Leveraging Registered Dietitian Nutritionists and Registered Nurses in Medication Management to Reduce Therapeutic Inertia.

Objective: To conduct a systematic review of studies that used registered dietitian nutritionists (RDNs) or registered nurses (RNs) to deliver pharmacological therapy using protocols for diabetes, dyslipidemia, or hypertension. Research Design and Methods: A database search of PubMed, the Cochrane Central Register of Controlled Trials, Ovid, and the Cumulative Index to Nursing and Allied Health Literature was conducted of literature published from 1 January 2000 to 31 December 2019. Results: Twenty studies met the inclusion criteria, representing randomized controlled trials (12), retrospective (1) and prospective cohort design studies (6), and time series (1). In all, the studies include 7,280 participants with a median study duration of 12 months (range 6-25 months). Fifteen studies were led by RNs alone, two by RDNs, and three by a combination of RDNs and RNs. All demonstrated improvements in A1C, blood pressure, or lipids. Thirteen studies provided a lifestyle behavior change component in addition to medication protocols. Conclusion: This systematic review provides evidence that RDN- and RN-led medication management using physician-approved protocols or treatment algorithms can lead to clinically significant improvements in diabetes, dyslipidemia, and hypertension management and is as good or better than usual care.

The impact of a population-based prevention program on cardiovascular events: Findings from the heart of new Ulm project.

BACKGROUND: Cardiovascular disease (CVD) and its associated risk factors are the principal drivers of mortality and healthcare costs in the United States with rural residents experiencing higher CVD death rates than their urban counterparts. METHODS: The purpose of this study was to examine incidence of major CVD events over 9 years of implementation of the Heart of New Ulm (HONU) Project, a rural population-based CVD prevention initiative. HONU interventions were delivered at individual, organizational, and community levels addressing clinical risk factors, lifestyle behaviors and environmental changes. The sample included 4,056 residents of New Ulm matched with 4,056 residents from a different community served by the same health system. The primary outcome was a composite of major CVD events (myocardial infarction, ischemic stroke, percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), and CVD-related death). Secondary outcomes were the individual CVD events and procedures. RESULTS: The proportion of residents in New Ulm with a major CVD event (7.79%) was not significantly different than the comparison community (8.43%, P = .290). However, the total number of events did differ by community with fewer events in New Ulm than the comparison community (447 vs 530, P = .005), with 48 fewer strokes (84 vs 132, P = .001) and 42 fewer PCI procedures (147 vs 189, P = 0.019) in New Ulm. Incidence of ischemic stroke was lower in the New Ulm community (1.85 vs 2.61, P = .020) than in the comparison community. Other specific CVD events did not have significantly different incidence or frequencies between the 2 communities. CONCLUSION: In HONU, the proportion of residents experiencing a CVD event was not significantly lower than a match comparison community. However, there was a significant reduction in the total number of CVD events in New Ulm, driven primarily by lower stroke, PCI, and CABG events in the intervention community.

Population-Level Reach of Cardiovascular Disease Prevention Interventions in a Rural Community: Findings from the Heart of New Ulm Project.

This study examines participation by residents of a rural community in programs implemented as part of The Heart of New Ulm (HONU) Project, a population-based cardiovascular disease (CVD) prevention initiative. The study compares participation rates for the various interventions to assess which were the most engaging in the priority community and identifies factors that differentiate participants vs. nonparticipants. Participation data were merged with electronic health record (EHR) data representing the larger community population to enable an analysis of participation in the context of the entire community. HONU individual-level interventions engaged 44% of adult residents in the community. Participation ranked as follows: (1) heart health screenings (37% of adult residents), (2) a year-long community weight loss intervention (12% of adult residents), (3) community health challenges (10% of adult residents), and (4) a phone coaching program for invited high CVD-risk residents (enrolled 6% of adult residents). Interventions that yielded the highest engagement were those that had significant staffing and recruited participants over several months, often with many opportunities to participate or register. Compared to nonparticipants, HONU participants were significantly older and a higher proportion were female, married, overweight or obese, and had high cholesterol. Participants also had a lower prevalence of smoking and diabetes than nonparticipants. Findings indicate community-based CVD prevention initiatives can be successful in engaging a high proportion of adult community members. Partnering with local health care systems can allow for use of EHR data to identify eligible participants and evaluate reach and engagement of the priority population.

JCL roundtable: Low-carbohydrate diets.

Low- and very-low-carbohydrate diets have long attracted popular interest in the US and variably throughout the world. The potential value of these diets was recognized recently in a Consensus Report from the American Diabetes Association and expanded in a Scientific Statement from the National Lipid Association. Scientific evidence remains incomplete, but is beginning to catch up with popular trends. In this JCL Roundtable, 3 experts discuss the evidence behind these diets, their current place in nutrition practice, and areas needing more study. The carbohydrate-insulin model of obesity is presented as one explanation for dietary effectiveness. Ongoing research will delineate this model further. The experts, all clinicians, give practical advice for when and how to incorporate low-carbohydrate principles into dietary counseling.

Connectedness: How Technology and Social Networks Are Advancing Diabetes Nutrition Care.

Editor's Note: This article is adapted from the address Ms. Boucher delivered as the recipient of the American Diabetes Association's (ADA's) Outstanding Educator in Diabetes Award for 2018. She delivered the address in June 2018 at the association's 78th Scientific Sessions in Orlando, Fla. A webcast of this speech is available for viewing at the ADA website (professional.diabetes.org/webcast/outstanding-educator-diabetes-award-lecture%E2%80%95connectedness%E2%80%94how-technology-and-social-networks).

Impact of ENHANCED (diEtitiaNs Helping pAtieNts CarE for Diabetes) Telemedicine Randomized Controlled Trial on Diabetes Optimal Care Outcomes in Patients with Type 2 Diabetes.

BACKGROUND: Clinical care for type 2 diabetes has improved but remains suboptimal. Collaborative, team-based models that maximize skills of different disciplines may improve care for individuals with diabetes, but few have been tested using rigorous research designs. OBJECTIVE: To investigate the efficacy of a registered dietitian nutritionist-led telemedicine program compared with that of a control group in terms of diabetes optimal care goals. DESIGN: A randomized controlled trial in which participants were assigned to a control or intervention group. PARTICIPANTS/SETTING: One hundred eighteen adults with type 2 diabetes (mean age, 60 years; 45% female) participated in the study between April 2016 and December 2017. Participants were recruited from separate primary care clinics in two rural Minnesota communities. INTERVENTION: For those assigned to the intervention, registered dietitian nutritionists used a treatment protocol to initiate and titrate therapies for blood glucose, hypertension, and lipid levels in addition to providing medical nutrition therapy; telemedicine visits supplemented usual care. MAIN OUTCOME MEASURES: Primary outcomes included composite and individual diabetes optimal care goals: hemoglobin A1c, blood pressure, not using tobacco, and taking a statin and aspirin (as appropriate). Secondary measures included physical activity, breakfast, fruits and vegetables, whole grains, body mass index, low-density lipoprotein, and medication adherence. STATISTICAL ANALYSIS: Mixed-model regression was used to examine outcomes between baseline and 1-year follow-up. RESULTS: A modest but significantly greater improvement in the number of diabetes optimal care measures met at follow-up was found in the intervention group (3.7 vs 3.2 in the control group [P=0.017]). Among individual measures, the intervention group had significantly greater medication use, with 2.5 and 2.2 higher odds (compared with the control group) of taking a statin [95% CI, 1.0 to 6.24]) and aspirin [95% CI, 0.90 to 5.19] as appropriate, respectively. CONCLUSIONS: ENHANCED (diEtitiaNs Helping pAtieNts CarE for Diabetes) findings suggest that registered dietitian nutritionists following medication treatment protocols can effectively improve care for adults with type 2 diabetes and can serve an instrumental role as part of the health care team in providing evidence-based, patient-centered care.

Assessing the impact of the heart of New Ulm Project on cardiovascular disease risk factors: A population-based program to reduce cardiovascular disease.

The Heart of New Ulm Project (HONU), is a population-based project designed to reduce modifiable cardiovascular disease (CVD) risk factors in the rural community of New Ulm, MN. HONU interventions address multiple levels of the social-ecological model. The community is served by one health system, enabling the use of electronic health record (EHR) data for surveillance. The purpose of this study was to assess if trends in CVD risk factors and healthcare utilization differed between a cohort of New Ulm residents age 40-79 and matched controls selected from a similar community, using EHR data from baseline (2008-2009) through three follow up time periods (2010-2011, 2012-2013, 2014-2015). Matching, using covariate balance sparse technique, yielded a sample of 4077 New Ulm residents and 4077 controls. We used mixed effects longitudinal models to examine trends over time between the two groups. Blood pressure, total cholesterol, low-density lipoprotein-cholesterol, and triglycerides showed better management in New Ulm over time compared to the controls. The proportion of residents in New Ulm with controlled blood pressure increased by 6.2 percentage points compared to an increase of 2 points in controls (p < 0.0001). As the cohort aged, 10-year ASCVD risk scores increased less in New Ulm (5.1) than the comparison community (5.9). The intervention and control community did not differ with regard to inpatient stays, smoking, or glucose. Findings suggest efficacy for the HONU project interventions for some outcomes.

Changing the restaurant food environment to improve cardiovascular health in a rural community: implementation and evaluation of the Heart of New Ulm restaurant programme.

OBJECTIVE: The goals of the present study were to: (i) describe the implementation of a programme to improve the restaurant food environment in a rural community; and (ii) describe how practices changed in community restaurants. DESIGN: The intervention included a baseline assessment of all community restaurants (n 32) and a report on how they could increase the availability and promotion of healthful options. The assessment focused on sixteen healthy practices (HP) derived from the Nutrition Environment Measures Survey for Restaurants. Restaurants were invited to participate at gold, silver or bronze levels based on the number of HP attained. Participating restaurants received dietitian consultation, staff training and promotion of the restaurant. All community restaurants were reassessed 1·5 years after baseline. SETTING: The restaurant programme was part of the Heart of New Ulm Project, a community-based CVD prevention programme in a rural community. SUBJECTS: All community restaurants (n 32) were included in the study. RESULTS: Over one-third (38 %) of community restaurants participated in the programme. At baseline, 22 % achieved at least a bronze level. This increased to 38 % at follow-up with most of the improvement among participating restaurants that were independently owned. Across all restaurants in the community, the HP showing the most improvement included availability of non-fried vegetables (63-84 %), fruits (41-53 %), smaller portions and whole grains. CONCLUSIONS: Findings demonstrate successes and challenges of improving healthful food availability and promotion in a community-wide restaurant programme.

Reach and effectiveness of the HeartBeat Connections telemedicine pilot program.

Introduction Innovative care delivery programs that support primary care providers are needed to reduce the burden of cardiovascular disease (CVD). HeartBeat Connections (HBC) is a primary prevention telemedicine program utilizing registered dietitian nutritionists (RDNs) and registered nurses (RNs) to deliver health coaching and medication therapy protocols for dyslipidaemia and hypertension among patients at high risk for developing CVD. Methods This retrospective cohort study documents the reach and six-month effectiveness of the HBC program for improving CVD risk factors. The sample included 1028 high-risk individuals aged 40-79 (without CVD or diabetes) served between 2010 and 2013 (326 participants, 702 eligible non-participants). Mixed-model analyses of variance were used to compare changes in outcome measures between baseline and six-month follow-up for participants and non-participants. Outcomes were also examined for three groups: non-participants, participants with 1-4 encounters, and participants with > 5 encounters. Results Nearly one-third of all eligible patients participated. There were no significant differences over time between HBC participants and non-participants in blood pressure or body mass. A higher proportion of HBC participants quit using tobacco (7.0 vs. 3.2%, p = 0.004) and achieved the low-density lipoprotein (LDL) program goal of < 100 mg/dL (8.9 vs. -1.1%, p = 0.009). Also, more favourable improvements in total and LDL cholesterol were observed among HBC participants with higher program engagement ( p < 0.05). Discussion The HBC telemedicine program resulted in significant improvement in some, but not all, CVD risk factors over six months. HBC reached many high-CVD-risk patients in the target region, which may confer population-level health benefits if this program can be scaled and sustained. Innovative, collaborative care delivery models like HBC can serve as a platform to systematically target and proactively engage at-risk populations, perhaps reducing patients' CVD risk.

Mediterranean Eating Pattern.

IN BRIEF The Mediterranean-style eating pattern (MEP) has long been touted as a healthful way of eating. However, the health benefits of the eating pattern and key elements contributing to those benefits are still being researched. In people with type 2 diabetes, the majority of studies report that the MEP improves glycemic control and cardiovascular risk factors. In people at risk for diabetes, the majority of studies report a protective effect of the MEP against the development of type 2 diabetes. Although more research is needed to determine whether study results can be achieved outside the Mediterranean geographical region, and especially in the United States, the high-quality individual foods and combinations of foods included in the MEP can be recommended as a healthful eating approach.

Lifestyle changes and prevention of metabolic syndrome in the Heart of New Ulm Project.

Prior research has shown that unhealthy lifestyles increase the risk for developing a number of chronic diseases, but there are few studies examining how lifestyle changes impact metabolic syndrome. This study analyzed the association between two-year changes in key lifestyle risk metrics and incident metabolic syndrome in adults. A retrospective cohort study was conducted using data from metabolic syndrome free adults in the Heart of New Ulm Project (New Ulm, MN). The outcome was incident metabolic syndrome observed two years after baseline in 2009. The primary predictor was change in optimal lifestyle score based on four behavioral risk factors, including smoking, alcohol use, fruit/vegetable consumption, and physical activity. In the analytical sample of 1059 adults, 12% developed metabolic syndrome by 2011. Multivariable regression models (adjusted for baseline lifestyle score, age, sex, education, cardiovascular disease, and diabetes) revealed that a two-year decrease in optimal lifestyle score was associated with significantly greater odds of incident metabolic syndrome (OR = 2.92; 95% CI: 1.69, 5.04; p < 0.001). This association was primarily driven by changes in obesity, fruit/vegetable consumption, and alcohol intake. As compared to improving poor lifestyle habits, maintaining a healthy lifestyle seemed to be most helpful in avoiding metabolic syndrome over the two-year study timeframe.

Changes in cardiovascular risk factors after 5 years of implementation of a population-based program to reduce cardiovascular disease: The Heart of New Ulm Project.

BACKGROUND: Population-based interventions aimed at reducing cardiovascular disease (CVD) hold significant potential and will be increasingly relied upon as the model for health care changes in the United States. METHODS: The Heart of New Ulm Project is a population-based project with health care, community, and workplace interventions addressing multiple levels of the social-ecological model designed to reduce modifiable CVD risk factors in rural New Ulm, MN. The community is served by one health system, enabling the use of electronic health record data for surveillance. Electronic health record data were extracted at baseline (2008-2009) and 2 follow-up periods (2010-2011, 2012-2013) for residents aged 40 to 79 years. Generalized estimating equations were used to fit longitudinal models of the risk factors. RESULTS: Of 7,855 residents in the target population, 80% had electronic health record data for each period. The prevalence of at goal (blood pressure [BP] <140/90 mm Hg) and (low-density lipoprotein cholesterol [LDL-C] <130 mg/dL) increased from 79.3% to 86.4% and 68.9% to 71.1%, respectively, from baseline to 5 years, with the largest reductions in BP and LDL-C seen in individuals not at goal at baseline. Blood pressure and lipid-lowering medication use increased from 41.8% to 44.0% and 25.3% to 29.1%, respectively. The proportion at goal for glucose increased from 46.9% to 48.2%. The prevalence body mass index <30 kg/m(2) (55%) did not change, whereas the proportion at-goal for high-density lipoprotein decreased from 63.8% to 58%, and smoking showed an increase from 11.3% to 13.6%. CONCLUSION: In a community participating in a multifaceted, population-based project aimed at reducing modifiable CVD risk factors, significant improvements in BP, LDL-C, and glucose were observed for 5 years, and body mass index remained stable in a state where obesity was increasing.

Lifestyle weight-loss intervention outcomes in overweight and obese adults with type 2 diabetes: a systematic review and meta-analysis of randomized clinical trials.

The majority of people with type 2 diabetes are overweight or obese, and weight loss is a recommended treatment strategy. A systematic review and meta-analysis was undertaken to answer the following primary question: In overweight or obese adults with type 2 diabetes, what are the outcomes on hemoglobin A1c (HbA1c) from lifestyle weight-loss interventions resulting in weight losses greater than or less than 5% at 12 months? Secondary questions are: What are the lipid (total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides) and blood pressure (systolic and diastolic) outcomes from lifestyle weight-loss interventions resulting in weight losses greater than or less than 5% at 12 months? And, what are the weight and metabolic outcomes from differing amounts of macronutrients in weight-loss interventions? Inclusion criteria included randomized clinical trial implementing weight-loss interventions in overweight or obese adults with type 2 diabetes, minimum 12-month study duration, a 70% completion rate, and an HbA1c value reported at 12 months. Eleven trials (eight compared two weight-loss interventions and three compared a weight-loss intervention group with a usual care/control group) with 6,754 participants met study criteria. At 12 months, 17 study groups (8 categories of weight-loss intervention) reported weight loss <5% of initial weight (-3.2 kg [95% CI: -5.9, -0.6]). A meta-analysis of the weight-loss interventions reported nonsignificant beneficial effects on HbA1c, lipids, or blood pressure. Two study groups reported a weight loss of ≥5%: a Mediterranean-style diet implemented in newly diagnosed adults with type 2 diabetes and an intensive lifestyle intervention implemented in the Look AHEAD (Action for Health in Diabetes) trial. Both included regular physical activity and frequent contact with health professionals and reported significant beneficial effects on HbA1c, lipids, and blood pressure. Five trials (10 study groups) compared weight-loss interventions of differing amounts of macronutrients and reported nonsignificant differences in weight loss, HbA1c, lipids, and blood pressure. The majority of lifestyle weight-loss interventions in overweight or obese adults with type 2 diabetes resulted in weight loss <5% and did not result in beneficial metabolic outcomes. A weight loss of >5% appears necessary for beneficial effects on HbA1c, lipids, and blood pressure. Achieving this level of weight loss requires intense interventions, including energy restriction, regular physical activity, and frequent contact with health professionals. Weight loss for many overweight or obese individuals with type 2 diabetes might not be a realistic primary treatment strategy for improved glycemic control. Nutrition therapy for individuals with type 2 diabetes should encourage a healthful eating pattern, a reduced energy intake, regular physical activity, education, and support as primary treatment strategies.

Two-year impact of lifestyle changes on workplace productivity loss in the Heart of New Ulm Project.

OBJECTIVE: Unhealthy lifestyles have been associated with lower workplace productivity and are the main targets of worksite wellness programmes. The degree to which workplace productivity increases over time in response to changes in lifestyle habits, however, remains unclear. The purpose of this study was to examine the association between 2-year changes in key lifestyle risk factors and workplace productivity loss. METHOD: A retrospective cohort of 1273 employed adults in 2009 and 2011 was studied from the Heart of New Ulm Project. The outcome was overall workplace productivity loss in 2011. Predictors included 2-year changes in smoking, alcohol use, fruit/vegetable consumption and physical activity, as well as an optimal lifestyle score based on a composite of these four factors. RESULTS: The adjusted model indicated that participants who continued to smoke over 2 years had significantly greater overall workplace productivity loss compared to those who remained non-smokers during the same timeframe (9.8% vs 2.5% productivity loss, p=0.031). Lifestyle improvements, however, were not associated with a reduction in workplace productivity loss. CONCLUSIONS: Employed adults in this cohort who quit smoking, moderated alcohol use, increased fruit/vegetable consumption, or increased physical activity over 2 years did not have less productivity loss compared to those whose lifestyle factors remained stable. In workforces where productivity is already high and/or lifestyle factors are generally healthy, further lifestyle improvements may have limited impact on employee productivity. Larger experimental studies in more diverse regions are needed to help guide employers' investments in lifestyle-oriented worksite wellness programmes.

Exploring electronic health records as a population health surveillance tool of cardiovascular disease risk factors.

The objective of this study was to examine the utility of using electronic health record (EHR) data for periodic community health surveillance of cardiovascular disease (CVD) risk factors through 2 research questions. First, how many years of EHR data are needed to produce reliable estimates of key population-level CVD health indicators for a community? Second, how comparable are the EHR estimates relative to those from community screenings? The study takes place in the context of the Heart of New Ulm Project, a 10-year population health initiative designed to reduce myocardial infarctions and CVD risk factor burden in a rural community. The community is served by 1 medical center that includes a clinic and hospital. The project screened adult residents of New Ulm for CVD risk factors in 2009. EHR data for 3 years prior to the heart health screenings were extracted for patients from the community. Single- and multiple-year EHR prevalence estimates were compared for individuals ages 40-79 years (N=5918). EHR estimates also were compared to screening estimates (N=3123). Single-year compared with multiyear EHR data prevalence estimates were sufficiently precise for this rural community. EHR and screening prevalence estimates differed significantly-systolic blood pressure (BP) (124.0 vs. 128.9), diastolic BP (73.3 vs. 79.2), total cholesterol (186.0 vs. 201.0), body mass index (30.2 vs. 29.5), and smoking (16.6% vs. 8.2%)-suggesting some selection bias depending on the method used. Despite differences between data sources, EHR data may be a useful source of population health surveillance to inform and evaluate local population health initiatives.

The impact of cooking classes on food-related preferences, attitudes, and behaviors of school-aged children: a systematic review of the evidence, 2003-2014.

INTRODUCTION: Cooking programs have been used to promote healthful eating among people of all ages. This review assesses the evidence on childhood cooking programs and their association with changes in food-related preferences, attitudes, and behaviors of school-aged children. METHODS: We systematically searched PubMed, Ovid-Medline, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases. We included primary research articles that involved cooking education programs for children and searched reference lists for eligible articles. Studies considered for review contained a hands-on cooking intervention; had participants aged 5 to 12 years; were published in a peer-reviewed journal on or after January 1, 2003; and were written in English. We used the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies to rate the strength of each article and assess bias. The following information was extracted from each study: study design, sample size, location, duration, intervention components, data collection methods, and outcomes. RESULTS: Eight studies met the inclusion criteria and used cooking education to influence children's food-related preferences, attitudes, and behaviors. Programs varied in duration, evaluation methods, and outcomes of interest. Self-reported food preparation skills, dietary intake, cooking confidence, fruit and vegetable preferences, attitudes toward food and cooking, and food-related knowledge were among the outcomes measured. Program exposure ranged from 2 sessions to regular instruction over 2 years, and the effect of cooking programs on children's food-related preferences, attitudes, and behaviors varied among the reviewed studies. CONCLUSIONS: Findings suggest that cooking programs may positively influence children's food-related preferences, attitudes, and behaviors. However, because study measurements varied widely, determining best practices was difficult. Further research is needed to fill knowledge gaps on ideal program length, long-term effects, and usefulness of parent engagement, tasting lessons, and other intervention components.