Visceral adiposity: A major mediator of the relationship between epicardial adiposity and cardiorespiratory fitness in adults.

BACKGROUND AND AIMS: Epicardial adiposity has been positively associated with visceral adipose tissue (VAT). Few studies have examined the association between cardiorespiratory fitness (CRF) and epicardial adiposity. Furthermore, whether this relationship was independent of VAT remains unexplored. Our purpose was to investigate the contribution of VAT in the relationships between CRF, physical activity (PA) and epicardial adipose tissue (EAT) in asymptomatic women and men. METHODS AND RESULTS: We examined the associations between EAT and VAT measured by magnetic resonance imaging, CRF measured by cardiopulmonary exercise testing, and PA assessed using pedometers and a 3-day PA journal in 239 apparently healthy adults (43 % women). Participants were compared according to EAT tertiles and CRF level in both sexes. Participants with the highest EAT level presented more VAT (p < 0.001), lower CRF (p < 0.01), and a more deteriorated cardiometabolic health score (p < 0.01) than those with the lowest EAT level. CRF was negatively associated with EAT in both sexes (p < 0.01). No significant relationship was found with PA (p = NS). Stepwise multivariable regression analyses showed that VAT explained most of the variance in EAT in women and men. Mediation analyses confirmed that VAT was a mediator of the association between CRF and EAT in both sexes. CONCLUSION: In women and men, VAT appears as a major mediator of the association between CRF and EAT thereby suggesting that managing VAT by improving CRF could help in the prevention of cardiometabolic disorders related to excess EAT.

Associations of insulin-like growth factor binding protein-2 with metabolic profile and hepatic fat deposition in asymptomatic men and women.

Low circulating levels of insulin-like growth-factor binding protein-2 (IGFBP-2) have been associated with increased adiposity and metabolic alterations such as insulin resistance, dyslipidemia, and nonalcoholic fatty liver disease in individuals with obesity. However, whether IGFBP-2 affects energy metabolism in the early stages of these disorders remains unclear. Herein, we hypothesized that plasma IGFBP-2 concentrations are inversely associated with early liver fat accumulation and alterations in lipid and glucose homeostasis in apparently healthy and asymptomatic men and women. Three hundred thirty-three middle-aged Caucasian men and women apparently healthy and without cardiovascular symptoms were enrolled for a cross-sectional cardiometabolic imaging study. Individuals with BMI ≥ 40 kg/m2, cardiovascular disease, dyslipidemia, hypertension, and diabetes were excluded. Fasting glucose and lipid profiles were measured and an oral glucose tolerance test was performed. Liver fat content was assessed by magnetic resonance spectroscopy. Volume of visceral adipose tissue (VAT) was evaluated by magnetic resonance imaging. Plasma IGFBP-2 levels were quantified by ELISA. Participants with low IGFBP-2 levels were characterized by a higher body fat mass (P < 0.0001), insulin resistance (P < 0.0001), higher plasma triglyceride (TG) (P < 0.0001), and lower HDL-cholesterol levels (P < 0.0001) in a sex-independent manner. IGFBP-2 levels were inversely correlated with hepatic fat fraction in both men (r = -0.36, P < 0.0001) and women (r = -0.40, P < 0.0001). IGFBP-2 concentrations were negatively associated with hepatic fat fraction independently of age and VAT in both men (R2 = 0.23, P = 0.012) and women (R2 = 0.27, P = 0.028). In conclusion, our findings show that even in asymptomatic, apparently healthy individuals, low IGFBP-2 levels are associated with a more deteriorated cardiometabolic risk profile and with a high hepatic fat content in a VAT-independent manner. However, IGFBP-2 does not appear to influence the established sexual dimorphism observed for metabolic variables and hepatic fat fraction. Additional studies are required to better understand the relationships between IGFBP-2 and liver fat content.NEW & NOTEWORTHY Faced with a paucity of reliable clinical etiologic markers for fatty liver, this research article demonstrates, for the first time, that low blood levels of the protein IGFBP-2 are associated with a more deteriorated cardiometabolic risk profile and with a high hepatic fat content independently of visceral fat volume and sex, even in asymptomatic, apparently healthy individuals.

Visceral adiposity and liver fat as mediators of the association between cardiorespiratory fitness and plasma glucose-insulin homeostasis.

Cardiorespiratory fitness (CRF) is positively associated with insulin sensitivity, whereas excessive levels of visceral adipose tissue (AT) and liver fat (LF) are both associated with insulin resistance and impaired plasma glucose-insulin homeostasis. To what extent levels of visceral AT and LF content contribute to the relationship between CRF and indices of plasma glucose-insulin homeostasis is uncertain. Our objective was to explore the interactions among CRF, visceral AT, and LF with glucose tolerance/insulin levels in asymptomatic and apparently healthy individuals. CRF was measured in 135 women and 177 men with a maximal treadmill graded exercise test. Indices of plasma glucose-insulin homeostasis were derived from a 3-h oral glucose tolerance test (OGTT) performed in the morning after a 12-h fast. Visceral AT levels and LF content were measured using magnetic resonance imaging and spectroscopy. For any given CRF level, women presented significantly lower visceral AT and LF than men as well as lower homeostasis model assessment of insulin resistance (HOMA-IR) and plasma glucose-insulin levels during the OGTT compared with men. In both sexes, there were significant negative correlations between CRF and HOMA-IR as well as glucose and insulin levels measured during the OGTT. Both glucose and insulin levels during the OGTT correlated positively with visceral AT and LF. In women and men, being in the top CRF tertile was associated with low levels of visceral AT and LF. Multivariable linear regression analyses suggested that visceral AT and LF were plausible mediators of the association between CRF and indices of plasma glucose-insulin homeostasis.

What methods have been used to estimate salt intake? A systematic review.

The relationship between salt intake and cardiovascular diseases is a contemporary scientific controversy, which has been attributed to the limits of the measures of salt intake used in the studies. Thus, this article sought to systematically review the literature on the methods used to estimate salt intake in different study designs. Of the 124 articles, 60.5% used only biochemical measures, 26.6% only self-report measures and 12.9% reported the combined use of both methods. The 24-hour urinary sodium excretion was the predominant biochemical method (79.1%) and the Food Frequency Questionnaire was the predominant self-report measure (36.4%). Interventional studies used mostly 24-hour urinary sodium excretion; while longitudinal studies used self-report measures. The question guiding the study and its design, as well as constraints related to costs, sample size and feasibility seems to influence the choice of the type of measurement.

Dietary sources of salt intake in adults and older people: a population-based study in a Brazilian town.

OBJECTIVE: To assess salt intake and its dietary sources using biochemical and self-report methods and to characterize salt intake according to sociodemographic and disease-related variables in a sample of the Brazilian population. DESIGN: Population-based cross-sectional survey. SETTING: Salt intake was assessed by biochemical (24 h urinary Na excretion) and self-report methods (sodium FFQ, 24 h dietary recall, seasoned-salt questionnaire, discretionary-salt questionnaire and total reported salt intake).ParticipantsAdults and older people (n 517) aged 20-80 years, living in Artur Nogueira, São Paulo, Brazil. RESULTS: Mean salt intake based on 24 h urinary Na excretion and total reported salt intake was 10·5 and 11·0 g/d, respectively; both measures were significantly correlated. Discretionary salt and seasoned salt were the most important sources of salt intake (68·2 %). Men in the study consumed more salt than women as estimated by 24 h urinary Na excretion (11·7 v. 9·6 g salt/d; P<0·0001). Participants known to be hypertensive added more salt to their meals but consumed less salty ultra-processed foods. Waist circumference in both sexes and BMI were positively correlated with salt intake estimated by 24 h urinary Na excretion. In addition, regression analysis revealed that being a young male or having a high waist circumference was a predictor of higher salt intake. CONCLUSIONS: Salt intake in this population was well above the recommended amount. The main source of salt intake came from salt added during cooking. Salt intake varied according to sex and waist circumference.

Patient experiences of a lifestyle program for metabolic syndrome offered in family medicine clinics: a mixed methods study.

BACKGROUND: Patient perspectives on new programs to manage metabolic syndrome (MetS) are critical to evaluate for possible implementation in the primary healthcare system. Participants' perspectives were sought for the Canadian Health Advanced by Nutrition and Graded Exercise (CHANGE) study, which enrolled 293 participants, and demonstrated 19% reversal of MetS after 1 year. The main purpose of this study was to examine participants' perceptions of their experiences with the CHANGE program, enablers and barriers to change. METHODS: A convergent parallel mixed methods design combined patients' perspectives collected by questionnaires (n = 164), with insights from focus groups (n = 41) from three sites across Canada. Qualitative data were thematically analyzed using interpretative description. Insights were organized within a socio-ecologic framework. RESULTS: Key aspects identified by participants included intra-individual factors (personal agency, increased time availability), inter-individual factors (trust, social aspects) and organizational factors (increased mental health support, tailored programs). CONCLUSION: Results revealed participants' overall support for the CHANGE program, especially the importance of an extended program under the guidance of a family physician along with a skilled and supportive team. Team delivery of a lifestyle program in primary care or family medicine clinics is a complex intervention and use of a mixed methods design was helpful for exploring patient experiences and key issues on enablers and barriers to health behavior change.

Drug samples in family medicine teaching units: a cross-sectional descriptive study: Part 2: portrait of drug sample management in Quebec.

OBJECTIVE: To draw a portrait of drug sample management in academic primary health care settings and assess conformity to existing Canadian guidelines. DESIGN: Descriptive cross-sectional survey. SETTING: All 33 family medicine teaching units (FMTUs) in Quebec that kept drug samples. PARTICIPANTS: Health care professionals or FMTU staff who managed drug samples (ie, managers). MAIN OUTCOME MEASURES: Drug sample managers completed a self-administered questionnaire between February and December 2013. Questionnaires inquired about sample selection, procurement, reception, storage, inventory, and disposal. Results were compared with the Canada's Research-Based Pharmaceutical Companies Code of Ethical Practices (2012) and the Canadian Medical Association Guidelines for Physicians in Interactions with Industry (2007). RESULTS: All 33 FMTUs responded to the questionnaire. According to managers, no FMTUs had written selection criteria to guide sample choice. Almost one-third (30%) of FMTUs had uncontrolled access to drug sample cabinets. Even though pharmaceutical companies must distribute drug samples to authorized professionals only, these professionals were involved in the procurement and the reception of samples in 79% and 56% of FMTUs, respectively. Only 15% of FMTUs kept track of samples distributed, 82% checked expiration dates, and 85% ensured proper disposal as recommended. CONCLUSION: The management of drug samples in the FMTUs in Quebec is heterogeneous, with many FMTUs and pharmaceutical companies not following Canadian guidelines.

Drug samples in family medicine teaching units: a cross-sectional descriptive study: Part 3: availability and use of drug samples in Quebec.

OBJECTIVE: To draw a portrait of drug sample distribution and to assess the concordance between drug samples distributed and the medical problems encountered in the ambulatory primary health care setting. DESIGN: Descriptive cross-sectional survey. A self-administered questionnaire was distributed to all health care professionals (HCPs) in family medicine teaching units (FMTUs) that kept drug samples between February and December 2013. Dispensers were defined as HCPs reporting the use of drug samples. Concurrently, an inventory log sheet was completed by managers of drug samples to document the contents of sample cabinets. Data from the Canadian Disease and Therapeutic Index were used as the criterion standard to assess the consistency between the drug samples found in the cabinets and the profile of the most frequent health problems encountered in primary care. SETTING: All 33 FMTUs that kept drug samples in Quebec. PARTICIPANTS: Health care professionals authorized to hand out drug samples (practising physicians, residents, pharmacists, and nurses), and managers of drug sample cabinets. MAIN OUTCOME MEASURES: Dispensing practices of HCPs; number of doses of each drug contained in the sample cabinets; total market value of the samples; concordance between the drug sample categories made available and the most common medical problems encountered in primary care; and data on safe handling, ethical issues, effect of the pharmaceutical industry on prescribing behaviour, and inventory of samples. RESULTS: Among 859 HCPs, 579 (67%) reported dispensing drug samples. A large proportion of dispensers (88%) were unable to find the specific drug they sought and half of them (51%) provided the patients with a drug sample even if it was not their first choice for treatment. The drug sample cabinet inventory revealed products from 292 different companies and identified a total of 382 363 medication doses for a total value of $201 872. We found gaps among types of drugs provided to patients, those the HCPs would consider useful, and those available in the cabinets. CONCLUSION: Drug samples available in FMTUs do not meet the needs of many patients and HCPs, suggesting that the main driving force for drug sample distribution is not patient care. Policies on drug samples in FMTUs should be uniform across the province, and management should be as strict as in community pharmacies. Otherwise, prohibiting their use should be considered.

Drug samples in family medicine teaching units: a cross-sectional descriptive study: Part 1: drug sample management policies and the relationship between the pharmaceutical industry and residents in Quebec.

OBJECTIVE: To determine the existence and the level of health care professional (HCP) knowledge of local policies regarding drug sample use and the relationship between residents and the pharmaceutical industry in academic primary health care settings. DESIGN: Descriptive cross-sectional survey. Health care providers were invited to complete a self-administered questionnaire on drug sample use between February and December 2013. Managers of drug samples were also asked to complete a specific questionnaire on drug sample management and policies and an inventory log sheet. Data about the existence of written policies were validated with health and social services centre (HSCC) directors or pharmacy departments and family medicine teaching unit (FMTU) directors between February and June 2014. SETTING: All 42 FMTUs in Quebec. PARTICIPANTS: All HCPs in the FMTUs authorized to hand out drug samples (practising physicians, residents, pharmacists, and nurses). Dispensers were defined as those who reported using drug samples. Managers were defined as HCPs or staff members who managed drug samples. MAIN OUTCOME MEASURES: Existence of written policies on drug sample use in HSCCs and FMTUs; whether FMTUs applied the HSCC policies if they existed; whether dispensers were aware of the existence of the policies; and whether policies on the relationships between residents and pharmaceutical companies existed. RESULTS: Among the 42 FMTUs, 33 (79%) kept drug samples. Of these, 30% (10 of 33) did not have policies about drug samples in the FMTU or in the HSCC. A total of 67% (579 of 859) of HCPs from these FMTUs reported using drug samples. Most dispensers did not know if a policy existed in their FMTU (n = 297; 51%) or their HSCC (n = 420; 73%). Eleven (26%) of the 42 FMTU directors reported having a policy regarding relationships between residents and the pharmaceutical industry. Most drug sample dispensers were not aware whether such a policy existed (n = 310; 54%). CONCLUSION: Many FMTUs did not have policies regarding drug samples or relationships between residents and the pharmaceutical industry. Variation in use and management of drug samples and the lack of knowledge of HCPs about the existence of policies point to the need to implement uniform policies in all FMTUs in Quebec.

The CHANGE program: Exercise intervention in primary care.

PROBLEM ADDRESSED: Primary care settings require a feasible program for integrating lifestyle interventions, which can reverse metabolic abnormalities, for patients in practice. OBJECTIVE OF PROGRAM: To integrate a lifestyle intervention program into existing primary care clinics with an interprofessional approach that includes dietitians and kinesiologists. PROGRAM DESCRIPTION: Canadian Health Advanced by Nutrition and Graded Exercise (CHANGE) provides a personalized approach to nutrition and exercise modification focusing on patients with metabolic syndrome. With CHANGE, exercise intervention is individualized (ie, tailored to individual preferences) and graded (ie, intensity is built up slowly over time); supervision and implementation of the program is conducted in a collaborative fashion between the family physician and the kinesiologist. Patients undergo an initial fitness assessment that determines their baseline aerobic, strength, and flexibility scores, and the same assessment is performed at 3 months and at 12 months. CONCLUSION: The CHANGE program demonstrates how interprofessional primary care teams can support patients with metabolic syndrome in achieving their health goals. By including dietitians and kinesiologists in primary care settings to work alongside family doctors, many barriers to lifestyle interventions can be overcome. The team's collaborative understanding of the patient combined with the patient's own sense of urgency for change creates the opportunity for the formation of new healthy lifestyle habits. Although results are preliminary, CHANGE appears to be a feasible, implementable, and effective program.

Exploratory analysis of the variable response to an intensive lifestyle change program for metabolic syndrome.

BACKGROUND: Substantial variability in response to lifestyle interventions has been recognized for many years, and researchers have begun to disentangle sources of error from inherent differences in individual responsiveness. The objective of this secondary analysis of an intensive lifestyle intervention (diet and exercise) for metabolic syndrome (MetS) was to identify potentially important differences among study completers grouped by treatment response as measured by change in a continuous metabolic syndrome score (Gurka/MetS). METHODS: All study completers from a 12-month primary care study were categorized into one of five groups according to change in the Gurka/MetS score. A change of 0.4 in z-score defined clinically relevant change in line with results of previous studies. Repeated measures analysis of variance was used to examine cardiovascular disease risk and individual clinical indicators of MetS over 12 months, looking for differences in response over time by the five groups. RESULTS: Of 176 participants, 50% (n = 88) had stable scores, 10% (n = 18) had relevant change scores in the first 3 months only and reverted toward baseline, 20% (n = 35) achieved meaningful change over the whole study, 11% (n = 20) had a delayed response at 3-12 months, and 9% (n = 15) demonstrated worsening scores. Significant differential patterns were noted for groups over the duration of the intervention (p < .001). Improvement in diet quality and fitness scores were similar across all groups. Other available variables were tested and did not account for the differences. CONCLUSION: Work is needed to identify key factors that account for differences in responses to lifestyle interventions that can be used to guide treatment decisions for intensive lifestyle interventions for this common condition. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01616563; first registered June 12, 2012.

Combination of Waist Circumference and Circulating Levels of IGFBP-2 as a Simple Screening Tool for Early Detection of Metabolic Dysfunction-Associated Steatotic Liver Disease.

Optimal non-invasive biomarkers for metabolic dysfunction-associated steatotic liver disease (MASLD) remain elusive, especially in the detection of early stages. This study tested in an asymptomatic cohort of 171 men (49.2 ± 8.6 years) and 131 women (51.8 ± 8.5 years) whether waist circumference (WC) and circulating levels of insulin-like growth factor-binding protein 2 (IGFBP-2) could identify individuals with liver fat >5% as assessed by magnetic resonance spectroscopy. Participants with high WC (> 85 or 90 cm for women and men, respectively) and low IGFBP-2 (< 260 or 230 ng/mL for women and men, respectively) were characterized by a higher risk of having MASLD (46.3%, p < 0.0001). Among the 68 individuals with MASLD, 73.5% fell into the subgroup with high WC and low IGFBP-2 concentrations (p < 0.0001). When combined, these markers reached a sensitivity of 73.5% and specificity of 75.2% for MASLD. Thus, WC and plasma IGFBP-2 levels might be useful as a novel, simple, and non-invasive index to support existing tools in the identification of individuals at risk of early-stage MASLD.

Implementing an Activity Tracker to Increase Motivation for Physical Activity in Patients With Diabetes in Primary Care: Strengths, Weaknesses, Opportunities and Threats (SWOT) Analysis.

BACKGROUND: Many projects related to technology implementation in the context of chronic diseases have been developed over the years to better manage lifestyle medicine interventions and improve patient care. However, technology implementation in primary care settings remains challenging. OBJECTIVE: The aim is to carry out a strengths, weaknesses, opportunities, and threats (SWOT) analysis (1) to assess satisfaction among patients with type 2 diabetes using an activity tracker to increase motivation for physical activity (PA) and (2) to explore the research and health care team's perceptions of this technology's implementation in a primary care setting. METHODS: A 3-month hybrid type 1 study, which included 2 stages, was conducted in an academic primary health center in Quebec City, Quebec, Canada. In stage 1, a total of 30 patients with type 2 diabetes were randomized to the intervention (activity tracker) group or the control group. In stage 2, a SWOT analysis was performed on both patients and health care professionals to determine the components of successful technology implementation. Two questionnaires were used to gather feedback: a satisfaction and acceptability questionnaire concerning an activity tracker (15 patients in the intervention group) and a questionnaire based on the SWOT elements (15 patients in the intervention group and 7 health care professionals). Both questionnaires contained quantitative and qualitative questions. Qualitative variables from open questions were synthesized in a matrix and ranked according to apparition frequency and global importance. A thematic analysis was performed by the first author and validated by 2 coauthors separately. The information gathered was triangulated to propose recommendations that were then approved by the team. Both quantitative (randomized controlled trial participants) and qualitative (randomized controlled trial participants and team) results were combined for recommendations. RESULTS: In total, 86% (12/14) of the participants were satisfied with their activity tracker use and 75% (9/12) felt that it incited them to stick to their PA program. The main strengths of the team members' perspectives were the project initiation and involvement of a patient partner, the study design, the team, and the device. The weaknesses were the budgetary constraints, the turnover, and the technical issues. The opportunities were the primary care setting, the loan of equipment, and common technology. The threats were recruitment issues, administrative challenges, technological difficulties, and a single research site. CONCLUSIONS: Patients with type 2 diabetes were satisfied with their activity tracker used to improve motivation for PA. Health care team members agreed that implementation can be done in primary care, but some challenges remain in using this technological tool in clinical practice regularly. TRIAL REGISTRATION: ClinicalTrials.gov NCT03709966; https://clinicaltrials.gov/ct2/show/NCT03709966.

Risk of Bias Mitigation for Vulnerable and Diverse Groups in Community-Based Primary Health Care Artificial Intelligence Models: Protocol for a Rapid Review.

BACKGROUND: The current literature identifies several potential benefits of artificial intelligence models for populations' health and health care systems' efficiency. However, there is a lack of understanding on how the risk of bias is considered in the development of primary health care and community health service artificial intelligence algorithms and to what extent they perpetuate or introduce potential biases toward groups that could be considered vulnerable in terms of their characteristics. To the best of our knowledge, no reviews are currently available to identify relevant methods to assess the risk of bias in these algorithms. The primary research question of this review is which strategies can assess the risk of bias in primary health care algorithms toward vulnerable or diverse groups? OBJECTIVE: This review aims to identify relevant methods to assess the risk of bias toward vulnerable or diverse groups in the development or deployment of algorithms in community-based primary health care and mitigation interventions deployed to promote and increase equity, diversity, and inclusion. This review looks at what attempts to mitigate bias have been documented and which vulnerable or diverse groups have been considered. METHODS: A rapid systematic review of the scientific literature will be conducted. In November 2022, an information specialist developed a specific search strategy based on the main concepts of our primary review question in 4 relevant databases in the last 5 years. We completed the search strategy in December 2022, and 1022 sources were identified. Since February 2023, two reviewers independently screened the titles and abstracts on the Covidence systematic review software. Conflicts are solved through consensus and discussion with a senior researcher. We include all studies on methods developed or tested to assess the risk of bias in algorithms that are relevant in community-based primary health care. RESULTS: In early May 2023, almost 47% (479/1022) of the titles and abstracts have been screened. We completed this first stage in May 2023. In June and July 2023, two reviewers will independently apply the same criteria to full texts, and all exclusion motives will be recorded. Data from selected studies will be extracted using a validated grid in August and analyzed in September 2023. Results will be presented using structured qualitative narrative summaries and submitted for publication by the end of 2023. CONCLUSIONS: The approach to identifying methods and target populations of this review is primarily qualitative. However, we will consider a meta-analysis if quantitative data and results are sufficient. This review will develop structured qualitative summaries of strategies to mitigate bias toward vulnerable populations and diverse groups in artificial intelligence models. This could be useful to researchers and other stakeholders to identify potential sources of bias in algorithms and try to reduce or eliminate them. TRIAL REGISTRATION: OSF Registries qbph8; https://osf.io/qbph8. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/46684.

The Longevity Protein Klotho: A Promising Tool to Monitor Lifestyle Improvements.

Aging is not a disease; it is a natural evolution of human physiology. Medical advances have extended our life expectancy, but chronic diseases and geriatric syndrome continue to affect the increasingly aging population. Yet modern medicine perpetuates an approach based on treatment rather than prevention and education. In order to help solve this ever-growing problem, a new discipline has emerged: lifestyle medicine. Nutrition, physical activity, stress management, restorative sleep, social connection, and avoidance of risky substances are the pillars on which lifestyle medicine is founded. The aim of this discipline is to increase healthspan and reduce the duration of morbidity by making changes to our lifestyle. In this review, we propose the use of klotho protein as a novel biomarker for lifestyle medicine in order to quantify and monitor the health status of individuals, as no integrative tool currently exists.

Plasma IGFBP-2 levels reveal heterogeneity in hepatic fat content in adults with excess visceral adiposity.

Lay summary: Obesity is frequently accompanied by a fatty liver. However, some individuals with high abdominal fat levels nevertheless have low levels of liver fat. Reasons for such discordant phenotypes are unclear. In this paper, we report that among asymptomatic individuals with high levels of visceral fat, low concentrations of IGFBP-2 in the circulation were associated with significantly higher hepatic fat content compared to those with high IGFBP-2 levels. We conclude that quantification of plasma IGFBP-2 concentrations may be useful to identify the early risk for liver fat accumulation in apparently healthy individuals without cardiovascular symptoms. Aim/hypothesis: Although excess visceral adiposity (VAT) is generally associated with increased liver fat (LF), recent evidence has revealed heterogeneity in LF content among adults with visceral obesity, potentially contributing to specific differences in cardiometabolic outcomes. Reasons for such discordant VAT-LF phenotypes are largely unknown. The present study aimed at assessing whether circulating levels of insulin growth-factor binding protein-2 (IGFBP-2) could be a useful biomarker in the identification of heterogenous and discordant VAT-LF phenotypes. Methods: A sample of 308 middle-aged Caucasian apparently healthy men and women without cardiovascular symptoms were studied for the present cross-sectional analyses. Fasting plasma glucose and lipid levels were assessed and an oral glucose tolerance test was performed. Hepatic fat fraction (HFF) was measured using magnetic resonance spectroscopy whereas VAT was assessed by magnetic resonance imaging. Plasma IGFBP-2 levels were quantified by ELISA. Participants were then classified on the basis of median VAT (81 mL) and IGFBP-2 levels (233 ng/mL). Results: Individuals with high levels of VAT were characterized by higher waist circumference, lower insulin sensitivity, as well as by higher plasma triglyceride and lower HDL-cholesterol levels. Plasma IGFBP-2 levels were inversely correlated with HFF (r = -0.39, p < 0.0001). Among men and women with high levels of VAT, those with low levels of IGFBP-2 had significantly higher HFF (7.5 ± 0.7%), compared to participants with high IGFBP-2 concentrations (3.2 ± 0.5%, p < 0.0001). Conclusion: In the presence of excess VAT, high IGFBP-2 concentrations are associated with low levels of LF. Although additional studies will be necessary to establish causality and further clarify the clinical implications of these observations, these findings are concordant with a novel function of IGFBP-2 in modulating susceptibility to non-alcoholic fatty liver disease (NAFLD) in the presence of visceral obesity.

Relationship between Cardiometabolic Factors and the Response of Blood Pressure to a One-Year Primary Care Lifestyle Intervention in Metabolic Syndrome Patients.

Systemic hypertension has been recognized as a modifiable traditional cardiovascular risk factor and influenced by many factors such as eating habits, physical activity, diabetes, and obesity. The objective of this cross-sectional study was to identify factors that predict changes in blood pressure induced by a one-year lifestyle intervention in primary care settings involving a collaboration between family physicians, dietitians, and exercise specialists. Patients with metabolic syndrome diagnosis were recruited by family physicians participating in primary care lifestyle intervention among several family care clinics across Canada. Participants for whom all cardiometabolic data at the beginning (T0) and the end (T12) of the one-year intervention were available were included in the present analysis (n = 101). Patients visited the dietitian and the exercise specialist weekly for the first three months and monthly for the last nine months. Diet quality, exercise capacity, anthropometric indicators, and cardiometabolic variables were evaluated at T0 and at T12. The intervention induced a statistically significant decrease in waist circumference (WC), systolic (SBP) and diastolic (DBP) blood pressure, and plasma triglycerides, and an increase in cardiorespiratory fitness (estimated VO2max). Body weight (p < 0.001), body mass index (BMI) (p < 0.001), and fasting blood glucose (p = 0.006) reduction, and VO2max increase (p = 0.048) were all related to changes in SBP. WC was the only variable for which changes were significantly correlated with those in both SBP (p < 0.0001) and DBP (p = 0.0004). Variations in DBP were not associated with changes in other cardiometabolic variables to a statistically significant extent. Twelve participants were identified as adverse responders (AR) in both SBP and DBP and displayed less favorable changes in WC. The beneficial effects of the primary care lifestyle intervention on blood pressure were significantly associated with cardiometabolic variables, especially WC. These findings suggest that a structured lifestyle intervention in primary care can help improve cardiometabolic risk factors in patients with metabolic syndrome and that WC should be systematically measured to better stratify the patient's hypertension risk.

Key process features of personalized diet counselling in metabolic syndrome: secondary analysis of feasibility study in primary care.

BACKGROUND: Personalized diet counselling, as part of lifestyle change programs for cardiometabolic risk conditions (combinations of prediabetes or type 2 diabetes, hypertension, dyslipidemia and high waist circumference) has been shown to reduce progression to type 2 diabetes overall. To identify key process of care measures that could be linked to changes in diet, we undertook a secondary analysis of a Canadian pre-post study of lifestyle treatment of metabolic syndrome (MetS). Diet counselling process measures were documented and association with diet quality changes after 3 months were assessed. Results of the primary study showed 19% reversal of MetS after 1 year. METHODS: Registered dietitians (RDs) reported on contact time, specific food behaviour goals (FBG), behaviour change techniques (BCT; adapted from the Michie CALO-RE taxonomy) and teaching resources at each contact. Diet quality was measured by 2005 Canadian Healthy Eating Index (HEI-C) and assessed for possible associations with individual BCT and FBG. RESULTS: Food behaviour goals associated with improved HEI-C at 3 months were: poultry more than red meat, increased plant protein, increased fish, increased olive oil, increased fruits and vegetables, eating breakfast, increased milk and alternatives, healthier fats, healthier snacks and increased nuts, with an adverse association noted for more use (> 2 times/ 3 months) of the balanced meal concept (F test; p < 0.001). Of 16 BCT, goal setting accounted for 15% of all BCT recorded, yet more goal setting (> 3 times/3 months) was associated with poorer HEI-C at 3 months (F test; p = 0.007). Only self-monitoring, feedback on performance and focus on past success were associated with improved HEI-C. CONCLUSIONS: These results identify key aspects of process that impact diet quality. Documentation of both FBG and BCT is highly relevant in diet counselling and a summary diet quality score is a promising target for assessing short-term counselling success.

The impact of anesthesia on glycine absorption in operative hysteroscopy: a randomized controlled trial.

BACKGROUND: Operative hysteroscopy requires the use of a distension medium and its absorption can lead to serious consequences from intravascular volume overload and water intoxication. We compared the impact of 2 types of anesthesia (general anesthesia and local anesthesia with sedation) on the absorption of glycine solution in operative hysteroscopy. METHODS: A randomized controlled trial was conducted over a 17-month period. Eligible patients undergoing operative hysteroscopy for abnormal uterine bleeding were randomized in 2 groups: a general anesthesia group and a local anesthesia with sedation group. The primary outcome was the median absorption of the glycine solution (10th-90th percentile) measured with an automated tandem canister system. Secondary outcomes included incidence of absorption >1000 mL, discontinued surgery because of excessive absorption, median change in serum sodium, postoperative hyponatremia, and patients' postoperative quality of life at 24 hours (8-item Short Form Health Survey questionnaire). Nonparametric analyses (Mann-Whitney U test, χ(2) test, and Fisher exact test) were used. RESULTS: Of 142 eligible patients, 95 agreed to participate and were randomized. Women who underwent general anesthesia had a higher median absorption of the glycine solution (10th-90th percentile) compared with women who underwent local anesthesia with sedation (480 mL [76-1300 mL] vs 253 mL [70-728 mL]; P = 0.005). General anesthesia was also associated with a higher rate of glycine solution absorption (>1000 mL [20% vs 4%; P = 0.009]) and a more rapid rate of decrease in serum sodium (≥10 mEq/L [8% vs 0%; P = 0.005]) than local anesthesia with sedation. Postoperative quality of life measures as rated by the patients were comparable between the 2 groups. CONCLUSION: Compared with general anesthesia, local anesthesia with sedation is associated with less glycine absorption and should be considered the preferred method of anesthesia for operative hysteroscopy.

Training family physicians and residents in family medicine in shared decision making to improve clinical decisions regarding the use of antibiotics for acute respiratory infections: protocol for a clustered randomized controlled trial.

BACKGROUND: To explore ways to reduce the overuse of antibiotics for acute respiratory infections (ARIs), we conducted a pilot clustered randomized controlled trial (RCT) to evaluate DECISION+, a training program in shared decision making (SDM) for family physicians (FPs). This pilot project demonstrated the feasibility of conducting a large clustered RCT and showed that DECISION+ reduced the proportion of patients who decided to use antibiotics immediately after consulting their physician. Consequently, the objective of this study is to evaluate, in patients consulting for ARIs, if exposure of physicians to a modified version of DECISION+, DECISION+2, would reduce the proportion of patients who decide to use antibiotics immediately after consulting their physician. METHODS/DESIGN: The study is a multi-center, two-arm, parallel clustered RCT. The 12 family practice teaching units (FPTUs) in the network of the Department of Family Medicine and Emergency Medicine of Université Laval will be randomized to a DECISION+2 intervention group (experimental group) or to a no-intervention control group. These FPTUs will recruit patients consulting family physicians and residents in family medicine enrolled in the study. There will be two data collection periods: pre-intervention (baseline) including 175 patients with ARIs in each study arm, and post-intervention including 175 patients with ARIs in each study arm (total n = 700). The primary outcome will be the proportion of patients reporting a decision to use antibiotics immediately after consulting their physician. Secondary outcome measures include: 1) physicians and patients' decisional conflict; 2) the agreement between the parties' decisional conflict scores; and 3) perception of patients and physicians that SDM occurred. Also in patients, at 2 weeks follow-up, adherence to the decision, consultation for the same reason, decisional regret, and quality of life will be assessed. Finally, in both patients and physicians, intention to engage in SDM in future clinical encounters will be assessed. Intention-to-treat analyses will be applied and account for the nested design of the trial will be taken into consideration. DISCUSSION: DECISION+2 has the potential to reduce antibiotics use for ARIs by priming physicians and patients to share decisional process and empowering patients to make informed, value-based decisions.