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An evolutionary perspective provides a unifying explanation for the modifiable risk factors and lifestyle-based interventions for the leading causes of morbidity and mortality globally. Non-communicable diseases develop from an evolutionary mismatch between the prior environment and modern patterns of behavior; however, it is unclear whether an evolutionary mismatch narrative could promote positive behavior change in patients. We hypothesize that educating patients about evolutionary mismatch could augment efforts to improve healthful behavior. Specifically, explaining the 'why' behind what is being recommended could promote health literacy and adherence. Furthermore, we offer suggestions of how clinicians could educate patients about evolutionary mismatch for key-lifestyle factors, diet and physical activity, as well as several specific modern diseases. We also consider how to sidestep patients' skepticism of evolutionary theory. Here, we lay the groundwork for research on how educating patients with an evolutionary mismatch narrative could impact health behaviors and improve outcomes.
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INTRODUCTION: Continuity is valued by patients, clinicians, and health systems for its association with higher-value care and satisfaction. Continuity is a commonly cited reason for entering primary care; however, it is difficult to achieve in residency settings. We sought to determine the effect of transitioning from a traditional "block" (13 4-week rotations per year) to a "clinic-first" (priority on outpatient continuity) curriculum on measures of continuity in our family medicine residency. METHODS: For the 3 years prior to and the 4 years following the transition from block to clinic-first curriculum (July 2011-June 2018, n = 51 block resident-years and n = 72 clinic-first resident-years), we measured resident panel size, clinic time, office visits, and both resident- and patient-sided continuity measures. We also defined a new longitudinal continuity measure, "familiar faces," which is the number of patients that a resident saw at least 3 times during residency. RESULTS: The transition from block to clinic-first curriculum increased panel size, clinic time for first- and second-year residents, overall total visits, and total number of clinic visits with paneled patients. Continuity measures demonstrated an increased resident-sided continuity at all training levels, an increase (first-year residents) or unchanged (second- and third-year residents) continuity from the patient perspective, and a near doubling of longitudinal continuity. CONCLUSION: Redesigning our family medicine residency curriculum from a traditional block schedule to a clinic-first curriculum improved our residents' continuity experience.
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Internado y Residencia , Instituciones de Atención Ambulatoria , Continuidad de la Atención al Paciente , Curriculum , Medicina Familiar y Comunitaria/educación , HumanosRESUMEN
Fast food consumption is linked to poor health, yet many older adults regularly consume fast food. Understanding factors contributing to fast food consumption is useful in the development of targeted interventions. The aim of this study was to characterize how fast food consumption relates to socio-demographic characteristics in a low-income sample of older adults. This study used cross-sectional survey data of 50 to79-year-olds (N-236) in urban safety-net clinics in 2010 in Kansas City, KS. Self-reported frequency of fast food consumption was modeled using ordinal logistic regression with socio-demographics as predictor variables. Participants were 56.8⯱â¯6.0 (mean⯱â¯SD) years old, 64% female, 45% non-Hispanic African American, and 26% Hispanic. Thirty-nine percent denied eating fast food in the past week, 36% ate once, and 25% ate fast food at least twice. Age was negatively correlated with fast food intake (râ¯=â¯-0.20, Pâ¯=â¯0.003). After adjusting for age, race-ethnicity, employment, and marital status, the association between education and fast food consumption differed by sex (Pinteractionâ¯=â¯0.017). Among women, higher education was associated with greater fast food intake (Spearman's correlation; râ¯=â¯0.28, Pâ¯=â¯0.0005); the association was not significant in men (râ¯=â¯-0.14, Pâ¯=â¯0.21). In this diverse, low-income population, high educational attainment (college graduate or higher) related to greater fast food intake among women but not men. Exploration of the factors contributing to this difference could inform interventions to curb fast food consumption or encourage healthy fast food choices among low-income, older adults.
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Background: Observational studies find associations between maternal docosahexaenoic acid (DHA) and greater fat-free mass and lower percentage of body fat, but randomized trials of prenatal DHA supplementation have not found significant intent-to-treat effects on childhood body composition. Objective: This study sought to explore associations between intrauterine DHA exposure and body composition and size at 5 y in the offspring of women who participated in a randomized trial of prenatal DHA supplementation (corn and soybean oil placebo or 600 mg/d). Design: At 5 y, body composition was measured by air displacement plethysmography in 154 offspring of women who had participated in the Kansas University DHA Outcomes Study and who had red blood cell (RBC) phospholipid (PL) fatty acids assessed at enrollment and delivery. We used linear regression models to analyze the relation among 3 indicators of intrauterine DHA exposure-1) intent-to-treat (placebo or DHA), 2) maternal RBC PL DHA status at delivery, and 3) change in maternal DHA (delivery minus enrollment)-and 6 outcomes of interest: 5-y fat mass, fat-free mass, percentage of body fat, height, weight, and body mass index z score. Results: Change in maternal RBC PL DHA correlated with higher fat-free mass (r = 0.21, P = 0.0088); the association was unchanged after adjustment for maternal, perinatal, and childhood dietary factors. Intent-to-treat and DHA status at delivery showed positive trends with fat-free mass that were not statistically significant. There was no evidence relating intrauterine DHA exposure to any other body composition measure. Conclusions: Change in maternal DHA status during pregnancy was related to higher offspring 5-y fat-free mass. The other 2 indicators of intrauterine exposure to DHA suggested a trend for higher offspring 5-y fat-free mass. Our findings agree with an earlier observational study from the United Kingdom. This trial was registered at clinicaltrials.gov as NCT00266825.
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Composición Corporal , Ácidos Docosahexaenoicos/administración & dosificación , Fenómenos Fisiologicos Nutricionales Maternos , Índice de Masa Corporal , Peso Corporal , Desarrollo Infantil , Preescolar , Suplementos Dietéticos , Método Doble Ciego , Eritrocitos/química , Femenino , Estudios de Seguimiento , Humanos , Masculino , Pletismografía , Embarazo , Atención Prenatal , Estudios ProspectivosRESUMEN
BACKGROUND & AIMS: We reported an association between cytologic atypia, a reversible biomarker of breast cancer risk, and lower omega-3/omega-6 fatty acid ratio in blood and breast tissue. Our goal was to develop and validate a dietary pattern index in this high-risk sample of U.S. women, and test its capacity to predict incidence in a nested case-control cohort of Canadian women from a randomized trial of a low-fat dietary intervention for primary prevention of breast cancer. METHODS: Food intake was measured by food frequency questionnaire in the U.S. sample (n = 65) and multiple dietary recalls in the Canadian sample (n = 220 cases; 440 controls). Principal component analysis identified a dietary pattern associated with atypia. We measured differences among dietary pattern tertiles in (a) fatty acid composition in blood lipids and breast tissue in the U.S. sample, and (b) risk of breast cancer subtypes in the Canadian cohort. Registered under ClinicalTrials.gov Identifier: NCT00148057. RESULTS: A Modern diet was characterized as consuming more grains, dairy, and sugar and less vegetables, fish and poultry; these women had lower tissue omega-3 fatty acids and higher omega-6 and trans fatty acids. The low-fat intervention increased the likelihood of a Modern diet after randomization. A Modern diet at baseline and post-randomization was associated with estrogen-receptor negative (ER-) breast cancer risk among those at least 160 cm tall. A Traditional diet (the reciprocal of Modern) at baseline was associated with lower ER-positive (ER+) risk in the comparison group, but not the low-fat intervention group. CONCLUSIONS: A Modern diet (high in grains, dairy, and sugar and low in vegetables, fish, and poultry) is associated with ER- breast cancer risk among taller women. Recommending dietary fat reduction may have untoward effects on breast cancer risk.
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Neoplasias de la Mama/prevención & control , Dieta con Restricción de Grasas , Dieta Saludable , Prevención Primaria/métodos , Conducta de Reducción del Riesgo , Adulto , Anciano , Estatura , Neoplasias de la Mama/epidemiología , Neoplasias de la Mama/metabolismo , Neoplasias de la Mama/patología , Canadá/epidemiología , Estudios de Casos y Controles , Dieta con Restricción de Grasas/efectos adversos , Ácidos Grasos/administración & dosificación , Ácidos Grasos/metabolismo , Conducta Alimentaria , Femenino , Humanos , Incidencia , Kansas/epidemiología , Modelos Lineales , Modelos Logísticos , Persona de Mediana Edad , Oportunidad Relativa , Análisis de Componente Principal , Estudios Prospectivos , Factores Protectores , Receptores de Estrógenos/metabolismo , Medición de Riesgo , Factores de RiesgoRESUMEN
BACKGROUND: Dietary habits established in early childhood and maternal socioeconomic status (SES) are important, complex, interrelated factors that influence a child's growth and development. The aim of this study was to define the major dietary patterns in a cohort of young US children, construct a maternal SES index, and evaluate their associations. METHODS: The diets of 190 children from a randomized, controlled trial of prenatal supplementation of docosahexaenoic acid (DHA) were recorded at 6-mo intervals from 2-4.5 years by 24-h dietary recall. Hierarchical cluster analysis of age-adjusted, average daily intake of 24 food and beverage groups was used to categorize diet. Unrotated factor analysis generated an SES score from maternal race, ethnicity, age, education, and neighborhood income. RESULTS: We identified two major dietary patterns: "Prudent" and "Western." The 85 (45%) children with a Prudent diet consumed more whole grains, fruit, yogurt and low-fat milk, green and non-starchy vegetables, and nuts and seeds. Conversely, those with a Western diet had greater intake of red meat, discretionary fat and condiments, sweet beverages, refined grains, French fries and potato chips, eggs, starchy vegetables, processed meats, chicken and seafood, and whole-fat milk. Compared to a Western diet, a Prudent diet was associated with one standard deviation higher maternal SES (95% CI: 0.80 to 1.30). CONCLUSIONS: We found two major dietary patterns of young US children and defined a single, continuous axis of maternal SES that differed strongly between groups. This is an important first step to investigate how child diet, SES, and prenatal DHA supplementation interact to influence health outcomes. TRIAL REGISTRATION: NCT00266825 . Prospectively registered on December 15, 2005.
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Dieta , Suplementos Dietéticos , Ácidos Docosahexaenoicos , Atención Prenatal/métodos , Fenómenos Fisiologicos de la Nutrición Prenatal , Clase Social , Adulto , Preescolar , Análisis por Conglomerados , Encuestas sobre Dietas , Femenino , Estudios de Seguimiento , Humanos , Masculino , Madres , Embarazo , Estudios Prospectivos , Estados UnidosRESUMEN
We investigated how timing influences the role of diet in breast cancer risk with a cross-sectional study of pre-malignant change in breast tissue. Women with an elevated risk of developing breast cancer (33 premenopausal and 32 postmenopausal) completed the National Cancer Institute's food frequency questionnaire and underwent random periareolar fine-needle aspiration for evaluation of cytologic atypia, an established risk biomarker. Fatty acid composition of breast adipose was measured in 32 (49%) subjects. We found that premenopausal and postmenopausal women had similar diets, but the associations between atypia and intake of total n-3 polyunsaturated fatty acids (PUFA) and soy differed by menopause status (both P interaction < 0.001). Total n-3 PUFA intake was inversely associated with atypia among premenopausal women (P < 0.0001), but not among postmenopausal women (P = 0.91); associations were similar for soy (P = 0.0003 and P = 0.48, respectively). This pattern of dietary interaction with menopause was mirrored in tissue fatty acids (P interaction < 0.05), wherein 1) higher levels of linolelaidic acid (an industrially-produced trans fat) and 2) lower levels of docosahexaenoic acid (the predominant long-chain n-3 PUFA) in breast adipose were associated with atypia in premenopausal (both P < 0.05) but not postmenopausal women (both P > 0.37). Dietary associations with breast cancer risk are stronger prior to menopause.
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Tejido Adiposo Blanco/metabolismo , Neoplasias de la Mama/prevención & control , Dieta Saludable , Menopausia , Cooperación del Paciente , Lesiones Precancerosas/prevención & control , Centros Médicos Académicos , Tejido Adiposo Blanco/patología , Adulto , Anciano , Biomarcadores de Tumor/sangre , Biomarcadores de Tumor/metabolismo , Biopsia con Aguja Fina , Neoplasias de la Mama/epidemiología , Neoplasias de la Mama/metabolismo , Neoplasias de la Mama/patología , Estudios de Cohortes , Estudios Transversales , Femenino , Humanos , Kansas/epidemiología , Persona de Mediana Edad , Posmenopausia , Lesiones Precancerosas/epidemiología , Lesiones Precancerosas/metabolismo , Lesiones Precancerosas/patología , Premenopausia , Prevalencia , Riesgo , AutoinformeRESUMEN
Higher intakes of the omega-3 eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) relative to the omega-6 arachidonic acid (AA) have been variably associated with reduced risk of premenopausal breast cancer. The purpose of this pilot trial was to assess feasibility and explore the effects of high-dose EPA and DHA on blood and benign breast tissue risk biomarkers before design of a placebo-controlled phase IIB trial. Premenopausal women with evidence of hyperplasia ± atypia by baseline random periareolar fine needle aspiration were given 1860 mg of EPA + 1500 mg of DHA ethyl esters daily for 6 months. Blood and benign breast tissue were sampled during the same menstrual cycle phase prestudy and a median of 3 weeks after last dose. Additional blood was obtained within 24 hours of last dose. Feasibility, which was predefined as 50% uptake, 85% retention, and 70% compliance, was demonstrated with 46% uptake, 94% completion, and 85% compliance. Cytologic atypia decreased from 77% to 38% (P = 0.002), and Ki-67 from a median of 2.1% to 1.0% (P = 0.021) with an increase in the ratio of EPA + DHA to AA in erythrocyte phospholipids but no change in blood hormones, adipokines, or cytokines. Exploratory breast proteomics assessment showed decreases in several proteins involved in hormone and cytokine signaling with mixed effects on those in the AKT/mTOR pathways. Further investigation of EPA plus DHA for breast cancer prevention in a placebo-controlled trial in premenopausal women is warranted.
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Biomarcadores de Tumor/análisis , Biomarcadores de Tumor/sangre , Neoplasias de la Mama/sangre , Neoplasias de la Mama/prevención & control , Ácidos Docosahexaenoicos/uso terapéutico , Ácido Eicosapentaenoico/uso terapéutico , Ácidos Grasos Omega-3/uso terapéutico , Adulto , Cromatografía en Capa Delgada , Combinación de Medicamentos , Ensayo de Inmunoadsorción Enzimática , Ácidos Grasos Omega-3/sangre , Estudios de Factibilidad , Femenino , Humanos , Hiperplasia/patología , Antígeno Ki-67/análisis , Persona de Mediana Edad , Proyectos Piloto , Lesiones Precancerosas/patología , Premenopausia , Reacción en Cadena en Tiempo Real de la PolimerasaRESUMEN
Associational studies suggest higher intakes/blood levels of the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) relative to the omega-6 arachidonic acid (AA) are associated with reduced breast cancer risk. We performed a pilot study of high-dose EPA + DHA in postmenopausal women to assess feasibility before initiating a phase IIB prevention trial. Postmenopausal women with cytologic evidence of hyperplasia in their baseline random periareolar fine needle aspiration (RPFNA) took 1,860 mg EPA +1500 mg DHA ethyl esters daily for 6 months. Blood and breast tissue were sampled at baseline and study conclusion for exploratory biomarker assessment, with P values uncorrected for multiple comparisons. Feasibility was predefined as 50% uptake, 80% completion, and 70% compliance. Trial uptake by 35 study entrants from 54 eligible women was 65%, with 97% completion and 97% compliance. Favorable modulation was suggested for serum adiponectin (P = 0.0027), TNFα (P = 0.016), HOMA 2B measure of pancreatic ß cell function (P = 0.0048), and bioavailable estradiol (P = 0.039). Benign breast tissue Ki-67 (P = 0.036), macrophage chemoattractant protein-1 (P = 0.033), cytomorphology index score (P = 0.014), and percent mammographic density (P = 0.036) were decreased with favorable effects in a proteomics array for several proteins associated with mitogen signaling and cell-cycle arrest; but no obvious overall effect on proteins downstream of mTOR. Although favorable risk biomarker modulation will need to be confirmed in a placebo-controlled trial, we have demonstrated feasibility for development of high-dose EPA and DHA ethyl esters for primary prevention of breast cancer.
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Biomarcadores de Tumor/sangre , Neoplasias de la Mama/prevención & control , Ácidos Docosahexaenoicos/uso terapéutico , Ácido Eicosapentaenoico/uso terapéutico , Ácidos Grasos Omega-3/sangre , Adulto , Anciano , Neoplasias de la Mama/sangre , Neoplasias de la Mama/patología , Cromatografía en Capa Delgada , Combinación de Medicamentos , Ácidos Grasos Omega-3/uso terapéutico , Estudios de Factibilidad , Femenino , Humanos , Hiperplasia/patología , Persona de Mediana Edad , Proyectos Piloto , Posmenopausia , Lesiones Precancerosas/patología , Reacción en Cadena en Tiempo Real de la Polimerasa , Proyectos de Investigación , Factores de RiesgoRESUMEN
Obesity induces chronic inflammation and is an established risk and progression factor for triple-negative breast cancers, including basal-like (BL) and claudin-low (CL) subtypes. We tested the effects of dietary supplementation with ethyl esters of the marine-derived anti-inflammatory omega-3 fatty acids eicosapentaenoic and docosahexaenoic acid (EPA+DHA; Lovaza) on growth of murine BL and CL mammary tumors. Female ovariectomized C57BL/6 mice were fed a control diet or a diet-induced obesity (DIO) diet with or without EPA+DHA (0.025%, resulting in blood levels of EPA and DHA comparable with women taking Lovaza 4 g/d) for 6 weeks. All mice were then orthotopically injected with Wnt-1 cells (a BL tumor cell suspension derived from MMTV-Wnt-1 transgenic mouse mammary tumors) or M-Wnt cells (a CL tumor cell line cloned from the Wnt-1 tumor cell suspension). Mice were killed when tumors were 1 cm in diameter. EPA+DHA supplementation did not significantly affect Wnt-1 or M-Wnt mammary tumor growth in normoweight control mice. However, EPA+DHA supplementation in DIO mice reduced growth of Wnt-1 and M-Wnt tumors; reduced leptin:adiponectin ratio and proinflammatory eicosanoids in the serum; improved insulin sensitivity; and decreased tumoral expression of COX-2 and phospho-p65. Thus, EPA+DHA supplementation in mouse models of postmenopausal BL and CL breast cancer offsets many of the protumorigenic effects of obesity. These preclinical findings, in combination with results from parallel biomarker studies in women, suggest that EPA+DHA supplementation may reduce the burden of BL and CL breast cancer in obese women.
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Claudina-1/metabolismo , Ácidos Grasos Omega-3/química , Neoplasias Mamarias Animales/metabolismo , Neoplasias Mamarias Experimentales/metabolismo , Obesidad/genética , Adiponectina/sangre , Animales , Composición Corporal , Línea Celular Tumoral , Ciclooxigenasa 2/metabolismo , Eicosanoides/sangre , Eritrocitos/citología , Ésteres/química , Femenino , Prueba de Tolerancia a la Glucosa , Inflamación , Leptina/sangre , Ratones , Ratones Endogámicos C57BL , Trasplante de Neoplasias , Obesidad/metabolismo , Proyectos Piloto , Posmenopausia , Factor de Transcripción ReIA/metabolismo , Proteína Wnt1/metabolismoRESUMEN
BACKGROUND: Medical and public health scientists are using evolution to devise new strategies to solve major health problems. But based on a 2003 survey, medical curricula may not adequately prepare physicians to evaluate and extend these advances. This study assessed the change in coverage of evolution in North American medical schools since 2003 and identified opportunities for enriching medical education. METHODS: In 2013, curriculum deans for all North American medical schools were invited to rate curricular coverage and perceived importance of 12 core principles, the extent of anticipated controversy from adding evolution, and the usefulness of 13 teaching resources. Differences between schools were assessed by Pearson's chi-square test, Student's t-test, and Spearman's correlation. Open-ended questions sought insight into perceived barriers and benefits. RESULTS: Despite repeated follow-up, 60 schools (39%) responded to the survey. There was no evidence of sample bias. The three evolutionary principles rated most important were antibiotic resistance, environmental mismatch, and somatic selection in cancer. While importance and coverage of principles were correlated (r = 0.76, P < 0.01), coverage (at least moderate) lagged behind importance (at least moderate) by an average of 21% (SD = 6%). Compared to 2003, a range of evolutionary principles were covered by 4 to 74% more schools. Nearly half (48%) of responders anticipated igniting controversy at their medical school if they added evolution to their curriculum. The teaching resources ranked most useful were model test questions and answers, case studies, and model curricula for existing courses/rotations. Limited resources (faculty expertise) were cited as the major barrier to adding more evolution, but benefits included a deeper understanding and improved patient care. CONCLUSION: North American medical schools have increased the evolution content in their curricula over the past decade. However, coverage is not commensurate with importance. At a few medical schools, anticipated controversy impedes teaching more evolution. Efforts to improve evolution education in medical schools should be directed toward boosting faculty expertise and crafting resources that can be easily integrated into existing curricula.
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Curriculum/tendencias , Educación de Pregrado en Medicina/métodos , Evaluación Educacional , Docentes Médicos/organización & administración , Facultades de Medicina/tendencias , Distribución de Chi-Cuadrado , Femenino , Predicción , Humanos , Masculino , Medicina , Evaluación de Necesidades , América del Norte , Encuestas y CuestionariosRESUMEN
The ratio of omega-3 to omega-6 fatty acids, especially the long-chain eicosapentaenoic acid (EPA) + docosahexaenoic acid (DHA) to arachidonic acid (AA) ratio, is inversely associated with breast cancer risk. We measured the association between cytologic atypia, a biomarker for short-term risk of breast cancer development, and omega-3 and omega-6 fatty acid intake and levels in blood and breast tissue. Blood and benign breast tissue, sampled by random periareolar fine-needle aspiration (RPFNA), was obtained from 70 women at elevated risk for breast cancer. Self-reported dietary intake was assessed by the NCI's Food Frequency Questionnaire. The fatty acid composition of five lipid compartments, red blood cell, plasma and breast phospholipids, and plasma and breast triaclyglycerides (TAG), was analyzed by gas chromatography as weight percent. Median daily intakes of EPA+DHA and total omega-3 fatty acids were 80 mg and 1.1 g, respectively. The median total omega-3:6 intake ratio was 1:10. Compared with women without atypia, those with cytologic atypia had lower total omega-3 fatty acids in red blood cell and plasma phospholipids and lower omega-3:6 ratios in plasma TAGs and breast TAGs (P < 0.05). The EPA+DHA:AA ratio in plasma TAGs was also lower among women with atypia. This is the first report of associations between tissue levels of omega-3 and omega-6 fatty acids and a reversible tissue biomarker of breast cancer risk. RPFNA cytomorphology could serve as a surrogate endpoint for breast cancer prevention trials of omega-3 fatty acid supplementation.
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Mama/metabolismo , Mama/patología , Ácidos Grasos Omega-3/metabolismo , Ácidos Grasos Omega-6/metabolismo , Adulto , Biopsia con Aguja Fina , Mama/química , Neoplasias de la Mama/metabolismo , Neoplasias de la Mama/patología , Estudios Transversales , Ingestión de Alimentos/fisiología , Ácidos Grasos Omega-3/análisis , Ácidos Grasos Omega-3/sangre , Ácidos Grasos Omega-6/análisis , Ácidos Grasos Omega-6/sangre , Femenino , Humanos , Persona de Mediana Edad , Encuestas Nutricionales , Factores de RiesgoRESUMEN
There has been much speculation about modern environments causing an epidemic of depression. This review aims to (1) determine whether depression rates have increased and (2) review evidence for possible explanations. While available data indicate rising prevalence and an increased lifetime risk for younger cohorts, strong conclusions cannot be drawn due to conflicting results and methodological flaws. There are numerous potential explanations for changing rates of depression. Cross-cultural studies can be useful for identifying likely culprits. General and specific characteristics of modernization correlate with higher risk. A positive correlation between a country's GDP per capita, as a quantitative measure of modernization, and lifetime risk of a mood disorder trended toward significance (p=0.06). Mental and physical well-being are intimately related. The growing burden of chronic diseases, which arise from an evolutionary mismatch between past human environments and modern-day living, may be central to rising rates of depression. Declining social capital and greater inequality and loneliness are candidate mediators of a depressiogenic social milieu. Modern populations are increasingly overfed, malnourished, sedentary, sunlight-deficient, sleep-deprived, and socially-isolated. These changes in lifestyle each contribute to poor physical health and affect the incidence and treatment of depression. The review ends with a call for future research and policy interventions to address this public health crisis.