Medication Deprescribing Among Patients With Type 2 Diabetes: A Qualitative Case Series of Lifestyle Medicine Practitioner Protocols.

This study is a qualitative case series of lifestyle medicine practitioners' protocols for medication de-escalation in the context of reduced need for glucose-lowering medications due to lifestyle modifications. Increasing numbers of lifestyle medicine practitioners report achieving reductions in medications among patients with type 2 diabetes, and in some cases remission, but limited data exist on the clinical decision-making process used to determine when and how medications are deprescribed. Practitioners interviewed here provide accounts of their deprescribing protocols. This information can serve as pilot data for other practitioners seeking examples of how deprescribing in the context of lifestyle medicine treatment is conducted.

Global status of diabetes prevention and prospects for action: A consensus statement.

Primary prevention of type 2 diabetes (T2D) should be achievable through the implementation of early and sustainable measures. Several randomized control studies that found success in preventing the progression to T2D in high-risk populations have identified early and intensive intervention based on an individualized prevention model as the key factor for participant benefit. The global prevalence of both overweight and obesity has now been widely recognized as the major epidemic of the 21st century. Obesity is a major risk factor for the progression from normal glucose tolerance to prediabetes and then to T2D. However, not all obese individuals will develop prediabetes or progress to diabetes. Intensive, multicomponent behavioural interventions for overweight and obese adults can lead to weight loss. Diabetes medications, including metformin, GLP-1 agonists, glitazones, and acarbose, can be considered for selected high-risk patients with prediabetes when lifestyle-based programmes are proven unsuccessful. Nutrition education is the cornerstone of a healthy lifestyle. Also, physical activity is an integral part of the prediabetes management plan and one of the main pillars in the prevention of diabetes. Mobile phones, used extensively worldwide, can facilitate communication between health professionals and the general population, and have been shown to be helpful in the prevention of T2D. Universal screening is needed. Noninvasive risk scores should be used in all countries, but they should be locally validated in all ethnic populations focusing on cultural differences around the world. Lifestyle interventions reduce the progression to prediabetes and diabetes. Nevertheless, many questions still need to be answered.

Healthy lifestyle interventions to combat noncommunicable disease-a novel nonhierarchical connectivity model for key stakeholders: a policy statement from the American Heart Association, European Society of Cardiology, European Association for Cardiovascular Prevention and Rehabilitation, and American College of Preventive Medicine.

Noncommunicable diseases (NCDs) have become the primary health concern for most countries around the world. Currently, more than 36 million people worldwide die from NCDs each year, accounting for 63% of annual global deaths; most are preventable. The global financial burden of NCDs is staggering, with an estimated 2010 global cost of $6.3 trillion (US dollars) that is projected to increase to $13 trillion by 2030. A number of NCDs share one or more common predisposing risk factors, all related to lifestyle to some degree: (1) cigarette smoking, (2) hypertension, (3) hyperglycemia, (4) dyslipidemia, (5) obesity, (6) physical inactivity, and (7) poor nutrition. In large part, prevention, control, or even reversal of the aforementioned modifiable risk factors are realized through leading a healthy lifestyle (HL). The challenge is how to initiate the global change, not toward increasing documentation of the scope of the problem but toward true action-creating, implementing, and sustaining HL initiatives that will result in positive, measurable changes in the previously defined poor health metrics. To achieve this task, a paradigm shift in how we approach NCD prevention and treatment is required. The goal of this American Heart Association/European Society of Cardiology/European Association for Cardiovascular Prevention and Rehabilitation/American College of Preventive Medicine policy statement is to define key stakeholders and highlight their connectivity with respect to HL initiatives. This policy encourages integrated action by all stakeholders to create the needed paradigm shift and achieve broad adoption of HL behaviors on a global scale.

Impact of a Shared Medical Appointment Lifestyle Intervention on Weight and Lipid Parameters in Individuals with Type 2 Diabetes: A Clinical Pilot.

BACKGROUND: There is a growing awareness that lifestyle behavior modifications may reduce weight and the atherogenic dyslipidemia associated with obesity and type 2 diabetes mellitus (T2DM). OBJECTIVE: We pilot the effectiveness of a diabetes educational program combining shared medical appointments (SMAs) with an 8-week DVD-based diabetes education program emphasizing a plant-based diet in lowering weight and lipids in individuals with T2DM. This pilot also employed a nonrandomized convenience sample to explore which of the educational program's target behaviors were associated with the greatest risk factor reduction. DESIGN: Forty-six adult patients with T2DM voluntarily self-selected to enroll in the educational quality improvement initiative run as part of a community clinical practice. Target behaviors measured weekly were (1) days with beans for breakfast, (2) days of exercise, (3) minutes of exercise per day, (4) days with light evening meals, (5) days with no evening meals, (6) days with no red meat, (7) days with plant-based diet, and (8) number of 8-ounce cups of water per day. Biometric measurements were taken at the beginning and end of the 2-month program. These included high-density lipoprotein (HDL), low-density lipoprotein (LDL), total cholesterol, and triglycerides. Weight was measured weekly. Regression analysis was performed to identify which target behaviors were associated with changes in lipids and weight. RESULTS: There was a statistically significant (F = 2.429; df = 8.21; p < 0.05) decrease in weight (mean -8.9 lbs, or 4.05 kg, or 4.1% body weight, p < 0.01) during the 8-week study period. There was a positive trend in all lipid parameters, but none reached statistical significance with this sample. Exploratory weighted least-squares regression found that weight loss in the study group was most associated with higher water consumption (t = 3.16; p < 0.01), days per week with no evening meal (t = 3.03; p < 0.01), and days per week consuming beans for breakfast (t = 2.06; p = 0.05. CONCLUSIONS: In this pilot study, the DVD-based educational program delivered as part of an SMA was associated with significant weight loss but insignificant lipid changes. Behavior changes most closely associated with weight loss were increasing water consumption, eliminating evening meals, and increasing the consumption of beans for breakfast. These potentially important findings in this small sample suggest the need for a randomized clinical trial with a larger and planned sample.

Review of flow rate estimates of the Deepwater Horizon oil spill.

The unprecedented nature of the Deepwater Horizon oil spill required the application of research methods to estimate the rate at which oil was escaping from the well in the deep sea, its disposition after it entered the ocean, and total reservoir depletion. Here, we review what advances were made in scientific understanding of quantification of flow rates during deep sea oil well blowouts. We assess the degree to which a consensus was reached on the flow rate of the well by comparing in situ observations of the leaking well with a time-dependent flow rate model derived from pressure readings taken after the Macondo well was shut in for the well integrity test. Model simulations also proved valuable for predicting the effect of partial deployment of the blowout preventer rams on flow rate. Taken together, the scientific analyses support flow rates in the range of ∼50,000-70,000 barrels/d, perhaps modestly decreasing over the duration of the oil spill, for a total release of ∼5.0 million barrels of oil, not accounting for BP's collection effort. By quantifying the amount of oil at different locations (wellhead, ocean surface, and atmosphere), we conclude that just over 2 million barrels of oil (after accounting for containment) and all of the released methane remained in the deep sea. By better understanding the fate of the hydrocarbons, the total discharge can be partitioned into separate components that pose threats to deep sea vs. coastal ecosystems, allowing responders in future events to scale their actions accordingly.

Strontium isotopes test long-term zonal isolation of injected and Marcellus formation water after hydraulic fracturing.

One concern regarding unconventional hydrocarbon production from organic-rich shale is that hydraulic fracture stimulation could create pathways that allow injected fluids and deep brines from the target formation or adjacent units to migrate upward into shallow drinking water aquifers. This study presents Sr isotope and geochemical data from a well-constrained site in Greene County, Pennsylvania, in which samples were collected before and after hydraulic fracturing of the Middle Devonian Marcellus Shale. Results spanning a 15-month period indicated no significant migration of Marcellus-derived fluids into Upper Devonian/Lower Mississippian units located 900-1200 m above the lateral Marcellus boreholes or into groundwater sampled at a spring near the site. Monitoring the Sr isotope ratio of water from legacy oil and gas wells or drinking water wells can provide a sensitive early warning of upward brine migration for many years after well stimulation.

Molecular dynamics simulations of turbostratic dry and hydrated montmorillonite with intercalated carbon dioxide.

Molecular dynamics simulations using classical force fields were carried out to study energetic and structural properties of rotationally disordered clay mineral-water-CO2 systems at pressure and temperature relevant to geological carbon storage. The simulations show that turbostratic stacking of hydrated Na- and Ca-montmorillonite and hydrated montmorillonite with intercalated carbon dioxide is an energetically demanding process accompanied by an increase in the interlayer spacing. On the other hand, rotational disordering of dry or nearly dry smectite systems can be energetically favorable. The distributions of interlayer species are calculated as a function of the rotational angle between adjacent clay layers.

Volumetrics of CO2 storage in deep saline formations.

Concern about the role of greenhouse gases in global climate change has generated interest in sequestering CO(2) from fossil-fuel combustion in deep saline formations. Pore space in these formations is initially filled with brine, and space to accommodate injected CO(2) must be generated by displacing brine, and to a lesser extent by compression of brine and rock. The formation volume required to store a given mass of CO(2) depends on the storage mechanism. We compare the equilibrium volumetric requirements of three end-member processes: CO(2) stored as a supercritical fluid (structural or stratigraphic trapping); CO(2) dissolved in pre-existing brine (solubility trapping); and CO(2) solubility enhanced by dissolution of calcite. For typical storage conditions, storing CO(2) by solubility trapping reduces the volume required to store the same amount of CO(2) by structural or stratigraphic trapping by about 50%. Accessibility of CO(2) to brine determines which storage mechanism (structural/stratigraphic versus solubility) dominates at a given time, which is a critical factor in evaluating CO(2) volumetric requirements and long-term storage security.

Dietary Interventions to Treat Type 2 Diabetes in Adults with a Goal of Remission: An Expert Consensus Statement from the American College of Lifestyle Medicine.

Objective: The objective of this Expert Consensus Statement is to assist clinicians in achieving remission of type 2 diabetes (T2D) in adults using diet as a primary intervention. Evidence-informed statements agreed upon by a multi-disciplinary panel of expert healthcare professionals were used. Methods: Panel members with expertise in diabetes treatment, research, and remission followed an established methodology for developing consensus statements using a modified Delphi process. A search strategist systematically reviewed the literature, and the best available evidence was used to compose statements regarding dietary interventions in adults 18 years and older diagnosed with T2D. Topics with significant practice variation and those that would result in remission of T2D were prioritized. Using an iterative, online process, panel members expressed levels of agreement with the statements, resulting in classification as consensus, near-consensus, or non-consensus based on mean responses and the number of outliers. Results: The expert panel identified 131 candidate consensus statements that focused on addressing the following high-yield topics: (1) definitions and basic concepts; (2) diet and remission of T2D; (3) dietary specifics and types of diets; (4) adjuvant and alternative interventions; (5) support, monitoring, and adherence to therapy; (6) weight loss; and (7) payment and policy. After 4 iterations of the Delphi survey and removal of duplicative statements, 69 statements met the criteria for consensus, 5 were designated as near consensus, and 60 were designated as no consensus. In addition, the consensus was reached on the following key issues: (a) Remission of T2D should be defined as HbA1c <6.5% for at least 3 months with no surgery, devices, or active pharmacologic therapy for the specific purpose of lowering blood glucose; (b) diet as a primary intervention for T2D can achieve remission in many adults with T2D and is related to the intensity of the intervention; and (c) diet as a primary intervention for T2D is most effective in achieving remission when emphasizing whole, plant-based foods with minimal consumption of meat and other animal products. Many additional statements that achieved consensus are highlighted in a tabular presentation in the manuscript and elaborated upon in the discussion section. Conclusion: Expert consensus was achieved for 69 statements pertaining to diet and remission of T2D, dietary specifics and types of diets, adjuvant and alternative interventions, support, monitoring, adherence to therapy, weight loss, and payment and policy. Clinicians can use these statements to improve quality of care, inform policy and protocols, and identify areas of uncertainty.

A machine learning framework for rapid forecasting and history matching in unconventional reservoirs.

We present a novel workflow for forecasting production in unconventional reservoirs using reduced-order models and machine-learning. Our physics-informed machine-learning workflow addresses the challenges to real-time reservoir management in unconventionals, namely the lack of data (i.e., the time-frame for which the wells have been producing), and the significant computational expense of high-fidelity modeling. We do this by applying the machine-learning paradigm of transfer learning, where we combine fast, but less accurate reduced-order models with slow, but accurate high-fidelity models. We use the Patzek model (Proc Natl Acad Sci 11:19731-19736, https://doi.org/10.1073/pnas.1313380110 , 2013) as the reduced-order model to generate synthetic production data and supplement this data with synthetic production data obtained from high-fidelity discrete fracture network simulations of the site of interest. Our results demonstrate that training with low-fidelity models is not sufficient for accurate forecasting, but transfer learning is able to augment the knowledge and perform well once trained with the small set of results from the high-fidelity model. Such a physics-informed machine-learning (PIML) workflow, grounded in physics, is a viable candidate for real-time history matching and production forecasting in a fractured shale gas reservoir.

Uncovering the Truth.

Finding the truth is important. In the field of lifestyle medicine the randomized controlled trial has significant limitations. Physicians and patients need to know the truth about the healthy lifestyle changes and their ability to prevent and reverse disease. To meet this challenge, the American College of Lifestyle Medicine has established a committee of experts (HEaLM), under the leadership of David Katz to create a level of evidence construct for ranking lifestyle medicine evidence that includes evidence from basic science and epidemiologic trials. This tool will be used by the new Expert Lifestyle Medicine Panel to create guidelines and standards of practice.

What Is Lifestyle Medicine?

Lifestyle Medicine is still being defined. The ACLM is making significant progress in defining it within the house of medicine. The new American and International Boards of Lifestyle Medicine go a long way in identifying the clinical parameters for this new specialty. The board review course defines the academic corpus in a clear way. Now that Lifestyle Medicine has clear borders it needs to be spread throughout the cultures of the world. People in all walks of life and levels of responsibility need to hear stories of individuals and communities that have their health improved by following the principles of Lietyle Medicine.

On the Cusp.

A new president is stepping into leadership at the American College of Lifestyle Medicine (ACLM). Opportunities abound. The fact that both diabetes and heart disease are reversible is a message that is not reaching the majority of the general public. But times are changing and lifestyle treatment is on the cusp of being accepted as the self-evident best treatment for chronic medical conditions. ACLM is poised to be the leader in this area. Our members passion and experience are our richest resources. Each member is encouraged to be involved with the different committees of ACLM. Choices include Conference Planning, Education, Research, practice Models, Publications, Awards, Business Development, Membership Development, Strategic Partnerships, Marketing and Communications.

Lifestyle Medicine in an Academic/Hospital Context.

The effective integration of lifestyle medicine into allopathic practices is an evolving necessity driven by limited resources and escalating costs. Efforts in the Florida Hospital system graduate medical education (GME) department to meet this challenge may be instructive to others. Efforts include the hiring of an experienced dietician with a focus on a whole food plant based diet and a patient engagement tool to identify areas where patients are ready to make change. Billing is done using existing finance structure with the goal of decreasing the overall cost of providing care within a Clinically Integrated Network (CIN) context. Additionally, one GME clinician's experience in clinical lifestyle based intervention identifies and comments on several practical clinical factors for bringing effective behavior change to individual patients: patient readiness, a knowledgeable health care provider, adequate time, as well as the effectiveness of the intervention.

Lifestyle Medicine: Making the Choices Clear?

Patients are often not aware of the reversibility of chronic lifestyle-related diseases and most physicians are not telling them. The present practice of communicating treatment effectiveness with relative risk reductions does not allow clinicians or patients to evaluate the relative effectiveness of our technotherapies or lifestyle interventions. Clinicians should use the clarity of "number needed to treat," "number needed to harm," and absolute risk in communicating with patients about all available therapies and then empower the patient to make the choices that fit their needs best.

Money Talks.

The cost of providing medical care is increasing. The driving forces include inherent health care system conflicts of interest and financial incentives for procedures and technology. Effective lifestyle medicine principles are not easily adopted and rewarded in the present environment. Recent moves toward outcomes-based pay systems offer the potential to demonstrate the effectiveness of lifestyle medicine principles while bypassing many of the biases, application delays, and political machinations of the traditional randomized control trial methodology. The American College of Lifestyle Medicine is uniquely positioned to be a leading organization in improving health, enhancing patient experience, and reducing the cost of care.

Back to Basics.

Non-drug therapy should be foundational to our treatment plans. These should be evidence-based. Drug based therapies rely heavily on randomized controlled trials while the evidence many lifestyle interventions relies more heavily on epidemiological studies. Both have weaknesses and strengths. Medicine needs a system for evaluating evidence that recognizes the strengths of both types of studies and includes some common measure such as Number Needed to Treat (NNT) and Number Needed to Harm (NNH).

Healthy Lifestyle Interventions to Combat Noncommunicable Disease­A Novel Nonhierarchical Connectivity Model for Key Stakeholders: A Policy Statement From the American Heart Association, European Society of Cardiology, European Association for Cardiovascular Prevention and Rehabilitation, and American College of Preventive Medicine.

Noncommunicable diseases (NCDs) have become the primary health concern for most countries around the world. Currently, more than 36 million people worldwide die from NCDs each year, accounting for 63% of annual global deaths; most are preventable. The global financial burden of NCDs is staggering, with an estimated 2010 global cost of $6.3 trillion (US dollars) that is projected to increase to $13 trillion by 2030. A number of NCDs share one or more common predisposing risk factors, all related to lifestyle to some degree: (1) cigarette smoking, (2) hypertension, (3) hyperglycemia, (4) dyslipidemia, (5) obesity, (6) physical inactivity, and (7) poor nutrition. In large part, prevention, control, or even reversal of the aforementioned modifiable risk factors are realized through leading a healthy lifestyle (HL). The challenge is how to initiate the global change, not toward increasing documentation of the scope of the problem but toward true action-creating, implementing, and sustaining HL initiatives that will result in positive, measurable changes in the previously defined poor health metrics. To achieve this task, a paradigm shift in how we approach NCD prevention and treatment is required. The goal of this American Heart Association/European Society of Cardiology/European Association for Cardiovascular Prevention and Rehabilitation/American College of Preventive Medicine policy statement is to define key stakeholders and highlight their connectivity with respect to HL initiatives. This policy encourages integrated action by all stakeholders to create the needed paradigm shift and achieve broad adoption of HL behaviors on a global scale.

A system model for geologic sequestration of carbon dioxide.

In this paperwe describe CO2-PENS, a comprehensive system-level computational model for performance assessment of geologic sequestration of CO2. CO2-PENS is designed to perform probabilistic simulations of CO2 capture, transport, and injection in different geologic reservoirs. Additionally, the long-term fate of CO2 injected in geologic formations, including possible migration out of the target reservoir, is simulated. The simulations sample from probability distributions for each uncertain parameter, leading to estimates of global uncertainty that accumulate through coupling of processes as the simulation time advances. Each underlying process in the system-level model is built as a module that can be modified as the simulation tool evolves toward more complex problems. This approach is essential in coupling processes that are governed by different sets of equations operating at different time-scales. We first explain the basic formulation of the system level model, briefly discuss the suite of process-level modules that are linked to the system level, and finally give an in-depth example that describes the system level coupling between an injection module and an economic module. The example shows how physics-based calculations of the number of wells required to inject a given amount of CO2 and estimates of plume size can impact long-term sequestration costs.