NASHFit: A randomized controlled trial of an exercise training program to reduce clotting risk in patients with NASH.

BACKGROUND AND AIMS: NASH is a common disease associated with increased rates of thromboembolism (TE). Although exercise training can lessen thrombotic risk in patients with vascular disease, whether similar findings are observed in patients with NASH is open for study. APPROACH AND RESULTS: We conducted a 20-week randomized controlled clinical trial involving patients with biopsy-confirmed NASH. Patients were randomly assigned (2:1 ratio) to receive either an exercise training program or standard clinical care. The primary endpoint was change in plasminogen activator inhibitor 1 (PAI-1) level, an established thrombotic biomarker. Twenty-eight patients were randomly assigned (18 exercise training and 10 standard clinical care). PAI-1 level was significantly decreased by exercise training when compared to standard clinical care (-40 ± 100 vs. +70 ± 63 ng/ml; p = 0.02). Exercise training decreased MRI proton density fat fraction (MRI-PDFF; -4.7 ± 5.6 vs. 1.2 ± 2.8% absolute liver fat; p = 0.01); 40% of exercise subjects had a ≥30% relative reduction in MRI-PDFF (histological response threshold) compared to 13% for standard of care (p < 0.01). Exercise training improved fitness (VO2 peak, +3.0 ± 5.6 vs. -1.8 ± 5.1 ml/kg/min; p = 0.05) in comparison to standard clinical care. CONCLUSIONS: This clinical trial showed that, independent of weight loss or dietary change, exercise training resulted in a significantly greater decrease in thrombotic risk than standard clinical care in patients with NASH, in parallel with MRI-PDFF reduction and improvement in fitness. Future studies are required to determine whether exercise training can directly impact patient outcomes and lower rates of TE.

Adapting an Evidence-Based Exercise and Education Program for Older Breast Cancer Survivors for the REJOIN Trial.

Physical activity (PA) promotes survival and mitigates symptoms in older breast cancer survivors (BCS), especially to reduce joint pain associated with adjuvant hormonal treatment. The purpose is to describe the adaptation process for an evidence-based exercise and education curriculum (i.e., Fit & Strong!) to support older BCS participating in the Using Exercise to Relieve Joint Pain and Improve Aromatase Inhibitor Adherence in Older Breast Cancer Survivors trial. We reviewed all educational materials with scientific/clinical experts to identify necessary content changes. Next, we conducted semistructured phone interviews with BCS to review all educational materials and conducted a real-time pretest for the trial. Overall, BCS found the adapted materials and experience acceptable (mean score of 9.2/10 for satisfaction). Content changes included simplifying exercise instructions, prioritizing content related to the trial goals, and updating photographs. Because of COVID, the pretest was conducted via Zoom. Our multistep adaptation process provided an acceptable intervention to meet the needs of older BCS. Lessons learned will be applied to the forthcoming pilot trial.

Exercise Training Reverses Gut Dysbiosis in Patients With Biopsy-Proven Nonalcoholic Steatohepatitis: A Proof of Concept Study.

Nonalcoholic fatty liver disease is the leading cause of liver disease worldwide and can progress to nonalcoholic steatohepatitis (NASH) through physical inactivity and gut dysbiosis.1 Exercise training reverses gut dysbiosis in non-NASH persons with obesity and in NASH animal models.2,3 Consequently, we conducted a proof-of-concept study investigating the effect of exercise training on gut dysbiosis in NASH patients.

Breaking Down Barriers to Physical Activity in Patients with Nonalcoholic Fatty Liver Disease.

BACKGROUND: Lifestyle changes, including physical activity, are the cornerstones of the treatment of nonalcoholic fatty liver disease (NAFLD). For unclear reasons, most NAFLD patients do not achieve the recommended amount of weekly activity. AIMS: Our aim was to measure perceived barriers to physical activity and enablers to exercise intervention. METHODS: Consecutive subjects aged 18-70 with NAFLD were prospectively enrolled. An exercise motivation questionnaire was administered to assess current behaviors and perceived barriers. RESULTS: Eighty-seven subjects (60% female) were enrolled with mean age 52 years and mean body mass index (BMI) 34.5 kg/m2. Metabolic comorbidities were common: 49% had hyperlipidemia, 42% hypertension, and 40% diabetes. The majority (75%) did not achieve ≥ 150 min/week of physical activity. Ninety-one percent agreed that activity was important in improving NAFLD; 88% desired to be more active. Lack of exercise resources and education from treating provider (47%), physical discomfort during exercise (44%), and time constraints (32%) were the most common barriers. Rates of fitness tracker (34%), gym (33%), exercise program (33%), and personal trainer (17%) use were low. CONCLUSIONS: While nearly all subjects with NAFLD identify physical activity to be important and desire to be more active, only a few meet activity recommendations. This discordance is due to a perceived lack of resources and education, physical discomfort, and time constraints. Better understanding of these barriers and behaviors are important to improve morbidity and mortality in NAFLD. Future behavioral research removing the identified barriers is of great importance to global public health and should be prioritized.

Social Media in the Diabetes Community: a Novel Way to Assess Psychosocial Needs in People with Diabetes and Their Caregivers.

PURPOSE OF REVIEW: Diabetes is a chronic disease that, regardless of type, requires intensive, ongoing self-management. As a result, people with diabetes (PWD) often have complex environmental, social, behavioral, and informational needs, many of which are unmet in healthcare settings and systems. To help meet these needs, many PWD interact with diabetes online communities (DOCs), including platforms such as Facebook, Twitter, and blogs, to share real-life support, problems, and concerns with other PWD, offering a rich source of data on patient-reported outcomes. This article reviews recent psychosocial needs and outcomes identified by studies of DOCs and/or their users. RECENT FINDINGS: Participation in DOCs appears driven by a need for psychosocial support, unmet by providers and the healthcare system, as well as a sense of duty to provide it to others. The most common activities observed in DOCs are giving and receiving various types of support: psychosocial, technical, informational, and self-management. General and specific challenges (e.g., continuous glucose monitoring) as well as frustrations and worries associated with those challenges are commonly expressed, leading to reciprocal sharing, support, and encouragement, in a judgment-free manner, from other PWD. This leads users to feel more understood, empowered, validated, less alone, and more supported. Negative findings were reported very rarely and focused more on how other participants used social media rather than on the exchange of misplaced or dangerous information or advice. Diabetes online communities have grown from unmet needs for problem-solving and psychosocial support for living with a complex condition and from the availability of a new communications medium (i.e., social media). This has enabled communities of peers to both seek and receive support for living with diabetes, providing an important supplement to what is provided in healthcare settings and offering valuable information about what is most important to PWD and their families, with the potential to improve psychosocial care.

Exercise Attenuates Ribosomal Protein Six Phosphorylation in Fatty Liver Disease.

INTRODUCTION: Nonalcoholic fatty liver disease (NAFLD) is the leading cause of liver disease worldwide. Nonalcoholic steatohepatitis (NASH), is a more severe type of NAFLD. Exercise improves NASH, by reversing steatosis, and may arrest fibrosis. However, the mechanisms underlying these interactions are unknown. AMP-activated protein kinase (AMPK) is a fuel-sensing enzyme that is activated by energy stress. Mammalian target of rapamycin in complex 1 (mTORC1) is a nutrient sensor that regulates protein synthesis. In NASH, AMPK activity is low and mTORC1 is high. In healthy persons, exercise activates AMPK and suppresses mTORC1. We examined the effects of exercise on hepatic ribosomal protein S6 phosphorylation, a downstream target of AMPK and mTORC1 in patients with NASH. METHODS: Three subjects with biopsy-proven NASH underwent a structured, 20-week aerobic exercise intervention, five-days a week for 30-min at a moderate intensity (40-55% of VO2max). Immunofluorescence staining for rpS6 phosphorylation in hepatic tissue was quantified by ImageJ software. RESULTS: Following 20-weeks of aerobic exercise, rpS6 levels were significantly attenuated (3.9 ± 1.9 pre-exercise vs. 1.4 +/0.4 post-exercise, p = 0.04). CONCLUSIONS: These findings suggest exercise modulates the AMPK/mTORC1 pathway in patients with NASH and may guide the design of future studies into the mechanism of how exercise improves NASH and possibly reverses fibrosis.

A case series of patients with left ventricular assist devices and concomitant mechanical heart valves.

Mechanical heart valves left in situ at the time of left ventricular assist device (LVAD) implantation are thought to potentially increase the risk of thromboembolism. Recommendations exist to replace dysfunctional mechanical mitral valves and any mechanical aortic valves at the time of LVAD implantation. Due to potential increases in cardiopulmonary bypass time and associated comorbidities with valve replacement, leaving a functional mechanical valve in place at LVAD implantation has been suggested to be a safe option. We retrospectively reviewed all patients with prior mechanical mitral or aortic valves undergoing LVAD implantation at our center between 2012 and 2017. Echocardiograms were read by a single cardiologist to assess for mechanical valve dysfunction. We identified 15 patients. Five patients had major bleeding requiring transfusion. On follow-up, 2 patients had hemorrhagic stroke and 2 had transient ischemic attach/ischemic stroke. In addition, 2 patients had LVAD thrombosis and 2 patients had LVAD driveline malfunction. Mild mechanical valve regurgitation was identified on follow-up echocardiograms of 2 patients. Rate of complications in patients with mechanical valves undergoing LVAD implantation was comparable to that reported for the general LVAD population. Leaving a functional mechanical valve in place at the time of LVAD implantation could be a reasonable alternative to valve replacement. More data are required to further guide patient care in these individuals.

Understanding stress reports in daily life: a coordinated analysis of factors associated with the frequency of reporting stress.

Although stress is a common experience in everyday life, a clear understanding of how often an individual experiences and reports stress is lacking. Notably, there is little information regarding factors that may influence how frequently stress is reported, including which stress dimension is measured (i.e., stressors-did an event happen, subjective stress-how stressed do you feel, conditional stress-how stressful a stressor was) and the temporal features of that assessment (i.e., time of day, day of study, weekday vs. weekend day). The purpose of the present study was to conduct a coordinated analysis of five independent ecological momentary assessment studies utilizing varied stress reporting dimensions and temporal features. Results indicated that, within days, stress was reported at different frequencies depending on the stress dimension. Stressors were reported on 15-32% of momentary reports made within a day; across days, the frequency ranged from 42 to 76% of days. Depending on the cutoff, subjective stress was reported more frequently ranging about 8-56% of all moments within days, and 40-90% of days. Likewise, conditional stress ranged from just 3% of moments to 22%, and 11-69% of days. For the temporal features, stress was reported more frequently on weekdays (compared to weekend days) and on days earlier in the study (relative to days later in the study); time of day was inconsistently related to stress reports. In sum, stress report frequency depends in part on how stress is assessed. As such, researchers may wish to measure stress in multiple ways and, in the case of subjective and conditional stress with multiple operational definitions, to thoroughly characterize the frequency of stress reporting.

Interest Among Primary Care Patients in Group Problem-Solving Gameplay for Mental Health.

Mental health programs to improve problem-solving skills and reduce stress through social gameplay can improve psychiatric outcomes, but little is known about whether adult patients are interested in using them. Primary care patients (n = 467) completed a cross-sectional survey to assess interest in using 2 types of group programs for mental health. A significantly greater percentage (23.7%) of patients expressed interest in a gameplay-based program than in interpersonal therapy (17.6%) (P < .001). Lonely patients and younger patients were more likely to report interest in gameplay. Results suggest that diverse patient populations are interested in using gameplay programs for mental health.

Global life satisfaction predicts ambulatory affect, stress, and cortisol in daily life in working adults.

Global life satisfaction has been linked with long-term health advantages, yet how life satisfaction impacts the trajectory of long-term health is unclear. This paper examines one such possible mechanism-that greater life satisfaction confers momentary benefits in daily life that accumulate over time. A community sample of working adults (n = 115) completed a measure of life satisfaction and then three subsequent days of ecological momentary assessment surveys (6 times/day) measuring affect (i.e., emotional valence, arousal), and perceived stress, and also provided salivary cortisol samples. Multilevel models indicated that people with higher (vs. lower) levels of life satisfaction reported better momentary affect, less stress, marginally lower momentary levels and significantly altered diurnal slopes of cortisol. Findings suggest individuals with high global life satisfaction have advantageous daily experiences, providing initial evidence for potential mechanisms through which global life satisfaction may help explain long-term health benefits.

The Relationship Between Self-Rated Health and Use of Parks and Participation in Recreation Programs, United States, 1991 and 2015.

We examined the relationship between self-rated health and use of parks and recreation program participation by using logistic regression to analyze data from representative national surveys conducted in 1991 and 2015. Neither park use nor program participation were significantly related to self-rated health in 1991; however, both were significantly related in 2015. The growing relationship between use of parks and recreation programs and self-rated health during this period is likely the result of broad national health promotion efforts and provides support for funding of capital and operational expenses for park and recreation services.

Engineering Online and In-Person Social Networks for Physical Activity: A Randomized Trial.

BACKGROUND: Social networks can influence physical activity, but little is known about how best to engineer online and in-person social networks to increase activity. PURPOSE: The purpose of this study was to conduct a randomized trial based on the Social Networks for Activity Promotion model to assess the incremental contributions of different procedures for building social networks on objectively measured outcomes. METHODS: Physically inactive adults (n = 308, age, 50.3 (SD = 8.3) years, 38.3 % male, 83.4 % overweight/obese) were randomized to one of three groups. The Promotion group evaluated the effects of weekly emailed tips emphasizing social network interactions for walking (e.g., encouragement, informational support); the Activity group evaluated the incremental effect of adding an evidence-based online fitness walking intervention to the weekly tips; and the Social Networks group evaluated the additional incremental effect of providing access to an online networking site for walking as well as prompting walking/activity across diverse settings. The primary outcome was mean change in accelerometer-measured moderate-to-vigorous physical activity (MVPA), assessed at 3 and 9 months from baseline. RESULTS: Participants increased their MVPA by 21.0 min/week, 95 % CI [5.9, 36.1], p = .005, at 3 months, and this change was sustained at 9 months, with no between-group differences. CONCLUSIONS: Although the structure of procedures for targeting social networks varied across intervention groups, the functional effect of these procedures on physical activity was similar. Future research should evaluate if more powerful reinforcers improve the effects of social network interventions. TRIAL REGISTRATION NUMBER: The trial was registered with the ClinicalTrials.gov (NCT01142804).

Is strength training associated with mortality benefits? A 15year cohort study of US older adults.

BACKGROUND: The relationship between strength training (ST) behavior and mortality remains understudied in large, national samples, although smaller studies have observed that greater amounts of muscle strength are associated with lower risks of death. We aimed to understand the association between meeting ST guidelines and future mortality in an older US adult population. METHODS: Data were analyzed from the 1997-2001 National Health Interview Survey (NHIS) linked to death certificate data in the National Death Index. The main independent variable was guideline-concordant ST (i.e. twice each week) and dependent variable was all-cause mortality. Covariates identified in the literature and included in our analysis were demographics, past medical history, and other health behaviors (including other physical activity). Given our aim to understand outcomes in older adults, analyses were limited to adults age 65years and older. Multivariate analysis was conducted using multiple logistic regression analysis. RESULTS: During the study period, 9.6% of NHIS adults age 65 and older (N=30,162) reported doing guideline-concordant ST and 31.6% died. Older adults who reported guideline-concordant ST had 46% lower odds of all-cause mortality than those who did not (adjusted odds ratio: 0.64; 95% CI: 0.57, 0.70; p<0.001). The association between ST and death remained after adjustment for past medical history and health behaviors. CONCLUSIONS: Although a minority of older US adults met ST recommendations, guideline-concordant ST is significantly associated with decreased overall mortality. All-cause mortality may be significantly reduced through the identification of and engagement in guideline-concordant ST interventions by older adults.

Is exercise used as medicine? Association of meeting strength training guidelines and functional limitations among older US adults.

OBJECTIVE: To determine the association between meeting strength training guidelines (≥2 times per week) and the presence of functional limitations among older adults. METHODS: This cross-sectional study used data from older adult participants (N=6763) of the National Health Interview Survey conducted in 2011 in the United States. RESULTS: Overall, 16.1% of older adults reported meeting strength training guidelines. For each of nine functional limitations, those with the limitation were less likely to meet strength training recommendations than those without the limitation. For example, 20.0% of those who reported no difficulty walking one-quarter mile met strength training guidelines, versus only 10.1% of those who reported difficulty (p<.001). In sum, 21.7% of those with no limitations (33.7% of sample) met strength training guidelines, versus only 15.9% of those reporting 1-4 limitations (38.5% of sample) and 9.8% of those reporting 5-9 limitations (27.8% of sample) (p<.001). CONCLUSION: Strength training is uncommon among older adults and even less common among those who need it the most. The potential for strength training to improve the public's health is therefore substantial, as those who have the most to gain from strength training participate the least.

Structural social support predicts functional social support in an online weight loss programme.

BACKGROUND: Online weight loss programmes allow members to use social media tools to give and receive social support for weight loss. However, little is known about the relationship between the use of social media tools and the perception of specific types of support. OBJECTIVE: To test the hypothesis that the frequency of using social media tools (structural support) is directly related to perceptions of Encouragement, Information and Shared Experiences support (functional support). DESIGN: Online survey. PARTICIPANTS: Members of an online weight loss programme. METHODS: The outcome was the perception of Encouragement (motivation, congratulations), Information (advice, tips) and Shared Experiences (belonging to a group) social support. The predictor was a social media scale based on the frequency of using forums and blogs within the online weight loss programme (alpha = 0.91). The relationship between predictor and outcomes was evaluated with structural equation modelling (SEM) and logistic regression, adjusted for sociodemographic characteristics, BMI and duration of website membership. RESULTS: The 187 participants were mostly female (95%) and white (91%), with mean (SD) age 37 (12) years and mean (SD) BMI 31 (8). SEM produced a model in which social media use predicted Encouragement support, but not Information or Shared Experiences support. Participants who used the social media tools at least weekly were almost five times as likely to experience Encouragement support compared to those who used the features less frequently [adjusted OR 4.8 (95% CI 1.8-12.8)]. CONCLUSIONS: Using the social media tools of an online weight loss programme at least once per week is strongly associated with receiving Encouragement for weight loss behaviours.

Clinician-targeted intervention and patient-reported counseling on physical activity.

INTRODUCTION: Limited time and lack of knowledge are barriers to physical activity counseling in primary care. The objective of this study was to examine the effectiveness of a clinician-targeted intervention that used the 5As (Ask, Advise, Agree, Assist, Arrange) approach to physical activity counseling in a medically underserved patient population. METHODS: Family medicine clinicians at 2 community health centers were randomized to Group 1 or Group 2 intervention. Both clinician groups participated in 4 training sessions on the 5As for physical activity counseling; Group 2 training took place 8 months after Group 1 training. Both groups were trained to refer patients to a community exercise program. We used a pre-post analysis to evaluate the effectiveness of the intervention on clinician use of 5As. Eligible patients (n = 319) rated their clinicians' counseling skills by using a modified Physical Activity Exit Interview (PAEI) survey. Clinicians (n = 10) self-assessed their use of the 5As through a survey and interviews. RESULTS: Both patient and clinician groups had similar sociodemographic characteristics. The PAEI score for both groups combined increased from 6.9 to 8.6 (on a scale of 0-15) from baseline to immediately postintervention (P = .01) and was 8.2 (P = .09) at 6-month follow-up; most of the improvement in PAEI score was due to increased use of 5As skills by Group 2 clinicians. Group 1 reported difficulty with problem solving, whereas Group 2 reported ease of referral to the community exercise program. CONCLUSION: A clinician training intervention showed mixed results for 5As physical activity counseling.

A strength training program for primary care patients, central Pennsylvania, 2012.

INTRODUCTION: Primary care providers can recommend strength training programs to use "Exercise as Medicine," yet few studies have examined the interest of primary care patients in these programs. METHODS: We conducted a cross-sectional survey of primary care patients in central Pennsylvania. Interest in participating in free group-based strength training and weight control programs was assessed, in addition to patient demographics, medical history, and quality of life. RESULTS: Among 414 patients, most (61.0%) were aged 54 or older, and 64.0% were female. More patients were interested in a strength training program (55.3%) than in a weight control program (45.4%). Nearly three-quarters (72.8%) of those reporting 10 or more days of poor physical health were interested in a strength training program compared with 49.5% of those reporting no days of poor physical health. After adjusting for potential confounders, those reporting poorer physical health had 2.7 greater odds (95% confidence interval, 1.4-5.1) of being interested in a strength training program compared with those reporting better physical health. Patients with hypertension, diabetes, or high cholesterol were not more interested in a strength training program than those without these conditions. CONCLUSION: Primary care practices may consider offering or referring patients to community-based strength training programs. This study observed high levels of interest in these widely available programs. Practices may also consider screening and referring those with poorer physical health, as they may be the most interested and have the most to gain from participating.

Supporting physical activity adoption through recommender system technology: A pilot study.

We tested the potential for recommender system technology to provide personalized physical activity (PA) suggestions for inactive young adults with high bodyweight. We developed a recommender system using data from the 2017 Behavioral Risk Factor Surveillance System and assessed interest in using the system among 47 young adults (mean age = 23.0 years; 63.4% female; 65.0% White; mean BMI = 29.4). Eleven of these participants (mean age = 23.6 years; 90.9% female, 63.6% White; average BMI = 28.5) also received a PA recommendation and a follow-up interview. Approximately half of the survey participants were willing to use the recommender system, and participants interested in the recommender system differed from those unwilling to try the system (e.g., more likely to be female, worse self-perceived health). Furthermore, eight of the 11 interviewees tried the PA recommended to them, but had mixed reviews of the system's accuracy. Although our recommender system requires improvements, such systems have promise for supporting PA adoption.

Personal goal setting eHealth component associated with improved weight loss at 6 months: A mixed methods secondary analysis.

Objective: Goal setting is a behavior change technique associated with improved change in outcomes. Digital (eHealth, mHealth) behavior change interventions often prescribe all goals with no opportunity for participants to create and track their own; thus, little is known about the types of goals participants create for themselves and their impacts on behavioral outcomes. This analysis describes the goals created by participants using an optional personal goal-setting component and evaluates the association between participant goal creation and weight loss in an eHealth adult weight loss intervention. Methods: This represents a mixed methods QUANT-qual design to understand the types of goals users create for themselves and their impacts on behavior change outcomes. Qualitative codes were applied for the topic, behavior/outcome focus, adherence to SMART criteria, and repetition with count summaries. Quantitative analyses applied regression modeling to determine if the number of goals set was associated with the 6-month weight change, controlling for covariates. Results: Participants (n = 363) set an average of 23.4 goals (SD = 22.7) over 6 months. Those who reached at least 5% weight loss set significantly more goals than those who lost between 1% and 4.99% or who lost <1% or gained weight (p's < 0.0001). Setting more personal goals was associated with significant weight loss reduction at 6 months, controlling for covariates (p's < 0.05). Conclusions: Greater use of a personal goal-setting feature was associated with improved weight loss outcomes among active users. This can be a low-investment addition to digital behavior change interventions to contribute to improved outcomes.