Project Today We Will Describe outcome measures relevant to healthy weight program HWP evaluations Identify valid reliable and generalizable tools andor methods to collect outcome measures ID: 912921
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Slide1
Outcome Measures
Session 4: Collaborative Learning
Project
Slide2Today We Will
…
Describe outcome measures relevant to healthy weight program (HWP) evaluations
Identify valid, reliable, and generalizable tools and/or methods to collect outcome measuresPrioritize outcome measures to identify core measures to include across HWPs
Slide3Anthropometric and Behavioral Outcomes
Bill
Stratbucker
, MD, MS
Associate Professor
Michigan State University
Slide4General Considerations
Identify outcomes of interestBalance feasibility and validityUnderstand / educate stakeholdersSet expectationsConsider non-anthropometric outcomesUse intermediate outcomesEncourage accountability of measurements
Slide5Anthropometrics - Examples
HeightWeightWaist circumferenceBody composition (body fat %, lean mass)
Slide6Anthropometrics - Reliability
Training of staffConsider the settingPortability of equipmentErroneous measurement (measuring twice to reduce error)
Avoid inconsistent methods of measurementConsider when to measure
Slide7Anthropometrics – Logistics
Cost of equipmentTimeFrequencyOveremphasis of weight (using kilograms)Privacy and acceptability of measurements (e.g., waist circumference)Caregiver(s), sibling(s) measured?
Slide8POWER Site Guidance
The validity of human measurements is crucial to the comparisons we will make between patients and between sites. It is essential to obtain consistent and accurate measurements and documentation. Rather than prescribe human measurement procedures, POWER offers the following guidance: (National Health and Nutrition Examination Survey (NHANES) Anthropometry Procedures Manual):
Height: Depending on the overall body conformation of the individual, all of the four contact points— head, shoulders, buttocks, and heels—may not touch the stadiometer backboard. In such instances, the patient should be as vertical as possible.
Weight: Patients are asked to remove shoes or any extra layers of clothing (sweaters, 2
nd shirt, belt). Pockets should be emptied (e.g., cell phone, wallet, keys) and any heavy jewelry should be removed.
Slide9Measuring Anthropometric Change Over Time
HeightWeightBMIBMIz% of the 95th percentileWeight gain velocity
Waist circumference
Slide10No trajectory change BMI%ile increases
BMIz increases%95th%ile increasesTrajectory alteredBMI%ile maintained
BMIz decreased%95
th%ile maintainedBMI maintainedBMI%ile decreasedBMIz decreased
%95th%ile decreasedBMI reduced
Potential Outcomes
Slide11Baseline Anthropometry
Variable
Mean
Standard
Deviation
BMI (kg/m
2
)
34.3
6.8
BMI percentile
98.7
1.3
BMI
z-score
2.37
0.36
Waist circumference (cm)
108.0
18.9
Percent body fat (%)
37.2
9.5
Slide12Z-Scores
Mean BMI z-score = 2.37
Slide13Variable
Baseline
Follow Up
BMI (kg/m
2)34.733.8
BMI z-score
2.39
2.27
BMI percentile
98.7
98.2
Percent
body fat (%)
36.9
33.3
71% of participants reduced their BMI percentile (i.e., reduced BMI trajectory)
Program Results: BMI Centiles
Slide14Variable
Baseline
Follow Up
Change
BMI (kg/m2)
35.8
34.2
-1.6
BMI z-score
2.42
2.26
-0.16
BMI percentile
98.8
98.0
-0.8
51% of participants reduced their BMI
Program Results: BMI Reduction
Slide15Clinically Meaningful Change
% who reached a threshold of improvement in BMIz or %95th%ile0.2 reduction BMIz (USPSTF)5% reduction in %95th
%ile (POWER)
Slide16Physiologic/Metabolic - Examples
Heart rateBlood pressureLipidsGlucoseHgbA1c
Slide17Physiologic/Metabolic
Training of staffEquipment needsRelationship with ordering medical providerSharing of dataLab testing vs. point-of-careNon-fasting vs. fasting
Slide18Physiologic/Metabolic
Measures of fitness (12-minute walk/run, FitnessGram Pacer, Heart rate recovery, etc.)Measures of strength (grip strength)Measures of motor skill developmentSpirometryAll are effort dependent
Slide19Variable
%
Elevated
Baseline
Follow UpChange
Systolic
BP (>120 mmHg)
30%
128.4
126.5
-1.9
Diastolic BP
(>80 mmHg)
10%
84.3
76.9
-7.4
Blood pressure changes in patients with elevated risk
Program Results: Biomarkers
Slide20Variable
Baseline
Follow Up
Change
Total cholesterol (mg/dL)160.2
156.7
-3.5
HDL (mg/
dL
)
41.0
44.5
3.5*
LDL (mg/
dL
)
95.8
87.4
-8.4*
Triglycerides (mg/
dL
)
111.5
114.0
2.5
Glucose (mg/
dL
)
90.9
87.6
-3.3
Mean changes in blood lipids and blood glucose* Statistically significant change (p<0.05)
Program Results: Biomarkers
Slide21Blood lipid changes in patients with elevated risk
Program Results: Biomarkers
Slide22Blood lipid changes in patients with elevated risk
Mean
HDL/LDL ratio
among those with elevated risk changed from
0.28 to
0.35
Program Results: Biomarkers
Slide2322% of patients had elevated blood glucose (>100 mg/dL)
On average, blood glucose levels were reduced to normal (20 mg/
dL reduction).
Program Results:
Prediabetes
Measuring Physiologic/Metabolic Change Over Time
Mean reduction in blood pressureMean reduction in Tchol, LDL, TGMean increase in HDLMean change of “at risk group”% in abnormal range that normalized
Slide25Lifestyle Behavior Change
NutritionPhysical activitySleepSelf-report questionnaireAccelerometer/pedometerLogging
Slide26Lifestyle Behaviors Assessment
FNPA, Family Nutrition and Physical Activity AssessmentFeeding practices surveyParenting style
Sources: Development and Preliminary Validation of a Family Nutrition and Physical Activity Assessment, Ihmels, et. al,
Int J Behav Nutr Phys Act
, 2009. The Feeding Practices and Structure Questionnaire: Construction and Initial Validation in a Sample of Australian First-time Mothers and Their 2-year olds, Jansen, E., et. al,
International Journal of
Behavioral
Nutrition and Physical Activity,
2014.
Slide27Lifestyle Behaviors Assessment
3-day, 7-day food logFood frequency questionnaire24-hour recall (self report, guided)Specific questions from larger survey (e.g., Youth Risk Behavior Survey)Example: Days per week children are engaged in moderate-to-vigorous physical activity
Slide28Slide29Changes in Sedentary Behaviors
*
*
Program Results: Behaviors
Slide30Variable
Baseline
Follow Up
Change
Physical activity (min/d)
18.0
38.3
20.3*
HR
sub-max (
bpm
)
131.32
126.43
-4.89
VO2
max (mL/kg/min)
26.34
27.69
1.35*
Changes in Physical Activity & Fitness
Program Results: Behaviors
Slide31Associated Health ConditionsAsthma
Sleep apneaNon-alcoholic steatohepatitisPrediabetes
Slide32Associated Health ConditionsDefinitions
DocumentationManaged vs. resolved
Slide33Measures Summary
Easy-to-more difficult, feasible-to-less feasibleHeight, weight (multiple outcome variations)Lifestyle behaviors (questions or full surveys)Fitness (resting heart rate,12 min walk/run, heart rate recovery)
Slide34Measures Summary
Easy-to-more difficult, feasible-to-less feasibleBlood pressureWaist circumference Body composition (skin fold, bioelectrical impedance analysis)Metabolic labs (point-of-care, non-fasting)
Slide35Measures Summary
Easy-to-more difficult, feasible-to-less feasibleStrengthMotor skill developmentSpirometryObjective measures of physical activity/nutrition (accelerometer, dietary recall interviews, photo food diary)
Associated health conditions
Slide36Psychosocial Outcomes
Elissa Jelalian, PhD
Professor
Brown University
Slide37General Considerations
What domains of child or caregiver behavior/feelings/attitudes do you expect will be impacted by your intervention?Who is best suited to report on the outcome?
Child < 7 years – caregiver proxyChild >
7 years – child report and/or caregiver proxy, depending on domain of interest
Slide38General domains: physical, social, emotional, and school functioning
Several studies document that children and teens with overweight/obesity report significant impairments in daily functioning relative to healthy weight peers
Among youth with overweight/obesity,
HRQoL decreases as BMI increasesImprovements in
HRQoL are associated with participation in weight control treatment
Health-Related Quality of Life (
HRQoL
)
Slide39General Measure: PedsQL
TM23 itemsMultiple domains:
PhysicalEmotional
Social supportSchool functioningAvailable formats: Child self-report: ages 5–7; 8–12; 13–18Parent proxy: ages 2–4, 5–7, 8–12, 13–18
https://www.pedsql.org/about_pedsql.html
Slide40“Sizing Me Up”
Self-report measuresChildren 5–13 yearsDomains: Emotional, physical, social avoidance, positive social attributes and teasing / marginalization
“Sizing Them Up”
Parent-report measure Youth 5–18 yearsDomains:
Emotional, physical, teasing / marginalization, positive attributes, mealtime challenges and school
Obesity-specific Measures of
HRQoL
The Impact of Weight on Quality of Life-Kids (IWQOL-Kids)
Youth 11
–
19 years
Caregiver proxy and adolescent self-report versions
Physical comfort, body esteem, social life, and family relations
Validated; shown to be responsive to weight change
Slide41Self-Esteem
Broadly defined as thoughts and feelings about oneselfSingle vs. multi-dimensional construct (e.g., academic, physical, social)Fairly consistent literature suggesting decreased self-concept in children with overweight/obesity compared to healthy weightParticular vulnerabilities - physical appearance and social functioningStronger relationship among adolescents, girls, and youth who experience teasing and peer victimization
Slide42Self-Esteem
Majority of studies document increases in self-esteem or components of self-esteem following participation in a pediatric weight control programMixed results as to whether these improvements are related to decreases in weight statusSelf-esteem related to physical appearance seems to show the most consistent improvement following intervention
Slide43Assessing Self-Esteem
Rosenberg Self-Esteem Scale:Unidimensional measure10-item scale that measures global self-worth by assessing both positive and negative feelings about the self Available at no cost
https://socy.umd.edu/about-us/using-rosenberg-self-esteem-scale
Slide44Self-perception Profile for Children/ Self-perception Profile for Adolescents Both measures include multiple domains of competence – e.g., physical appearance, social competence, as well as global self-worth
Can administer subscales of interest rather than the entire questionnaireNeed to monitor administration due to item formatDimensional Measures of Self-Esteem
https://portfolio.du.edu/SusanHarter/page/44210
Slide45Intervention-related Improvements in Self-esteem
Slide46Weight-related Teasing
Commonly endorsed among youth with overweight/obesityPerceptions of Teasing Scale (POTS): 11-items total
General weight teasing (6 items; e.g., people made jokes about you being heavy)General competency (5 items; e.g., “People laughed at you because you didn’t understand something”)
Frequency and associated distress
Slide47Mood
Children’s Depression Inventory 2 (CDI):Children and adolescents aged 7–17 yearsSelf-report and parent report measures
28 items; short form = 12 itemsGold standard, but costly and requires some credentialing
PROMIS® (Patient-Reported Outcomes Measurement Information System) - person-centered measures that evaluate physical, mental, and social health in adults and childrenPROMIS Pediatric Item Bank v2.0:
14-item measureCan be accessed at no cost
Slide48Weight and Shape Concerns/Body Image
Definition of weight and shape concerns – the extent to which weight influences overall feelings about oneselfMay be more appropriate to assess in older children and adolescentsMcKnight Risk Factor Survey: Lengthy measure, but several potentially relevant scales/items: weight teasing; body appearance
“In the past year, how happy have you been with the way your body looks?”; “In the past year, how much has your weight made a difference to how you feel about yourself?”
Body Dissatisfaction Scale: Asks teens to rate their satisfaction with nine body parts on a Likert scale, from ‘extremely satisfied’ to ‘extremely dissatisfied; appropriate for adolescentsFigural Drawings: Comparison between current and ideal
Slide49“Distal” OutcomesSocial anxiety
Family functioningSocial support
Slide50Cautions and Considerations
Screening versus observation of change resulting from interventionExtreme weight control behaviorsLoss of control/binge eatingImplications of assessment for follow-upAvoid measures that provide diagnostic informationAvoid measures that assess specific risk – e.g., suicidal ideation, unless there is a clear plan for responding in real time
Slide51AccessibilityPhysical environmentMaterials and resources
Participant- interventionist communicationUtility of treatment – e.g., topics, effectivenessConvenienceCostDuration
Overall satisfactionOther domains – e.g., challenges, recommendations for improvement
Treatment Satisfaction
Slide52Cost Analyses
Slide53General Considerations
Cost-effectiveness analysis: Does an intervention provide value relative to an existing intervention
Value = cost/relative to health outcomeCost and health outcomesBudget impact analysis:
Assesses whether the valued intervention is affordablePayer perspectiveFocus is on cost
Slide54Costs of Program Delivery: Intervention
Facilitator/coach time spentTrainingDelivering interventionParticipant contacts outside of intervention deliveryMaterial preparation
Multiply hours by hourly wageSpaceCost of materials
Slide55Costs of Program Delivery: Participants
Travel timeTransportation timeOpportunity costs for lost wages – if program time is displacing work timeParticipant time can be estimated based on an average hourly wage rate of US adults from the Bureau of Labor Statistics
Slide56Cost EffectivenessCalculate cost of intervention per unit change in weight status measure for child and caregiver
Slide57RecommendationsBrief assessments that are available at no-cost and are likely to show improvement
HRQoLKey self-esteem domains – physical appearance; global self-worthSatisfaction with intervention to document program strengths and inform quality improvement
Slide58Resources
http://www.healthmeasures.net/explore-measurement-systems/promis/intro-to-promis/list-of-pediatric-measureshttps://www.herc.research.va.gov/include/page.asp?id=budget-impact-analysis
Slide59Discussion Questions
What outcome measures does your program evaluate and why?
What
outcome measures do you believe should be prioritized for HWP evaluation?
What tools and/or methods do you use to evaluate your program’s
outcom
e
measures outlined in Q1?
How does your program use outcome evaluation data to enhance outcomes?