Predicting Non-Alcoholic Fatty Liver Disease for Adults Using Practical Clinical Measures: Evidence from the Multi-ethnic Study of Atherosclerosis.

BACKGROUND: Many adults have risk factors for non-alcoholic fatty liver disease (NAFLD). Screening all adults with risk factors for NAFLD using imaging is not feasible. OBJECTIVE: To develop a practical scoring tool for predicting NAFLD using participant demographics, medical history, anthropometrics, and lab values. DESIGN: Cross-sectional. PARTICIPANTS: Data came from 6194 white, African American, Hispanic, and Chinese American participants from the Multi-Ethnic Study of Atherosclerosis cohort, ages 45-85 years. MAIN MEASURES: NAFLD was identified by liver computed tomography (≤ 40 Hounsfield units indicating > 30% hepatic steatosis) and data on 14 predictors was assessed for predicting NAFLD. Random forest variable importance was used to identify the minimum subset of variables required to achieve the highest predictive power. This subset was used to derive (n = 4132) and validate (n = 2063) a logistic regression-based score (NAFLD-MESA Index). A second NAFLD-Clinical Index excluding laboratory predictors was also developed. KEY RESULTS: NAFLD prevalence was 6.2%. The model included eight predictors: age, sex, race/ethnicity, type 2 diabetes, smoking history, body mass index, gamma-glutamyltransferase (GGT), and triglycerides (TG). The NAFLD-Clinical Index model excluded GGT and TG. In the NAFLD-MESA model, the derivation set achieved an AUCNAFLD-MESA = 0.83 (95% CI, 0.81 to 0.86), and the validation set an AUCNAFLD-MESA = 0.80 (0.77 to 0.84). The NAFLD-Clinical Index model was AUCClinical = 0.78 [0.75 to 0.81] in the derivation set and AUCClinical = 0.76 [0.72 to 0.80] in the validation set (pBonferroni-adjusted < 0.01). CONCLUSIONS: The two models are simple but highly predictive tools that can aid clinicians to identify individuals at high NAFLD risk who could benefit from imaging.

Changes in Biomarkers of Non-Alcoholic Fatty Liver Disease (NAFLD) upon Access to Avocados in Hispanic/Latino Adults: Secondary Data Analysis of a Cluster Randomized Controlled Trial.

Non-alcoholic fatty liver disease (NAFLD) is a public health concern and Hispanic/Latinos are disproportionately affected. There is evidence for favorable effects of dietary intake of monounsaturated fatty acids (MUFA) on NAFLD, yet studies examining avocados as a source of MUFA on hepatic function have not been assessed. We investigated the effects of low (3) vs. high (14) avocado allotment on biomarkers of NAFLD, oxidative stress, and NAFLD fibrosis score in a sample of Hispanic/Latino adults. Primary outcomes include hepatic function biomarkers [gamma glutamyltransferase (GGT), high-sensitivity c-reactive protein (hsCRP), and NAFLD fibrosis score]. Unpaired, two-sided t-tests were used to assess mean differences between intervention groups at 6 months and analysis of covariance models were used to adjust for diet quality and change in avocado intake from baseline to 6 months. Multivariable linear regression models evaluated the baseline and post-intervention association between avocado allotment group and outcomes, adjusting for covariates and stratifying by prediabetes status. No statistically significant differences were observed between low and high avocado allotment groups in liver enzymes, GGT, hsCRP or NAFLD fibrosis score. Findings persisted after stratifying by prediabetes status. Varied intake of avocados resulted in no effects on biomarkers of NAFLD in healthy adults, free of severe chronic disease.

Prevalence and associated factors of complementary and integrative medicine use in patients afflicted with COVID-19.

BACKGROUND: Complementary and Integrative Medicine (CIM) is often taken up by individuals seeking relief from different diseases. This study investigates the prevalence and associated factors of CIM use in patients with COVID-19. METHODS: In this telephone-based, cross-sectional study, data on CIM usage were collected from COVID-19 patients from February till June 2020 in Fars province, Iran using a researcher-made checklist. Additionally, we asked about the patients' attitudes toward these treatments. RESULTS: Out of 453 patients diagnosed with COVID-19, 400 (88.30%) responded to our calls and agreed to participate in the study. Among them, 276 patients reported using CIM to treat COVID-19 [prevalence: 69% (95% CI: 64.2 to 73.5)]. The most frequently used herbal medicine among COVID-19 patients was ginger (n = 273, 98.9%), thyme (n = 263, 95.3%), and black cumin (n = 205, 74.3%). Most of these patients were recommended to use herbal medicine by their families and friends (n = 96, 34.8%). Univariable logistic regression revealed that age under 50 years old, residency in urban areas (including the capital of the province and small cities), employment, academic education, and being an outpatient were statistically significant factors resulting in CIM usage. Multivariable logistic regression revealed that CIM use among outpatients was 3.65 times more than among inpatients. In addition, patients under 50 years old used CIM 85% more than older patients. Ultimately, only 9 (3.3%) patients consulted with their doctors regarding these medications. No side effects due to CIM use were reported. CONCLUSION: Many patients with COVID-19 used CIM, but few consulted with their physicians in this regard. Therefore, physicians should ask their patients about CIM usage, and patients should also report their use of CIM therapies during their medical visits. Furthermore, age and hospitalization status affected CIM use among patients with COVID-19.

A naturopathic treatment approach for mild and moderate COVID-19: A retrospective chart review.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has led to significant morbidity and mortality. Although COVID-19 vaccination is available, therapeutic options are still needed. The goal of the present manuscript is to report on a treatment strategy used in a naturopathic medical practice for mild and moderate COVID-19. DESIGN: A retrospective chart review was conducted of 30 consecutive patients diagnosed with mild and moderate COVID-19 who were provided multi-nutrient, herbal, and probiotic treatment in a rural, out-patient, naturopathic primary care setting. MAIN OUTCOMES MEASURES: The primary outcome was treatment safety; secondary outcomes included changes in symptoms, progression to severe COVID-19, incidence of long COVID, and recovery time. RESULTS: No side effects or adverse events were reported from treatment and all patients experienced resolution of symptoms presumed to be associated with COVID-19 infection. One patient who had been ill for 28 days prior to presentation was hospitalized. Five patients had an illness duration of more than one month. Time to treatment was correlated with duration of illness post-treatment (r = 0.63, p < 0.001) and more symptoms at presentation was correlated with a longer duration of illness (r = 0.52, p < 0.01). CONCLUSIONS: In this retrospective chart review, a multi-nutrient, herbal, and probiotic therapeutic approach for mild and moderate COVID-19 appeared to be well-tolerated. Delay in seeking treatment after symptom onset, as well as more symptoms at presentation, were correlated with a longer duration of illness. This treatment strategy may have clinical benefit, warranting prospective clinical trials with confirmed COVID-19 cases.

Effects of Different Allotments of Avocados on the Nutritional Status of Families: A Cluster Randomized Controlled Trial.

Avocados are a nutrient-dense plant-food, but limited trial-derived evidence exists about the effects of avocado intake on family nutritional status. We investigated the impact of two levels of avocado allotment, plus a standard nutrition education intervention on the nutritional status of Hispanic/Latino families. Seventy-two families consisting of at least three members of ≥5 years of age and residing in the same home, free of severe chronic disease, not on specific diets, and self-identified of Hispanic heritage, were randomized to one of two levels of avocado allotment (low = 3/week/family or high = 14/week/family) for 6 months plus 12 bi-weekly nutrition education sessions. The primary outcomes included change in a family's total energy and macro- and micronutrient intakes. Primary analysis was intention-to-treat with unpaired, two-sided t-tests to assess mean changes between groups at 6 months. At 6 months, the high avocado allotment group had a significant reduction in energy intake, carbohydrate, animal and vegetable protein, saturated and polyunsaturated fat, calcium, magnesium, sodium, potassium, iron, and vitamin D intakes (all p < 0.05). A high allotment of avocados significantly reduced self-reported energy intake by 29% kcal/family/day, compared to a 3% kcal/family/day reduction in families who received a low allotment. Culturally-appropriate plant-food interventions may alter the nutritional status of at-risk families.

Program evaluation of trauma-informed yoga for vulnerable populations.

BACKGROUND: Trauma is highly prevalent among vulnerable populations, including those who are incarcerated, in treatment for substance use, or seeking mental health services. Trauma-informed yoga seeks to create a safer yoga practice for individuals with a trauma history and may improve emotional and physical wellbeing. Thus, we conducted an evaluation of a trauma-informed yoga program to gain insight into participant experiences. METHODS: Trauma-informed yoga classes were led by trained volunteers and held in three sectors that work with vulnerable populations: corrections and reentry, substance use treatment and recovery, and community and mental health. Data were collected via anonymous survey using a retrospective pre-post design. The survey instrument captured reasons for student participation and perceived effects of yoga on emotional and physical wellbeing. RESULTS: Students were motivated to participate in yoga classes by expectations of physical, mental, and spiritual benefit. Students reported perceived improvements in emotional and physical wellbeing and greater use of self-regulation skills after starting yoga. CONCLUSION: Our findings suggest trauma-informed yoga is perceived as beneficial by vulnerable individuals, especially those in the correctional system or recovering from substance use. Our results support the value of offering trauma-informed yoga in institutionalized and community settings. Improvements in emotional and physical wellbeing warrant formal study.

Effect of a Nutrition Support Formula in Adults With Inflammatory Bowel Disease: A Pilot Study.

BACKGROUND: Due to the high prevalence of nutrient deficiencies in patients with inflammatory bowel disease (IBD), routine monitoring of nutrient status and supplementation are recommended. OBJECTIVE: This preliminary study was implemented to prospectively identify potential effects of a nutrition support formula on blood nutrient parameters in adults with IBD. METHODS: Ten adults with Crohn's disease or ulcerative colitis were recruited from the Portland, Oregon, metropolitan area into a single-arm, open-label pilot study. Participants consumed a nutrition support beverage twice daily for 12 weeks. The formula contained a mixture of micronutrients (including methylated forms of folate and vitamin B12), macronutrients, and phytonutrients (including curcumin, xanthohumol, ginger compounds, and quercetin). Primary measures were the following parameters: folate, vitamin B12, red blood cell (RBC) count, hemoglobin, hematocrit, electrolytes, and albumin. Exploratory measures included a food frequency questionnaire, circulating blood cell counts, and inflammatory markers. RESULTS: Nine participants completed the study and one withdrew. Adherence was 98%. Serum folate increased 48.7% (P = .029), serum vitamin B12 increased 17.4% but did not reach statistical significance (P = .053), and red cell distribution width (RDW) decreased 9.2% (P = .012) over the 12-week study period. There were minimal shifts in total white blood cell (WBC) counts (-1.0%, P = .845), but percent neutrophils decreased 10.4% (P = .042) and absolute lymphocyte count increased 18.6% (P = .048). RBC count, hemoglobin, hematocrit, electrolytes, albumin, and inflammatory markers did not change significantly. Post hoc analysis demonstrated that neutrophil-lymphocyte ratio (NLR) decreased 18.4% (not significant, P = .061). CONCLUSION: Serum folate and RDW improved in adults with IBD after 12 weeks. Modulation of leukocyte subtypes was also observed, including a decrease in neutrophils and an increase in lymphocytes, with no change in total WBC count. A randomized, controlled study to further examine effects of the nutrition support formula will be initiated to follow up on this promising, but preliminary investigation.

Randomized controlled trials investigating the relationship between dietary pattern and high-sensitivity C-reactive protein: a systematic review.

CONTEXT: Elevated serum concentration of high-sensitivity C-reactive protein (hsCRP), a biomarker of systemic inflammation, is associated with increased risk for coronary heart disease (CHD) and cardiovascular events (CVEs). Because elevations in hsCRP often occur in parallel with elevations in low-density lipoproteins (LDLs) and both biomarkers are reduced by hydroxymethylglutaryl-CoA reductase inhibitors (ie, statin drugs), efforts to determine nonpharmacological treatments to lower hsCRP remain limited. Dietary modifications in particular are rarely discussed as viable clinical interventions yet merit investigation. OBJECTIVE: This systematic review was performed to assess the relationship between dietary patterns and hsCRP among individuals enrolled in randomized controlled trials. DATA SOURCES: National Library of Medicine (ie, MEDLINE) and Google Scholar searches were performed using the search terms "C-reactive protein," "CRP," "dietary pattern," and/or "diet" to identify articles published between January 2000 and October 2017. DATA EXTRACTION: Data were extracted and analyzed according to PRISMA guidelines. Identified abstracts were reviewed and cross-referenced for relevance to dietary pattern. Full-text manuscripts were then abstracted for their principal findings. Fifty-six manuscripts met inclusion criteria for detailed review. RESULTS: Clinical trials of dietary interventions to reduce hsCRP are mixed in quality and findings. Several specific dietary patterns may reduce hsCRP, including low-fat, low-carbohydrate, Mediterranean, Portfolio, Paleolithic, and the Dietary Approaches to Stop Hypertension (DASH) diets. However, results were mixed for the majority of dietary patterns (eg, low-glycemic load diets). CONCLUSION: Information available to date suggests that a wide variety of dietary patterns may impact serum hsCRP, although studies are mixed in quality. The efficacy of dietary patterns for the treatment of elevated hsCRP as a strategy for primary prevention of CHD may be best elucidated in randomized clinical trials in healthy participants with elevated hsCRP but low or normal traditional risk factors, or by using more aggressive dietary modifications in high-risk patients. Given current incidence and prevalence of CHD risk factors, additional randomized controlled trials of this type are justified and needed.

Associations between γ-glutamyltransferase (GGT) and biomarkers of atherosclerosis: the Multi-ethnic Study of Atherosclerosis (MESA).

OBJECTIVE: To evaluate associations between total serum γ-glutamyltransferase activity (GGT) and biomarkers of arteriosclerosis in the Multi-Ethnic Study of Atherosclerosis (MESA), including 6783 participants from four ethnic subgroups, i.e., White, Chinese, Black and Hispanic. METHODS: Associations between fasting total serum GGT activity and oxidized low-density lipoproteins (oxLDL), interleukin-6 (IL-6), C-reactive protein (CRP), and soluble intercellular adhesion molecule-1 (sICAM-1) were assessed. Following evaluation of linear trends between GGT and biomarkers of interest, multivariable linear regression models were serially adjusted for age, gender, site, ethnicity (M1); M1+lifestyle variables (M2); M2+traditional cardiovascular risk factors plus medications (M3); and M3+metabolic status (M4). Interactions were evaluated between GGT and age and ethnicity in all models. RESULTS: Linear trends were positive and significant between GGT and oxLDL, IL-6, CRP and sICAM-1 in crude models, and trends remained significant in all ethnic subgroups for CRP (p<0.0001) and sICAM-1 (p<0.001), and for IL-6 except in the Chinese. Trends between GGT and oxLDL were significant in the entire cohort and the White subgroup (p<0.0001), but not in other ethnic subgroups. Multivariable models demonstrated continuous strong, positive associations between GGT and CRP, IL-6 and sICAM-1. Associations between GGT and oxLDL were attenuated upon adjustment for LDL-C and other traditional risk factors. All models were attenuated with adjustment for metabolic status. No age interactions were evident. CONCLUSIONS: Our findings support the hypothesis that total serum GGT activity represents the impact of metabolic disease on vascular injury and atherosclerosis.

Effects of oral glutathione supplementation on systemic oxidative stress biomarkers in human volunteers.

BACKGROUND: The tripeptide glutathione (GSH) is the most abundant free radical scavenger synthesized endogenously in humans. Increasing mechanistic, clinical, and epidemiological evidence demonstrates that GSH status is significant in acute and chronic diseases. Despite ease of delivery, little controlled clinical research data exist evaluating the effects of oral GSH supplementation. OBJECTIVES: The study objectives were to determine the effect of oral GSH supplementation on biomarkers of systemic oxidative stress in human volunteers. DESIGN: This was a randomized, double-blind, placebo-controlled clinical trial. SETTING/LOCATION: The study was conducted at Bastyr University Research Institute, Kenmore, WA and the Bastyr Center for Natural Health, Seattle, WA. SUBJECTS: Forty (40) adult volunteers without acute or chronic disease participated in this study. INTERVENTION: Oral GSH supplementation (500 mg twice daily) was given to the volunteers for 4 weeks. OUTCOME MEASURES: Primary outcome measures included change in creatinine-standardized, urinary F2-isoprostanes (F2-isoP) and urinary 8-hydroxy-2'-deoxyguanosine (8-OHdG). Changes in erythrocyte GSH concentrations, including total reduced glutathione (GSH), oxidized glutathione (GSSG), and their ratio (GSH:GSSG) were also measured by tandem liquid chromatography/mass spectrometry. Analysis of variance was used to evaluate differences between groups. RESULTS: There were no differences in oxidative stress biomarkers between treatment groups at baseline. Thirty-nine (39) participants completed the study per protocol. Changes in creatinine standardized F2-isoP (ng/mg creatinine) (0.0±0.1 versus 0.0±0.1, p=0.38) and 8-OHdG (µg/g creatinine) (-0.2±3.3 versus 1.0±3.2, p=0.27) were nonsignificant between groups at week 4. Total reduced, oxidized, and ratio measures of GSH status were also unchanged. CONCLUSIONS: No significant changes were observed in biomarkers of oxidative stress, including glutathione status, in this clinical trial of oral glutathione supplementation in healthy adults.

CAM: naturopathic dietary interventions for patients with type 2 diabetes.

OBJECTIVE: To test feasibility, acceptability, and preliminary effectiveness of a naturopathic dietary intervention in patients with Type 2 diabetes. METHODS: Prospective observational pilot study evaluating the change in clinical and patient-centered outcome measures following a 12-week individualized and group dietary education program delivered in naturopathic primary care. RESULTS: HbA1c improved in all participants (n = 12); mean - 0.4% +/- 0.49% SD, (p = 0.02). Adherence to healthful eating increased from 3.5 d/wk to 5.3 d/wk (p = 0.05). Specific nutritional behavior modification included: days/week consuming ≥5 servings of fruit/vegetables (p = 0.01), attention to fat intake (p = 0.05), and -11.3% carbohydrate reduction. Measures of physical activity, self-efficacy and self-management also improved significantly. CONCLUSION: A naturopathic dietary approach to diabetes appears to be feasible to implement among Type 2 diabetes patients. The intervention may also improve self-management, glycemic control, and have influences in other domains of self-care behaviors. Clinical trials evaluating naturopathic approaches to Type 2 diabetes are warranted.

Are Additional Lipid Measures Useful?

Total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) are the well-established standards by which clinicians identify individuals at risk for coronary artery disease (CAD), yet nearly 50% of people who have a myocardial infarction have normal cholesterol levels. Measurement of additional biomarkers may be useful to more fully stratify patients according to disease risk. The typical lipid panel includes TC, LDL-C, high-density lipoprotein cholesterol (HDL-C), and triglycerides (TGs). Emerging biomarkers for cardiovascular risk include measures of LDL-C pattern, size, and density; LDL particle number; lipoprotein(a); apolipoproteins (apoA1 and apoB100 being the most useful); C-reactive protein; and lipoprotein-associated phospholipase A(2). Some of these emerging biomarkers have been proven to add to, or be more accurate than, traditional risk factors in predicting coronary artery disease and, thus, may be useful for clinical decision-making in high-risk patients and in patients with borderline traditional risk factors. However, we still believe that until treatment strategies can uniquely address these added risk factors-ie, until protocols to rectify unhealthy findings are shown to improve cardiovascular outcomes-healthcare providers should continue to focus primarily on helping patients reach optimal LDL-C, HDL-C, and TG levels.