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Gardner CD, Landry MJ, Perelman D, Petlura C, Durand LR, Aronica L, Crimarco A, Cunanan KM, Chang A, Dant CC, Robinson JL, Kim SH. Effect of a ketogenic diet versus Mediterranean diet on glycated hemoglobin in individuals with prediabetes and type 2 diabetes mellitus: The interventional Keto-Med randomized crossover trial. Am J Clin Nutr 2022; 116:640-652. [PMID: 35641199 PMCID: PMC9437985 DOI: 10.1093/ajcn/nqac154] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 03/09/2022] [Accepted: 05/25/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Consensus has not been reached on what constitutes an optimal diet in individuals with prediabetes and type 2 diabetes mellitus (T2DM), especially between low-carbohydrate options. OBJECTIVES We compared 2 low-carbohydrate diets with 3 key similarities (incorporating nonstarchy vegetables and avoiding added sugars and refined grains) and 3 key differences (incorporating compared with avoiding legumes, fruits, and whole, intact grains) for their effects on glucose control and cardiometabolic risk factors in individuals with prediabetes and T2DM. METHODS Keto-Med was a randomized, crossover, interventional trial. Forty participants aged ≥18 years with prediabetes or T2DM followed the well-formulated ketogenic diet (WFKD) and the Mediterranean-plus diet (Med-Plus) for 12 weeks each, in random order. The diets shared the 3 key similarities noted above. The Med-Plus incorporated legumes, fruits, and whole, intact grains, while the WFKD avoided them. The primary outcome was the percentage change in glycated hemoglobin (HbA1c) after 12 weeks on each diet. Secondary and exploratory outcomes included percentage changes in body weight, fasting insulin, glucose, and blood lipids; average glucose from continuous glucose monitor (CGM), and nutrient intake. RESULTS The primary analysis was of 33 participants with complete data. The HbA1c values did not differ between diets at 12 weeks. Triglycerides decreased more for the WFKD [percentage changes, -16% (SEM, 4%) compared with -5% (SEM, 6%) for the Med-Plus; P = 0.02] and LDL cholesterol was higher for the WFKD [percentage changes, +10% (SEM, 4%) compared with -5% (SEM, 5%) for the Med-Plus; P = 0.01]. Weight decreased 8% (SEM, 1%) compared with 7% (SEM, 1%) and HDL cholesterol increased 11% (SEM, 2%) compared with 7% (SEM, 3%) for the WFKD compared with the Med-Plus, respectively; however, there was a significant interaction of diet × order for both. Participants had lower intakes of fiber and 3 nutrients on the WFKD compared with the Med-Plus. Twelve-week follow-up data suggest the Med-Plus is more sustainable. CONCLUSIONS HbA1c values were not different between diet phases after 12 weeks, but improved from baseline on both diets, likely due to several shared dietary aspects. The WFKD led to a greater decrease in triglycerides, but also had potential untoward risks from elevated LDL cholesterol and lower nutrient intakes from avoiding legumes, fruits, and whole, intact grains, as well as being less sustainable. This trial was registered at clinicaltrials.gov as NCT03810378.
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Affiliation(s)
- Christopher D Gardner
- Stanford Prevention Research Center, Department of Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Matthew J Landry
- Stanford Prevention Research Center, Department of Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Dalia Perelman
- Stanford Prevention Research Center, Department of Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Christina Petlura
- Stanford Prevention Research Center, Department of Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Lindsay R Durand
- Stanford Prevention Research Center, Department of Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Lucia Aronica
- Stanford Prevention Research Center, Department of Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Anthony Crimarco
- Stanford Prevention Research Center, Department of Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Kristen M Cunanan
- Quantitative Sciences Unit, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Annie Chang
- Stanford Prevention Research Center, Department of Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Christopher C Dant
- Stanford Prevention Research Center, Department of Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Jennifer L Robinson
- Stanford Prevention Research Center, Department of Medicine, School of Medicine, Stanford University, Stanford, CA, USA
| | - Sun H Kim
- Division of Endocrinology, Gerontology and Metabolism, Department of Medicine, Stanford University Medical Center, Stanford, CA, USA
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Sarraju A, Seninger C, Parameswaran V, Petlura C, Bazouzi T, Josan K, Grewal U, Viethen T, Mundl H, Luithle J, Basobas L, Touros A, Senior MJT, De Lombaert K, Mahaffey KW, Turakhia MP, Dash R. Pandemic-proof recruitment and engagement in a fully decentralized trial in atrial fibrillation patients (DeTAP). NPJ Digit Med 2022; 5:80. [PMID: 35764796 PMCID: PMC9240050 DOI: 10.1038/s41746-022-00622-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 05/19/2022] [Indexed: 11/09/2022] Open
Abstract
The Coronavirus Disease 2019 (COVID-19) pandemic curtailed clinical trial activity. Decentralized clinical trials (DCTs) can expand trial access and reduce exposure risk but their feasibility remains uncertain. We evaluated DCT feasibility for atrial fibrillation (AF) patients on oral anticoagulation (OAC). DeTAP (Decentralized Trial in Afib Patients, NCT04471623) was a 6-month, single-arm, 100% virtual study of 100 AF patients on OAC aged >55 years, recruited traditionally and through social media. Participants enrolled and participated virtually using a mobile application and remote blood pressure (BP) and six-lead electrocardiogram (ECG) sensors. Four engagement-based primary endpoints included changes in pre- versus end-of-study OAC adherence (OACA), and % completion of televisits, surveys, and ECG and BP measurements. Secondary endpoints included survey-based nuisance bleeding and patient feedback. 100 subjects (mean age 70 years, 44% women, 90% White) were recruited in 28 days (traditional: 6 pts; social media: 94 pts in 12 days with >300 waitlisted). Study engagement was high: 91% televisits, 85% surveys, and 99% ECG and 99% BP measurement completion. OACA was unchanged at 6 months (baseline: 97 ± 9%, 6 months: 96 ± 15%, p = 0.39). In patients with low baseline OACA (<90%), there was significant 6-month improvement (85 ± 16% to 96 ± 6%, p < 0.01). 86% of respondents (69/80) expressed willingness to continue in a longer trial. The DeTAP study demonstrated rapid recruitment, high engagement, and physiologic reporting via the integration of digital technologies and dedicated study coordination. These findings may inform DCT designs for future cardiovascular trials.
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Affiliation(s)
- Ashish Sarraju
- Division of Cardiovascular Medicine & Cardiovascular Institute, Stanford University School of Medicine, Palo Alto, California, USA.,Center for Digital Health, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Clark Seninger
- Center for Digital Health, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Vijaya Parameswaran
- Division of Cardiovascular Medicine & Cardiovascular Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | | | - Tamara Bazouzi
- Division of Cardiovascular Medicine & Cardiovascular Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Kiranbir Josan
- Division of Cardiovascular Medicine & Cardiovascular Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | | | | | | | | | - Leonard Basobas
- Stanford Center for Clinical Research (SCCR), Palo Alto, CA, USA
| | - Alexis Touros
- Stanford Center for Clinical Research (SCCR), Palo Alto, CA, USA
| | | | | | - Kenneth W Mahaffey
- Division of Cardiovascular Medicine & Cardiovascular Institute, Stanford University School of Medicine, Palo Alto, California, USA.,Stanford Center for Clinical Research (SCCR), Palo Alto, CA, USA
| | - Mintu P Turakhia
- Division of Cardiovascular Medicine & Cardiovascular Institute, Stanford University School of Medicine, Palo Alto, California, USA.,Center for Digital Health, Stanford University School of Medicine, Palo Alto, CA, USA.,VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Rajesh Dash
- Division of Cardiovascular Medicine & Cardiovascular Institute, Stanford University School of Medicine, Palo Alto, California, USA.
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Josan K, Touros A, Petlura C, Parameswaran V, Grewal U, Senior M, Viethen T, Mundl H, Seninger C, Luithle J, Mahaffey K, Turakhia M, Dash R. Validation of a pandemic-proof, decentralized cardiovascular trial: scalable design produces rapid recruitment, high engagement and protocol adherence in DeTAP (Decentralized Trial in Afib Patients). Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.3177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The COVID-19 pandemic has curtailed clinical trial activity significantly. Decentralized clinical trial (DCT) designs may lower cost, expand trial access, and reduce exposure risk for patients and staff. Whether such designs can be used for large, pivotal drug trials is not known.
Purpose
We performed a feasibility study to inform whether a large phase 3 Cardiovascular DCT can achieve high quality trial results and also withstand health crises such as the COVID-19 pandemic. The DeTAP (Decentralized Trial in Afib Patients) was a single-arm, observational study that integrated a suite of digital health technologies, including paired home sensor devices, into a 100% virtual trial experience for atrial fibrillation (AF) patients on anticoagulation.
Methods
We recruited 100 AF patients over age 55 on oral anticoagulation (OAC) by traditional methods or by social media ads placed California-wide. Subjects completed an online prescreening, uploaded their active OAC prescription, and completed an e-consent via SMS message link. Participants downloaded a customized study app to integrate surveys and data from study-supplied wireless blood pressure (BP) and 6 lead EKG sensors (Figure 1A). Participants completed pre- and post-study engagement surveys, weekly OAC adherence surveys, 4 study televisits, 4 ECG/BP readings, and 4 post-study surveys over a 6 month period. The primary endpoints were protocol engagement-based measurements that quantified percent completion of: 1) televisits 2) surveys, 3) ECG/BP readings requirements. Secondary endpoints were the % changes in: 1) OAC adherence (OACA), 2) nuisance bleeding (NB), 3) individual patient engagement surveys.
Results
100 participants were recruited in 26 days (traditional: 6 in 2 weeks; social media: 94 in 12 days) with a dramatic surge in enrollment driven by social media ads (Figure 1B, Table). A recruitment overflow occurred with >200 eligible candidates on a waitlist. All key study completion metrics showed high compliance: televisit (91%); surveys (85%); ECG/BP completion (90%). Overall OACA was unchanged, but for subjects who reported low initial OACA, there was significant improvement at 6 months (85±16% to 98±6%; p=0.002). 47 participants (57%) reported NB, which did not correlate with OACA. Participant engagement measure scores (PAM-13) trended higher (baseline, 70%; 6 months, 74%, p=0.32). Lastly, study participants exhibited strong interest in participating in a larger experimental drug DCT study (90%) in the future.
Conclusion
The DeTAP study, conducted fully during the COVID-19 pandemic, demonstrates that a decentralized CV medical intervention trial is feasible and can achieve rapid recruitment, high study retention, physiologic and adverse event reporting, and high study engagement via the proper integration of digital technologies and a dedicated DCT study coordination effort. These findings could be informative for virtualizing large pivotal clinical trials at scale.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Bayer AG Figure 1. DeTAP Study Design and Recruitment TimelineTable 1. DeTAP Results
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Affiliation(s)
- K Josan
- Stanford University Medical Center, Medicine, Stanford, United States of America
| | - A Touros
- Stanford University Medical Center, Stanford Center for Clinical Research, Stanford, United States of America
| | - C Petlura
- Stanford University Medical Center, Stanford Center for Clinical Research, Stanford, United States of America
| | - V Parameswaran
- Stanford University Medical Center, Medicine, Stanford, United States of America
| | | | - M Senior
- Huma Inc., London, United Kingdom
| | | | | | - C Seninger
- Stanford University Medical Center, Medicine, Stanford, United States of America
| | | | - K Mahaffey
- Stanford University Medical Center, Medicine, Stanford, United States of America
| | - M Turakhia
- Stanford University Medical Center, Medicine, Stanford, United States of America
| | - R Dash
- Stanford University Medical Center, Medicine, Stanford, United States of America
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Crimarco A, Springfield S, Petlura C, Streaty T, Cunanan K, Lee J, Fielding-Singh P, Carter MM, Topf MA, Wastyk HC, Sonnenburg ED, Sonnenburg JL, Gardner CD. A randomized crossover trial on the effect of plant-based compared with animal-based meat on trimethylamine-N-oxide and cardiovascular disease risk factors in generally healthy adults: Study With Appetizing Plantfood-Meat Eating Alternative Trial (SWAP-MEAT). Am J Clin Nutr 2020; 112:1188-1199. [PMID: 32780794 PMCID: PMC7657338 DOI: 10.1093/ajcn/nqaa203] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/29/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Despite the rising popularity of plant-based alternative meats, there is limited evidence of the health effects of these products. OBJECTIVES We aimed to compare the effect of consuming plant-based alternative meat (Plant) as opposed to animal meat (Animal) on health factors. The primary outcome was fasting serum trimethylamine-N-oxide (TMAO). Secondary outcomes included fasting insulin-like growth factor 1, lipids, glucose, insulin, blood pressure, and weight. METHODS SWAP-MEAT (The Study With Appetizing Plantfood-Meat Eating Alternatives Trial) was a single-site, randomized crossover trial with no washout period. Participants received Plant and Animal products, dietary counseling, lab assessments, microbiome assessments (16S), and anthropometric measurements. Participants were instructed to consume ≥2 servings/d of Plant compared with Animal for 8 wk each, while keeping all other foods and beverages as similar as possible between the 2 phases. RESULTS The 36 participants who provided complete data for both crossover phases included 67% women, were 69% Caucasian, had a mean ± SD age 50 ± 14 y, and BMI 28 ± 5 kg/m2. Mean ± SD servings per day were not different by intervention sequence: 2.5 ± 0.6 compared with 2.6 ± 0.7 for Plant and Animal, respectively (P = 0.76). Mean ± SEM TMAO concentrations were significantly lower overall for Plant (2.7 ± 0.3) than for Animal (4.7 ± 0.9) (P = 0.012), but a significant order effect was observed (P = 0.023). TMAO concentrations were significantly lower for Plant among the n = 18 who received Plant second (2.9 ± 0.4 compared with 6.4 ± 1.5, Plant compared with Animal, P = 0.007), but not for the n = 18 who received Plant first (2.5 ± 0.4 compared with 3.0 ± 0.6, Plant compared with Animal, P = 0.23). Exploratory analyses of the microbiome failed to reveal possible responder compared with nonresponder factors. Mean ± SEM LDL-cholesterol concentrations (109.9 ± 4.5 compared with 120.7 ± 4.5 mg/dL, P = 0.002) and weight (78.7 ± 3.0 compared with 79.6 ± 3.0 kg, P < 0.001) were lower during the Plant phase. CONCLUSIONS Among generally healthy adults, contrasting Plant with Animal intake, while keeping all other dietary components similar, the Plant products improved several cardiovascular disease risk factors, including TMAO; there were no adverse effects on risk factors from the Plant products.This trial was registered at clinicaltrials.gov as NCT03718988.
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Affiliation(s)
- Anthony Crimarco
- Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Sparkle Springfield
- Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Christina Petlura
- Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Taylor Streaty
- Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Kristen Cunanan
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, CA, USA
| | - Justin Lee
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, CA, USA
| | - Priya Fielding-Singh
- Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Matthew M Carter
- Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, USA
| | - Madeline A Topf
- Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, USA
| | - Hannah C Wastyk
- Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, USA
- Department of Bioengineering, Stanford University School of Medicine, Stanford, CA, USA
| | - Erica D Sonnenburg
- Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, USA
- Center for Human Microbiome Studies, Stanford University, Stanford, CA, USA
| | - Justin L Sonnenburg
- Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, USA
- Center for Human Microbiome Studies, Stanford University, Stanford, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Christopher D Gardner
- Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA, USA
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Petlura C, Walter L, Werstuck G. Abstract 670: A Metabolic Approach to Examining the Hexosamine Biosynthetic Pathway and Its Role in the Development of Diabetes-Associated Atherosclerosis. Arterioscler Thromb Vasc Biol 2014. [DOI: 10.1161/atvb.34.suppl_1.670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Diabetes is a disease affecting millions of people worldwide, and is a major independent risk factor for cardiovascular disease (CVD). Despite a vast amount of research, the molecular mechanisms that link diabetes to CVD are not well understood. Current evidence suggests that increased flux through the hexosamine biosynthetic pathway (HBP) contributes to the development of hyperglycemia-associated diabetic complications. Our data suggest that increased HBP flux can induce vascular ER stress and accelerate atherogenesis in a mouse model. We hypothesized that this process can be attenuated by inhibiting the first and rate-limiting enzyme in the HBP - glutamine fructose-6-phosphate amidotransferase (GFAT) - using small molecules.
Methods and Results:
Using high-performance liquid chromatography coupled to mass spectrometry (HPLC-MS) we have developed a methodology to monitor and quantify the levels of the end product of the HBP, uridine diphosphate
N
-acetylglucosamine (UDP-GlcNAc). Treatment of HepG2 cells with glucosamine (0.2-5 mM), or adenovirus-directed overexpression of GFAT caused a 3-7 fold increase in UDP-GlcNAc (
P<
0.001 &
P<
0.05, respectively). Inhibition of GFAT with three novel compounds - amrinone, lapachol or alloxan - decreased levels of UDP-GlcNAc by 1.5 (
P<
0.05), 3 (
P<
0.05) and 3.5-fold (
P<
0.001), respectively. Furthermore, we show that by modulating HBP flux, we can regulate ER stress levels in cultured HepG2 cells. The physiological relevance of this mechanism is supported by evidence of HBP augmentation in a hyperglycemic mouse model.
Conclusions:
These results support a role for the HBP in the development of atherosclerosis. Currently, MALDI imaging mass spectrometry is being performed on tissue sections to compare the levels of UDP-GlcNAc directly in hyperglycemic vs. normoglycemic mice. These studies may lead to the identification and validation of novel targets for the development of new pharmaceuticals to prevent diabetic atherosclerosis.
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Affiliation(s)
| | - Lisa Walter
- Chemistry and Chemical Biology, McMaster Univ, Hamilton, Canada
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Petlura C, Walter LA, Werstuck GH. Examining the Hexosamine Biosynthetic Pathway and Its Role in the Development of Diabetes-Associated Atherosclerosis: A Metabolomic Approach. Can J Cardiol 2013. [DOI: 10.1016/j.cjca.2013.07.258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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