A Relationship Between Mortality and Eating Breakfast and Fiber.

BACKGROUND: Recent studies suggest that intermittent fasting or skipping breakfast may be good strategies for weight loss and better health. The objective of this study was to determine whether regular breakfast is associated with overall or cardiovascular mortality. METHODS: Cohort study with follow-up mortality data from the NHANES 1999-2002. National weighted sample. Outcomes were overall and cardiovascular mortality; secondary was fiber intake. RESULTS: Out of 5761 participants, there were 4778 (82.9%) identified as breakfast eaters and 2027 deaths (35.2%); 469 (23.1%) deaths were due to cardiovascular diseases. The average daily intake of calories was 2015, and fiber was 16.3 g/day. A total of 17.7%, 66.0%, and 11.4% of participants had diabetes, hypertension, and cardiovascular diseases, respectively. Analysis showed breakfast eaters were older, had lower body mass index, and ate more calories and fiber daily than non-breakfast eaters. Cox proportional hazard regression analyses showed that compared to non-breakfast eaters, the breakfast eaters were less likely to experience mortality after multivariable adjustments (overall mortality: hazard ratio [HR], 0.69; 95% confidence interval [CI], 0.57-0.84 and cardiovascular mortality: HR, 0.45; 95% CI, 0.32-0.63). For the breakfast eaters, fiber intake >25 g/day was associated with 21% (HR, 0.79; 95% CI, 0.66-0.96) reduction in all-cause mortality after multivariable adjustments. CONCLUSIONS: Regular daily intake of breakfast appears to be associated with lower overall and cardiovascular mortality, particularly when consuming fiber >25 g/day. Further studies examining specific breakfast foods and the timing of foods would be helpful.

Glucosamine/Chondroitin and Mortality in a US NHANES Cohort.

BACKGROUND: Limited previous studies in the United Kingdom or a single US state have demonstrated an association between intake of glucosamine/chondroitin and mortality. This study sought to investigate the association between regular consumption of glucosamine/chondroitin and overall and cardiovascular (CVD) mortality in a national sample of US adults. METHODS: Combined data from 16,686 participants in National Health and Nutrition Examination Survey 1999 to 2010, merged with the 2015 Public-use Linked Mortality File. Cox proportional hazards models were conducted for both CVD and all-cause mortality. RESULTS: In the study sample, there were 658 (3.94%) participants who had been taking glucosamine/chondroitin for a year or longer. During followup (median, 107 months), there were 3366 total deaths (20.17%); 674 (20.02%) were due to CVD. Respondents taking glucosamine/chondroitin were less likely to have CVD mortality (hazard ratio [HR] = 0.51; 95% CI, 0.28-0.92). After controlling for age, use was associated with a 39% reduction in all-cause (HR = 0.61; 95% CI, 0.49-0.77) and 65% reduction (HR = 0.35; 95% CI, 0.20-0.61) in CVD mortality. Multivariable-adjusted HR showed that the association was maintained after adjustment for age, sex, race, education, smoking status, and physical activity (all-cause mortality, HR = 0.73; 95% CI, 0.57-0.93; CVD mortality, HR = 0.42; 95% CI, 0.23-0.75). CONCLUSIONS: Regular intake of glucosamine/chondroitin is associated with lower all-cause and CVD mortality in a national US cohort and the findings are consistent with previous studies in other populations. Prospective studies to confirm the link may be warranted.

Improving Chronic Obstructive Pulmonary Disease (COPD) Symptoms Using a Team-Based Approach.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States (US), with West Virginia bearing a disproportionate disease burden. Complex COPD cases can be difficult to manage during a standard primary care provider (PCP) visit, and pharmacological treatment regimens should be individually tailored to each patient. METHODS: To address these needs, the West Virginia University Department of Family Medicine created an interdisciplinary COPD specialty clinic that uses a team-based approach to treat patients with COPD. In order to evaluate the effectiveness of the specialty clinic, we conducted a retrospective chart review to examine the impact of the clinic on patient hospitalizations, emergency department visits, and urgent care visits six months and one year before and after initiating care at the clinic. We also examined the impact of the clinic on patients' self-reported nicotine dependency, COPD symptoms, and tobacco use behavior. Patients referred to the clinic and having at least one visit from February 2015 to February 2019 were included in this study (n = 149). RESULTS: Patients treated at the COPD specialty clinic had significantly fewer hospital admissions and ED visits six months after and one year after initiating care at the clinic as compared to six months before and one year before, respectively. Patients at this clinic also reported smoking significantly fewer cigarettes per day with significantly fewer self-identifying as smokers and experiencing significantly reduced COPD symptoms. CONCLUSION: An interdisciplinary, team-based approach was effective for improving the health of COPD patients in an Appalachian academic primary care practice.

The Dietary Inflammatory Index Is Associated With Diabetes Severity.

OBJECTIVE: The Dietary Inflammatory Index (DII) is a recently developed dietary inflammation assessment tool. The current study examined the association between DII and the presence and severity of diabetes in adults age ≥20 years. RESEARCH DESIGN AND METHODS: Cross-sectional analysis of 4434 adult participants in the National Health and Nutrition Examination Survey (NHANES 2013 to 2014). The DII was calculated based on 24-hour dietary recall data. Linear and logistic regression models were used to estimate the relationship and control for possible confounding factors. RESULTS: Among 4434 participants, mean age was 49.4 years, mean BMI (body mass index) was 29.3 kg/m2, and mean DII (higher is more inflammatory) was 0.65 (range, -3.41 to +9.05). The mean DII scores in participants with and without diabetes were 0.79 and 0.50, respectively (P = .0098). Participants with Hemoglobin A1c (HgbA1c) >9% had higher DII scores than those with 6.5% to 9% HgbA1c (1.37 vs 0.54, P = .0002) and those with <6.5% HgbA1c (1.37 vs 0.50, P < .0001). With 1 point increase in the DII score, odds of having diabetes increased by 13% (95% CI, 1.02 to 1.24). Among the individuals with diabetes, we also observed a significant association between severity of diabetes and DII scores; with 1 point increase in DII score, the odds of having HgbA1c higher than 9% increased by 43% (95% CI, 1.21 to 1.68). CONCLUSIONS: The DII had a significant association with diabetes and a stronger association when HgbA1c >9%. Further research will help clarify the association between inflammation and diet and the utility of the DII as a tool in risk assessment and management of patients with diabetes.

Outcomes in an Interdisciplinary Diabetes Clinic in Rural Primary Care.

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of an interdisciplinary diabetes team model of care in assisting patients to achieve improved glucose control in a primary care rural setting. METHODS: A family medicine clinic at a rural university medical center developed an interdisciplinary diabetes team clinic composed of a certified diabetes educator/dietitian, a case manager, a pharmacist, nursing staff, a family medicine resident, a psychologist, and a board-certified family medicine attending physician. Patients were referred if their hemoglobin A1c (HbA1c) was ≥9% (75 mmol/mol); patients were seen for an initial consultation and for additional visits as needed. RESULTS: A total of 94 patients attended an initial visit and at least 1 follow-up within 6 months. Mean age was 57 ± 13 years, and 54% were female. Median time from the initial intensive diabetes clinic visit to a follow-up visit was 2.8 months. There was a significant reduction in median HbA1c percentage from 10.25% (88.5 mmol/mol) ± 1.4% (range 73-104 mmol/mol) at the initial intensive diabetes clinic visit to 8.7% (72 mmol/mol) ± 1.8% (range 52-92 mmol/mol) at a 1- to 6-month follow-up (z = -7.161, P < 0.001) and a significant difference between baseline HbA1c (10.25% [88.5 mmol/mol] ± 1.4% [range 73-104 mmol/mol]) and latest HBA1c (1-18 months later) 8.4% (68 mmol/mol) ± 2.2% (range 44-92 mmol/mol; z = -7.022, P < 0.001). Overall, 86% of patients had a lower HbA1c at follow-up, and 33% had an HbA1c <8% (64 mmol/mol). There were no differences in patients' blood pressure, immunization rates, or lipid values between baseline and follow-up visits (P > 0.05). CONCLUSIONS: An interdisciplinary team approach to glycemic control can achieve significant reductions in HbA1c in the rural primary care setting.

Multimorbidity Trends in United States Adults, 1988-2014.

IMPORTANCE: The simultaneous presence of multiple conditions in one patient (multi-morbidity) is a key challenge facing primary care. OBJECTIVE: The purpose of this study was to determine the prevalence of multi-morbidity and to document changes in prevalence during the last 25 years. DESIGN/SETTING: Cross-sectional study using multiple years (1988-2014) of the National Health and Nutrition Examination Survey (NHANES) were analyzed. SETTING: Multiple years (1988 to 2014) of the National Health and Nutrition Examination Survey (NHANES) from the United States were analyzed. PARTICIPANTS: Noninstitutionalized adults. MAIN OUTCOMES AND MEASURES: Number of chronic conditions per individual analyzed by age, race, gender, and socioeconomic factors. RESULTS: A total of 57,303 individuals were surveyed regarding the presence of multi-morbidity in separate surveys spanning 1988-2014. The overall current prevalence in 2013-2014 of >2 morbidities was 59.6% (95% CI 58.1%-61.1%), 38.5% had 3 or more, and 22.7% had 4 or more morbidities, which was significantly higher than in 1988 (45.7%, 95% CI 43.5%-47.8%, with >2 morbidities). Among individuals with 2 or more morbidities, 54.1% have obesity compared to 41.9% in 1988. Among adults age >65, prevalence was 91.8% for 2 or more morbidities. Whites and Blacks had significantly higher prevalence (59.2% and 60.1%) than Hispanic or "other" race (45.0%, P < .0001). Women (58.4%) had more current multi-morbidities (>2) than men (55.9%, P = .01). CONCLUSIONS AND RELEVANCE: Multimorbidity is common and has been increasing over the last 25 years. This finding has implications for public health policy and anticipated health costs for the coming years.

Dissemination Approaches to Participating Primary Care Providers in a Quality Improvement Program Addressing Opioid Use in Central Appalachia.

OBJECTIVES: Practice-based research networks (PBRNs) have been described as new clinical laboratories for primary care research and dissemination. PBRNs, however, have struggled to disseminate research results in a meaningful way to participating providers and clinics. METHODS: The Central Appalachia Inter-Professional Pain Education Collaborative was developed to work with PBRN clinics using quality improvement methods, deliver statewide continuing education activities to address the issue of opioid use in patients with chronic pain, and develop a multimodal mechanism to disseminate project results to clinics and participating providers. RESULTS: Successful change in the delivery of chronic pain care was dependent on the clinic's commitment to a team-based, patient-centered approach. Statistically significant improvements were shown in 10 of 16 process measures, and 80% of the participants agreed that the quality improvement process activity increased their knowledge and would improve their performance in managing patients with chronic pain, as well as patient outcomes in their practice. CONCLUSIONS: The Central Appalachia Inter-Professional Pain Education Collaborative project used an extensive and innovative dissemination plan under the rubric of "continual dissemination." Unlike traditional dissemination efforts that focus on summary presentations, this initiative used a continual dissemination approach that updated participants quarterly through multiple means throughout the project, which improved engagement in the project.

Retirement and Healthy Lifestyle: A National Health and Nutrition Examination Survey (NHANES) Data Report.

BACKGROUND: The objective of this study was to compare the rates of healthy lifestyle adherence among retired late-middle-aged adults with rates among those who are still working. METHODS: A national cross-sectional study using data from the National Health and Nutrition Examination survey (NHANES). The main outcome was the proportion of retires versus nonretirees who were adherent to ideal or intermediate goals of the American Heart Association's Life's Simple 7, cardiovascular factors including physical activity, healthy diet, healthy weight, smoking status, total cholesterol, glucose, and blood pressure. RESULTS: Retirees were more likely than nonretirees to have poorly controlled blood pressure (23.9% vs 15.1%; P = .05). However, there were no differences in healthy weight, smoking rates, healthy diet, or glucose or cholesterol control (P > .05). In controlled logistic regression analyses, retirees were more likely to be physically active than nonretirees (odds ratio, 1.85; 95% confidence interval, 1.11-3.09), but were not more likely to be following any other Life's Simple 7 factors. CONCLUSIONS: Retired adults were more likely to be physically active but were not more likely to be adhering to most of the Life's Simple 7 lifestyle and cardiovascular risk factors. More public health attention to encouraging healthy lifestyles during the transition into retirement may be warranted.

Patient Attitudes and Participation in Hand Co-Washing in an Outpatient Clinic Before and After a Prompt.

Despite recent national emphasis, outpatient hand washing can be less than optimal. We tested a new approach involving both patient and physician hand washing. The study consisted of 384 questionnaires, 184 from phase 1 and 200 from phase 2. Patients stated doctors washed their hands 96.6% before examining them pre-intervention and 99.5% of the time post-intervention. Patients endorsed the importance of hand washing 98.7% of the time. "Co-washing" may offer a process to increase the practice of hand washing and decrease infection risk.

Cardiovascular Health Status in Baby Boomers with Diabetes Mellitus.

OBJECTIVES: The objective of this study was to assess the cardiovascular health status of baby boomers with diabetes mellitus (DM) in comparison to the same-age population with DM 10 years previously. METHODS: The study was conducted in baby boomers with DM using data from the National Health and Nutrition Examination Survey (NHANES) 2009-2012 compared with NHANES 1999-2002. Cardiovascular health metrics were derived from the American Heart Association's Life's Simple 7. The primary outcome was the comparison of the proportion of individuals with each characteristic, including healthy diet, healthy weight, not smoking, exercising regularly, and maintaining an optimal level of glycated hemoglobin (HbA1C), cholesterol, and blood pressure. RESULTS: Current baby boomers with DM (NHANES 2009-2012) had more obesity (70.9% vs 58.8%; P = 0.009) and a lower proportion of ideal physical activity (20.9% vs 31.7%; P = 0.01) than people of the same age 10 years ago; fewer than 1% adhere to an ideal healthy diet. Current baby boomers more often had ideal cholesterol (59.4% vs 47.2; P = 0.01) and reached an ideal HbA1C (51.0% vs 43.4%; P = 0.047). Blood pressure control, adherence to ideal diet, and smoking rates were not significantly different from 10 years ago. In logistic regression analyses controlling for likely confounders, baby boomers persisted in having more obesity and exercising less often, and reaching an ideal cholesterol level more often (P < 0.01). CONCLUSIONS: Although improving in cholesterol and HbA1C, baby boomers demonstrated worsening in several key cardiovascular health indicators, particularly obesity and physical activity.

Patient Attitudes toward Weight Related Discussions in Rural Appalachian Primary Care Clinics.

PURPOSE: West Virginia (WV) consistently has one of the highest rates of obesity, nationally, yet previous studies suggest that conversations about weight with providers are infrequent. This study's aim was to determine frequency and type of weight-related discussions occurring in WV primary care clinics and whether discussions differed according to weight status. METHODS: A cross-sectional survey was completed by patients in rural primary care practices. Participants answered questions related to demographics, obesity related illnesses, experience receiving a physician mediated discussion, and attitude and beliefs related to weight. RESULTS: Among the total of 490 surveys collected, a little more than half of the participants (56.9%) have discussed weight with their physician; a majority of participants (89.5%) thought a physician should tell risks associated with an unhealthy weight; 78.3% participants felt weight loss is important to them; 86.1% participants believed weight affects their health. Participants with obesity were more likely than participants who are overweight to discuss weight with their physician (71.8 vs.44.0%, p<0.0001), and believed that their physicians helped them lose weight previously (29.4% vs 9.9%, p<0.0001) and can help them lose weight in the future (92.9% vs. 71.1, p<0.0001). CONCLUSION: Physicians are often having weight related discussions with patients with obesity however this discussion happens less with overweight patients. Practitioners may want to be more attentive to addressing weight related issues in overweight patients.

Patient Understanding of Body Mass Index (BMI) in Primary Care Practices: A Two-State Practice-based Research (PBR) Collaboration.

BACKGROUND: The concept of body mass index (BMI) may not be well understood by patients. The purpose of this study was to evaluate patients' knowledge of BMI in the primary care setting. METHODS: Adult patients seen in 18 practices in West Virginia and New Jersey were invited to complete a voluntary survey. The survey assessed the patient's baseline knowledge of BMI as well as demographic information and whether the patient had known chronic conditions associated with increased BMI, including hypertension, hyperlipidemia, diabetes mellitus, and sleep apnea. RESULTS: While the majority (59.9%) of primary care patients knew the meaning of BMI and that it is related to obesity, there was little knowledge of BMI cutoff values; more than 80% of responses were incorrect when asked to define specific BMI levels and their meaning. Self-awareness of obesity was limited as well, with only 16.4% aware of their own personal BMI. Furthermore, nearly 70% of patients could not recall having discussed BMI with their physician. CONCLUSION: Findings indicate low comprehension of the term BMI. Increasing awareness of BMI may help patients address this key risk factor and significantly affect public health.

Impact of daily cooling treatment on skin inflammation in patients with chronic venous disease.

People with chronic venous disease are at high risk for developing venous leg ulcers. Inflammation is posited as a pathological factor for this chronic condition as evidenced by persistently elevated skin temperature. As part of a larger trial to test the effects of a cooling regimen on leg ulcer prevention, the objective of this preliminary study was to evaluate the first 30 days of intense daily cooling. Compared to a placebo control cuff, a gel cuff applied to the most severely affected lower leg skin for 30 min daily showed no statistically significant differences between temperatures taken in the home at baseline compared to those measured at the 1 month follow up visit. There were also no differences in temperatures noted between the two groups, although the temperatures in the treatment group were lower 30 min after treatment, an indication of adherence. There was no discernable decrease or increase in temperature at a given time point during the 30 day treatment period compared to the control group. It may be better to have patients monitor skin temperature on a daily basis and then apply the cuff as necessary, rather than requiring daily cooling based on baseline measurement. This "prn" approach may provide a sufficient cooling milieu to prevent escalation of inflammation and thwart ulcer occurrence or recurrence. Clinical trials registration #NCT01509599.

Intake of key chronic disease-related nutrients among baby boomers.

OBJECTIVES: The dietary habits of baby boomers (people born between 1946 and 1964) undoubtedly will have a substantial impact on their future health; however, dietary information regarding the intake of key chronic disease-related nutrients is lacking for this generation. The objective of this study was to compare the dietary intake of key chronic disease-related nutrients of the baby boomer generation with the previous generation of middle-aged adults. METHODS: National cross-sectional study comparison analyzing data from the National Health and Nutrition Examination Survey (NHANES) including NHANES III (1988-1994) and the NHANES for 2007-2010, focused on adult respondents ages 46 to 64 years who were not institutionalized at the time of each survey. The two cohorts were compared with regard to dietary intake of key nutritional components. The main outcome measures were intake of total calories, sodium, cholesterol, fat, fruits, vegetables, vitamin C, water, and fiber. RESULTS: The baby boomers' average daily intake of nutrients exceeded that of the previous generation of middle-aged adults for total calories (2118/1999), total fat (82/76 g), sodium (3513/3291 mg), and cholesterol (294/262 g; all P < 0.001). The intake of vitamin C (105/89 g), water (1208/1001 g), and vegetables (199/229 g) was less than that of the previous generation (P < 0.001), and the dietary intake of fruit and fiber was unchanged. In regression analyses, dietary changes remained significant after controlling for age, race, sex, and socioeconomic status (all P < 0.01). CONCLUSIONS: The study findings document higher dietary intake of key chronic disease-related nutrients along with reduced vegetable intake among baby boomers compared with the previous generation of middle-aged adults. These findings are indicative of a diet that may contribute to increased rates of chronic disease among individuals in this age group.

Expanding models for rural primary care in West Virginia.

This review paper outlines current and newer rural healthcare organizational models to improve availability and access to healthcare services for our state's large rural population. Included in the review are several suggested models for addressing rural healthcare needs: (a) the rural interdisciplinary medical home model; (b) the spoke and wheel model; (c) medical center/community linkages; (d) technology-based outreach modalities, such as tele-health; (e) part-time physician care and (f) expanding the role of health education centers to improve rural primary care. The overall goal is to stimulate exploration, funding and adoption of some of these models and advocate novel methods of addressing and reducing healthcare disparities in rural West Virginia.

Capitated payments to primary care providers and the delivery of patient education.

INTRODUCTION: Patient education is a critical component of the patient-centered medical home and is a powerful and effective tool in chronic disease management. However, little is known about the effect of practice payment on rates of patient education during office encounters. METHODS: For this study we took data from the 2009 National Ambulatory Medical Care Survey. This was a cross-sectional analysis of patient visits to primary care providers to determine whether practice payment in the form of capitated payments is associated within patient education being included more frequently during office visits compared with other payment methods. RESULTS: In a sample size of 9863 visits in which capitation status was available and the provider was the patient's primary care provider, the weighted percentages of visits including patient education were measured as a percentages of education (95% confidence intervals): <25% capitation, 42.7% (38.3-47.3); 26% to 50% capitation, 37.6% (23.5-54.2); 51% to 75% capitation, 38.4% (28.1-49.8); >75% capitation, 74.0% (52.2-88.1). In an adjusted logistic model controlling for new patients (yes/no), number of chronic conditions, number of medications managed, number of previous visits within the year, and age and sex of the patients, the odds of receiving education were reported as odds ratios (95% confidence intervals): <25% capitation, 1.00 (1.00-1.00); 26% to 50% capitation, 0.77 (0.38-1.58); 51% to 75% capitation, 0.81 (0.53-1.25); and >75% capitation, 3.38 (1.23-9.30). CONCLUSIONS: Patients are more likely to receive education if their primary care providers receive primarily capitated payment. This association is generally important for health policymakers constructing payment strategies for patient populations who would most benefit from interventions that incorporate or depend on patient education, such as populations requiring management of chronic diseases.