"Living Well with Chronic Pain": Integrative Pain Management via Shared Medical Appointments.

OBJECTIVE: To evaluate the effectiveness of a multidisciplinary, nonpharmacological, integrative approach that uses shared medical appointments to improve health-related quality of life and reduce opioid medication use in patients with chronic pain. DESIGN: This is a retrospective, pre-post review of "Living Well with Chronic Pain" shared medical appointments (August 2016 through May 2018). SETTING: The appointments included eight 3-hour-long visits held once per week at an outpatient wellness facility. SUBJECTS: Patients with chronic, non-cancer-related pain. METHODS: Patients received evaluation and evidence-based therapies from a team of integrative and lifestyle medicine professionals, as well as education about nonpharmacological therapeutic approaches, the etiology of pain, and the relationship of pain to lifestyle factors. Experiential elements focused on the relaxation techniques of meditation, yoga, breathing, and hypnotherapy, while patients also received acupuncture, acupressure, massage, cognitive behavioral therapy, and chiropractic education. Patients self-reported data via the Patient-Reported Outcomes Measurement Information System (PROMIS-57) standardized questionnaire. Use of opioid medications was evaluated in morphine milligram equivalents. RESULTS: A total of 178 participants completed the PROMIS-57 questionnaire at the first and the last visits. Statistically significant improvements in all domains (Physical Functioning, Anxiety, Depression, Fatigue, Social Roles, Pain Interference, and Sleep Disturbance) were observed (P < 0.001) between the pre-intervention (visit 1) and post-intervention (visit 8) scores. Average opioid use decreased nonsignificantly over the 8-week intervention, but the lower rate of opioid use was not sustained at 6 and 12 months' follow-up. CONCLUSIONS: Patients suffering from chronic pain who participated in a multidisciplinary, nonpharmacological treatment approach delivered via shared medical appointments experienced reduced pain and improved measures of physical, mental, and social health without increased use of opioid pain medications.

"Go! to Sleep": A Web-Based Therapy for Insomnia.

BACKGROUND: Insomnia is a common complaint of individuals presenting to healthcare providers and is associated with decreased quality of life and higher healthcare utilization. In-person cognitive behavioral therapy (CBT) is an effective treatment for insomnia but is hindered by cost and limited access to treatment. Initial research suggests that Web-based CBT may mitigate these obstacles. INTRODUCTION: This study tests the effectiveness of a Web-based program for insomnia based on principles of CBT and stress management. MATERIALS AND METHODS: We conducted a randomized trial with wait-list controls among adults with primary insomnia (n = 88). Two hundred sixty-three adults with comorbid insomnia were also included and analyzed separately. The intervention was a 6-week online program, and effectiveness was measured via the Insomnia Severity Index (ISI). RESULTS: Baseline ISI score for the intervention group (n = 43) was 17.0; 16.6 for the control group (n = 45). At first follow-up, the intervention group (n = 25) had a mean change from baseline of -7.3 (95% CI: -9.0, -5.6), sustained through second follow-up, while the control group (n = 35) had a change of -1.3 (-2.7, 0.1). The between-group difference was statistically significant (p < 0.001). Participants in the comorbid insomnia group had a baseline ISI score of 16.7 with improvement similar to the primary insomnia group (-6.9; -7.6, -6.2). DISCUSSION: We observed clinically meaningful improvements in insomnia severity in adults with primary or comorbid insomnia. Sustained improvement over 4 months underscores the effectiveness of a well-constructed online CBT for insomnia program. CONCLUSIONS: Go! to Sleep

Fibroblast activation protein: Pivoting cancer/chemotherapeutic insight towards heart failure.

An important mechanism for cancer progression is degradation of the extracellular matrix (ECM) which is accompanied by the emergence and proliferation of an activated fibroblast, termed the cancer associated fibroblast (CAF). More specifically, an enzyme pathway identified to be amplified with local cancer progression and proliferation of the CAF, is fibroblast activation protein (FAP). The development and progression of heart failure (HF) irrespective of the etiology is associated with left ventricular (LV) remodeling and changes in ECM structure and function. As with cancer, HF progression is associated with a change in LV myocardial fibroblast growth and function, and expresses a protein signature not dissimilar to the CAF. The overall goal of this review is to put forward the postulate that scientific discoveries regarding FAP in cancer as well as the development of specific chemotherapeutics could be pivoted to target the emergence of FAP in the activated fibroblast subtype and thus hold translationally relevant diagnostic and therapeutic targets in HF.

An acute social stressor decreases reinforcing value of both high and low energy-dense food in college students in a randomized controlled trial.

It is well known that a large portion of the population elevates their intake of high energy-dense foods during times of stress; however, it is understudied whether stress affects the reinforcing value of a food reward. Further knowledge of this relationship may help us better understand the positive correlation between reinforcing value of food and obesity. Therefore, it was tested if an acute stressor would increase the reinforcing value of low or high energy-dense food. Participants (N = 70) were randomized to a stress or no-stress condition after which they were allowed to work to gain access to a food reward and reading time. To determine if high energy-dense food was specifically affected, half the participants from each stress manipulation were randomly assigned to work for either grapes or chocolate candies. Participants in the stress condition worked less for food access than those in the no-stress condition, for both low and high energy-dense foods, but stress did not affect the reinforcing value of reading time. These results indicate that, contrary to our hypothesis, in a sample of college students, an acute stressor decreased reinforcing value of food, with no difference between a low and high energy-dense food item.

Lifestyle Medicine-Focused Shared Medical Appointments to Improve Risk Factors for Chronic Diseases and Quality of Life in Breast Cancer Survivors.

OBJECTIVES: Poor lifestyle choices play a significant role in the development and progression of preventable chronic diseases, including cancer. In this study, we evaluate the effectiveness of a comprehensive lifestyle medicine intervention on chronic disease risk factors and quality of life in breast cancer survivors. DESIGN: This is a retrospective review of a clinical program from January 2016 to July 2017. SETTINGS/LOCATION: It includes seven 2-h group medical visits held every other week at an outpatient wellness facility. SUBJECTS: Eligible participants are breast cancer survivors who have completed treatment, including those who remain on hormonal therapy. INTERVENTION: Patients receive education and experience in nutrition, culinary medicine, physical activity, and stress relief practices. OUTCOME MEASURES: Participants' weight, body mass index (BMI), body fat mass, lean body mass, and percent body fat were measured at visit 1 and visit 7. Standard validated questionnaires were used to measure perceived stress, depression, patient activation, physical and mental quality of life, dietary fat consumption, and dietary fruit, vegetable, and fiber consumption. RESULTS: A total of 31 patients participated in the group visits. Pre-post comparison data were not available for 10 patients. More than three-quarters of the 21 breast cancer survivors who attended 5 or more of the 7 group visits and provided data at the first and the last group visit decreased their body weight. On average, patients lost 4.9 pounds (-2.6%, p < 0.01), and their BMI decreased by 0.8 kg/m2 (-2.5%, p < 0.01). Changes in psychosocial variables of perceived stress, depression, patient activation, and quality of life trended in a positive direction, but did not reach statistical significance. Patients reported a significant decrease in average weekly fat consumption (-31.5%, p < 0.01). Most patients found the program educational and enjoyable, and nearly half of them described it as life changing. CONCLUSIONS: Breast cancer survivors could employ the prescribed lifestyle modifications to produce clinically relevant health benefits. Interdisciplinary teams of health care professionals may help breast cancer survivors with chronic diseases implement evidence-based, individualized, and effective lifestyle prescription through group medical visits.

Comprehensive Lifestyle Modification Intervention to Improve Chronic Disease Risk Factors and Quality of Life in Cancer Survivors.

OBJECTIVES: Healthy lifestyle modifications, including weight management, regular physical activity, prudent diet, and stress relief, have been identified as key components of tertiary cancer prevention. In this study, we evaluate the effectiveness of a comprehensive, lifestyle medicine intervention, Lifestyle 180®, on chronic disease risk factors and quality of life in cancer survivors. DESIGN: Retrospective subgroup analysis of a clinical program. SETTINGS/LOCATION: An outpatient medical facility. SUBJECTS: Lifestyle 180 participants with a diagnosis of past cancer. INTERVENTION: Sixty-four hours of intensive nutrition, culinary medicine, physical activity, and stress relief practices over a 6-month period, with 9- and 12-month follow-up. OUTCOME MEASURES: Pre-postanalysis (baseline vs. 12 months) included biometrics: weight, body mass index (BMI), waist circumference, and blood pressure; standard laboratory tests: lipids, C-reactive protein, fasting insulin/glucose, and insulin resistance; and empirically validated questionnaires: perceived stress, depression, and quality of life. RESULTS: Fifty-eight cancer survivors participated in Lifestyle 180. Average age was 63 years, roughly 75% of participants were female, and the greatest majority had a diagnosis of breast, prostate, or skin cancer. Diagnosis of hyperlipidemia, hypertension, diabetes, and prediabetes presented in 47%, 57%, 22%, and 50% of patients, respectively. Forty-five percent of patients were obese, 24% were overweight, and 16% were depressed. At 12 months, participants lost an average of 14 pounds (-6.6%, p < 0.001) and 2.6 inches off their waist (-5.9%, p < 0.001). BMI decreased significantly by an average of 2.4 kg/m2 (-6.8%, p < 0.001). Significant decreases from well-managed baseline levels also occurred in most measured biomarkers (average change: high-density lipoprotein +3.3 mg/dL, p < 0.05; triglycerides -23.0 mg/dL, p < 0.01; C-reactive protein -1.3 mg/L, p < 0.01; fasting insulin -4.2 µU/mL, p < 0.05; and homeostasis model assessment-insulin resistance -1.5, p < 0.01; n = 40). Changes in psychosocial variables included significant improvements in perceived stress (-20%, p < 0.01) and quality of life (+54%, p < 0.001). We were unable to detect a difference in depressive symptoms. CONCLUSIONS: Cancer survivors participating in a comprehensive intervention could employ the prescribed lifestyle modifications to produce clinically relevant health and quality-of-life benefits. These data support the American Cancer Society (ACS) and American Society of Clinical Oncology (ASCO) recommendations to incorporate healthy lifestyle modifications into long-term cancer survivorship care.

A way to reverse CAD?

PURPOSE: Plant-based nutrition achieved coronary artery disease (CAD) arrest and reversal in a small study. However, there was skepticism that this approach could succeed in a larger group of patients. The purpose of our follow-up study was to define the degree of adherence and outcomes of 198 consecutive patient volunteers who received counseling to convert from a usual diet to plant-based nutrition. METHODS: We followed 198 consecutive patients counseled in plant-based nutrition. These patients with established cardiovascular disease (CVD) were interested in transitioning to plant-based nutrition as an adjunct to usual cardiovascular care. We considered participants adherent if they eliminated dairy, fish, and meat, and added oil. RESULTS: Of the 198 patients with CVD, 177 (89%) were adherent. Major cardiac events judged to be recurrent disease totaled one stroke in the adherent cardiovascular participants­a recurrent event rate of .6%, significantly less than reported by other studies of plant-based nutrition therapy. Thirteen of 21 (62%) nonadherent participants experienced adverse events. CONCLUSION: Most of the volunteer patients with CVD responded to intensive counseling, and those who sustained plant-based nutrition for a mean of 3.7 years experienced a low rate of subsequent cardiac events. This dietary approach to treatment deserves a wider test to see if adherence can be sustained in broader populations. Plant-based nutrition has the potential for a large effect on the CVD epidemic.