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James W. West, MD, Quality Improvement Awards: Tackling a weighty issue

April 1, 2009
by Deanna Staub, MHA, LHRM, CPHQ, Mark A. Vargo, PhD, and Tommi L. Leveille
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Operation PAR develops an education program to counteract weight gain among clients enrolled in a methadone program

According to the Centers for Disease Control and Prevention, the percentage of obese adults had doubled from 15% of the population in 1976-1980 to 32.9% in 2003-2004. At Operation PAR, an integrated addiction and mental health services provider headquartered in Pinellas Park, Florida, methadone staff expressed concerns about weight gain in their client population, so the Performance Improvement Program's Pharmacy and Therapeutics (P&T) Committee initiated a study to determine if methadone clients were gaining weight while in the program.

The study's first year (2004-2005) examined new admissions into 4 methadone outpatient programs. Each client's weight (at baseline and 1, 3, 6, 9, and 12 months), height at baseline (used to calculate body mass index, BMI), methadone dosage level (at 1, 3, 6, 9, and 12 months), and gender were recorded, as well as his/her treatment site. Women pregnant at intake or who became pregnant during the study were excluded from the results. Weight gain through the first 9 months was analyzed. Of the 250 new admissions to the programs, 154 clients had been in the programs long enough to have 9 months of data.

A chi-square analysis indicated a statistically significant shift in BMI categories (chi-square value = 144.29, d.f. = 9, p-value < 0.000). Of the 49 clients who shifted categories from baseline, 35 (71.4%) moved to a “worse” category of weight (i.e., away from normal), and 14 (28.6%) moved to a “better” category (i.e., toward normal) (table). Clients gained an average of 11.6 lbs during 9 months and significantly shifted into unhealthier BMI categories. Among the 55 clients with 12 months of data, the average weight gain was 22.1 lbs. Analysis indicated a statistically nonsignificant difference in mean weight gain between the program sites or gender, and no evidence was found for site effect or gender effect on weight gain. We did not analyze the factors for the weight gain.
Members of the pharmacy and therapeutics committee. top row (l to r): bob carpentier, eleanor tierney, carol thornton, mary planthaber, gayle callahan. bottom row: william cox, mary lenard, deanna staub, michael sheehan, md. absent: joanne armstrong, dianne clarke, marcy dallao

Members of the Pharmacy and Therapeutics Committee. Top row (l to r): Bob Carpentier, Eleanor Tierney, Carol Thornton, Mary Planthaber, Gayle Callahan. Bottom row: William Cox, Mary Lenard, Deanna Staub, Michael Sheehan, MD. Absent: Joanne Armstrong, Dianne Clarke, Marcy Dallao. Photo by Bruce Baynard


Table. BMI at baseline and 9 months

BMI category

Number (percent) of clients at baseline

Number (percent) of clients at 9 months

Underweight

6 (3.9%)

1 (0.6%)

Normal

71 (46.1%)

56 (36.4%)

Overweight

47 (30.5%)

60 (39.0%)

Obese

30 (19.5%)

37 (24.0%)

Total

154 (100%)

154 (100%)


Based on the first year of data, the P&T Committee decided to implement a nutrition education program as part of monthly counseling services. Eight single-page educational handouts were developed with a dietitian and certified dietary manager to address everyday eating habits:

  • Nutrition basics

  • Explanation of body mass index

  • Tips for choosing healthy foods when eating out

  • Fats of life

  • How to read food labels

  • Myths and facts about snacking

  • Use of salt

  • Facts about sugar

The nutrition education program involved reviewing these handouts with clients. To determine if the program was effective, the project was extended into a second year, during which nursing staff collected data on the same variables at the same time intervals. The second-year project aimed to determine:

  1. What is the effect of enrollment in a methadone program on weight during a 2-year period?

  2. Does the nutrition education program have any effect on weight gain?

To answer the first question, the clinic in Bradenton continued documenting clients' methadone dose and weight through the second year but did not provide them nutritional education. To answer the second question, the Pasco clinic also continued documenting clients' methadone dose and weight through the second year but provided nutritional education monthly throughout the year. At the Clearwater clinic, staff collected data for all new methadone clients and provided nutritional education throughout the year.

During the 2-year period, clients at all three locations continued to gain weight. On average, females gained twice as much weight as males (41 vs. 20 lbs) over 2 years at the Bradenton clinic. However, at the Pasco Clinic, which offered nutritional education, females gained only an average 22.5 lbs and the males 9.5 lbs after 2 years. At the Clearwater clinic, where the nutrition education program was implemented at admission, weight gain after 1 year was an average 12.3 lbs for females and 4.5 lbs for men (For detailed statistical information, e-mail dstaub@operpar.org).

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