An Unconditional Cash Transfer Program for Low-Income New Yorkers Affected by COVID-19.

Early in the pandemic, New York City's public hospital system partnered with multiple philanthropic foundations to offer an unconditional cash transfer program for low-income New Yorkers affected by COVID-19. The $1000 cash transfers were designed to help people meet their most immediate health and social needs and were incorporated into healthcare delivery and contact tracing workflows as a response to the public health emergency. To better understand program recipients' experiences, researchers conducted 150 telephone surveys with randomly sampled cash transfer recipients and 20 in-depth qualitative interviews with purposefully sampled survey participants. Survey participants were predominantly Latinx (87%) and women (65%). The most common reported uses of the $1000 were food and rent. Most participants (79%) reported that without the $1000 cash transfer they would have had difficulty paying for basic expenses or making ends meet, with specific positive effects reported related to food, housing, and ability to work. The majority of survey participants reported that receiving the cash assistance somewhat or greatly improved their physical health (83%) and mental health (89%). Qualitative interview results generally supported the survey findings.

Factors associated with COVID-19 vaccine receipt at two integrated healthcare systems in New York City: a cross-sectional study of healthcare workers.

OBJECTIVES: To examine the factors associated with COVID-19 vaccine receipt among healthcare workers and the role of vaccine confidence in decisions to vaccinate, and to better understand concerns related to COVID-19 vaccination. DESIGN: Cross-sectional anonymous survey among front-line, support service and administrative healthcare workers. SETTING: Two large integrated healthcare systems (one private and one public) in New York City during the initial roll-out of the COVID-19 vaccine. PARTICIPANTS: 1933 healthcare workers, including nurses, physicians, allied health professionals, environmental services staff, researchers and administrative staff. PRIMARY OUTCOME MEASURES: The primary outcome was COVID-19 vaccine receipt during the initial roll-out of the vaccine among healthcare workers. RESULTS: Among 1933 healthcare workers who had been offered the vaccine, 81% had received the vaccine at the time of the survey. Receipt was lower among black (58%; OR: 0.14, 95% CI 0.1 to 0.2) compared with white (91%) healthcare workers, and higher among non-Hispanic (84%) compared with Hispanic (69%; OR: 2.37, 95% CI 1.8 to 3.1) healthcare workers. Among healthcare workers with concerns about COVID-19 vaccine safety, 65% received the vaccine. Among healthcare workers who agreed with the statement that the vaccine is important to protect family members, 86% were vaccinated. Of those who disagreed, 25% received the vaccine (p<0.001). In a multivariable analysis, concern about being experimented on (OR: 0.44, 95% CI 0.31 to 0.6), concern about COVID-19 vaccine safety (OR: 0.39, 95% CI 0.28 to 0.55), lack of influenza vaccine receipt (OR: 0.28, 95% CI 0.18 to 0.44), disagreeing that COVID-19 vaccination is important to protect others (OR: 0.37, 95% CI 0.27 to 0.52) and black race (OR: 0.38, 95% CI 0.24 to 0.59) were independently associated with COVID-19 vaccine non-receipt. Over 70% of all healthcare workers responded that they had been approached for vaccine advice multiple times by family, community members and patients. CONCLUSIONS: Our data demonstrated high overall receipt among healthcare workers. Even among healthcare workers with concerns about COVID-19 vaccine safety, side effects or being experimented on, over 50% received the vaccine. Attitudes around the importance of COVID-19 vaccination to protect others played a large role in healthcare workers' decisions to vaccinate. We observed striking inequities in COVID-19 vaccine receipt, particularly affecting black and Hispanic workers. Further research is urgently needed to address issues related to vaccine equity and uptake in the context of systemic racism and barriers to care. This is particularly important given the influence healthcare workers have in vaccine decision-making conversations in their communities.

Cross-sectional study evaluating the seroprevalence of SARS-CoV-2 antibodies among healthcare workers and factors associated with exposure during the first wave of the COVID-19 pandemic in New York.

OBJECTIVE: Estimate the seroprevalence of SARS-CoV-2 antibodies among New York City Health and Hospitals (NYC H+H) healthcare workers during the first wave of the COVID-19 pandemic, and describe demographic and occupational factors associated with SARS-CoV-2 antibodies among healthcare workers. DESIGN: Descriptive, observational, cross-sectional study using a convenience sample of data from SARS-CoV-2 serological tests accompanied by a demographic and occupational survey administered to healthcare workers. SETTING: A large, urban public healthcare system in NYC. PARTICIPANTS: Participants were employed by NYC H+H and either completed serological testing at NYC H+H between 30 April 2020 and 30 June 2020, or completed SARS-CoV-2 antibody testing outside of NYC H+H and were able to self-report results from the same time period. PRIMARY OUTCOME MEASURE: SARS-CoV-2 serostatus, stratified by key demographic and occupational characteristics reported through the demographic and occupational survey. RESULTS: Seven hundred and twenty-seven survey respondents were included in analysis. Participants had a mean age of 46 years (SD=12.19) and 543 (75%) were women. Two hundred and fourteen (29%) participants tested positive or reported testing positive for the presence of SARS-CoV-2 antibodies (IgG+). Characteristics associated with positive SARS-CoV-2 serostatus were Black race (25% IgG +vs 15% IgG-, p=0.001), having someone in the household with COVID-19 symptoms (49% IgG +vs 21% IgG-, p<0.001), or having a confirmed COVID-19 case in the household (25% IgG +vs 5% IgG-, p<0.001). Characteristics associated with negative SARS-CoV-2 serostatus included working on a COVID-19 patient floor (27% IgG +vs 36% IgG-, p=0.02), working in the intensive care unit (20% IgG +vs 28% IgG-, p=0.03), being employed in a clinical occupation (64% IgG +vs 78% IgG-, p<0.001) or having close contact with a patient with COVID-19 (51% IgG +vs 62% IgG-, p=0.03). CONCLUSIONS: Results underscore the significance that community factors and inequities might have on SARS-CoV-2 exposure for healthcare workers.

Surge and Mortality in ICUs in New York City's Public Healthcare System.

OBJECTIVES: To evaluate the impact of ICU surge on mortality and to explore clinical and sociodemographic predictors of mortality. DESIGN: Retrospective cohort analysis. SETTING: NYC Health + Hospitals ICUs. PATIENTS: Adult ICU patients with coronavirus disease 2019 admitted between March 24, and May 12, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Hospitals reported surge levels daily. Uni- and multivariable analyses were conducted to assess factors impacting in-hospital mortality. Mortality in Hispanic patients was higher for high/very high surge compared with low/medium surge (69.6% vs 56.4%; p = 0.0011). Patients 65 years old and older had similar mortality across surge levels. Mortality decreased from high/very high surge to low/medium surge in, patients 18-44 years old and 45-64 (18-44 yr: 46.4% vs 27.3%; p = 0.0017 and 45-64 yr: 64.9% vs 53.2%; p = 0.002), and for medium, high, and very high poverty neighborhoods (medium: 69.5% vs 60.7%; p = 0.019 and high: 71.2% vs 59.7%; p = 0.0078 and very high: 66.6% vs 50.7%; p = 0.0003). In the multivariable model high surge (high/very high vs low/medium odds ratio, 1.4; 95% CI, 1.2-1.8), race/ethnicity (Black vs White odds ratio, 1.5; 95% CI, 1.1-2.0 and Asian vs White odds ratio 1.5; 95% CI, 1.0-2.3; other vs White odds ratio 1.5, 95% CI, 1.0-2.3), age (45-64 vs 18-44 odds ratio, 2.0; 95% CI, 1.6-2.5 and 65-74 vs 18-44 odds ratio, 5.1; 95% CI, 3.3-8.0 and 75+ vs 18-44 odds ratio, 6.8; 95% CI, 4.7-10.1), payer type (uninsured vs commercial/other odds ratio, 1.7; 95% CI, 1.2-2.3; medicaid vs commercial/other odds ratio, 1.3; 95% CI, 1.1-1.5), neighborhood poverty (medium vs low odds ratio 1.6, 95% CI, 1.0-2.4 and high vs low odds ratio, 1.8; 95% CI, 1.3-2.5), comorbidities (diabetes odds ratio, 1.6; 95% CI, 1.2-2.0 and asthma odds ratio, 1.4; 95% CI, 1.1-1.8 and heart disease odds ratio, 2.5; 95% CI, 2.0-3.3), and interventions (mechanical ventilation odds ratio, 8.8; 95% CI, 6.1-12.9 and dialysis odds ratio, 3.0; 95% CI, 1.9-4.7) were significant predictors for mortality. CONCLUSIONS: Patients admitted to ICUs with higher surge scores were at greater risk of death. Impact of surge levels on mortality varied across sociodemographic groups.

IMPACT OF MULTIDISCIPLINARY PROCESS IMPROVEMENT INTERVENTIONS ON GLUCOMETRICS IN A NONCRITICALLY ILL SETTING.

Objective: This study aimed to assess the impact of multidisciplinary process improvement interventions on glycemic control in the inpatient setting of an urban community hospital, utilizing the daily simple average as the primary glucometric measure. Methods: From 2010-2014, five process of care interventions were implemented in the noncritical care inpatient units of the study hospital. Interventions included education of medical staff, implementation of hyperglycemia and hypoglycemia protocols, computerized insulin order entry, and coordination of meal tray delivery with finger stick and insulin administration. Unpaired t tests compared pre- and postintervention process measures. Simple average daily glucose measure was the primary glucometric outcome. Secondary outcome measures included frequency of hyperglycemia and hypoglycemia. Glucose outcomes were compared with an in-network hospital that did not implement the respective interventions. Results: A total of 180,431 glucose measurements were reported from 4,705 and 4,238 patients from the intervention and comparison hospitals, respectively. The time between bolus-insulin administration and breakfast tray delivery was significantly reduced by 81.7 minutes (P<.00005). The use of sliding scale insulin was sustainably reduced. Average daily glucose was reduced at both hospitals, and overall rates of hypoglycemia were low. Conclusion: A multidisciplinary approach at an urban community hospital with limited resources was effective in improving and sustaining processes of care for improved glycemic control in the noncritical care, inpatient setting. Abbreviations: IQR = interquartile range; JMC = Jacobi Medical Center; NCBH = North Central Bronx Hospital.

Study protocol for a pragmatic trial of the Consult for Addiction Treatment and Care in Hospitals (CATCH) model for engaging patients in opioid use disorder treatment.

BACKGROUND: Treatment for opioid use disorder (OUD) is highly effective, yet it remains dramatically underutilized. Individuals with OUD have disproportionately high rates of hospitalization and low rates of addiction treatment. Hospital-based addiction consult services offer a potential solution by using multidisciplinary teams to evaluate patients, initiate medication for addiction treatment (MAT) in the hospital, and connect patients to post-discharge care. We are studying the effectiveness of an addiction consult model [Consult for Addiction Treatment and Care in Hospitals (CATCH)] as a strategy for engaging patients with OUD in treatment as the program rolls out in the largest municipal hospital system in the US. The primary aim is to evaluate the effectiveness of CATCH in increasing post-discharge initiation and engagement in MAT. Secondary aims are to assess treatment retention, frequency of acute care utilization and overdose deaths and their associated costs, and implementation outcomes. METHODS: A pragmatic trial at six hospitals, conducted in collaboration with the municipal hospital system and department of health, will be implemented to study the CATCH intervention. Guided by the RE-AIM evaluation framework, this hybrid effectiveness-implementation study (Type 1) focuses primarily on effectiveness and also measures implementation outcomes to inform the intervention's adoption and sustainability. A stepped-wedge cluster randomized trial design will determine the impact of CATCH on treatment outcomes in comparison to usual care for a control period, followed by a 12-month intervention period and a 6- to 18-month maintenance period at each hospital. A mixed methods approach will primarily utilize administrative data to measure outcomes, while interviews and focus groups with staff and patients will provide additional information on implementation fidelity and barriers to delivering MAT to patients with OUD. DISCUSSION: Because of their great potential to reduce the negative health and economic consequences of untreated OUD, addiction consult models are proliferating in response to the opioid epidemic, despite the absence of a strong evidence base. This study will provide the first known rigorous evaluation of an addiction consult model in a large multi-site trial and promises to generate knowledge that can rapidly transform practice and inform the potential for widespread dissemination of these services. TRIAL REGISTRATION: NCT03611335.

Insulin non-persistence among people with type 2 diabetes: how to get your patients to stay on insulin therapy.

Continuing use of medication is key to effective treatment and positive health outcomes, particularly in chronic conditions such as diabetes. However, in primary care, non-persistence (i.e. discontinuing or interrupting treatment) with insulin therapy is a common problem among patients with type 2 diabetes. To help primary care physicians manage patients who are non-persistent or likely not to be persistent, this review aimed to provide an overview of modifiable and non-modifiable factors associated with insulin non-persistence as well as practical strategies to address them. Data were extracted from published studies evaluating factors associated with non-persistence among patients with type 2 diabetes. A targeted literature review was performed using PubMed to identify recent studies (2000-2016) reporting measures of non-persistence with insulin therapy. Practical strategies to identify and prevent non-persistence were based on the authors' direct experience in primary care. Non-modifiable factors associated with non-persistence included gender, age, prior treatments, and cost of therapy. Before/at insulin initiation, modifiable factors included patients' perception of diabetes, preference for oral medication, and concerns/expectations about treatment complexity, inconvenience, or side effects. After initiation, modifiable factors included syringe use, difficulties during the first week of therapy, side effects, and insufficient glycemic control. Open-ended and patient-centered questions and a blame-free environment can help physicians identify, prevent, and reduce non-persistence behaviors. Possible questions to start a conversation with patients are provided. Effective physician-patient communication is essential to the management of diabetes. Primary care physicians should be familiar with the most common reasons for insulin non-persistence.

Telephone Intervention to Improve Diabetes Control: A Randomized Trial in the New York City A1c Registry.

INTRODUCTION: Scalable self-management interventions are necessary to address suboptimal diabetes control, especially among minority populations. The study tested the effectiveness of a telephone behavioral intervention in improving glycemic control among adults with diabetes in the New York City A1c Registry. DESIGN: RCT comparing a telephone intervention to print-only intervention in the context of the A1c Registry program. SETTING/PARTICIPANTS: Nine hundred forty-one adults with diabetes and hemoglobin A1c (A1c) >7% from a low-income, predominantly Latino population in the South Bronx were recruited from the A1c Registry. INTERVENTION: All study participants were mailed print diabetes self-management materials at baseline and modest lifestyle incentives quarterly. Only the telephone participants received four calls from health educators evenly spaced over 1 year if baseline A1c was >7%-9%, or eight calls if baseline A1c was >9%. Medication adherence was the main behavioral focus and, secondarily, nutrition and exercise. MAIN OUTCOME MEASURES: Primary outcome was difference between two study arms in change in A1c from baseline to 1 year. Secondary outcomes included diabetes self-care activities, including self-reported medication adherence. Data were collected in 2008-2012 and analyzed in 2012-2014. RESULTS: Participants were predominantly Latino (67.7%) or non-Latino black (28%), with 69.7% foreign-born and 55.1% Spanish-speaking. Among 694 (74%) participants with follow-up A1c, mean A1c decreased by 0.9 (SD=0.1) among the telephone group compared with 0.5 (SD=0.1) among the print-only group, a difference of 0.4 (95% CI=0.09, 0.74, p=0.01). The intervention had significant effect when baseline A1c was >9%. Both groups experienced similar improvements in self-care activities, medication adherence, and intensification. CONCLUSIONS: A telephone intervention delivered by health educators can be a clinically effective tool to improve diabetes control in diverse populations, specifically for those with worse metabolic control identified using a registry. This public health approach could be adopted by health systems supported by electronic record capabilities. CLINICALTRIALS. GOV REGISTRATION: NCT00797888.

Impact of a focused nutrition educational intervention coupled with improved access to fresh produce on purchasing behavior and consumption of fruits and vegetables in overweight patients with diabetes mellitus.

PURPOSE: The purpose of this study was to test the impact of distributing coupons redeemable at farmers markets plus an educational intervention on fruit and vegetable (F&V) purchase and consumption in overweight patients with type 2 diabetes (T2DM). METHODS: Seventy-eight participants with T2DM being followed at Jacobi Medical Center, a large public hospital in the Bronx, New York, were randomized to receive the standard of care or a 1-hour session focused on benefits of F&V consumption and $6 in coupons. Questionnaires assessed demographics, F&V intake, and farmers market purchasing at baseline and 12 weeks. Clinical parameters were obtained through chart review at baseline and at 12 weeks. RESULTS: Participants were predominantly Latino, females, and low income. At 12 weeks, there was a statistically significant increase in the number of participants in the intervention arm who reported purchasing from a farmers market. In addition, there was a minimal increase in fresh fruit intake in the intervention arm at 12 weeks. CONCLUSION: Focused education combined with a small economic incentive resulted in an increase in purchasing behavior and fresh fruit intake per day. A more intense behavioral intervention combined with increased access may result in a significant impact on obesity and diabetes, particularly among low-income and racially diverse communities.

Predictors of sustained reduction in energy and fat intake in the Diabetes Prevention Program Outcomes Study intensive lifestyle intervention.

BACKGROUND: Few lifestyle intervention studies examine long-term sustainability of dietary changes. OBJECTIVE: To describe sustainability of dietary changes over 9 years in the Diabetes Prevention Program and its outcomes study, the Diabetes Prevention Program Outcomes Study, among participants receiving the intensive lifestyle intervention. DESIGN: One thousand seventy-nine participants were enrolled in the intensive lifestyle intervention arm of the Diabetes Prevention Program; 910 continued participation in the Diabetes Prevention Program Outcomes Study. Fat and energy intake derived from food frequency questionnaires at baseline and post-randomization Years 1 and 9 were examined. Parsimonious models determined whether baseline characteristics and intensive lifestyle intervention session participation predicted sustainability. RESULTS: Self-reported energy intake was reduced from a median of 1,876 kcal/day (interquartile range [IQR]=1,452 to 2,549 kcal/day) at baseline to 1,520 kcal/day (IQR=1,192 to 1,986 kcal/day) at Year 1, and 1,560 kcal/day (IQR=1,223 to 2,026 kcal/day) at Year 9. Dietary fat was reduced from a median of 70.4 g (IQR=49.3 to 102.5 g) to 45 g (IQR=32.2 to 63.8 g) at Year 1 and increased to 61.0 g (IQR=44.6 to 82.7 g) at Year 9. Percent energy from fat was reduced from a median of 34.4% (IQR=29.6% to 38.5%) to 27.1% (IQR=23.1% to 31.5%) at Year 1 but increased to 35.3% (IQR=29.7% to 40.2%) at Year 9. Lower baseline energy intake and Year 1 dietary reduction predicted lower energy and fat gram intake at Year 9. Higher leisure physical activity predicted lower fat gram intake but not energy intake. CONCLUSIONS: Intensive lifestyle intervention can result in reductions in total energy intake for up to 9 years. Initial success in achieving reductions in fat and energy intake and success in attaining activity goals appear to predict long-term success at maintaining changes.

Dietary patterns in Blacks and Hispanics with diagnosed diabetes in New York City's South Bronx.

BACKGROUND: An understanding of dietary patterns in diverse populations may guide the development of food-based, rather than nutrient-based, recommendations. OBJECTIVE: We identified and determined predictors of dietary patterns in low-income black and Hispanic adults with diagnosed diabetes. DESIGN: A food-frequency questionnaire was used to assess dietary intake in 235 adults living in the South Bronx, New York City, NY. We used principal factor analysis with promax rotation to identify dietary patterns. Multivariate linear regression models were used to test associations between demographic variables and dietary pattern scores. RESULTS: The following 5 dietary patterns were identified: pizza and sweets, meats, fried foods, fruit and vegetables, and Caribbean starch. The Caribbean starch and fruit and vegetables patterns were high in fruit and vegetables and low in trans fats. In multivariate analyses, sex, language spoken, years living in the United States, and region of birth were significant predictors of dietary patterns. Compared with English speakers, Spanish speakers were less likely to have high scores in pizza and sweets (P = 0.001), meat (P = 0.004), and fried food (P = 0.001) patterns. Participants who lived longer in the United States were less likely to have a meat (P = 0.024) or Caribbean starch pattern (P < 0.001). In Hispanics, the consumption of foods in the Caribbean starch pattern declined for each year that they lived in the United States. CONCLUSIONS: In adults with diagnosed diabetes who were living in the South Bronx, a Caribbean starch pattern, which included traditional Hispanic and Caribbean foods, was consistent with a healthier dietary pattern. In developing dietary interventions for this population, one goal may be to maintain healthy aspects of traditional diets. This trial was registered at clinicaltrials.gov as NCT00797888.

Training residents in obesity counseling: incorporating principles of motivational interviewing to enhance patient centeredness.

BACKGROUND: The US Preventive Services Task Force and the American Academy of Pediatrics recommend that physicians screen patients for obesity and practice counseling interventions to achieve modest (4%-8%) weight loss. Despite this, physicians frequently do not document obesity and/or counsel on weight loss. Our goal was to develop an innovative, easily disseminated workshop to improve resident physicians' skills and confidence in weight-loss counseling. METHODS: We developed a tailored 3-hour interactive Obesity Counseling Workshop. The approach incorporates principles of motivational interviewing, a set of listening and counseling skills designed to enhance patient centeredness and promote behavior change. Adult learning theory served as the foundation for program delivery. The half-day session is administered monthly to internal medicine and pediatric residents on outpatient rotations. KEY RESULTS: To date 77 residents (44 internal medicine and 33 pediatric) have completed the workshop, with approximately even distribution of postgraduate year (PGY)-1, PGY-2, and PGY-3 level residents. Forty-two were women and less than half planned to pursue a primary care-oriented career. Residents completed a 10-item workshop evaluation, with each category scoring an average of 3.5 or greater on a 4-point Likert scale. Residents reported the workshop was well organized and addressed an important topic; they enjoyed the role-playing with observation and feedback. CONCLUSIONS: Residents welcomed the opportunity to participate in an interactive workshop focused on obesity counseling and behavior change, and particularly liked putting new skills into practice with role-playing and receiving real-time feedback. Future analyses will determine the workshop's effect on knowledge, skills, and self-efficacy.

Diabetes-specific quality of life after a low-carbohydrate and low-fat dietary intervention.

PURPOSE: The purpose of the study was to examine the impact of a 12-month weight loss intervention with either a low-carbohydrate or a low-fat diet on quality of life (QOL) among obese patients with type 2 diabetes. METHODS: Participants were enrolled in a randomized trial comparing a low-carbohydrate to a low-fat diet in type 2 diabetes. QOL was assessed with the Diabetes-39 questionnaire, which measures QOL within 5 distinct scales: anxiety and worry, diabetes control, energy and mobility, social burden, and sexual functioning. Repeated measures ANOVA compared change in QOL scales at baseline and 6 and 12 months. RESULTS: Forty-six participants completed all measures. Following 12 months, there was a significant reduction in the scores related to sexual function and energy and mobility, suggesting improvement in QOL related to these domains. These changes were not significantly different between dietary arms. Changes in weight, A1C, and dietary composition were not significantly correlated with changes in QOL. CONCLUSIONS: Participants with diabetes have various options for weight loss. Dietary interventions with either low-carbohydrate or low-fat diets may lead to some improvements in QOL in patients with type 2 diabetes.

Differential effects of low-carbohydrate and low-fat diets on inflammation and endothelial function in diabetes.

OBJECTIVE: To characterize acute (postprandial) and chronic (after a 6-month period of weight loss) effects of a low-carbohydrate vs. a low-fat diet on subclinical markers of cardiovascular disease (CVD) in adults with type 2 diabetes. DESIGN: At baseline and 6 months, measures of C-reactive protein (CRP), interleukin-6 (IL-6), soluble intercellular adhesion molecule (sICAM) and soluble E-selectin were obtained from archived samples (n = 51) of participants randomized in a clinical trial comparing a low-carbohydrate and a low-fat diet. In a subset of participants (n = 27), postprandial measures of these markers were obtained 3 h after a low-carbohydrate or low-fat liquid meal. Endothelial function was also measured by reactive hyperemic peripheral arterial tonometry during the meal test. Paired t tests and unpaired t tests compared within- and between-group changes. RESULTS: There were no significant differences observed in postprandial measures of inflammation or endothelial function. After 6 months, CRP (mean ± S.E.) decreased in the low-fat arm from 4.0 ± 0.77 to 3.0 ± 0.77 (P = .01). In the low-carbohydrate arm, sICAM decreased from 234 ± 22 to 199 ± 23 (P = .001), and soluble E-selectin decreased from 93 ± 10 to 82 ± 10 (P = .05.) A significant correlation between change in high-density lipoprotein and change in soluble E-selectin (r = -0.33, P = .04) and with the change in ICAM (r = -0.43, P = .01) was observed. CONCLUSIONS: Low-carbohydrate and low-fat diets both have beneficial effects on CVD markers. There may be different mechanisms through which weight loss with these diets potentially reduces CVD risk.

Resident physician attitudes and competence about obesity treatment: need for improved education.

BACKGROUND: Obesity is a common problem in primary care, but little is known about Internal Medicine residents' attitudes towards obesity treatment. OBJECTIVE: To describe resident attitudes about obesity treatment. METHODS: Cross-sectional survey of 101 Internal Medicine residents in Philadelphia, PA, and Bronx, NY. Responses to 18 items on a Likert scale assessed resident attitudes. Weight loss goals were assessed with open-ended questions to a clinical scenario. ANOVA with trend analysis compared questionnaire responses to resident postgraduate year (PGY) level. Associations between clinic site, PGY level, and dichotomized Likert responses were tested with chi-square analysis. RESULTS: 19% of residents felt competent in prescribing weight loss programs. Few residents (18%) considered the current recommendations of a 5-10% reduction in body weight to be successful in an obese hypothetical patient. Third-year residents reported greater feelings of negativity towards obese patients than first- and second year residents (p<.05) CONCLUSIONS: Resident physicians do not feel competent in treating obesity and have unrealistic weight loss goals; third-year residents had more negative attitudes about obese patients compared to residents in their 1(st) or 2(nd) year of training. These areas are targets for further resident education about obesity management.

Low-carbohydrate diets: an update on current research.

The diabetes and obesity epidemics have stimulated research to assess the benefits and potential risks of low-carbohydrate diets. Carbohydrate comprises less than 45% of calories in carbohydrate-restricted diets, but very low carbohydrate ketogenic diets may restrict carbohydrate to 20 g initially with variability in the carbohydrate level subsequently. Some research suggests that low-carbohydrate diets may achieve better early weight loss than comparison diets higher in carbohydrate. Studies of up to 1 year suggest that weight loss on low-carbohydrate diet is comparable with fat-restricted diets with higher carbohydrate content. Limited research has been conducted to evaluate low-carbohydrate diets in managing type 2 diabetes. Although science continues to advance in this field, current research suggests that low-carbohydrate diets can be a viable option for achieving weight loss and may have beneficial effects on glycemic control, triglyceride levels, and high-density lipoprotein cholesterol levels in some patients.

Trends and disparities in provider diagnosis of overweight analysis of NHANES 1999-2004.

Rates of overweight and obesity are disproportionately high within minority populations. This study examined the trends in provider diagnosis of overweight from 1999 to 2004 and examined whether there were differences in provider diagnosis based on race/ethnicity. We examined data from 4,071 adults with BMI >or=30 who participated in the National Health and Nutrition Examination Surveys (NHANES) (1999-2004). Provider diagnosis was determined by self-report. From 1999 to 2004, the provider diagnosis of overweight decreased from 71 to 64% (P = 0.003). After controlling for potential confounders, non-Hispanic blacks and Mexican Americans were less likely to report a provider diagnosis of overweight compared to non-Hispanic whites. Odds ratio (OR) (95% confidence interval (CI)) for non-Hispanic blacks was 0.6 (95% CI, 0.4-0.8) and for Mexican Americans was 0.7 (95% CI, 0.4-1.0) compared to non-Hispanic whites. Reasons for this disparity warrant further investigation.

Comparative study of the effects of a 1-year dietary intervention of a low-carbohydrate diet versus a low-fat diet on weight and glycemic control in type 2 diabetes.

OBJECTIVE: To compare the effects of a 1-year intervention with a low-carbohydrate and a low-fat diet on weight loss and glycemic control in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: This study is a randomized clinical trial of 105 overweight adults with type 2 diabetes. Primary outcomes were weight and A1C. Secondary outcomes included blood pressure and lipids. Outcome measures were obtained at 3, 6, and 12 months. RESULTS: The greatest reduction in weight and A1C occurred within the first 3 months. Weight loss occurred faster in the low-carbohydrate group than in the low-fat group (P = 0.005), but at 1 year a similar 3.4% weight reduction was seen in both dietary groups. There was no significant change in A1C in either group at 1 year. There was no change in blood pressure, but a greater increase in HDL was observed in the low-carbohydrate group (P = 0.002). CONCLUSIONS: Among patients with type 2 diabetes, after 1 year a low-carbohydrate diet had effects on weight and A1C similar to those seen with a low-fat diet. There was no significant effect on blood pressure, but the low-carbohydrate diet produced a greater increase in HDL cholesterol.