Carla Jimenez's story is not just about weight loss. It's about talent, acceptance, and breaking barriers in Hollywood. While weight loss journeys often dominate narratives, Jimenez's experience highlights the importance of valuing comedic talent and challenging stereotypes.
Embracing the Role of Alba in "The Mick"
In the television series "The Mick," Carla Jimenez embodies the character of Alba, a multifaceted individual who serves as a guardian to the Pemberton children. Alba's character is portrayed as a rebel, unafraid to explore unconventional experiences. What sets Alba apart is that she is never the target of jokes related to her weight or age.
Jimenez expressed her appreciation for the role, emphasizing that she was hired for her comedic talent rather than her physical appearance. She noted that the humor associated with Alba's character stems from the material and is not dependent on age or weight. This aspect of the role resonated with Jimenez, as it allowed her to showcase her comedic abilities without being subjected to stereotypical jokes.
Body Diversity in Hollywood
When asked about body diversity in Hollywood, Jimenez acknowledged that progress has been made, but challenges still exist. She noted that many doors remain closed, making it difficult for actors who do not fit conventional beauty standards to find opportunities.
Despite these challenges, Jimenez has remained steadfast in her commitment to roles that align with her values. She has turned down roles that would compromise her self-respect and emphasized the importance of actors not sacrificing their pride for the sake of employment.
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The Importance of Self-Acceptance
Jimenez's experience underscores the importance of self-acceptance and challenging societal norms. Her role as Alba celebrates individuality and defies stereotypes, sending a positive message to viewers.
Overweight and Obesity in Individuals with Mental Illnesses
Overweight and obesity are widespread problems, but are disproportionately prevalent among individuals with serious mental illnesses. Lifestyle change interventions effectively facilitate weight loss, including among this group. Such interventions are helpful because they address access to and affordability of healthy foods, safe places to exercise, and education and skills that support attempts to lose weight and improve and maintain health. Because lifestyle modification interventions have only recently been adapted for overweight people with mental illnesses, we have little information on the experiences of those participating in these interventions, including what motivates them to change their lifestyles, what enables adoption of healthier habits, which components of interventions are most valued, and what additional resources and supports are needed to further maximize benefit.
As part of a 24-month study of the STRIDE weight loss and lifestyle-change program for adults taking antipsychotic medications, researchers interviewed a sample of study participants at three time points to assess lifestyle change barriers and facilitators across the first 18 months of study participation. As part of a process evaluation of the STRIDE mixed-methods randomized control trial, qualitative interviews with intervention and control group participants were conducted at 3, 9, and 18 months (mid-way through the intensive phase of the intervention; mid-way through the maintenance phase; 6 months after the intervention ended).
STRIDE participants were at least 18 years of age, stable on antipsychotic medications for at least 30 days, and had a BMI≥27. Those interested in the study (n=408) participated in a screening visit. Researchers excluded anyone who was pregnant or planning a pregnancy during the study period, enrolled or planned to enroll in a weight-reduction program, planning or had completed bariatric surgery, or had cognitive impairment that prevented informed consent. Two hundred participants were randomized to intervention or control conditions.
The intervention consisted of 24 weekly meetings that targeted readiness to change; included interactive, participant-centered delivery of lifestyle education information along with a 20-minute walk; encouraged skills practice, self-monitoring and feedback; and facilitated group interactions and support. Intervention participants could consult with interventionists by telephone as needed. These were similar to food logs used in PREMIER. Interventionists reviewed logs with participants weekly and gave feedback. Six monthly group maintenance sessions followed the weekly meetings. All sessions were co-led by a mental health counselor and another interventionist familiar with nutrition interventions.
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All participants completed questionnaires, laboratory and anthropometric measures, and were weighed at baseline, 6, 12, and 24 months. The protocol and main outcomes are described elsewhere. The study was approved by the Kaiser Permanente Northwest Institutional Review Board.
Interviews addressed efforts to change eating habits, increase exercise, and lose weight, and explored barriers to and facilitators of those changes. Intervention arm participants were also asked specifically about engagement with the intervention. The intervention was delivered in eight cohorts and researchers attempted to select ten intervention participants and three control participants from each cohort for interviews. Researchers also oversampled minority group members at each time point and balanced the 3-month interview sample on BMI category (27-34.9, ≥35), the stratification criteria used for randomization. For the 9-month interviews, weight change from baseline to 6 months was calculated; at the 18-month interviews, 12-month weight change was calculated, sampling from those who had lost or gained weight in order to gather information from people with differential experiences. Researchers attempted to contact 91 participants and were unable to reach three; three more agreed to the interview but did not complete the interview despite efforts to reschedule.
Master’s- and doctoral-level research staff conducted the interviews, which were 30-60 minutes long and were audio-recorded and transcribed verbatim. The research team read transcripts throughout data collection to ensure accuracy, then developed a general descriptive coding scheme. Code definitions included examples of text generated after careful reading of a subset of transcripts. Analyses for this report were based on text coded, using Atlas.ti (Friese, 2011), with the broad descriptor “barriers and facilitators.” Coded text was further reviewed for subthemes and explanations of: 1) how and why specific barriers and facilitators affected participants, and 2) circumstances under which barriers and facilitators were encountered. To ensure rigor, check coding was completed on 15% of the transcripts, achieving 79% agreement between primary and secondary coders.
Interviewees averaged 48 years old; 36% were men, and 21% were members of racial or ethnic minorities. Participants had diagnoses of schizophrenia or schizoaffective disorder (41%), bipolar disorder (20%), affective psychosis (37%) or PTSD (2%). Forty-six (55%) were from Kaiser Permanente cohorts and 38 (45%) were from community mental health centers. BASIS-24 depression subscale scores averaged 1.7 (SD=1.0) and psychosis subscale scores averaged 0.84 (SD=1.0).
Twelve themes were identified in the analyses of lifestyle change barriers and facilitators. Barriers tended to be consistent across intervention and control arms, and stable across time. Reasons for wanting to enroll and participate in STRIDE did not differ by study arm.
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On the topic of health and health risks, one participant who was worried about her family history of diabetes, said “One of the reasons why I wanted to be part of this study was to be healthier… My dad was a big guy and he developed diabetes, and he had to have surgeries and all kinds of stuff. I don’t want to do that later in life. You know, I’m trying to avoid getting diabetes. I don’t want to have to go through any weight loss surgery and stuff like that. That’s stuff I worry about”; (intervention arm, 9 months). Some STRIDE participants felt that the intensity or rapidity of their weight gain on psychiatric medications necessitated action. “When I went on Zyprexa I gained a hundred pounds, very quickly. And that was really frustrating for me, because I had worked really hard to get me down to where I was”; (control arm, 3 months). Another participant noted that she was “hoping to get some kind of control over my weight. I have been on medications that have severely increased my weight…And just hoping and praying that this will…work.
Early in analyses, it was noted that many participants’ experiences with lifestyle change barriers and facilitators were similar to those reported in lifestyle change studies in other populations. Family members who did not support improved lifestyle were particularly problematic when it came to making dietary changes or managing tempting foods. Temptation to eat junk food and exposure to unhealthy eating among family members were commonly noted: “My husband verbally supports me but he eats whatever he wants to eat and has it in the house”; (intervention arm, 9 months). Social gatherings also presented barriers: “If I’m at my mom’s place then she usually has some food out there…[and] my wife likes to go out to McDonald’s quite a bit. Social situations where I’m encouraged to eat…restaurants often offer huge portions.
Participants reported various ways that the pleasant flavors of unhealthy foods presented barriers to healthier eating choices. It is noteworthy that the desire for pleasant-tasting but unhealthy foods was distinct from the dislike of healthy foods. In fact, some participants said they enjoyed eating healthy foods as a result of their participation in the intervention: “I’m finding out that I like some things that I didn’t think I’d like. You know, like….more vegetables, more fruit. Ever since the program, I think I’ve ate a lot more of that kind of stuff than I have in years”; (intervention arm, 18 months). Nevertheless, many more interviewees mentioned the lure of unhealthy foods: “I’m not using anything [learned in the program] now…I decided I like eating badly”; (intervention arm, 18 months).
The most commonly named barrier to physical exercise was bad weather, mentioned by many participants, across all interview time points. “I’m kind of an all or nothing person. And the weather holds me back. I count on walking outside a lot…in the spring it was so beautiful that I was out walking and focusing on my diet. And then I got sloppy with that. I don’t like to walk in the mall, and I don’t like to walk in the cold, the rain”; (intervention arm, 3 months).
Receiving positive attention for weight loss was a common facilitator that fortified change efforts. One woman said “My family is starting to notice that I’m losing weight. I like the positive comments…I feel like I’ve got more energy and more motivation to do stuff”; (intervention arm, 3 months). For another participant, continued weight loss or maintaining weight during the less intensive phase of the intervention helped keep up momentum: “The reinforcement of coming in and having [group leader] weigh me, write it down.
Certain barriers, while also commonly observed in the general population, appeared to be more detrimental to behavior change efforts in the sample of individuals with serious mental illnesses. In the sample, mental health symptoms were mentioned as barriers to both healthy eating and regular exercise. A link between depression and poor eating choices was typical: “I was just feeling really horrible. And I make bad food choices when I’m feeling really horrible, which gets me more depressed, you know? And it’s kind of a cycle”; (intervention arm, 3 months). Another said, “The more symptomatic I get, the harder it is to get myself out of the house to do stuff…And I’m trying to exercise because it helps clear my head of stuff”; (intervention arm, 9 months).
Another common response across participants was what they called “laziness,” generally described as a lack of motivation or a weariness that came with having to maintain the effort that dietary changes and regular exercise require. “Yeah, laziness. [Chuckles] You know what I mean? Sometimes I just don’t feel like making something nutritional. So I’ll have a bowl of cereal with sugar on it”; (intervention arm, 3 months). Another participant said: “I just get lazy sometimes. I just don’t want to do it, so I sit on the couch and watch TV”; (intervention arm, 9 months). This feeling is not uncommon among those attempting to lose weight generally, nor is it unique to the sample.
Several participants described how exercise motivation interacted with social support, and it was common for participants to mention loss of external exercise motivation when exercise partners were not available: “…having a buddy to walk with helps a lot. You can talk while you’re walking and it doesn’t seem like it is taking so long to do the walk. So that helps. That’s one of the reasons why I do it with my friend. When I’m at home I don’t have anybody to walk with. So there’s not so much of a reason to do it”; (intervention arm, 9 months). To the extent that one’s mental illness has resulted in social skills deficits or social isolation, accountability to a group and social support that make it easier to receive encouragement and reinforcement for healthy behavior may be particularly important. Another participant said, “I used to exercise with a group of people, and we just always met at the gym all the time. We gave each other a lot of support and stuff, and had a really good time. That was when I lost quite a bit of weight during the time.
The most important facilitator of dietary changes and increased exercise was active engagement in the intervention. Attendance at the weekly group sessions, along with turning in a weekly food and exercise log and being weighed, were important motivators for the majority of intervention participants. Several people noted that accountability to self, to other group members, and to group leaders is what led to behavior changes. For example, one participant reported: “Well, just knowing that I want to be accountable, because I don’t want to disappoint the group or…myself, I guess”; (intervention arm, 3 months). Another participant noted: “The accountability of being part of the group is very important…I had pretty much given up on trying to get to a reasonable weight. Group facilitation of exercise was also important; participants liked the 20-minute walk that was part of each intervention session. Several participants noted feeling accountable to exercising with the group: “[T]he walking [is helpful]. The exercise portion …
Vedolizumab Treatment for Paediatric Ulcerative Colitis
Biologics are recommended to treat paediatric ulcerative colitis (UC) that is chronically active or steroid-dependent despite aminosalicylic acids (5-ASA) and thiopurine treatments. In the current case, the article describes a successful long-term treatment with vedolizumab in a 9-year-old boy with severe UC and primary non-response to infliximab. Concomitant azathioprine was used, and steroid refractoriness was also detected. Drug and anti-drug antibody levels were negative after infliximab induction so a switch to a 6-week-induction vedolizumab regimen followed by a maintenance regimen as a monotherapy was decided. The clinical response and tolerability to vedolizumab allowed long-term disease remission. Vedolizumab is currently non-authorised to treat paediatric patients and there is limited data on long-term treatments to date. Vedolizumab could be considered a second-line biologic therapy in paediatrics when there is a lack of primary response to anti-tumour necrosis factor inhibitors (anti-TNF) or disease remains chronically active or steroid-dependent. The case report demonstrates that vedolizumab therapy is an effective option for achieving long-term responses in children with ulcerative colitis who experience failure with other treatments.
Ulcerative colitis (UC) is an inflammatory bowel disease (IBD) that can affect paediatric and adolescent patients, often presenting a more severe disease course than in adults. Pharmacological treatments for paediatric UC are mainly used to induce and maintain disease remission and optimise growth and quality of life. Biologics should be considered to treat uncontrolled paediatric UC that is chronically active or where the patient has depended on steroids despite aminosalicylic acids (5-ASA) and thiopurine treatments.
Vedolizumab is a humanised α4β7-integrin antagonist, which inhibits T-lymphocyte migration into inflamed intestinal tissue down-regulating intestine inflammation mediated by UC. In 2016, the patient was admitted to the emergency room with a history of having diarrhoea for 5 months. He had 3-5 liquid bloody stools a day, rectal tenesmus, abdominal pain and anorexia. Colonoscopy findings (Mayo Score 3), alterations of analytical parameters (calprotectin level 2287.0 mg/kg stool, normal value ≤50 mg/kg stool) and the biopsy assessment confirmed UC. The patient initiated treatment with both oral and rectal mesalazine (75 mg/kg/day and 500 mg/day, respectively) when required. After 4 months, oral methylprednisolone 1 mg/kg/day was added due to lack of response. Owing to clinical improvement, a tapering steroid regimen was performed. Notwithstanding, the patient’s symptoms worsened and steroids were re-introduced resulting in lower response. At this time, oral azathioprine 1 mg/kg/day was added. Due to a lack of response to salicylates, oral mesalazine was discontinued and the azathioprine dose was increased to 2 mg/kg/day. After 4 weeks of treatment with azathioprine 2 mg/kg/day, regular laboratory monitoring revealed raised transaminase. Hepatic toxicity was suspected and the azathioprine dose was reduced to 1 mg/kg/day resulting in improved liver enzyme values. One year after the onset of UC, laboratory monitoring showed analytical abnormalities suggestive of cholestasis. Magnetic resonance imaging (MRI) revealed irregularity in the walls of the left intrahepatic bile duct and the extrahepatic bile duct, mainly from the common hepatic and from the distal common bile duct. Primary sclerosing cholangitis was detected through anatomopathological study and treatment with oral ursodeoxycholic acid 15 mg/kg/day and fat-soluble vitamins was initiated.
After the fourth dose of infliximab, the patient came to the emergency room with fever lasting 4 days and bloody diarrhoea, thus drug and anti-drug antibody levels were measured to assist in optimising treatment through drug scalation or treatment switch. Drug and anti-drug antibody levels resulted in <0.01 µg/mL and<0 ng/mL, respectively. In January 2019, biologic treatment with intravenous vedolizumab at 6 mg/kg was initiated as an intravenous induction regimen at 0, 2, and 6, weeks followed by a maintenance regimen. The concomitant therapy was oral azathioprine, rectal mesalazine and steroids, although methylprednisolone was tapered down. After 6 weeks, a clinical improvement and weight gain of 5 kg were observed. The stools were solid, non-hematic and calprotectin decreased to 104 mg/kg stool. In March 2022, after 3 years of being treated with vedolizumab, the patient was still in remission with no abnormal findings in colonoscopy. The treatment has been well-tolerated and no signs of intolerance have been observed.
This case is consistent with previously published evidence and suggests that vedolizumab could be an effective and safe alternative to treat paediatric UC. A multicentre retrospective review study performed in three centres in the United States that included 22 children with UC receiving vedolizumab showed that, at 14 week follow-up, 13 patients were in remission according to the Paediatric Ulcerative Colitis Activity Index (PUCAI). There were no infusion-related reactions or serious adverse events at the end of the follow-up. Similarly, the retrospective multi-centre experience from the Paediatric IBD Porto Group of ESPGHAN that assessed 64 paediatric patients with IBD showed that steroid-free remission at the 14 week follow-up was achieved in 37% and 14% of patients with UC and Crohn’s disease (CD), respectively. Moreover, this study only reported three minor drug-related adverse events. Another observational study performed in 12 children from Austria (seven with CD and five with UC) showed that in the UC cohort, complete clinical remission was reached in two patients at week 2, in one patient at week 6, and in one patient at week 14. In this study, one patient discontinued therapy due to a severe general systemic allergic reaction with dyspnoea after the second infusion of vedolizumab. Moreover, another multicentre study performed in Spain included 42 children with IBD (28 with UC and 14 with CD), 22 (52.4%) of whom achieved remission at week 14 (35.7% with CD and 60.7% with UC). Regarding adverse effects, three patients (7.1%) presented with headache, one with alopecia, one with anaemia and one with dermatitis. Another study performed in Poland included 16 patients with IBD (12 with UC) and clinical response at the week 4 dose was observed in 56.3%. No infusion reactions or serious adverse events/infections were observed. These previously mentioned studies only reported short-term experiences with vedolizumab use (1 year follow-up at the most). The case study enhances the published evidence but reports data on a 3 year successful treatment, contributing to existing data on the efficacy and safety of vedolizumab in paediatric patients. At week 14 of vedolizumab treatment, the patient was in clinical remission and remained asymptomatic after 3 years without adverse effects and opportunistic infections.