A Combined Patient and Provider Intervention for Management of Osteoarthritis in Veterans: A Randomized Clinical Trial

BACKGROUND

Management of osteoarthritis requires both medical and behavioral strategies, but some recommended therapies are underused.

OBJECTIVE

To examine the effectiveness of a combined patient and provider intervention for improving osteoarthritis outcomes.

DESIGN

Cluster randomized clinical trial with assignment to osteoarthritis intervention and usual care groups. (ClinicalTrials.gov: NCT01130740).

SETTING

Department of Veterans Affairs Medical Center in Durham, North Carolina.

PARTICIPANTS

30 providers (clusters) and 300 outpatients with symptomatic hip or knee osteoarthritis.

INTERVENTION

The telephone-based patient intervention focused on weight management, physical activity, and cognitive behavioral pain management. The provider intervention involved delivery of patient-specific osteoarthritis treatment recommendations to primary care providers through the electronic medical record.

MEASUREMENTS

The primary outcome was total score on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 12 months. Secondary outcomes were WOMAC function and pain subscale scores, physical performance (Short Physical Performance Battery), and depressive symptoms (Patient Health Questionnaire-8). Linear mixed models that were adjusted for clustering of providers assessed between-group differences in improvement in outcomes.

RESULTS

At 12 months, WOMAC scores were 4.1 points lower (indicating improvement) in the osteoarthritis intervention group versus usual care (95% CI, -7.2 to -1.1 points; P = 0.009). WOMAC function subscale scores were 3.3 points lower in the intervention group (CI, -5.7 to -1.0 points; P = 0.005). WOMAC pain subscale scores (P = 0.126), physical performance, and depressive symptoms did not differ between groups. Although more patients in the osteoarthritis intervention group received provider referral for recommended osteoarthritis treatments, the numbers who received them did not differ.

LIMITATION

The study was conducted in a single Veterans Affairs medical center.

CONCLUSION

The combined patient and provider intervention resulted in modest improvement in self-reported physical function in patients with hip and knee osteoarthritis.

PRIMARY FUNDING SOURCE

Department of Veterans Affairs, Health Services Research and Development Service.

Glycemic load, exercise, and monitoring blood glucose (GEM): A paradigm shift in the treatment of type 2 diabetes mellitus

AIMS

This preliminary RCT investigated whether an integrated lifestyle modification program that focuses on reducing postprandial blood glucose through replacing high with low glycemic load foods and increasing routine physical activities guided by systematic self-monitoring of blood glucose (GEM) could improve metabolic control of adults with type 2 diabetes mellitus, without compromising other physiological parameters.

METHODS

Forty-seven adults (mean age 55.3 years) who were diagnosed with type 2 diabetes mellitus for less than 5 years (mean 2.1 years), had HbA1c ≥ 7% (mean 8.4%) and were not taking blood glucose lowering medications, were randomized to routine care or five 1-h instructional sessions of GEM. Assessments at baseline and 6 months included a physical exam, metabolic and lipid panels, and psychological questionnaires.

RESULTS

The GEM intervention led to significant improvements in HbA1c (decreasing from 8.4 to 7.4% [69-57 mmol/mol] compared with 8.3 to 8.3% [68-68 mmol/mol] for routine care; Interaction p<.01) and psychological functioning without compromising other physiological parameters.

CONCLUSIONS

Consistent with a patient-centered approach, GEM appears to be an effective lifestyle modification option for adults recently diagnosed with type 2 diabetes mellitus.

Comparison of low- and high-carbohydrate diets for type 2 diabetes management: a randomized trial

BACKGROUND

Few well-controlled studies have comprehensively examined the effects of very-low-carbohydrate diets on type 2 diabetes (T2D).

OBJECTIVE

We compared the effects of a very-low-carbohydrate, high-unsaturated fat, low-saturated fat (LC) diet with a high-carbohydrate, low-fat (HC) diet on glycemic control and cardiovascular disease risk factors in T2D after 52 wk.

DESIGN

In this randomized controlled trial that was conducted in an outpatient research clinic, 115 obese adults with T2D [mean ± SD age: 58 ± 7 y; body mass index (in kg/m(2)): 34.6 ± 4.3; glycated hemoglobin (HbA1c): 7.3 ± 1.1%; duration of diabetes: 8 ± 6 y] were randomly assigned to consume either a hypocaloric LC diet [14% of energy as carbohydrate (carbohydrate <50 g/d), 28% of energy as protein, and 58% of energy as fat (<10% saturated fat)] or an energy-matched HC diet [53% of energy as carbohydrate, 17% of energy as protein, and 30% of energy as fat (<10% saturated fat)] combined with supervised aerobic and resistance exercise (60 min; 3 d/wk). Outcomes were glycemic control assessed with use of measurements of HbA1c, fasting blood glucose, glycemic variability assessed with use of 48-h continuous glucose monitoring, diabetes medication, weight, blood pressure, and lipids assessed at baseline, 24, and 52 wk.

RESULTS

Both groups achieved similar completion rates (LC diet: 71%; HC diet: 65%) and mean (95% CI) reductions in weight [LC diet: -9.8 kg (-11.7, -7.9 kg); HC diet: -10.1 kg (-12.0, -8.2 kg)], blood pressure [LC diet: -7.1 (-10.6, -3.7)/-6.2 (-8.2, -4.1) mm Hg; HC diet: -5.8 (-9.4, -2.2)/-6.4 (-8.4, -4.3) mm Hg], HbA1c [LC diet: -1.0% (-1.2%, -0.7%); HC diet: -1.0% (-1.3%, -0.8%)], fasting glucose [LC diet: -0.7 mmol/L (-1.3, -0.1 mmol/L); HC diet: -1.5 mmol/L (-2.1, -0.8 mmol/L)], and LDL cholesterol [LC diet: -0.1 mmol/L (-0.3, 0.1 mmol/L); HC diet: -0.2 mmol/L (-0.4, 0.03 mmol/L)] (P-diet effect ≥ 0.10). Compared with the HC-diet group, the LC-diet group achieved greater mean (95% CI) reductions in the diabetes medication score [LC diet: -0.5 arbitrary units (-0.7, -0.4 arbitrary units); HC diet: -0.2 arbitrary units (-0.4, -0.06 arbitrary units); P = 0.02], glycemic variability assessed by measuring the continuous overall net glycemic action-1 [LC diet: -0.5 mmol/L (-0.6, -0.3 mmol/L); HC diet: -0.05 mmol/L (-0.2, -0.1 mmol/L); P = 0.003], and triglycerides [LC diet: -0.4 mmol/L (-0.5, -0.2 mmol/L); HC diet: -0.01 mmol/L (-0.2, 0.2 mmol/L); P = 0.001] and greater mean (95% CI) increases in HDL cholesterol [LC diet: 0.1 mmol/L (0.1, 0.2 mmol/L); HC diet: 0.06 mmol/L (-0.01, 0.1 mmol/L); P = 0.002].

CONCLUSIONS

Both diets achieved substantial weight loss and reduced HbA1c and fasting glucose. The LC diet, which was high in unsaturated fat and low in saturated fat, achieved greater improvements in the lipid profile, blood glucose stability, and reductions in diabetes medication requirements, suggesting an effective strategy for the optimization of T2D management. This trial was registered at www.anzctr.org.au as ACTRN12612000369820.

Effects of provision of type 2 diabetes genetic risk feedback on patient perceptions of diabetes control and diet and physical activity self-efficacy

OBJECTIVE

We examined effects of providing type 2 diabetes genetic risk feedback on controllability perceptions.

METHODS

This is a secondary analysis of a randomized controlled trial in which overweight/obese Veterans Affairs patients without diabetes received conventional type 2 diabetes risk counseling that included either (1) personalized diabetes genetic risk feedback (genetic risk arm) or (2) eye disease counseling (comparison arm). Perceived diabetes control, and dietary and physical activity self-efficacy were compared between study arms, and between the comparison arm and each of 3 DNA-based genetic risk levels.

RESULTS

Participants (N=531) were predominately male, middle-age, and African American. Immediately post-counseling, perceived diabetes control was higher for the genetic risk arm (risk levels combined) than the comparison arm (p=0.005). In analyses by genetic risk levels, low genetic risk participants reported higher perceived diabetes control than comparison participants (p=0.007). Immediately post-counseling, low genetic risk participants reported higher dietary self-efficacy in situations when mood is negative compared with controls(p=0.01). At 3 months, no differences in constructs were observed.

CONCLUSION

Genetic risk feedback for diabetes has temporary effects on perceived controllability among patients with low genetic risk.

PRACTICE IMPLICATIONS

Clinicians and other stakeholders should consider the limited effects on behavior change of diabetes genetic risk feedback.

Effect of Allowing Choice of Diet on Weight Loss: A Randomized Trial

BACKGROUND

Choosing a diet rather than being prescribed one could improve weight loss.

OBJECTIVE

To examine whether offering choice of diet improves weight loss.

DESIGN

Double-randomized preference trial of choice between 2 diets (choice) versus random assignment to a diet (comparator) over 48 weeks. (ClinicalTrials.gov: NCT01152359).

SETTING

Outpatient clinic at a Veterans Affairs medical center.

PATIENTS

Outpatients with a body mass index of at least 30 kg/m2.

INTERVENTION

Choice participants received information about their food preferences and 2 diet options (low-carbohydrate diet [LCD] or low-fat diet [LFD]) before choosing and were allowed to switch diets at 12 weeks. Comparator participants were randomly assigned to 1 diet for 48 weeks. Both groups received group and telephone counseling for 48 weeks.

MEASUREMENTS

The primary outcome was weight at 48 weeks.

RESULTS

Of 105 choice participants, 61 (58%) chose the LCD and 44 (42%) chose the LFD; 5 (3 on the LCD and 2 on the LFD) switched diets at 12 weeks, and 87 (83%) completed measurements at 48 weeks. Of 102 comparator participants, 53 (52%) were randomly assigned to the LCD and 49 (48%) were assigned to the LFD; 88 (86%) completed measurements. At 48 weeks, estimated mean weight loss was 5.7 kg (95% CI, 4.3 to 7.0 kg) in the choice group and 6.7 kg (CI, 5.4 to 8.0 kg) in the comparator group (mean difference, -1.1 kg [CI, -2.9 to 0.8 kg]; P = 0.26). Secondary outcomes of dietary adherence, physical activity, and weight-related quality of life were similar between groups at 48 weeks.

LIMITATIONS

Only 2 diet options were provided. Results from this sample of older veterans might not be generalizable to other populations.

CONCLUSION

Contrary to expectations, the opportunity to choose a diet did not improve weight loss.

Implementation and evaluation of the VA DPP clinical demonstration: protocol for a multi-site non-randomized hybrid effectiveness-implementation type III trial

Background

The Diabetes Prevention Program (DPP) study showed that lifestyle intervention resulted in a 58% reduction in incidence of type 2 diabetes among individuals with prediabetes. Additional large randomized controlled trials have confirmed these results, and long-term follow-up has shown sustained benefit 10–20 years after the interventions ended. Diabetes is a common and costly disease, especially among Veterans, and despite strong evidence supporting the feasibility of type 2 diabetes prevention, the DPP has not been widely implemented. The first aim of this study will evaluate implementation of the Veterans Affairs (VA) DPP in three VA medical centers. The second aim will assess weight and hemoglobin A1c (A1c) outcomes, and the third aim will determine the cost-effectiveness and budget impact of implementation of the VA DPP from a health system perspective.

Methods/Design

This partnered multi-site non-randomized systematic assignment study will use a highly pragmatic hybrid effectiveness-implementation type III mixed methods study design. The implementation and administration of the VA DPP will be funded by clinical operations while the evaluation of the VA DPP will be funded by research grants. Seven hundred twenty eligible Veterans will be systematically assigned to the VA DPP clinical demonstration or the usual care VA MOVE!® weight management program. A multi-phase formative evaluation of the VA DPP implementation will be conducted. A theoretical program change model will be used to guide the implementation process and assess applicability and feasibility of the DPP for VA. The Consolidated Framework for Implementation Research (CFIR) will be used to guide qualitative data collection, analysis, and interpretation of barriers and facilitators to implementation. The RE-AIM framework will be used to assess Reach, Effectiveness, Adoption, Implementation, and Maintenance of the VA DPP. Twelve-month weight and A1c change will be evaluated for the VA DPP compared to the VA MOVE! program. Mediation analyses will be conducted to identify whether program design differences impact outcomes.

Discussion

Findings from this pragmatic evaluation will be highly applicable to practitioners who are tasked with implementing the DPP in clinical settings. In addition, findings will determine the effectiveness and cost-effectiveness of the VA DPP in the Veteran population.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0250-0) contains supplementary material, which is available to authorized users.

Association between bariatric surgery and long-term survival

IMPORTANCE

Accumulating evidence suggests that bariatric surgery improves survival among patients with severe obesity, but research among veterans has shown no evidence of benefit.

OBJECTIVE

To examine long-term survival in a large multisite cohort of patients who underwent bariatric surgery compared with matched control patients.

DESIGN, SETTING, AND PARTICIPANTS

In a retrospective cohort study, we identified 2500 patients (74% men) who underwent bariatric surgery in Veterans Affairs (VA) bariatric centers from 2000-2011 and matched them to 7462 control patients using sequential stratification and an algorithm that included age, sex, geographic region, body mass index, diabetes, and Diagnostic Cost Group. Survival was compared across patients who underwent bariatric surgery and matched controls using Kaplan-Meier estimators and stratified, adjusted Cox regression analyses.

EXPOSURES

Bariatric procedures, which included 74% gastric bypass, 15% sleeve gastrectomy, 10% adjustable gastric banding, and 1% other.

MAIN OUTCOMES AND MEASURES

All-cause mortality through December 2013.

RESULTS

Surgical patients (n = 2500) had a mean age of 52 years and a mean BMI of 47. Matched control patients (n = 7462) had a mean age of 53 years and a mean BMI of 46. At the end of the 14-year study period, there were a total of 263 deaths in the surgical group (mean follow-up, 6.9 years) and 1277 deaths in the matched control group (mean follow-up, 6.6 years). Kaplan-Meier estimated mortality rates were 2.4% at 1 year, 6.4% at 5 years, and 13.8% at 10 years for surgical patients; for matched control patients, 1.7% at 1 year, 10.4% at 5 years, and 23.9% at 10 years. Adjusted analysis showed no significant association between bariatric surgery and all-cause mortality in the first year of follow-up (adjusted hazard ratio [HR], 1.28 [95% CI, 0.98-1.68]), but significantly lower mortality after 1 to 5 years (HR, 0.45 [95% CI, 0.36-0.56]) and 5 to 14 years (HR, 0.47 [95% CI, 0.39-0.58]). The midterm (>1-5 years) and long-term (>5 years) relationships between surgery and survival were not significantly different across subgroups defined by diabetes diagnosis, sex, and period of surgery.

CONCLUSIONS AND RELEVANCE

Among obese patients receiving care in the VA health system, those who underwent bariatric surgery compared with matched control patients who did not have surgery had lower all-cause mortality at 5 years and up to 10 years following the procedure. These results provide further evidence for the beneficial relationship between surgery and survival that has been demonstrated in younger, predominantly female populations.

Clinic variation in recruitment metrics, patient characteristics and treatment use in a randomized clinical trial of osteoarthritis management

Background

The Patient and PRovider Interventions for Managing Osteoarthritis (OA) in Primary Care (PRIMO) study is one of the first health services trials targeting OA in a multi-site, primary care network. This multi-site approach is important for assessing generalizability of the interventions. These analyses describe heterogeneity in clinic and patient characteristics, as well as recruitment metrics, across PRIMO study clinics.

Methods

Baseline data were obtained from the PRIMO study, which enrolled n = 537 patients from ten Duke Primary Care practices. The following items were examined across clinics with descriptive statistics: (1) Practice Characteristics, including primary care specialty, numbers and specialties of providers, numbers of patients age 55+, urban/rural location and county poverty level; (2) Recruitment Metrics, including rates of eligibility, refusal and randomization; (3) Participants’ Characteristics, including demographic and clinical data (general and OA-related); and (4) Participants’ Self-Reported OA Treatment Use, including pharmacological and non-pharmacological therapies. Intraclass correlation coefficients (ICCs) were computed for participant characteristics and OA treatment use to describe between-clinic variation.

Results

Study clinics varied considerably across all measures, with notable differences in numbers of patients age 55+ (1,507-5,400), urban/rural location (ranging from “rural” to “small city”), and proportion of county households below poverty level (12%-26%). Among all medical records reviewed, 19% of patients were initially eligible (10%-31% across clinics), and among these, 17% were randomized into the study (13%-21% across clinics). There was considerable between-clinic variation, as measured by the ICC (>0.01), for the following patient characteristics and OA treatment use variables: age (means: 60.4-66.1 years), gender (66%-88% female), race (16%-61% non-white), low income status (5%-27%), presence of hip OA (26%-68%), presence both knee and hip OA (23%-61%), physical therapy for knee OA (24%-61%) and hip OA (0%-71%), and use of knee brace with metal supports (0%-18%).

Conclusions

Although PRIMO study sites were part of one primary care practice network in one health care system, clinic and patient characteristics varied considerably, as did OA treatment use. This heterogeneity illustrates the importance of including multiple, diverse sites in trials for knee and hip OA, to enhance the generalizability and evaluate potential for real-world implementation.

Trial registration

Clinical Trial Registration Number: NCT 01435109

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-413) contains supplementary material, which is available to authorized users.

A very low-carbohydrate, low-saturated fat diet for type 2 diabetes management: a randomized trial

OBJECTIVE

To comprehensively compare the effects of a very low-carbohydrate, high-unsaturated/low-saturated fat diet (LC) with those of a high-unrefined carbohydrate, low-fat diet (HC) on glycemic control and cardiovascular disease (CVD) risk factors in type 2 diabetes (T2DM).

RESEARCH DESIGN AND METHODS

Obese adults (n = 115, BMI 34.4 ± 4.2 kg/m(2), age 58 ± 7 years) with T2DM were randomized to a hypocaloric LC diet (14% carbohydrate [<50 g/day], 28% protein, and 58% fat [<10% saturated fat]) or an energy-matched HC diet (53% carbohydrate, 17% protein, and 30% fat [<10% saturated fat]) combined with structured exercise for 24 weeks. The outcomes measured were as follows: glycosylated hemoglobin (HbA1c), glycemic variability (GV; assessed by 48-h continuous glucose monitoring), antiglycemic medication changes (antiglycemic medication effects score [MES]), and blood lipids and pressure.

RESULTS

A total of 93 participants completed 24 weeks. Both groups achieved similar completion rates (LC 79%, HC 82%) and weight loss (LC -12.0 ± 6.3 kg, HC -11.5 ± 5.5 kg); P ≥ 0.50. Blood pressure (-9.8/-7.3 ± 11.6/6.8 mmHg), fasting blood glucose (-1.4 ± 2.3 mmol/L), and LDL cholesterol (-0.3 ± 0.6 mmol/L) decreased, with no diet effect (P ≥ 0.10). LC achieved greater reductions in triglycerides (-0.5 ± 0.5 vs. -0.1 ± 0.5 mmol/L), MES (-0.5 ± 0.5 vs. -0.2 ± 0.5), and GV indices; P ≤ 0.03. LC induced greater HbA1c reductions (-2.6 ± 1.0% [-28.4 ± 10.9 mmol/mol] vs. -1.9 ± 1.2% [-20.8 ± 13.1 mmol/mol]; P = 0.002) and HDL cholesterol (HDL-C) increases (0.2 ± 0.3 vs. 0.05 ± 0.2 mmol/L; P = 0.007) in participants with the respective baseline values HbA1c >7.8% (62 mmol/mol) and HDL-C <1.29 mmol/L.

CONCLUSIONS

Both diets achieved substantial improvements for several clinical glycemic control and CVD risk markers. These improvements and reductions in GV and antiglycemic medication requirements were greatest with the LC compared with HC. This suggests an LC diet with low saturated fat may be an effective dietary approach for T2DM management if effects are sustained beyond 24 weeks.

Study design and protocol for a theory-based behavioral intervention focusing on maintenance of weight loss: the Maintenance After Initiation of Nutrition TrAINing (MAINTAIN) study

BACKGROUND

Obesity is a significant public health problem. Although various lifestyle approaches are effective for inducing significant weight loss, few effective behavioral weight maintenance strategies have been identified. It has been proposed that behavior maintenance is a distinct state that involves different psychological processes and behavioral skills than initial behavior change. Previously, we created a conceptual model that distinguishes behavior initiation from maintenance. This model was used to generate Maintenance After Initiation of Nutrition TrAINing (MAINTAIN), an intervention to enhance weight loss maintenance following initiation. The effectiveness of MAINTAIN is being evaluated in an ongoing trial, the rationale and procedures of which are reported herein.

METHODS/DESIGN

Veterans aged ≤ 75 with body mass index ≥ 30 kg/m(2) participate in a 16-week, group-based weight loss program. Participants who lose ≥ 4 kg by the end of 16 weeks (target n = 230) are randomized 1:1 to receive (a) usual care for 56 weeks or (b) MAINTAIN, a theoretically-informed weight loss maintenance intervention for 40 weeks, followed by 16 weeks of no intervention contact. MAINTAIN involves 3 in-person group visits that transition to 8 individualized telephone calls with decreasing contact frequency. MAINTAIN focuses on satisfaction with outcomes, weight self-monitoring, relapse prevention, and social support. We hypothesize that, compared to usual care, MAINTAIN will result in at least 3.5 kg less regain and better relative levels of caloric intake and physical activity over 56 weeks, and that it will be cost-effective.

DISCUSSION

If effective, MAINTAIN could serve as a model for redesigning existing weight loss programs.

CLINICALTRIALSGOV IDENTIFIER

NCT01357551.

Differentiating Behavior Initiation and Maintenance: Theoretical Framework and Proof of Concept

Although many interventions are effective for health behavior initiation, maintenance has proven elusive. Interventions targeting maintenance often extend the duration with which initiation content is delivered or the duration of follow-up without intervention. We posit that health behavior initiation and maintenance require separate psychological processes and skills. To determine the value of operationalizing maintenance as a process separate from initiation, we conducted a pilot study of a telephone-delivered intervention to assist people in transitioning from behavior initiation to maintenance. Participants were 20 veterans who had initiated lifestyle changes during a randomized controlled trial of a cholesterol reduction intervention. After completing the randomized controlled trial, these participants were enrolled in the pilot maintenance intervention, which involved three monthly telephone calls from a nurse interventionist focusing on behavioral maintenance skills. To evaluate the feasibility and acceptability of this intervention, we assessed recruitment and retention rates as well as 4-month pre-post changes in health behaviors and associated psychological processes. We also conducted individual interviews with participants after study completion. Although not powered to detect significant changes, there was evidence of improvement in dietary intake and of maintenance of physical activity and low-density lipoprotein cholesterol during the 4-month maintenance study. Participants found it helpful to plan for relapses, self-monitor, and obtain social support, but they had mixed reactions about reflecting on satisfaction with outcomes. Participants accepted the intervention and desired ongoing contact to maintain accountability. This pilot maintenance intervention warrants further evaluation in a randomized controlled trial.

Obesity-related health status changes and weight-loss treatment utilization

BACKGROUND

Behavioral weight-loss treatment can improve health, yet it is underutilized. Factors leading to initiation of weight-loss treatment are not well characterized. In particular, it is unknown whether changes in obesity-related health status contribute to weight-loss treatment initiation.

PURPOSE

To determine if recent weight change or diagnosis of an obesity-related comorbidity was associated with utilization of a behavioral weight-loss program in an integrated healthcare setting.

METHODS

In a retrospective cohort study of 45,272 Veterans Affairs (VA) patients with BMI >30, logistic regression was used to examine whether recent weight change or obesity-related comorbidities newly diagnosed in the past 6 months were associated with initiation of a VA behavioral weight management program (called MOVE!) in 2010 or sustained MOVE! use (eight or more sessions). Weight change in prior year was categorized as >3% weight loss; weight stable (<3% change); or weight gain of 3%-4.9%, 5%-9.9%, or ≥10%. Data were analyzed in 2013.

RESULTS

Patients were 91% male, 68% white, and had a mean age of 58 years. Patients were more likely to initiate treatment if they had ≥3% weight gain (3%-4.9%: OR=1.64, 95% CI=1.52, 1.77; 5%-9.9%: OR=1.99, 95% CI=1.84, 2.16; ≥10%: OR=2.68, 95% CI=2.32, 3.10) or were newly diagnosed with any obesity-related comorbidity (ORs: 2.14-3.59). Weight change and new comorbidity diagnoses were not associated, however, with sustained MOVE! use.

CONCLUSIONS

Adverse obesity-related health events were associated with initiation of behavioral weight-loss treatment offered in an integrated healthcare setting.

Evaluating cough assessment tools: a systematic review

BACKGROUND

Little is known about the comparative validity, reliability, or responsiveness of instruments for assessing cough frequency or impact, where the term impact encompasses both cough severity and the impact of cough on health-related quality of life.

METHODS

We conducted a systematic review to evaluate instruments that assess cough frequency or impact in adults, adolescents, and children with acute or chronic cough.

RESULTS

Seventy-eight studies were included, of which eight were randomized controlled trials and 70 were observational studies. In all age groups, audio and video electronic recording devices had good reliability compared with other methods of assessing cough frequency but had variable correlation with other cough assessments, such as visual analog scale scores, quality-of-life questionnaires, cough diaries, and tussigenic challenges. Among adult and adolescent patients, the Leicester Cough Questionnaire (LCQ) and the Cough-Specific Quality-of-Life Questionnaire (CQLQ) were valid and reliable, showing high intraclass and test-retest correlations. Among children, the Parent Cough-Specific Quality of Life Questionnaire and Pediatric Cough Questionnaire were valid and reliable.

CONCLUSIONS

Electronic recording devices can be valid assessments of cough frequency. The LCQ and CQLQ for adults and the Parent Cough-Specific Quality of Life questionnaire for children are valid instruments for assessing cough impact. There is limited but insufficient evidence to determine the reliability or concurrent validity of the different types of cough diaries or visual analog scale scores. There are also limited data to support the responsiveness of recording devices. There is good responsiveness data for the LCQ and CQLQ, but more evidence is needed.

Efficacy and tolerability of treatments for chronic cough: a systematic review and meta-analysis

BACKGROUND

Understanding the comparative effectiveness of treatments for patients with unexplained or refractory cough is important to increase awareness of proven therapies and their potential adverse effects in this unique population.

METHODS

We performed a literature search for English-language studies published up to June 2012 that compared symptomatic therapies for chronic cough. Two investigators screened each abstract and full-text article for inclusion, abstracted data, and rated quality. Meta-analysis with random-effects models was used to summarize effects of treatments.

RESULTS

We identified 49 studies (3,067 patients) comprising 68 therapeutic comparisons. Of the studied agents, opioid and certain nonopioid and nonanesthetic antitussives had demonstrated efficacy for chronic cough in adults. Compared with placebo, effect sizes (standardized mean differences for cough severity and rate ratios for cough frequency) for opioids were 0.55 (95% CI, 0.38-0.72; P &lt; .0001) and 0.57 (95% CI, 0.36-0.91; P = .0260), respectively. For dextromethorphan, effect sizes were 0.37 (95% CI, 0.19-0.56; P = .0008) and 0.40 (95% CI, 0.18-0.85; P = .0248), respectively. The overall strength of evidence was limited by inconsistency and imprecision of results and by small numbers of direct comparisons. Nonpharmacologic therapies and the management of cough in children were infrequently studied.

CONCLUSIONS

Although evidence is limited, opioid and certain nonopioid and nonanesthetic antitussives demonstrated efficacy for treating chronic cough in adults. There is a need for further studies in patients with unexplained or refractory cough as well as for more systematic study designs, assessment of patient-centered outcomes, and reporting.

Trends in energy and macronutrient intakes by weight status over four decades

OBJECTIVE

To examine whether the recent increasing prevalence of obesity was accompanied by variations in energy and macronutrient intakes by weight status.

DESIGN

Time series of cross-sectional surveys.

SETTING

National Health and Nutrition Examination Surveys (NHANES) in the USA.

SUBJECTS

Adult participants of NHANES I (1971-1974), II (1976-1980), III (1988-1994) and continuous (1999-2004).

RESULTS

Daily energy intake increased over time for men (9832 to 11 652 kJ, P < 0·01) and women (6418 to 8142 kJ, P < 0·01) in all BMI classes. Percentage of energy intake from carbohydrate increased over time (men: 42·7% to 48·0%, P < 0·01; women: 45·4% to 50·6%, P < 0·01), whereas percentage of energy intake from fat (men: 36·7% to 33·1%, P < 0·01; women: 36·1% to 33·8%, P < 0·01) and protein (men: 16·4% to 15·1%, P < 0·01; women: 16·9% to 14·7%, P < 0·01) decreased. With surveys combined, daily energy intake varied among BMI classes for women (underweight/normal weight: 7460 kJ; overweight: 6799 kJ; obese I: 7033 kJ; obese II/III: 7401 kJ; P < 0·01) but not men. Percentage of energy intake from carbohydrate decreased with increasing BMI class (men: 46·6% to 45·5%, P < 0·01; women: 49·0% to 48·6%, P < 0·01) whereas percentage of energy intake from fat (men: 34·3% to 36·5%, P < 0·01; women: 34·4% to 35·4%, P < 0·01) and protein (men: 15·3% to 16·5%, P < 0·01; women: 15·2% to 16·0%, P < 0·01) increased. Interactions of survey period and BMI class were not statistically significant.

CONCLUSIONS

Time trends in energy and macronutrient intakes were similar across BMI classes. Research examining how individuals respond differently to varying dietary compositions may provide greater insight about contributors to the rise in obesity.

Characterizing weekly self-reported antihypertensive medication nonadherence across repeated occasions

BACKGROUND

Little is known about weekly variability in medication nonadherence both between and within persons.

PURPOSE

To characterize medication nonadherence across repeated, closely spaced occasions.

METHODS

This prospective cohort study comprised four unannounced telephone assessment occasions, each separated by approximately 2 weeks. On each occasion, adult outpatients taking at least a single antihypertensive medication completed a measure of extent of, and reasons for, nonadherence.

RESULTS

Two hundred and sixty-one participants completed 871 (83%) of 1,044 occasions. Nonadherence was reported on 152 (17.5%) of 871 occasions by 93 (36%) of 261 participants. The most commonly endorsed reasons for nonadherence were forgetting (39.5%), being busy (23.7%), and traveling (19.7%). Among 219 participants completing at least three occasions, 50% of the variability in extent of nonadherence was a result of within-person fluctuations, and 50% was a result of between-person differences.

CONCLUSION

Interventions to reduce nonadherence should be informed by variability in the extent of nonadherence and specific reasons for nonadherence.

Two diets with different haemoglobin A1c and antiglycaemic medication effects despite similar weight loss in type 2 diabetes

We analysed participants with type 2 diabetes (n = 46) within a larger weight loss trial (n = 146) who were randomized to 48 weeks of a low-carbohydrate diet (LCD; n = 22) or a low-fat diet + orlistat (LFD + O; n = 24). At baseline, mean body mass index (BMI) was 39.5 kg/m(2) (s.d. 6.5) and haemoglobin A1c (HbA1c) 7.6% (s.d. 1.3). Although the interventions reduced BMI similarly (LCD -2.4 kg/m(2) ; LFD + O -2.7 kg/m(2) , p = 0.7), LCD led to a relative improvement in HbA1c: -0.7% in LCD versus +0.2% in LFD + O [difference -0.8%, 95% confidence interval (CI) = -1.6, -0.02; p = 0.045]. LCD also led to a greater reduction in antiglycaemic medications using a novel medication effect score (MES) based on medication potency and total daily dose; 70.6% of LCD versus 30.4% LFD + O decreased their MES by ≥50% (p = 0.01). Lowering dietary carbohydrate intake demonstrated benefits on glycaemic control beyond its weight loss effects, while at the same time lowering antiglycaemic medication requirements.

Impact of behavioral interventions in the management of adults with type 2 diabetes mellitus

Research on the role of behavior change as an efficacious intervention for adults with type 2 diabetes is evolving. Searching PubMed and Ovid Medline, we identified and reviewed primarily randomized controlled trials from 2010 to 2013 of adults managing type 2 diabetes without insulin. All studies are evaluated in terms of the rigor of their design and their impact on glycosylated hemoglobin. The most efficacious interventions appear to be low-carbohydrate/glycemic load diets, combined aerobic and resistance training, and self-monitoring of blood glucose, which educates patients about the impact of their food selections and physical activity on their blood glucose.

The relationship between pretreatment dietary composition and weight loss during a randomised trial of different diet approaches

BACKGROUND

Identifying pretreatment dietary habits that are associated with weight-loss intervention outcomes could help guide individuals' selection of weight-loss approach among competing options. A pretreatment factor that may influence weight-loss outcomes is macronutrient intake.

METHODS

Overweight and obese Durham Veterans Affairs outpatients were randomised to a weight-loss intervention with a low-carbohydrate diet (n = 71) or orlistat medication therapy plus a low-fat diet (n = 73). Percentage fat, carbohydrate and protein intake prior to treatment were measured using 4-day food records. Linear mixed-effects models were used to determine whether pretreatment percentage macronutrient intake influenced weight trajectories and weight loss in each weight-loss condition.

RESULTS

Participant's mean age was 53 years, baseline body mass index was 39.3 kg m(-2) and 72% were male. A higher pretreatment percentage carbohydrate intake was associated with less rapid initial weight loss (P = 0.02) and less rapid weight regain (P = 0.03) in the low-carbohydrate diet condition but was not associated with weight trajectories in the orlistat plus low-fat diet condition. In both conditions, a higher pretreatment percentage fat intake was associated with more rapid weight regain (P < 0.01). Pretreatment percentage protein intake was not associated with weight trajectories. None of the pretreatment macronutrients were associated with weight loss on study completion in either condition.

CONCLUSIONS

Selection of a weight-loss approach on the basis of pretreatment macronutrient intake is unlikely to improve weight outcomes at the end of a 1-year treatment. However, pretreatment macronutrient intake may have implications for tailoring of interventions to slow weight regain after weight loss.

Nutrition therapy recommendations for the management of adults with diabetes

There is no standard meal plan or eating pattern that works universally for all people with diabetes. In order to be effective, nutrition therapy should be individualized for each patient/client based on his or her individual health goals; personal and cultural preferences; health literacy and numeracy; access to healthful choices; and readiness, willingness, and ability to change. Nutrition interventions should emphasize a variety of minimally processed nutrient dense foods in appropriate portion sizes as part of a healthful eating pattern and provide the individual with diabetes with practical tools for day-to-day food plan and behavior change that can be maintained over the long term.

The influence of a physician and patient intervention program on dietary intake

BACKGROUND

Efficient dietary interventions for patients with hypertension in clinical settings are needed.

OBJECTIVE

To assess the separate and combined influence of a physician intervention (MD-I) and a patient intervention (PT-I) on dietary intakes of patients with hypertension.

DESIGN

A nested 2×2 design, randomized controlled trial conducted over 18 months.

PARTICIPANTS

A total of 32 physicians and 574 outpatients with hypertension.

INTERVENTION

MD-I included training modules addressing the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure hypertension management guidelines and lifestyle modification. PT-I included lifestyle coaching to adopt the Dietary Approaches to Stop Hypertension (DASH) eating pattern, reduce sodium intake, manage weight, increase exercise, and moderate alcohol intake.

MAIN OUTCOME MEASURES

Dietary intakes were measured by the Block Food Frequency Questionnaire. Concordance with the DASH dietary pattern was estimated by a DASH score.

STATISTICAL ANALYSES

The main effects of MD-I and PT-I, and their interaction, were evaluated using analysis of covariance.

RESULTS

After 6 months of intervention, MD-I participants significantly increased intakes of potassium, fruits, juices, and carbohydrate; decreased intake of fat; and improved overall dietary quality as measured by the Healthy Eating Index. PT-I intervention resulted in increased intakes of carbohydrate, protein, fiber, calcium, potassium, fruits and fruit juices, vegetables, dairy and Healthy Eating Index score, and decreased intakes in fat, saturated fat, cholesterol, sodium, sweets, and added fats/oils/sweets. In addition, PT-I improved overall DASH concordance score. The change in DASH score was significantly associated with the changes in blood pressure and weight at 6 months. At 18 months, most changes reversed back toward baseline levels, including the DASH score.

CONCLUSIONS

Both MD-I and PT-I improved eating patterns at 6 months with some sustained effects at 18 months. Even though all dietary changes observed were consistent with the DASH nutrient targets or food group guidelines, only the PT-I intervention was effective in improving the overall DASH concordance score. This finding affirms the role of medical nutrition therapy in long-term intensive interventions for hypertension risk reduction and weight management and underlines the need for development of maintenance strategies. Furthermore, this study emphasizes the importance of collaborations among physicians, registered dietitians and other dietetics practitioners, and lay health advisors while assisting patients to make healthy behavior changes.

Recruitment and retention rates in behavioral trials involving patients and a support person: a systematic review

BACKGROUND

Recruitment and retention challenges impede the study of behavioral interventions among patient-support person dyads.

PURPOSE

The aim of the study was to characterize recruitment and retention rates of behavioral interventions involving dyads.

METHODS

Using PRISMA guidelines and with the guidance of a medical librarian, we searched Medline, EMBASE, Cochrane Controlled Trials, PsycInfo, and CINAHL from inception until July 2011. Eligible articles involved RCTs of behavioral interventions targeting adult patients with a non-psychiatric illness and a support person. Sample and study characteristics, recruitment and retention strategies, and recruitment and retention rates were abstracted in duplicate. Quality of reporting was determined on a 5-point scale. Due to the heterogeneity in data reporting and missing data, a narrative synthesis was undertaken.

RESULTS

53 unique studies involving 8081 dyads were included. 9 studies were ascertained to have a "high quality" of reporting. A majority of the studies did not report target sample size, time to complete recruitment, and sample sizes at each follow-up time point. Strategies employed to recruit support persons were rarely reported. 16 studies did not report the number of dyads screened. The mean recruitment rate was 51.2% (range: 4.3%-95.4%), and mean retention rate was 77.5% (range: 36%-100%).

CONCLUSIONS

Details regarding recruitment and retention methodology were sparse in these interventions. Where available, data suggests that resources need to be devoted towards recruitment of sample but that retention rates are generally adequate.

Considering patient diet preference to optimize weight loss: design considerations of a randomized trial investigating the impact of choice

A variety of diet approaches achieve moderate weight loss in many individuals. Yet, most diet interventions fail to achieve meaningful weight loss in more than a few individuals, likely due to inadequate adherence to the diet. It is widely conjectured that targeting the diet to an individual's food preferences will enhance adherence, thereby improving weight loss. This article describes the design considerations of a study protocol aimed at testing this hypothesis. The study is a 2-arm randomized trial recruiting 216 medical outpatients with BMI ≥30 kg/m(2) followed for 48 weeks. Participants in the experimental arm (Choice) select from two of the most widely studied diets for weight loss, a low-carbohydrate, calorie-unrestricted diet (LCD) or a low-fat, reduced-calorie diet (LFD). The participant's choice is informed by results from a validated food preference questionnaire and a discussion of diet options with trained personnel. Choice participants are given the option to switch to the other diet after three months, if desired. Participants in the Control arm are randomly assigned to follow one of the two diets for the duration of follow-up. The primary outcome is weight assessed every 2-4 weeks for 48 weeks. Secondary outcomes include adherence to diet by food frequency questionnaire and obesity-specific health-related quality of life. If assisting patients to choose their diet enhances adherence and increases weight loss, the results will support the provision of diet options to patients who desire weight loss, and bring us one step closer to remediating the obesity epidemic faced by our healthcare systems.

Demand for weight loss counseling after copayment elimination

INTRODUCTION

Overweight and obesity are public health issues in the United States, and veterans have a higher rate of overweight and obesity than the general population. Our objective was to examine whether copayment elimination increased use of a weight loss clinic by veterans.

METHODS

We examined clinic use by 44,411 new patients seen in a Veterans Affairs (VA) MOVE! weight management clinic before the copayment elimination and clinic use by 64,398 new patients seen in the year after copayment elimination. We examined clinic use via mixed-effects models for patients who were already exempt from copayment and patients who were newly exempt from copayment. We used 2 outcomes before and after copayment elimination: 1) the ratio of number of clinic visits by new users with the mean number of MOVE! clinic visits by all users, and 2) the number of clinic visits by each new user in the 6 months after their first visit. All models were adjusted for patient and clinic factors.

RESULTS

Among newly exempt patients, the clinic-standardized rate of new use increased by 2.2% after the copayment was eliminated but increased 12% among already exempt veterans. This finding was confirmed in adjusted analyses. Analysis of number of clinic visits adjusted for patient and clinic factors also found that exempt and nonexempt veterans had similar numbers of repeat clinic visits.

CONCLUSION

We saw an unexpected larger increase in demand among veterans who receive all VA care for free. These results suggest that VA should not assume that copayment reductions for selective preventive services will motivate patient change and achieve intended system-level outcomes.

Achieving health for a lifetime: a community engagement assessment focusing on school-age children to decrease obesity in Durham, North Carolina

BACKGROUND

Obesity is a prominent problem in the United States and in North Carolina. One way of combating it is with community-engaged interventions that foster collaboration between health-oriented organizations and community residents.

PURPOSE

Our purpose was to assemble a multifaceted group in Durham, North Carolina, to identify factors affecting obesity-related lifestyle behaviors; assess policies, resources, and the population's perception of the problem of obesity; and develop plans to improve health outcomes related to obesity.

METHODS

A team consisting of more than 2 dozen partners was assembled to form Achieving Health for a Lifetime (AHL) in order to study and address obesity in the community, initially focusing on elementary school-age children. The team developed a resource guide by collecting information by telephone interviews of provider organizations; geospatial resource maps were created using high-resolution geographic information systems, Duke's Data Support Repository, and county and city records; and focus groups were conducted using the nominal group technique.

RESULTS

The AHL team, in collaboration with 2 other teams focused on diabetes and cardiovascular disease, identified 32 resources for diabetes, 20 for obesity, and 13 for cardiovascular disease. Using Geographic Information Systems (GIS), the team identified an area of Durham that had only 1 supermarket, but 34 fast-food restaurants and 84 convenience stores.

LIMITATIONS

The focus on particular neighborhoods means that the information obtained might not pertain to all neighborhoods.

CONCLUSION

The AHL team was able to assemble a large community partnership in Durham that will allow the members of the community to continue to work toward making residents healthier. Communities facing similar challenges can learn from this experience.

A randomized controlled trial to evaluate the effectiveness of CouPLES: a spouse-assisted lifestyle change intervention to improve low-density lipoprotein cholesterol

OBJECTIVE

This randomized controlled trial evaluated the effectiveness of a telephone-delivered, spouse-assisted lifestyle intervention to reduce patient LDL-C.

METHOD

From 2007 to 2010, 255 outpatients with LDL-C>76 mg/dL and their spouses from the Durham Veterans Affairs Medical Center were randomized to intervention or usual care. The intervention comprised nine monthly goal-setting telephone calls to patients and support planning calls to spouses. Outcomes were assessed at 11 months.

RESULTS

Patients were 95% male and 65% White. LDL-C did not differ between groups (mean difference = 2.3 mg/dL, 95% CI = -3.6, 8.3, p = 0.44), nor did the odds of meeting goal LDL-C (OR = 0.95, 95% CI = 0.6, 1.7; p = 0.87). Intakes of calories (p = 0.03), total fat (p = 0.02), and saturated fat (p = 0.02) were lower for the intervention group. Cholesterol and fiber intake did not differ between groups (p = 0.11 and 0.26, respectively). The estimated rate of moderate intensity physical activity per week was 20% higher in the intervention group (IRR = 1.2, 95% CI = 1.0, 1.5, p = 0.06). Most participants did not experience a change in cholesterol medication usage during the study period in the intervention (71.7%) and usual care (78.9%) groups.

CONCLUSION

This intervention might be an adjunct to usual primary care to improve adherence to lifestyle behaviors.

Enhanced fitness: a randomized controlled trial of the effects of home-based physical activity counseling on glycemic control in older adults with prediabetes mellitus

OBJECTIVES

To determine whether a home-based multicomponent physical activity counseling (PAC) intervention is effective in reducing glycemic measures in older outpatients with prediabetes mellitus.

DESIGN

Controlled clinical trial.

SETTING

Primary care clinics of the Durham Veterans Affairs (VA) Medical Center between September 29, 2008, and March 25, 2010.

PARTICIPANTS

Three hundred two overweight (body mass index 25-45 kg/m(2) ), older (60-89) outpatients with impaired glucose tolerance (fasting blood glucose 100-125 mg/dL, glycosylated hemoglobin (HbA1c) <7%) randomly assigned to a PAC intervention group (n = 180) or a usual care control group (n = 122).

INTERVENTION

A 12-month, home-based multicomponent PAC program including one in-person baseline counseling session, regular telephone counseling, physician endorsement in clinic with monthly automated encouragement, and customized mailed materials. All study participants, including controls, received a consultation in a VA weight management program.

MEASUREMENTS

The primary outcome was a homeostasis model assessment of insulin resistance (HOMA-IR), calculated from fasting insulin and glucose levels at baseline and 3 and 12 months. HbA1c was the secondary indicator of glycemic control. Other secondary outcomes were anthropometric measures and self-reported physical activity, health-related quality of life, and physical function.

RESULTS

There were no significant differences between the PAC and control groups over time for any of the glycemic indicators. Both groups had small declines over time of approximately 6% in fasting blood glucose (P < .001), and other glycemic indicators remained stable. The declines in glucose were not sufficient to affect the change in HOMA-IR scores due to fluctuations in insulin over time. Endurance physical activity increased significantly in the PAC group (P < .001) and not in the usual care group.

CONCLUSION

Home-based telephone counseling increased physical activity levels but was insufficient to improve glycemic indicators in older outpatients with prediabetes mellitus.

Systematic review and meta-analysis of clinical trials of the effects of low carbohydrate diets on cardiovascular risk factors

A systematic review and meta-analysis were carried out to study the effects of low-carbohydrate diet (LCD) on weight loss and cardiovascular risk factors (search performed on PubMed, Cochrane Central Register of Controlled Trials and Scopus databases). A total of 23 reports, corresponding to 17 clinical investigations, were identified as meeting the pre-specified criteria. Meta-analysis carried out on data obtained in 1,141 obese patients, showed the LCD to be associated with significant decreases in body weight (-7.04 kg [95% CI -7.20/-6.88]), body mass index (-2.09 kg m(-2) [95% CI -2.15/-2.04]), abdominal circumference (-5.74 cm [95% CI -6.07/-5.41]), systolic blood pressure (-4.81 mm Hg [95% CI -5.33/-4.29]), diastolic blood pressure (-3.10 mm Hg [95% CI -3.45/-2.74]), plasma triglycerides (-29.71 mg dL(-1) [95% CI -31.99/-27.44]), fasting plasma glucose (-1.05 mg dL(-1) [95% CI -1.67/-0.44]), glycated haemoglobin (-0.21% [95% CI -0.24/-0.18]), plasma insulin (-2.24 micro IU mL(-1) [95% CI -2.65/-1.82]) and plasma C-reactive protein, as well as an increase in high-density lipoprotein cholesterol (1.73 mg dL(-1) [95%CI 1.44/2.01]). Low-density lipoprotein cholesterol and creatinine did not change significantly, whereas limited data exist concerning plasma uric acid. LCD was shown to have favourable effects on body weight and major cardiovascular risk factors; however the effects on long-term health are unknown.

Clinical use of a carbohydrate-restricted diet to treat the dyslipidemia of the metabolic syndrome

BACKGROUND

The metabolic syndrome is characterized by an atherogenic dyslipidemia identifiable using lipoprotein subclass analysis. This study assesses the effect of a carbohydrate-restricted diet on the dyslipidemia of the metabolic syndrome in a clinical setting.

METHODS

This is a retrospective chart review of patients attending a preventive medicine clinic using lipoprotein subclass analysis (by NMR spectroscopy) to identify the atherogenic dyslipidemia. If present, patients were counseled to begin a carbohydrate-restricted diet (< 20 g/day). Patients already on statin therapy were included only if the medication dose was not changed. The outcomes were changes in body weight, fasting serum lipid profiles and serum lipoprotein subclasses.

RESULTS

Of 122 patients identified, 80 patients had complete pre- and post-treatment data. The mean (+/-SD) age was 66 +/- 9 years, baseline weight was 85 +/- 12 kg, BMI was 28.1 +/- 3.6, 73% were male, 99% were Caucasian. Sixty-five percent were taking statin medication. Carbohydrate-restriction led to a 13% reduction in total cholesterol, 16% reduction in LDL cholesterol, 38% reduction in triglycerides, and a 13% increase in HDL cholesterol (all p values < 0.001). Carbohydrate-restriction also led to a reduction in LDL particle concentration of 28%, a reduction in small LDL of 82%, a reduction of large VLDL of 62%, and an increase in large HDL of 30% (all p values < 0.001).

CONCLUSIONS

A carbohydrate-restricted diet recommendation led to improvements in lipid profiles and lipoprotein subclass traits of the metabolic syndrome in a clinical outpatient setting, and should be considered as a treatment for the metabolic syndrome.

Clinical experience of a carbohydrate-restricted diet for the metabolic syndrome

BACKGROUND

Our objective was to analyze a restricted carbohydrate dietary approach compared to a standard low-fat diet plus medication plan as treatment for weight loss and the metabolic syndrome.

METHODS

This was a retrospective analysis of patients attending an outpatient weight and metabolism management program, including periodic individual visits combined with either a carbohydrate-restricted diet (with multivitamin and essential fatty acids supplementation) or low-fat/low-calorie diet + phentermine/fenfluramine. The main outcome measurements were total body weight and fasting serum lipid profiles. Clinical data were maintained on standardized flow sheets.

RESULTS

One hundred twenty-two patients had complete baseline and follow-up information. Sixty-six were treated with a carbohydrate-restricted diet without medication, and 56 were treated with a combination of low-fat/low-calorie diet and medication. Weight loss occurred in both groups, but was greater in the medication group: the carbohydrate-restricted group lost a mean of 9.5 kg over 15.0 weeks (0.63 kg/week); the low-fat/low-calorie diet + medication group lost a mean of 14.1 kg over a mean duration of 20.2 weeks (0.70 kg/week), p < 0.01. The carbohydrate-restricted group had a greater reduction in triglycerides (p = 0.02) and triglyceride/HDL ratio (p = 0.01), and a greater increase in HDL (p < 0.001) than the medication group.

CONCLUSIONS

In this outpatient program, a carbohydrate-restricted diet and a low-fat/low-calorie diet + medication led to weight loss, but the carbohydrate-restricted diet had a more favorable effect on triglycerides and HDL. Because of the effects on weight, triglycerides, and HDL, a carbohydrate-restricted diet may be useful for the treatment of metabolic syndrome.

Age and sex differences in prospective effects of health goals and motivations on daily leisure-time physical activity

OBJECTIVE

To examine relationships between health goals, types of motivation for those goals, and daily leisure-time physical activity (LTPA), and whether these relationships differ by age or sex.

METHODS

From 2005 to 2008, 710 participants in and around Berlin, Germany provided life goals and motivational attributes of those goals at baseline, then reported LTPA daily for 25 days.

RESULTS

Having (vs. not having) a goal of physical health predicted higher odds of engaging in LTPA for younger but not older participants (under age 30; OR=1.26, p=0.048), and was not related to duration of LTPA episodes. Effect of intrinsic motivation for the health goal differed by sex: for females, higher intrinsic motivation predicted higher odds of LTPA (OR=1.19, p=0.001), but was not related to duration. For males, higher intrinsic motivation predicted lower LTPA odds marginally (OR=0.70, p=0.054) but predicted longer duration (estimate=18.27 min, p<0.001). More approach motivation for the health goal predicted longer duration of LTPA episodes (0.67 min, p=0.022).

CONCLUSIONS

One size does not fit all in LTPA intervention design. Future research should identify the mechanisms by which health goals and motivations affect health behavior.

Correlates of daily leisure-time physical activity in a community sample: Narrow personality traits and practical barriers

OBJECTIVE

Previous studies examining correlates of leisure time physical activity (LTPA) have identified personality factors that are correlated with LTPA and practical factors that impede LTPA. The purpose of the present study was to test how several narrow traits predict daily reports of LTPA and to test whether traits that predict LTPA moderate the effects of practical barriers.

METHODS

1192 participants completed baseline measures of personality, then reported their LTPA and several situational and environmental factors daily for 25 days. We used generalized estimating equations to measure how personality traits, practical barriers, and interactions between these factors affected (1) the odds of engaging in LTPA and (2) the duration of daily LTPA.

RESULTS

Higher standing on Activity and Discipline and lower standing on Assertiveness predicted greater odds of engaging in LTPA and longer duration of LTPA, and higher standing on Aesthetics predicted shorter duration of LTPA. Poor weather conditions and less leisure time were associated with less LTPA, and effects of these barriers were generally greater among participants 30 and older. In participants older than 30, poor weather was associated with less LTPA among those with lower standing on Activity but was not associated with LTPA among those high in Activity. Despite Discipline's overall positive association with LTPA, less leisure time and less routineness were greater barriers for those high in Discipline.

CONCLUSIONS

Assessing narrow personality traits could help target LTPA interventions to individual patients' needs and could help identify important new personality dynamics that affect LTPA.

Effects of low-carbohydrate diets versus low-fat diets on metabolic risk factors: a meta-analysis of randomized controlled clinical trials

The effects of low-carbohydrate diets (≤45% of energy from carbohydrates) versus low-fat diets (≤30% of energy from fat) on metabolic risk factors were compared in a meta-analysis of randomized controlled trials. Twenty-three trials from multiple countries with a total of 2,788 participants met the predetermined eligibility criteria (from January 1, 1966 to June 20, 2011) and were included in the analyses. Data abstraction was conducted in duplicate by independent investigators. Both low-carbohydrate and low-fat diets lowered weight and improved metabolic risk factors. Compared with participants on low-fat diets, persons on low-carbohydrate diets experienced a slightly but statistically significantly lower reduction in total cholesterol (2.7 mg/dL; 95% confidence interval: 0.8, 4.6), and low density lipoprotein cholesterol (3.7 mg/dL; 95% confidence interval: 1.0, 6.4), but a greater increase in high density lipoprotein cholesterol (3.3 mg/dL; 95% confidence interval: 1.9, 4.7) and a greater decrease in triglycerides (-14.0 mg/dL; 95% confidence interval: -19.4, -8.7). Reductions in body weight, waist circumference and other metabolic risk factors were not significantly different between the 2 diets. These findings suggest that low-carbohydrate diets are at least as effective as low-fat diets at reducing weight and improving metabolic risk factors. Low-carbohydrate diets could be recommended to obese persons with abnormal metabolic risk factors for the purpose of weight loss. Studies demonstrating long-term effects of low-carbohydrate diets on cardiovascular events were warranted.

Updated report on comparative effectiveness of ACE inhibitors, ARBs, and direct renin inhibitors for patients with essential hypertension: much more data, little new information

OBJECTIVES

A 2007 systematic review compared angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) in patients with hypertension. Direct renin inhibitors (DRIs) have since been introduced, and significant new research has been published. We sought to update and expand the 2007 review.

DATA SOURCES

We searched MEDLINE and EMBASE (through December 2010) and selected other sources for relevant English-language trials.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

We included studies that directly compared ACE inhibitors, ARBs, and/or DRIs in at least 20 total adults with essential hypertension; had at least 12 weeks of follow-up; and reported at least one outcome of interest. Ninety-seven (97) studies (36 new since 2007) directly comparing ACE inhibitors versus ARBs and three studies directly comparing DRIs to ACE inhibitor inhibitors or ARBs were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

A standard protocol was used to extract data on study design, interventions, population characteristics, and outcomes; evaluate study quality; and summarize the evidence.

RESULTS

In spite of substantial new evidence, none of the conclusions from the 2007 review changed. The level of evidence remains high for equivalence between ACE inhibitors and ARBs for blood pressure lowering and use as single antihypertensive agents, as well as for superiority of ARBs for short-term adverse events (primarily cough). However, the new evidence was insufficient on long-term cardiovascular outcomes, quality of life, progression of renal disease, medication adherence or persistence, rates of angioedema, and differences in key patient subgroups.

LIMITATIONS

Included studies were limited by follow-up duration, protocol heterogeneity, and infrequent reporting on patient subgroups.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Evidence does not support a meaningful difference between ACE inhibitors and ARBs for any outcome except medication side effects. Few, if any, of the questions that were not answered in the 2007 report have been addressed by the 36 new studies. Future research in this area should consider areas of uncertainty and be prioritized accordingly.

Patient and provider interventions for managing osteoarthritis in primary care: protocols for two randomized controlled trials

BACKGROUND

Osteoarthritis (OA) of the hip and knee are among the most common chronic conditions, resulting in substantial pain and functional limitations. Adequate management of OA requires a combination of medical and behavioral strategies. However, some recommended therapies are under-utilized in clinical settings, and the majority of patients with hip and knee OA are overweight and physically inactive. Consequently, interventions at the provider-level and patient-level both have potential for improving outcomes. This manuscript describes two ongoing randomized clinical trials being conducted in two different health care systems, examining patient-based and provider-based interventions for managing hip and knee OA in primary care.

METHODS / DESIGN

One study is being conducted within the Department of Veterans Affairs (VA) health care system and will compare a Combined Patient and Provider intervention relative to usual care among n = 300 patients (10 from each of 30 primary care providers). Another study is being conducted within the Duke Primary Care Research Consortium and will compare Patient Only, Provider Only, and Combined (Patient + Provider) interventions relative to usual care among n = 560 patients across 10 clinics. Participants in these studies have clinical and / or radiographic evidence of hip or knee osteoarthritis, are overweight, and do not meet current physical activity guidelines. The 12-month, telephone-based patient intervention focuses on physical activity, weight management, and cognitive behavioral pain management. The provider intervention involves provision of patient-specific recommendations for care (e.g., referral to physical therapy, knee brace, joint injection), based on evidence-based guidelines. Outcomes are collected at baseline, 6-months, and 12-months. The primary outcome is the Western Ontario and McMasters Universities Osteoarthritis Index (self-reported pain, stiffness, and function), and secondary outcomes are the Short Physical Performance Test Protocol (objective physical function) and the Patient Health Questionnaire-8 (depressive symptoms). Cost effectiveness of the interventions will also be assessed.

DISCUSSION

Results of these two studies will further our understanding of the most effective strategies for improving hip and knee OA outcomes in primary care settings.

TRIAL REGISTRATION

NCT01130740 (VA); NCT 01435109 (NIH).

Low HDL predicts differential blood pressure effects from two weight-loss approaches: a secondary analysis of blood pressure from a randomized, clinical weight-loss trial

Examining predictors of blood-pressure (BP) response to weight-loss diets might provide insight into mechanisms and help guide clinical care. We examined whether certain baseline patient characteristics (e.g. diet, medical history and laboratory tests) predicted BP response to two weight-loss diet approaches that differ in macronutrient content. One hundred and forty-six overweight adult outpatients were randomized to either a low-carbohydrate diet (N = 72) or orlistat plus a low-fat diet (N = 74) for 48 weeks. Predictors of BP reduction were evaluated using a structured approach and random effects regression models. Participants were 56% African-American, 72% male and 53 (±10) years-old. Of the variables considered, low baseline high-density lipoprotein (HDL) predicted greater reduction in BP in those patients who received the low-carbohydrate diet (p = 0.03 for systolic BP; p = 0.03 for diastolic BP and p = 0.02 for mean arterial pressure). A low HDL level may identify patients who will have greater BP improvement on a low-carbohydrate diet.

Effects of counseling techniques on patients' weight-related attitudes and behaviors in a primary care clinic

OBJECTIVE

Examine primary care physicians' use of counseling techniques when treating overweight and obese patients and the association with mediators of behavior change as well as change in nutrition, exercise, and weight loss attempts.

METHODS

We audio recorded office encounters between 40 physicians and 461 patients. Encounters were coded for physician use of selected counseling techniques using the Motivational Interviewing Treatment Integrity (MITI) scale. Patient motivation and confidence as well as Fat and Fiber Diet score (1-4), Framingham physical activity questionnaire (MET-minutes), and weight loss attempts (yes/no) were assessed by surveys. Generalized linear models were fit, including physician, patient, and visit level covariates.

RESULTS

Patients whose physicians were rated higher in empathy improved their Fat and Fiber intake 0.18 units (95% CI 0, 0.4). When physicians used "MI consistent" techniques, patients reported higher confidence to improve nutrition (OR 2.57, 95% CI 1.2, 5.7).

CONCLUSION

When physicians used counseling techniques consistent with MI principles, some of their patients' weight-related attitudes and behaviors improved.

PRACTICE IMPLICATIONS

Physicians may not be able to employ formal MI during a clinic visit. However, use of counseling techniques consistent with MI principles, such as expression of empathy, may improve patients' weight-related attitudes and behaviors.

Preventive care in relation to obesity: an analysis of a large, national survey

BACKGROUND

Reports from the 1990s observed lower receipt of preventive care services among obese individuals, but a few recent studies in older adults and Department of Veterans Affairs (VA) patients have failed to do so. Additional studies, using population-based samples, are needed to understand whether disparities in care by obesity continue to exist in the U.S.

PURPOSE

To investigate whether receipt of preventive care services varies in relation to BMI.

METHODS

This study used data from the 2008 and 2009 Behavioral Risk Factor Surveillance System (analyzed in 2011), a state-based national telephone survey of non-institutionalized U.S. adults, to examine associations between receipt of preventive services (influenza and pneumococcal vaccination; cholesterol and HIV screening; fecal occult blood test; colonoscopy/sigmoidoscopy, mammogram, and Pap) and BMI category (normal, 18.5-24.9; overweight, 25-29.9; obese Class I, 30-34.9; obese Class II, 35-39.9; and obese Class III, ≥40), after adjusting for confounding factors.

RESULTS

Receipt was lower for mammography and Pap testing (6.1 and 5.6 percentage points, respectively, relative to normal weight women) in obese Class III women. For immunizations, cholesterol screening, and colon cancer screening, receipt was similar or greater in overweight and obese individuals.

CONCLUSIONS

This study suggests that for most services, obese individuals received as much if not more preventive health care as normal-weight individuals. Although these findings are reassuring, the evidence for disparities for cervical and breast cancer screening in obese women demonstrates that efforts to ensure more equitable service delivery are still needed.