Matthew Feldman, Ph.D., MSW Jenny Torino, M.S., R.D. Gay Men’s Health Crisis

1. Moving from practice evaluation to intervention research: Group services to improve body image and nutrition among HIV-positive men who have sex with men (MSM) Matthew Feldman, Ph.D., MSW Jenny Torino, M.S., R.D. Gay Men’s Health Crisis

2. Overview • Overview of program evaluation at GMHC • Creation, implementation, and evaluation of a group to help MSM living with HIV/AIDS adopt healthy nutritional habits by improving body image • Process of moving from program evaluation to intervention research

3. Program Evaluation at GMHC Process Evaluation • Are service goals being met? • Is a service being used? • Is the target population for a service being reached? Outcome Evaluation • Are there improvements in the target behavior?

4. Program Evaluation Resources at GMHC • Department of Health Informatics • Program Services Evaluation Committee

5. Recent Evaluation Projects Process Evaluation • Rapid Response System • Care Coordination deliverables Outcome Evaluation • Art therapy • Body Image Group

6. Body image among people living with HIV/AIDS Three main spheres of influence on body image1 • Physical • Psychological • Social 1Chapman, 1998

7. Physical aspects of body image • Physical changes impact how we feel about our bodies • Illness increases awareness of the body • Anti-contagion measures • Regular CD4 count and viral loads • Bodily changes due to side effects from medications

8. Psychological aspects of body image • Anxiety • Fear • Frustration • Uncertainty about the cause of bodily changes and declining health

9. Social aspects of body image Five dimensions of stigma1 • Concealability • Course/predictability • Peril • Disruptiveness • Origin 1Jones et al., 1984

10. Body Image among men living with HIV/AIDS • 31% of HIV-positive or at-risk men reported negative body image1 • Current perception of body image was less than prior to HIV infection and greater than their perception of how others view people with HIV.2 1Sharma et al., 2007 2Martinez et al., 2005

11. Body Image among men living with HIV/AIDS • Body image dissatisfaction is associated with depression, anxiety, stress, poor self-reported health, and a lack of social support among people living with HIV/AIDS (PLWHA).1,2 • HIV-positive men may engage in potentially harmful behaviors to attempt to control bodily changes, including taking steroids and unhealthy nutritional habits.3-5 1Fingeret et al., 2007 2Sharma et al., 2007 3Halkitis et al., 2004 4Power et al., 2003 5Reynolds et al., 2006

12. Body image among MSM MSM are more likely than heterosexual men to: • Have an eating disorder diagnosis1-3 • Experience body image dissatisfaction4-12 • Be more preoccupied with their weight13,14 • Report lower ideal weights and desire to be thinner6,15,16 1Carlat et al., 1997 9Siever,1994 2Feldman & Meyer, 2007 10Silberstein et al.,1989 3Herzog et al., 1984 11Yager et al., 1988 4Beren et al., 1996 12Yelland & Tiggemann, 2004 5Conner et al., 2004 13Brand et al., 1992 6Kaminski et al., 2002 14Gettelman & Thompson, 1993 7Lakkis et al., 1999 15Brand et al., 1992 8Russell & Keel, 2002 16Herzog et al., 1991

13. Body image among MSM living with HIV/AIDS Themes1 • Weight loss as a visible sign of HIV/disease progression • Avoiding social and sexual activities to pre-empt self consciousness • Experience food as a chore • History of body image dissatisfaction pre-dating HIV • Pervasiveness of gay bodily ideals • Feeling let down by the body • Not knowing when/where weight loss will stop 1Tate & George (2001)

14. Nutrition and HIV • Malnutrition • Metabolic Complications • High Cholesterol • High Blood Sugar • High Triglycerides

15. Body image dissatisfaction and health behaviors • Dietary Restraint • Overeating • Misuse of vitamin, mineral and herbal supplements • Over exercising • Eating Disorders

16. Nutritional Interventions • Nutrition counseling positively impacts weight, calorie intake, CD4 count and quality of life in PLWHA.1-5 • Nutrition and exercise interventions are successful in improving serum lipids and blood sugar levels.6-8 1Chlebowski et al., 1995 2Rabeneck et al., 1998 3Schweck et al., 1999 4Tabi et al., 2006 5Topping et al., 1995 6 Barrios et al., 2002 7Thoni et al., 2002 8Yarasheski et al., 2001

17. Interventions with mental health and nutritional elements • Nutritional Components: • Diet and exercise education and/or counseling1-3 • Mental Health Components: • Support groups1 • Stress management1,2 • Behavior therapy2,3 • Motivational Interviewing3 1Kaiser et al., 1996 2Segal-Issacson et al., 2006 3Reid & Courtney, 2007

18. Interventions with mental health and nutritional elements • Interventions focusing on mental health and nutrition have been successful in improving: • Quality-of-life1-2 • CD4 counts1 • Dietary patterns3 1Kaiser et al., 1996 2Reid & Courtney, 2007 3 Segal-Isaacson et al., 2006

19. Behavioral mediation of the relationship between psychosocial factors and disease progression HIV Disease Progression - CD4 decline - Viral Load Increase - AIDS diagnosis - AIDS defining illness • Psychosocial Factors • Body Image Dissatisfaction Behavioral Mechanisms - Poor nutritional habits Gore-Felton & Koopman, 2008

20. Study Aims To evaluate the effectiveness of a 14-week group Intervention in improving nutritional habits and body image among MSM living with HIV/AIDS.

21. Recruitment and data collection Recruited clients through open houses at GMHC’s dining room Group members completed measures at baseline and at a 3-month reassessment point

22. Intervention • 14 weeks • Weekly 90 minute sessions • Transportation and healthy snacks provided • Group closed to new members after the third session

23. Intervention Curriculum 1. Nutrition and Exercise Education 2. Stress and Coping 3. Media Literacy

24. Measures Nutritional measures Rapid Eating Assessment for Participants-Short Version (REAP-S, Segal-Isaacson et al., 2004) Nutrition knowledge test Body Image measures Body Image Scale (BIS; Martinez et al., 2005) Eating Attitudes Test (EAT-26; Garner et al., 1982)

25. Sample description (n=10) • Mean age: 48 years-old (SD= 1.91; Range= 38-61 years) • African American: 60%; Latino: 40% • Gay/bisexual: 80% • At least some high school: 40%

26. Results

27. Discussion Strengths • Psychoeducation modality • Men of color • High rate of participation Limitations • Small sample • Lack of strict eligibility Criteria • Low literacy

28. Potential changes for future group cycles • Stricter eligibility criteria • Additional tools to measure body image, quality of life • Revised Nutrition Knowledge Test • Revising content of intervention • Women’s Body Image Group

29. Moving towards intervention research: Progress and opportunities • Submitted paper summarizing evaluation to AIDS Care • Designing quantitative study to assess the prevalence of body image dissatisfaction among MSM living with HIV/AIDS • Conference call with NIMH project officer to discuss next steps in applying for a grant to support further development and testing of this intervention

30. Moving towards intervention research: Challenges • Ethical challenges of more rigorous research designs in the context of community-based organizations • Thin line between research and evaluation: When is consultation with an IRB necessary?