The Role of Positive Deviance in Simplifying Complicated Changes

Christopher N. Sciamanna, MD, MPHProfessor of Medicine and Public Health Sciences

Chief, Division of General Internal MedicinePennsylvania State University

1999

2008

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Epidemic, BRFSS Data

National Health and Nutrition Examination Survey, 1994-2004

Diabetes Epidemic, NHANES Data

The benefits of weight loss; blood pressure

Stevens, V.J., et al., Long-term weight loss and changes in blood pressure: results of the Trials of Hypertension Prevention, phase II. Ann Intern Med, 2001. 134(1): p. 1-11.

The benefits of weight loss; diabetes control

Pi-Sunyer, X., et al., Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes: one-year results of the look AHEAD trial. Diabetes Care, 2007. 30(6): p. 1374-83.

Content of Typical Weight Loss Program: The Behavioral “Package”

• Food and activity record keeping (self-monitoring)• Controlling cues associated with eating (stimulus control)• Nutrition education• Slowing eating• Physical activity• Problem-solving• Cognitive restructuring (cognitive therapy)

Foster, G.D., A.P. Makris, and B.A. Bailer, Behavioral treatment of obesity. Am J Clin Nutr, 2005. 82(1 Suppl): p. 230S-235S.

Efficacy of Various Interventions for Weight Loss Over Time

Franz, M.J., et al., Weight-loss outcomes: a systematic review and meta-analysis of weight-loss clinical trials with a minimum 1-year follow-up. J Am Diet Assoc, 2007. 107(10): p. 1755-67.

Baranowski, T., K. W. Cullen, et al. (2003). "Are current health behavioral change models helpful in guiding prevention of weight gain efforts?" Obes Res 11 Suppl: 23S-43S.

Why is behavior change so hard?

Behaviors are made up of many, many possible new habits.

LEARN MANUAL: change requires >150 habits (e.g., breakfast, water)

Which habits for whom and in what order?

Why is behavior change so hard?

Wansink, B., et. al., Mindless Eating: The 200 Daily Food Decisions We Overlook. Environment and Behavior, 2007. 39(1): p. 106-123.

Why is behavior change so hard?

Sciamanna, Tate, Wing, et. al. (2000). Arch Intern Med 160(15): 2334-2339.

It’s so hard, doctors don’t talk about it

Are behaviors strategies or practices?

Where would decreased caloric density fit in this model?

What do we know about effective weight control practices? Eating Behaviors

Inventory

O'Neil, P.M., et al., Development and Validation of the Eating Behavior Inventory. Journal of Behavioral Assessment, 1979. 1(2): p. 123-132.

O'Neil, P.M. and S. Rieder, Utility and validity of the eating behavior inventory in clinical obesity research: a review of the literature. Obes Rev, 2005. 6(3): p. 209-16.

What do we know about effective weight control practices? French and Jeffery

French, S.A., R.W. Jeffery, and D. Murray, Is dieting good for you?: Prevalence, duration and associated weight and behaviour changes for specific weight loss strategies over four years in US adults. Int J Obes Relat Metab Disord, 1999. 23(3): p. 320-7.

What do we know about effective weight control practices? National Weight Control

Registry

Klem, M.L., et al., A descriptive study of individuals successful at long-term maintenance of substantial weight loss. Am J Clin Nutr, 1997. 66(2): p. 239-46.

National Weight Control Registry: Practice use and improved weight loss

maintenance• Lower fat diet (Wyatt, 1995)• Regular breakfast (Wyatt, 2002)• Less dietary variety (Raynor, 2005)• Less television viewing (Raynor, 2006)• Self-weighing (Butryn, 2007)

National Weight Control Registry: Methodological Limitations

• Limited number of practices surveyed• Self-selected sample (mainly female, educated)• Used little to examine differences in practices and weight

change• Weight data is self-reported• Weight loss was, on average, 5.5 years ago

Positive Deviance: What is it?

APPLICATIONS• Avoiding HIV Infection

(Friedman, 2008)• Improving Myocardial Infarction

Care (Bradley, 2006)• Smoking cessation (Awofeso,

2008)• Business practices (Collins,

2001)• Infection rates (Hopkins, 2002)

Positive Deviance: Improving Myocardial Infarction Care

WHAT DID THEY DO?• Emergency medical service

routinely calls in or transmits results of ECG

• Dedicated space in triage area for immediate ECG

• Undergo an ECG en route to hospital

• An attending cardiologist is always at the hospital

Positive Deviance: Improving Myocardial Infarction Care

Bradley, E.H., et al., Strategies for reducing the door-to-balloon time in acute myocardial infarction. N Engl J Med, 2006. 355(22): p. 2308-20.

Applying Positive Deviance to Weight Loss Maintenance: Study Design

STUDY 1: QUALITATIVE• In-depth interviews • 65 adults successful in long-term weight loss (30 lbs, 1

year)• Willing to provide a non-family reference to validate loss

IN-DEPTH INTERVIEW QUESTIONS:• “What habits do you use regularly now to lose weight or to

maintain a healthy weight?” • Now, let’s start with the action habits – What do you DO

regularly that you think helps you to lose weight or to maintain a healthy weight?

• Now, let’s discuss your mental habits – What do you THINK ABOUT OR REMIND YOURSELF OF regularly that you think helps you lose weight or to maintain a healthy weight?

Applying Positive Deviance to Weight Loss Maintenance: Collapsing Practices

Replace high-calorie foods or drinks with those that have fewer calories.

• “I choose sherbet over ice cream”• “I choose fish and poultry at restaurants and avoid pasta”• “I drink skim milk and eat light yogurt… I use splenda in my

tea”

Eat plenty of fruits or vegetables• “I buy fruits and vegetables for smoothies. I love beet, carrot,

celery, honey bells (type of orange) smoothies” • “I have always eaten well. I love fruits and vegetables and

salad…. Eating salad can make me full in my head, but not in my stomach. I have to have a salad with lunch and dinner”

• “I have added more fruits and vegetables to my diet”

Applying Positive Deviance to Weight Loss Maintenance: Survey

DESIGN• Population: 1212 US Adults (Knowledge Networks, Inc)• Cross-sectional survey• Response Rate: 67.6% (of 1793)

KEY VARIABLES• Maximum weight• Weight 1 year ago• Current weight• Trying to lose weight• How long ago started current weight loss attempt• Practice use in past week (never, seldom, occasionally,

often, very often)

Applying Positive Deviance to Weight Loss Maintenance: Survey

MODIFIED VARIABLES

WEIGHT LOSS IN CURRENT ATTEMPT• Current weight – weight at beginning of weight loss attempt• Limited to those trying to lose weight (n=592)• Higher weight loss (> 5 lbs) v. Lower weight loss (≤ 5 lbs)

LONG-TERM WEIGHT LOSS MAINTAINER• Weight 1 year ago at least 10% less than maximum weight• Current weight at least 10% less than maximum weight• Limited to those whose BMI at maximum weight was > 25.0

PRACTICE USE• High (often/very often) v. Low use (never, seldom,

occasionally)

Applying Positive Deviance to Weight Loss Maintenance: Results

FREQUENCIES• 64.7% overweight or obese (v. 63.2 – BRFSS)• 70.3% non-hispanic white (v. 65.6 – Census)• 21.0% long-term weight loss maintenance (v. 17.3% in

NHANES)• 3.0% using a weight loss program• 60.4% avoid eating or drinking too much while out

Applying Positive Deviance to Weight Loss Maintenance: Results

ADJUSTED ANALYSIS• Most dietary practices were associated with short-term

success• Only a few dietary practices were associated with long-term

success• Only one cognitive practice was associated with short-term

success• Many cognitive practices were associated with long-term

success, though none are in the EBI, NWCR or measure from French and Jeffery. Some are in newer measure from Nothwehr.

• Only one physical activity practice was associated with long-term success; having a routine.

• Only one tracking practice was associated with long-term success; self-weighing

• Only 4 practices were associated with long-term success but NOT short-term success

Applying Positive Deviance to Weight Loss Maintenance: Limitations

• Cross-sectional study• One question used to measure a practice• No reliability data• Weight self-report is inaccurate• No observational data• No interviews were done with people who were not

successful

Applying Positive Deviance to Weight Loss Maintenance: Conclusions

• All practices may not be helpful• Practices associated with success differ during weight control

process• Practices that were helpful early on, may not be helpful later

on• Is there a silent transition?• Might maintenance interventions just require the use of

different practices?• Does this just mean that use of practices decreases over

time

• One question used to measure a practice• No reliability data• Weight self-report is inaccurate• No observational data• No data from people who were not successful

Applying Positive Deviance to Weight Loss Maintenance: Next Steps

• Can an intervention be created simply by encouraging the use of specific practices?

• If it were that simple it could be used by: doctors, successful peers, online (www.achievetogether.com)

• How to create a similar, validated measure.• How to address the barriers to implementing practices?• Could this approach be used for other behaviors

THANK YOU!

Any questions, please email cns10@psu.edu

Obesity Epidemic, BRFSS Data

Obesity Epidemic, BRFSS Data

Obesity Epidemic, BRFSS Data

Obesity Epidemic, BRFSS Data

Obesity Epidemic, BRFSS Data

Obesity Epidemic, BRFSS Data

Obesity Epidemic, BRFSS Data

CASE

• Your patient is a 43 year old white male nonsmoker, with controlled hypertension on lisinopril, persistent asthma and intermittent depression. His father had type 2 diabetes, an MI at age 61 and his mother had an MI at age 74. His BMI is 29.4. He has no diabetes or known heart disease. His total cholesterol is 245, his HDL is 62, his TG are 165 and his LDL is 150 and his liver function tests are normal.

• How many risk factors for CAD does he have?

CAD RISK FACTORS

Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III)." JAMA, 285(19): 1001;

2486-97.

RISK FACTORS1.Hypertension only

NOTES--OBESITY not a RF--DIABETES not a RF, but guides TX goal

NEXT STEPS

• Your patient is a 43 year old white male nonsmoker, with controlled hypertension on lisinopril, persistent asthma and intermittent depression. His father had type 2 diabetes, an MI at age 61 and his mother had an MI at age 74. His BMI is 29.4. He has no diabetes or known heart disease. His total cholesterol is 245, his HDL is 62, his TG are 165 and his LDL is 150 and his liver function tests are normal.

• What is the next best step:• 1. Encourage him to lose weight and change his diet and recheck his

lipids in 12 months.• 2. Start him on a low dose of a statin and recheck his lipids and liver

function in 2 months.• 3. Start him on fish oil and recheck his lipids and liver function in 2

months• 4. Start him on long-acting Niacin 500mg and increase it to 2000mg

over the next month and recheck lipids and liver function in 2 months.

ATP3 Guidelines (JAMA, 2001)

ANSWER; Encourage weight loss and recheck in 12 months

When to calculate Framingham Risk:……… 2+ Risk FactorsLDL to start treatment then depends on 10 year risk.

AFCAPS (Downs, JAMA, 1998)

DESIGN: RCT (6605 subjects, mainly men)INCLUSION: No CAD, average LDL (150), below average HDL (36)TREATMENT: Lovostatin 20 (↑ to 40 if LDL>110) v. Placebo

AFCAPS Results on Lipids

AFCAPS: Effects on Mortality

How many people would you need to treat to prevent one CAD event?

NUMBER NEEDED TO TREAT (MKSAP 14, Foundations of Internal Medicine,

Page 16)

* p<0.05, ** p<0.01

ANSWER: 25 (NUMBER NEEDED TO TREAT)

NNT= 1/ (Incidence in Placebo- Incidence in Active Treatment)

1 / (.109-.068)1 / (.041) ~ 25

Why use NNT?

CASE 2

Your patient is a 62 year old male with a history of type 2 diabetes, hypertension, high cholesterol and smoking, who has been taking atorvastatin for 3 years and he comes in with complaints of muscle aches in his quadriceps and arms, but not his shoulders. Your history and examination reveal no trauma, weakness or joint swelling.  What would be the next best step? 1. Stop the atorvastatin for 3 months and see if symptoms improve?2. Switch the atorvastatin to simvastatin to see if symptoms improve?3. Switch the atorvastatin to pravastatin to see if symptoms improve?4. Check a CPK to rule out myositis5. Check an ESR to rule out polymyalgia rheumatica

CASE 2: Answer 4: Check CPK

Jacobson, The Safety of Aggressive Statin Therapy, Mayo Clinic Proceedings, 2006

CASE 2

Your patient is a 62 year old male with a history of type 2 diabetes, hypertension, high cholesterol and smoking, who has been taking atorvastatin for 3 years (LDL = 105) and he comes in with complaints of muscle aches in his quadriceps and arms, but not his shoulders. Your history and examination reveal no trauma, weakness or joint swelling. Two months later he feels fine and now is asking if he should have his C-Reactive Protein Tested?

Should you do it?

JUPITER

DESIGN: Randomized Controlled Trial: (Rosuvastatin 20mg v. placebo)SUBJECTS: 17,800 men, normal LDL, elevated CRP (>2.0), TG<500EXCLUDED: CVD, statin or HRT use, inflammatory conditionsNOTE: He would not have been included, as he is on a statin

JUPITER: Effect on Lipids, CRP

JUPITER, Effect on CAD Incidence

CASE 3

A 58 year old patient of yours has diabetes and an LDL of 133 (target < 100 in diabetes), despite being on 80 mg of atorvastatin. Other than verifying adherence to the medication, what should you recommend? 1. Add Ezetimibe 10mg2.Add Niacin 500mg and increase to 1000mg over next month3.Add Fenofibrate 200 mg4.Add Cholestyramine 4 grams/day5. Recheck lipids on 12 months

CASE 3: Niacin or Cholestyramine

Nicotinic Acid: Contraindication: Diabetes (relative)

Ezetimibe

DESIGN: RCT (Simvastatin 80mg ± Ezetimibe 10mg)SUBJECTS: 720 Patients with Familial HypercholesterolemiaEXCLUDED: CVD, statin or HRT use, inflammatory conditions

ENHANCE: Effects on Lipids

ENHANCE: Effects on Intimal Medial Thickness

What is the safest statin?

Simvastatin – Rosuvastatin - Pravastatin - Lovastatin - Atorvastatin

Pravastatin: The rest are mainly metabolized via the Cytochrome P450 3A4 pathway, which is busy at metabolizing many other drugs. Rosuvastatin is probably second, as it is mainly metabolized by another pathyway.

Statin Interactions

Name the top drug classes with interactions with statins?

1. Fibrates (muscle toxicity)2. Coumadin (increased INR – all statins)3. Azole antifungals (muscle toxicity)4. Digoxin (muscle toxicity)5. Macrolides (muscle toxicity)6. Protease inhibitors (muscle toxicity)

CASE 4

Your 62 year old patient with diabetes loses 30 pounds and gets his LDL to 99 and he is quite happy. His TG, however, remain elevated at 212. His BMI is now 26.5, down from 28.1. What do you recommend? A.Start fish oil at 1000mg per day and increase to 2000mg per day before checking lipids in 2 monthsB.B. Start 500mg/day extended release niacin and increase to 1000mg/day before checking lipids in 2 monthsC. Congratulate him on his weight loss and see if he can lose some moreD. Ask him to cut down on dietary fats

CASE 4

ANSWER: C

Dietary Changes

The diet component that is most likely to raise triglycerides is? 1. Fat2. Carbohydrate3. Protein

CARBOHYDRATES

Correctly answered by 78% of Cardiologists, 47% of Internists.

DOES DIET AND WEIGHT LOSS MAKE A DIFFERENCE?

DESIGN: RCT (3 types of diet)SUBJECTS: 811 overweight adultsDIETS: % fat, protein, and carbohydrates in the four diets were 20, 15, and 65%; 20, 25, and 55%; 40, 15, and 45%; and 40, 25, and 35%.

Sacks: Dietary Adherence

Sacks: Effect on Weight

Sacks: Effect on Cholesterol

Can People Lose Weight and Keep it Off?