing strategies such as a shared decision-making approach and the 5As to discuss treatment options can facilitate formulating an obesity treatment plan. Utilizing telehealth, a team-based approach, and community partnering can increase patient access to intensive behavioral interventions. Future studies should evaluate other cost-effective methods to implement obesity care into the PC setting.

Background: Obesity is a major risk factor for CVD. Standard behavioral treatment (SBT) typically requires face-to-face sessions, is expensive, has limited evidence for sustained weight loss, and critically, is not available to many with obesity. Using innovative mobile technology to provide real-time tailored feedback (FB) to the self-monitoring (SM) of diet, physical activity, and weight can improve lifestyle and weight management habits. It can be accessible to those without access to SBT, or to those not wishing to participate in a structured, in-person program. We report short-term, 6-month weight findings from the SMARTER Trial. Methods: SMARTER tests the efficacy of adding automated FB to smartphone SM compared to SM alone on weight loss. We randomized 502 adults with overweight/obesity to either 1) SM alone (n=251) or 2) SM+FB (n=251). The SM+FB group received up to 3 FB pop-up messages/day on their smartphone which were tailored to data in SM entries and delivered at random times during waking hours. Participants used a smartphone app to self-report diet, a Fitbit Charge 2 to monitor physical activity, and a digital Bluetooth scale for weight tracking. At baseline, all had a 90-min one-on-one session with a dietitian on behavioral changes to target weight loss. Percent weight loss from baseline to 6 months and the percentage of participants having at least a 5% weight loss at 6 months were compared between treatment groups using an intention to treat (ITT) approach with either parametric or non-parametric group comparisons. Missing assessment weights at 6 months were imputed using participants’ weight tracking data. Results: Groups had similar demographic characteristics and anthropometric measures at baseline (all p≥.05). The sample was mostly female (79.5%,399/502) and white (84.3%, 423/502) with mean BMI of 33.10 ± 3.93 kg/m 2 . There was no difference between groups in having weight data available at 6 months (SM: 84.9%, 213/251), SM+FB: 83.7%, 210/251); p=.713). Based on ITT analyses, there was no significant difference between the two groups in mean percent weight loss from baseline to 6 months (SM: Mean= -3.24% [SD=5.27], SM+FB: Mean= -3.16% [SD=5.50]; p=.860). Similar results were obtained using non-parametric methods, further supporting no difference in percent weight loss between the groups (SM: Median= -2.25% [IQR=5.53], SM+FB: Median= -2.45% [IQR=6.88]; p=.962). Overall, 30.1%,151/502) achieved at least 5% weight loss at 6 months, with similar percentages between treatment groups (SM: 28.3%,71/251, SM+FB: 31.9%, 80/251); p=.381). Conclusions: These findings demonstrate excellent 6-month assessment completion rates. We did not support our hypothesis that participants in the SM+FB group would show greater weight loss at 6 months than those in the SM group. It is possible that weight loss outcomes may differ between groups in the second half of the 12-month intervention.

The COVID‐19 pandemic is a public health crisis, having killed more than 514 000 US adults as of March 2, 2021. COVID‐19 mitigation strategies have unintended consequences on managing chronic conditions such as hypertension, a leading cause of cardiovascular disease and health disparities in the United States. During the first wave of the pandemic in the United States, the combination of observed racial/ethnic inequities in COVID‐19 deaths and social unrest reinvigorated a national conversation about systemic racism in health care and society. The 4th Annual University of Utah Translational Hypertension Symposium gathered frontline clinicians, researchers, and leaders from diverse backgrounds to discuss the intersection of these 2 critical social and public health phenomena and to highlight preexisting disparities in hypertension treatment and control exacerbated by COVID‐19. The discussion underscored environmental and socioeconomic factors that are deeply embedded in US health care and research that impact inequities in hypertension. Structural racism plays a central role at both the health system and individual levels. At the same time, virtual healthcare platforms are being accelerated into widespread use by COVID‐19, which may widen the divide in healthcare access across levels of wealth, geography, and education. Blood pressure control rates are declining, especially among communities of color and those without health insurance or access to health care. Hypertension awareness, therapeutic lifestyle changes, and evidence‐based pharmacotherapy are essential. There is a need to improve the implementation of community‐based interventions and blood pressure self‐monitoring, which can help build patient trust and increase healthcare engagement.

Purpose. Stroke increases risk for disability. Obesity and diabetes also increase risk for disability in the general population, but their association with disability in stroke survivors is unknown. We examined disability risk associated with obesity and diabetes in stroke survivors across six disability types: hearing, vision, cognition, mobility, and basic and instrumental activities of daily living (ADLs).Materials and Methods. Data from 37,955 community-dwelling US stroke survivors aged ≥18 years were analyzed from the 2017 and 2018 Behavioral Risk Factor Surveillance System. Linear regression was used to calculate prevalence of each disability type. Survivors were stratified by obesity versus normal weight and diabetes vs no diabetes, and logistic regression was used to calculate adjusted odds ratios (AOR) for each disability type, adjusted for demographic information.Results. Prevalences of disability types ranged from 14.2% to 36.0%. Among survivors with obesity, odds were elevated for mobility (AOR: 1.68) and basic ADL (AOR: 1.55) disability. Among survivors with diabetes, odds were elevated for all disability types (AOR range: 1.15-1.71).Conclusion. Stroke survivors with obesity or diabetes experience increased risk for disability compared to survivors without these chronic conditions. Interventions for managing disability, obesity, and diabetes concomitantly may be warranted and deserve further consideration.

Background It is unclear whether faster progression of atherosclerosis explains the higher risk of cardiovascular events in CKD. The objectives of this study were to 1. Characterize the associations of CKD with presence and morphology of atherosclerotic plaques on carotid magnetic resonance imaging (MRI) and 2. Examine the associations of baseline CKD and carotid atherosclerotic plaques with subsequent cardiovascular events. Methods In a subgroup (N = 465) of Systolic Blood Pressure Intervention Trial. (SPRINT) participants, we measured carotid plaque presence and morphology at baseline and after 30-months with MRI. We examined the associations of CKD (baseline eGFR 2) with progression of carotid plaques and the SPRINT cardiovascular endpoint. Results One hundred and ninety six (42%) participants had CKD. Baseline eGFR in the non-CKD and CKD subgroups were 77 ± 14 and 49 ± 8 ml/min/1.73 m2, respectively. Lipid rich necrotic-core plaque was present in 137 (29.5%) participants. In 323 participants with both baseline and follow-up MRI measurements of maximum wall thickness, CKD was not associated with progression of maximum wall thickness (OR 0.62, 95% CI 0.36 to 1.07, p = 0.082). In 96 participants with necrotic core plaque at baseline and with a valid follow-up MRI, CKD was associated with lower odds of progression of necrotic core plaque (OR 0.41, 95% CI 0.17 to 0.95, p = 0.039). There were 28 cardiovascular events over 1764 person-years of follow-up. In separate Cox models, necrotic core plaque (HR 2.59, 95% CI 1.15 to 5.85) but not plaque defined by maximum wall thickness or presence of a plaque component (HR 1.79, 95% CI 0.73 to 4.43) was associated with cardiovascular events. Independent of necrotic core plaque, CKD (HR 3.35, 95% CI 1.40 to 7.99) was associated with cardiovascular events. Conclusions Presence of necrotic core in carotid plaque rather than the presence of plaque per se was associated with increased risk of cardiovascular events. We did not find CKD to be associated with faster progression of necrotic core plaques, although both were independently associated with cardiovascular events. Thus, CKD may contribute to cardiovascular disease principally via mechanisms other than atherosclerosis such as arterial media calcification or stiffening. Trial Registration NCT01475747, registered on November 21, 2011.

BACKGROUND There is growing interest in identifying and recruiting research participants from health systems using electronic health records (EHRs). However, few studies have described the practical aspects of the recruitment process or compared electronic recruitment methods to in-person recruitment, particularly across health systems. OBJECTIVE The objective of this study was to describe the steps and efficiency of the recruitment process and participant characteristics by recruitment strategy. METHODS EHR-based eligibility criteria included being an adult patient engaged in outpatient primary or bariatric surgery care at one of 5 health systems in the PaTH Clinical Research Network and having ≥2 weight measurements and 1 height measurement recorded in their EHR within the last 5 years. Recruitment strategies varied by site and included one or more of the following methods: (1) in-person recruitment by study staff from clinical sites, (2) US postal mail recruitment letters, (3) secure email, and (4) direct EHR recruitment through secure patient web portals. We used descriptive statistics to evaluate participant characteristics and proportion of patients recruited (ie, efficiency) by modality. RESULTS The total number of eligible patients from the 5 health systems was 5,051,187. Of these, 40,048 (0.8%) were invited to enter an EHR-based cohort study and 1085 were enrolled. Recruitment efficiency was highest for in-person recruitment (33.5%), followed by electronic messaging (2.9%), including email (2.9%) and EHR patient portal messages (2.9%). Overall, 779 (65.7%) patients were enrolled through electronic messaging, which also showed greater rates of recruitment of Black patients compared with the other strategies. CONCLUSIONS We recruited a total of 1085 patients from primary care and bariatric surgery settings using 4 recruitment strategies. The recruitment efficiency was 2.9% for email and EHR patient portals, with the majority of participants recruited electronically. This study can inform the design of future research studies using EHR-based recruitment.

BACKGROUND Most adults are not achieving recommended levels of physical activity (150 minutes/week, moderate-to-vigorous intensity). Inadequate activity levels are associated with numerous poor health outcomes, and clinical recommendations endorse physical activity in the front-line treatment of obesity, diabetes, dyslipidemia, and hypertension. A framework for physical activity prescription and referral has been developed, but has not been widely implemented. This may be due, in part, to the lack of feasible and effective physical activity intervention programs designed to coordinate with clinical care delivery. OBJECTIVE This manuscript describes the protocol for a pilot randomized controlled trial (RCT) that tests the efficacy of a 13-week online intervention for increasing physical activity in adult primary care patients (aged 21-70 years) reporting inadequate activity levels. The feasibility of implementing specific components of a physical activity clinical referral program, including screening for low activity levels and reporting patient program success to referring physicians, will also be examined. Analyses will include participant perspectives on maintaining physical activity. METHODS This pilot study includes a 3-month wait-listed control RCT (1:1 ratio within age strata 21-54 and 55-70 years). After the RCT primary end point at 3 months, wait-listed participants are offered the full intervention and all participants are followed to 6 months after starting the intervention program. Primary RCT outcomes include differences across randomized groups in average step count, moderate-to-vigorous physical activity, and sedentary behavior (minutes/day) derived from accelerometers. Maintenance of physical activity changes will be examined for all participants at 6 months after the intervention start. RESULTS Recruitment took place between October 2018 and May 2019 (79 participants were randomized). Data collection was completed in February 2020. Primary data analyses are ongoing. CONCLUSIONS The results of this study will inform the development of a clinical referral program for physical activity improvement that combines an online intervention with clinical screening for low activity levels, support for postintervention behavior maintenance, and feedback to the referring physician. CLINICALTRIAL ClinicalTrials.gov NCT03695016; https://clinicaltrials.gov/ct2/show/NCT03695016. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/18891

Introduction: The AHA created “Life’s Simple Seven” metrics to measure progress toward the goal of improving the cardiovascular (CV) health of all Americans, classifying each metric as “ideal”, “intermediate,” or “poor”. Few studies have examined the impact of behavioral lifestyle interventions on CV health metrics. We evaluated changes in CV health metrics during the course of a CDC recognized Diabetes Prevention Program-based lifestyle intervention known as Group Lifestyle Balance (DPP-GLB). Hypothesis: DPP-GLB will be associated with improvements in CV health metrics after 6 months of intervention and maintenance of these improvements at 12 months post-baseline. Methods: We used combined data from two similar intervention trials (occurring 6 years apart) offering a 12 month DPP-GLB program in the community setting to overweight/obese individuals with prediabetes and/or metabolic syndrome. Changes in individual CV health metrics (BMI, blood pressure, total cholesterol, fasting blood glucose, physical activity; measures of smoking and diet were not available) and total metric score (sum of metric profile where ideal=2, intermediate=1 and poor=0 for each metric, possible “total “range of 0-10) were considered after 6 and 12 months of intervention. Results: Among 222 participants (76%) with complete data for all 5 metrics at intervention baseline, 6 and 12 month follow up, there was a significant beneficial shift from baseline to 6 and 12 months in the proportion of participants within CV health metric categories for BMI, physical activity and blood pressure (Figure 1). Total metric score also improved significantly (p Conclusions: The DPP-GLB intervention was successful in improving CV health metrics at both 6 and 12 months, demonstrating the potential of this program to decrease CVD risk.

PURPOSE Many medical schools require scholarly research projects. However, outcomes data from these initiatives are scarce. The authors studied the impact of the Scholarly Research Project (SRP), a four-year longitudinal requirement for all students at the University of Pittsburgh School of Medicine (UPSOM), on research productivity and residency match. METHOD The authors conducted a longitudinal study of non-dual-degree UPSOM graduates in 2006 (n = 121, non-SRP participants) versus 2008 (n = 118), 2010 (n = 106), and 2012 (n = 132), all SRP participants. The authors used PubMed for publication data, National Resident Matching Program for residency match results, and Blue Ridge Institute for Medical Research for National Institutes of Health funding rank for residency-affiliated academic institutions. RESULTS Research productivity of students increased for those completing the SRP, measured as a greater proportion of students with publications (27.3% in 2006 vs. 45.8% in 2008, 55.7% in 2010, and 54.5% in 2012; P < .001) and first-authorship (9.9% in 2006 vs. 26.3% in 2008, 33.0% in 2010, and 35.6% in 2012; P < .001). Across years, there was a significantly greater proportion of students with peer-reviewed publications matched in higher-ranked residency programs (57.0% with publications in the top 10%, 52.7% in the top 10%-25%, 32.4% in the top 25%-50%, 41.2% in the bottom 50%, and 45.2% in unranked programs; P = .018). CONCLUSIONS Longitudinal research experiences for medical students may be one effective tool in fostering student publications and interest in extending training in a research-focused medical center.

Objective The increase in maternal morbidity has resulted in higher need for maternal–fetal medicine (MFM) subspecialty care. To meet the rising demand, particularly in rural areas, the use of MFM telemedicine services has increased. This study describes the structure, implementation, and patient and child health outcomes associated with a large health system's MFM telemedicine program. Study Design Observational electronic health record data are used to compare maternal and childbirth outcomes between patients receiving care via telemedicine or in-person visits through regression analysis. Average patient time and resources saved are calculated, and patient satisfaction scores are reported. Results The telemedicine patients experienced similar outcomes to the in-person group, indicating that MFM telemedicine can serve as an effective substitute for in-person care. MFM telemedicine patients saved $90.28 per consult in travel and work-related expenses. An overwhelming majority of MFM telemedicine patients were satisfied with their visit and indicated that they would be interested in receiving care via telemedicine in the future. Conclusion The results indicate that the patients may benefit financially and experience similar outcomes when telemedicine programs are appropriately designed to eliminate access barriers and provide high-quality care.

Background: Accurate blood pressure (BP) measurement is essential to hypertension diagnosis and management. Automated office blood pressure (AOBP) and home blood pressure measurement (HBPM) may improve assessment, but barriers exist in primary care settings. Methods: We implemented an AOBP/HBPM program in a primary care clinic in 2015 to 2016. Patients with elevated BP determined by guideline-quality observed BP measurement and/or AOBP entered the HBPM program. Patients with average home BP ≥ 135/85 mm Hg provided HBPM results for medication adjustment. Clinic staff and patients completed satisfaction questionnaires. Results: Initial HBPM results in 183 patients with elevated office BP revealed white-coat BP elevation in 35% of untreated patients and in 37% of treated patients. The prevalence of white-coat BP elevation was similar whether enrollment BP was by observed BP or AOBP. Subsequent HBPM facilitated BP control in 49% of patients with elevated home BP. Most providers, staff, and patients endorsed the utility of the program. Barriers to implementation included a temporary period of incorrect AOBP technique, patients failing to provide HBPM results, and incorrect HBPM technique. Discussion: Our clinic-based AOBP/HBPM program detected white-coat BP elevation in one third of enrolled patients, facilitated control of home BP, and was acceptable to staff and patients. We identified barriers to be addressed to ensure sustainability.

INTRODUCTION: U.S. black women have the highest rates of obesity and report frequent binge eating behaviors. To our knowledge, no intervention research has aimed to treat binge eating specifically among black women. The purpose of this study was to investigate the feasibility and preliminary effect of Appetite Awareness Treatment (AAT), an 8-week cognitive-behavioral binge eating intervention, among black women with obesity, and who report binge eating. METHODS: Participants (N=31), had a mean (±SD) age of 48.8 ±12.8 years, a body mass index of 33.7 ± 3.9 kg/m(2), and reported at least one binge or loss of control (LOC) eating episode monthly over the last three months. Using a randomized controlled trial design, black women were randomized to AAT or a wait-list control group (WAIT) group. We examined recruitment, attendance, retention, and adherence. Linear mixed models explored preliminary differences between the AAT and WAIT on the primary outcome variables of binge eating and eating self-efficacy measured at baseline and 8-weeks. RESULTS: Approximately one-third of screened participants were eligible and did enroll. Participants completed 55% of homework assignments, and attended 59% of intervention sessions. Retention to AAT was 87.5%. Compared to participants in the WAIT group, AAT participants had greater decreases in binge eating scores and greater improvements in eating self-efficacy scores at the end of Week 8. CONCLUSION: Results suggest that AAT is feasible among black women with binge eating behaviors, with evidence of preliminary efficacy, providing a rationale for a trial of AAT in a larger sample of black women.

Sedentary behavior (SB) has recently been recognized as a strong risk factor for cardiovascular disease, with new guidelines encouraging adults to „sit less, move more.‟ Yet, there are few randomized trials demonstrating that reducing SB improves cardiovascular health. The Effect of Reducing Sedentary Behavior on Blood Pressure (RESET BP) randomized clinical trial addresses this gap by testing the effect of a 3-month SB reduction intervention on resting systolic BP. Secondary outcomes include other BP measures, pulse wave velocity, plasma renin activity and aldosterone, and objectively-measured SB (via thigh-mounted activPAL) and physical activity (via waist-worn GT3X accelerometer). RESET BP has a targeted recruitment of 300 adults with desk jobs, along with elevated, non-medicated BP (systolic BP 120–159 mmHg or diastolic BP 80–99 mmHg) and physical inactivity (self-reported aerobic physical activity below recommended levels). The multi-component intervention promotes 2–4 fewer hours of SB per day by replacing sitting with standing and light-intensity movement breaks. Participants assigned to the intervention condition receive a sit-stand desk attachment, a wrist-worn activity prompter, behavioral counseling every two weeks (alternating in-person and phone), and twice-weekly automated text messages. Herein, we review the study rationale, describe and evaluate recruitment strategies based on enrollment to date, and detail the intervention and assessment protocols. We also document our mid-trial adaptations to participant recruitment, intervention deployment, and outcome assessments due to the intervening COVID-19 pandemic. Our research methods, experiences to date, and COVID-specific accommodations could inform other research studying BP and hypertension or targeting working populations, including those seeking remote methods.

BackgroundThe previously published results of the Systolic Blood Pressure Intervention Trial showed that among participants with hypertension and an increased cardiovascular risk, but without diabetes, the rates of cardiovascular events were lower among those who were assigned to a target systolic blood pressure of less than 120 mm Hg (intensive treatment) than among those who were assigned to a target of less than 140 mm Hg (standard treatment). Whether such intensive treatment affected patient-reported outcomes was uncertain; those results from the trial are reported here. MethodsWe randomly assigned 9361 participants with hypertension to a systolic blood-pressure target of less than 120 mm Hg or a target of less than 140 mm Hg. Patient-reported outcome measures included the scores on the Physical Component Summary (PCS) and Mental Component Summary (MCS) of the Veterans RAND 12-Item Health Survey, the Patient Health Questionnaire 9-item depression scale (PHQ-9), patient-reported satisfaction with their...

BackgroundIn the Systolic Blood Pressure Intervention Trial (SPRINT), adults at high risk for cardiovascular disease who received intensive systolic blood-pressure control (target

Background Weight regain after intentional loss is common. Most evidence-based weight management programs focus on short-term loss rather than long-term maintenance. Objective To evaluate the benefit of coaching in an electronic health record (EHR)-based weight maintenance intervention. Design Randomized controlled trial. (ClinicalTrials.gov: NCT01946191). Setting Practices affiliated with an academic medical center. Participants Adult outpatients with body mass index (BMI) of 25 kg/m2 or higher, intentional weight loss of at least 5% in the previous 2 years, and no bariatric procedures in the previous 5 years. Intervention Participants were randomly assigned to EHR tools (tracking group) versus EHR tools plus coaching (coaching group). The EHR tools included weight, diet, and physical activity tracking flow sheets; standardized surveys; and reminders. The coaching group received 24 months of personalized coaching through the EHR patient portal, with 24 scheduled contacts. Measurements The primary outcome was weight change at 24 months. Secondary outcomes included 5% weight loss maintenance and changes in BMI, waist circumference, number of steps per day, health-related quality of life, physical function, blood pressure, and satisfaction. Results Among 194 randomly assigned participants (mean age, 53.4 years [SD, 12.2]; 143 [74%] women; 171 [88%] white), 157 (81%) completed the trial. Mean baseline weight and BMI were 85.8 kg (SD, 19.1) and 30.4 kg/m2 (SD, 5.9). At 24 months, mean weight regain (± SE) was 2.1 ± 0.62 kg and 4.9 ± 0.63 kg in the coaching and tracking groups, respectively. The between-group difference in weight change at 24 months was significant (-2.86 kg [95% CI, -4.60 to -1.11 kg]) in the linear mixed model. At 24 months, 65% of participants in the coaching group and 50% in the tracking group maintained weight loss of at least 5%. Limitation Single-site trial, which limits generalizability. Conclusion Among adults with intentional weight loss of at least 5%, use of EHR tools plus coaching resulted in less weight regain than EHR tools alone. Primary funding source Agency for Healthcare Research and Quality and National Institutes of Health.

OBJECTIVES Concern about falling is common among older hypertension patients and could impact decisions to intensify blood pressure therapy. Our aim was to determine whether intensive therapy targeting a systolic blood pressure (SBP) of 120 mm Hg is associated with greater changes in concern about falling when compared with standard therapy targeting an SBP of 140 mm Hg. DESIGN Subsample analysis of participants randomized to either intensive or standard therapy in the Systolic Blood Pressure Intervention Trial (SPRINT). SETTING Approximately 100 outpatient sites. PARTICIPANTS A total of 2313 enrollees in SPRINT; participants were all age 50 or older (mean = 69 y) and diagnosed with hypertension. MEASUREMENTS Concern about falling was described by the shortened version of the Falls Efficacy Scale International as measured at baseline, 6 months, 1 year, and annually thereafter. RESULTS Concern about falling showed a small but significant increase over time among all hypertension patients. No differences were noted, however, among those randomized to intensive vs standard therapy (P = .95). Among participants younger than 75 years, no increase in concern about falling over time was noted, but among participants aged 75 years and older, the mean falls self-efficacy score increased by .3 points per year (P