Maternal chronic hypertension in women veterans.

OBJECTIVE: To describe the prevalence of maternal chronic hypertension (MCH), assess how frequently blood pressure is controlled before pregnancy among those with MCH, and explore management practices for antihypertensive medications (AHM) during the pre-pregnancy and pregnancy periods. DATA SOURCES, STUDY SETTING, AND STUDY DESIGN: We conducted a descriptive observational study using data abstracted from the Veterans Health Administration (VA) inclusive of approximately 11 million Veterans utilizing the VA in fiscal years 2010-2019. DATA COLLECTION/EXTRACTION METHODS: Veterans aged 18-50 were included if they had a diagnosis of chronic hypertension before a documented pregnancy in the VA EMR. We identified chronic hypertension and pregnancy with diagnosis codes and defined uncontrolled blood pressure as ≥140/90 mm Hg on at least one measurement in the year before pregnancy. Sensitivity models were conducted for individuals with at least two blood pressure measurements in the year prior to pregnancy. Multivariable logistic regression explored the association of covariates with recommended and non-recommended AHMs received 0-6 months before pregnancy and during pregnancy. PRINCIPAL FINDINGS: In total, 8% (3767/46,178) of Veterans with a documented pregnancy in VA data had MCH. Among 2750 with MCH meeting inclusion criteria, 60% (n = 1626) had uncontrolled blood pressure on at least one BP reading and 31% (n = 846) had uncontrolled blood pressure on at least two BP readings in the year before pregnancy. For medications, 16% (n = 437) received a non-recommended AHM during pregnancy. Chronic kidney disease (OR = 3.2; 1.6-6.4) and diabetes (OR = 2.3; 1.7-3.0) were most strongly associated with use of a non-recommended AHM during pregnancy. CONCLUSIONS: Interventions are needed to decrease the prevalence of MCH, improve preconception blood pressure control, and ensure optimal pharmacologic antihypertensive management among Veterans of childbearing potential.

Breast cancer survivors with pain: an examination of the relationships between body mass index, physical activity, and symptom burden.

PURPOSE: Overweight and obesity are common for breast cancer survivors and associated with high symptom burden (i.e., pain, fatigue, depressive symptoms). Physical activity may protect breast cancer survivors with higher body mass indexes (BMI) from increased symptoms. However, the role of physical activity in buffering the relationship between higher BMI and greater symptoms is unclear. METHODS: Baseline data from a randomized trial investigating Pain Coping Skills Training among breast cancer survivors (N = 327) with pain were used to examine the relationship between self-reported BMI (kg/m2) and physical activity level (Rapid Assessment of Physical Activity; suboptimal vs. optimal) with pain (Brief Pain Inventory; severity and interference), fatigue (PROMIS-Fatigue short form), and depressive symptoms (Center for Epidemiological Studies Depression Scale). Analyses were conducted in SPSS. Hayes PROCESS macro (Model 1) assessed whether physical activity moderated the relationship between BMI and symptoms. RESULTS: Lower BMI (B = .06, p < .01) and optimal physical activity (B = - .69, p < .01) were independently associated with lower pain interference. Lower BMI was also associated with lower pain severity (B = .04, p < .001). Neither BMI nor physical activity was associated with fatigue or depressive symptoms. Physical activity did not moderate the relationship between BMI and symptoms. CONCLUSIONS: Among breast cancer survivors experiencing pain, higher BMI and being less physically active were related to greater pain (i.e., severity and/or interference). Physical activity did not buffer the relationships between BMI and pain, fatigue, and depressive symptoms, suggesting that physical activity alone may not be sufficient to influence the strength of the relationships between BMI and symptoms.

Association between Gentrification and Health and Healthcare Utilization.

There is tremendous interest in understanding how neighborhoods impact health by linking extant social and environmental drivers of health (SDOH) data with electronic health record (EHR) data. Studies quantifying such associations often use static neighborhood measures. Little research examines the impact of gentrification-a measure of neighborhood change-on the health of long-term neighborhood residents using EHR data, which may have a more generalizable population than traditional approaches. We quantified associations between gentrification and health and healthcare utilization by linking longitudinal socioeconomic data from the American Community Survey with EHR data across two health systems accessed by long-term residents of Durham County, NC, from 2007 to 2017. Census block group-level neighborhoods were eligible to be gentrified if they had low socioeconomic status relative to the county average. Gentrification was defined using socioeconomic data from 2006 to 2010 and 2011-2015, with the Steinmetz-Wood definition. Multivariable logistic and Poisson regression models estimated associations between gentrification and development of health indicators (cardiovascular disease, hypertension, diabetes, obesity, asthma, depression) or healthcare encounters (emergency department [ED], inpatient, or outpatient). Sensitivity analyses examined two alternative gentrification measures. Of the 99 block groups within the city of Durham, 28 were eligible (N = 10,807; median age = 42; 83% Black; 55% female) and 5 gentrified. Individuals in gentrifying neighborhoods had lower odds of obesity (odds ratio [OR] = 0.89; 95% confidence interval [CI]: 0.81-0.99), higher odds of an ED encounter (OR = 1.10; 95% CI: 1.01-1.20), and lower risk for outpatient encounters (incidence rate ratio = 0.93; 95% CI: 0.87-1.00) compared with non-gentrifying neighborhoods. The association between gentrification and health and healthcare utilization was sensitive to gentrification definition.

Centering equity: Addressing structural and social determinants of health to improve maternal and infant health outcomes.

Despite decades of investment and improvements in infant health in the United States, efforts to ensure the health and well-being of birthing people, especially those from racialized and minoritized communities, have been underfunded and neglected. As a result, many birthing people do not have access to the quality care they deserve and suffer disproportionately from adverse health outcomes such as severe maternal morbidity and maternal mortality. Through a Reproductive Justice lens, this paper will discuss structural causes for maternal health disparities as well as some of the structural solutions necessary to support the correction of centuries of discrimination on the basis of race, sex, gender, and other minoritized identities.

Weight Change for Pediatric Completers in a National Weight Loss Program.

Overweight and obese children in low-income households have limited access to weight loss programs. Low-cost programs should be evaluated in this population. The objective of the current study is to determine weight change among 7 to 17-year-old participants in Take Off Pounds Sensibly (TOPS), a national, low-cost weight loss program. This nonconcurrent prospective study analyzes the cumulative change in weight z-score for overweight and obese children and adolescents who joined TOPS from 2008 to 2011 and consecutively renewed their annual membership. The study includes 586 individuals. At 1-year, cumulative mean (SD) weight z-score change was -0.13 (31). In general, mean change in weight z-scores was no different in subsequent years. Mean weight z-score of children and adolescent TOPS participants who renew their program membership decreased significantly in the first year. Randomized controlled trials should prospectively evaluate this program in children and adolescents.

Exploring the presence of multiple abnormal non-motor features in patients with cervical dystonia.

This study's aim was to investigate prevalence of four non-motor symptoms in patients with cervical dystonia and healthy controls to explore whether the presence of multiple non-motor features is associated with cervical dystonia diagnosis. Fifteen patients with cervical dystonia and 15 healthy controls underwent non-invasive testing of spatial discrimination threshold, temporal discrimination threshold, vibration-induced illusion of movement, and kinesthesia. All spatial discrimination threshold, temporal discrimination threshold, and vibration-induced illusion of movement measures were converted to standardized Z scores with scores >2.0 considered abnormal. Any incorrect kinesthesia response was considered abnormal. Prevalence of each abnormal non-motor feature was compared between groups using a chi-squared test. A higher proportion of patients with cervical dystonia had abnormal spatial discrimination threshold (p = 0.01) and abnormal kinesthesia (p = 0.03) scores compared to healthy control subjects. There were no significant differences between the proportion of patients with cervical dystonia versus healthy controls for abnormal temporal discrimination threshold (p = 0.07) or abnormal vibration-induced illusion of movement (p = 0.14). Forty-seven percent of patients with cervical dystonia (7/15) demonstrated one abnormal non-motor feature, 20% (3/15) displayed two abnormal features, and 13% (2/15) displayed three abnormal features. Kinesthesia was the only non-motor feature identified as abnormal in the control group (20%, 3/15). All four tests demonstrated high specificity (80-100%) and low-moderate sensitivity (13-60%). These findings suggest that non-motor feature testing, specifically for spatial discrimination threshold and kinesthesia, could be a highly specific diagnostic tool to inform cervical dystonia diagnosis. Further investigation is needed to confirm these findings.

Predictors of long-term weight loss trajectories during a behavioral weight loss intervention: An exploratory analysis.

BACKGROUND: Substantial interindividual variability in response to behavioral weight loss interventions remains a critical challenge in obesity treatment. An improved understanding of the complex factors that contribute to this variability may improve obesity treatment outcomes. OBJECTIVE: To identify weight change trajectories during a behavioral weight loss intervention and to explore differences between trajectory groups in sociodemographic, biologic, behavioral, and psychosocial factors. METHODS: Adults (n = 170, 40 ± 9 years, BMI 34 ± 4 kg/m2, 84% female) participated in an 18-month behavioral weight loss intervention. Weight was measured at 0, 3, 6, 9, 12, 15, 18, and 24 months. Among participants with at least two weights after baseline (n = 140), clusters of longitudinal trajectories of changes in weight were identified using a latent class growth mixture model. The association between baseline factors or changes in factors over time and trajectory group was examined. RESULTS: Two weight change trajectories were identified: "weight regainers" (n = 91) and "weight loss maintainers" (n = 49). Black participants (90%, 19/21) were more likely than non-Black participants to be regainers versus maintainers (p < 0.01). Maintainers demonstrated greater increases in device-measured physical activity, autonomous motivation for exercise, diet self-efficacy, cognitive restraint, and engagement in weight management behaviors and greater reductions in barriers for exercise, disinhibition, and depressive symptoms over 24 months versus regainers (p < 0.05). CONCLUSION: Maintainers and regainers appear to be distinct trajectories that are associated with specific sociodemographic, behavioral, and psychosocial factors. Study results suggest potential targets for more tailored, multifaceted interventions to improve obesity treatment outcomes.

Retrospective cohort study of changes in estimated glomerular filtration rate for patients prescribed a low carb diet.

PURPOSE OF REVIEW: Obesity and diabetes contribute to chronic kidney disease (CKD) and accelerate the loss of kidney function. Low carbohydrate diets (LCDs) are associated with weight loss and improved diabetes control. Compared to the typical Western diet, LCDs contain more protein, so individuals with CKD are not included in studies of LCDs. Therefore, there are no studies of LCDs for weight loss and their effects on kidney function. RECENT FINDINGS: Obesity, hyperglycemia, and hyperinsulinemia can be detrimental to kidney function. LCDs may improve kidney function in patients with obesity and diabetes because they are associated with weight loss, improve blood sugar control, and decrease endogenous insulin production and exogenous insulin requirements. SUMMARY: In this study, for patients with mildly reduced and moderately to severely reduced kidney function who were prescribed an LCD, their estimated glomerular filtration rate (eGFR) was either unchanged or improved. For those with normal or elevated eGFR, their kidney function was slightly decreased. For those without diabetes, greater weight loss was associated with improved eGFR. Future studies should prospectively measure low carbohydrate dietary adherence and physical activity and directly measure changes in GFR and albuminuria for participants with CKD before and during that diet.

The degree of engagement of overweight/obese adult women in the recommended activities of the Chilean "Vida Sana" program is directly correlated with its effectiveness / El grado de participación de las mujeres adultas con sobrepeso/obesidad en las actividades recomendadas por el programa chileno "Vida Sana" se correlaciona directamente con su efectividad

Introduction: the Chilean Ministry of Health implements the Vida Sana (VS) program with the objective of reducing risk factors for chronic diseases in overweight/obese (OW/OB) individuals, aged 2-64. Objective: to determine the effectiveness of VS in OW/OB women (20-44 yrs) in terms of their engagement in the recommended activities. These consist of participating in a minimum number each of three core activities (psychologist consultations, lifestyle workshops, and physical activity sessions) during 6 months, to obtain a 5 % weight loss and improved physical fitness (PF). Methods: a retrospective study involving secondary analyses of the 2017 VS database (n = 5,179 OW/OB women). We determined effectiveness by: a) comparing changes in weight and PF in participants who achieved one or both outcomes, using t-tests and tests of proportions, and b) assessing the probability of achieving the program's goal, according to participation in 1, 2, or 3 core activities, individually and jointly, using the OR (95 % CI) and trend analysis. Results: around 32 %, 88 %, and 29 % of women achieved 5 % weight loss, improved PF, and both, respectively. The high percentage of women who improved PF was due to a permissive criterion. Although 20 % of women attained the program's goal with 0 engagement, among participants, the ORs (95 % CI) for achieving the program's goal when engaging in 1, 2, or 3 core activities were 1.55 (CI 1.2-2.03), 2.34 (1.76-3.11), and 3.5 (2.21-5.53), respectively. Conclusion: effectiveness parallels degree of engagement in the recommended activities of VS. A characterization of a program's participation rate is crucial for improving its effectiveness. (AU)

Introducción: el objetivo del programa chileno Vida Sana (VS) es reducir los factores de riesgo de enfermedades crónicas en personas de 2-64 años con sobrepeso/obesidad (SP/OB). Objetivo: determinar la efectividad del programa VS en mujeres SP/OB (20-44 años) a través de su participación en cada una de las actividades recomendadas (consultas con psicólogo, talleres y actividad física) durante 6 meses, para lograr perder un 5 % de peso y mejorar la condición física (CF). Métodos: estudio retrospectivo con análisis secundario de la base de datos VS de 2017 (n = 5179 mujeres SP/OB). Se determinó la efectividad: a) comparando los cambios en el peso y la CF de las participantes que lograron uno o ambos resultados, usando el test de la "t" y el de proporciones; b) evaluando la probabilidad de lograr el objetivo de acuerdo con la participación en 1, 2 o 3 actividades, de manera individual y conjunta, calculando los OR (IC 95 %) y el análisis de tendencias. Resultados: el 32 %, 88 % y 29 % de las mujeres perdieron un 5 % de peso, mejoraron la CF o consiguieron ambas cosas, respectivamente. El alto porcentaje que mejoró la CF se debió a un criterio permisivo. Aunque el 20 % de las mujeres lograron el objetivo del programa con una participación "0", los OR (IC del 95 %) de lograr el objetivo al participar en 1, 2 o 3 de las actividades fueron de 1,55 (IC: 1,2-2,03), 2,34 (IC: 1,76-3,11) y 3,5 (IC: 2,21-5,53), respectivamente. Conclusión: la efectividad del programa VS se asocia directamente con el grado de participación en las actividades. Caracterizar la participación de un programa es clave para mejorar su efectividad. (AU)

Management of Stage 1 Hypertension in Adults With a Low 10-Year Risk for Cardiovascular Disease: Filling a Guidance Gap: A Scientific Statement From the American Heart Association.

High blood pressure (BP) is the leading cause of worldwide cardiovascular disease morbidity and mortality. Patients and clinicians dealing with hypertension have benefited from the evidence of event-based randomized controlled clinical trials. One result from those trials has been the development of evidence-based guidelines. The commitment to using evidence from these event-based randomized trials has been a cornerstone in the development of guideline treatment recommendations. However, in some situations, evidence from event-based trials is not available to guideline writers or clinicians for assistance in treatment decision making. Such is the case for the management of many patients with stage 1 hypertension. The purpose of this scientific statement is to provide information complementary to the 2017 Hypertension Clinical Practice Guidelines for the patient with untreated stage 1 hypertension (systolic BP/diastolic BP, 130-139/80-89 mm Hg) with a 10-year risk for atherosclerotic cardiovascular disease <10% who fails to meet the systolic BP/diastolic goal (<130/80 mm Hg) after 6 months of guideline-recommended lifestyle therapy. This statement provides evidence from sources other than event-based randomized controlled clinical trials and offers therapy options for consideration by clinicians.

The degree of engagement of overweight/obese adult women in the recommended activities of the Chilean "Vida Sana" program is directly correlated with its effectiveness.

INTRODUCTION: Introduction: the Chilean Ministry of Health implements the Vida Sana (VS) program with the objective of reducing risk factors for chronic diseases in overweight/obese (OW/OB) individuals, aged 2-64. Objective: to determine the effectiveness of VS in OW/OB women (20-44 yrs) in terms of their engagement in the recommended activities. These consist of participating in a minimum number each of three core activities (psychologist consultations, lifestyle workshops, and physical activity sessions) during 6 months, to obtain a 5 % weight loss and improved physical fitness (PF). Methods: a retrospective study involving secondary analyses of the 2017 VS database (n = 5,179 OW/OB women). We determined effectiveness by: a) comparing changes in weight and PF in participants who achieved one or both outcomes, using t-tests and tests of proportions, and b) assessing the probability of achieving the program´s goal, according to participation in 1, 2, or 3 core activities, individually and jointly, using the OR (95 % CI) and trend analysis. Results: around 32 %, 88 %, and 29 % of women achieved 5 % weight loss, improved PF, and both, respectively. The high percentage of women who improved PF was due to a permissive criterion. Although 20 % of women attained the program´s goal with 0 engagement, among participants, the ORs (95 % CI) for achieving the program´s goal when engaging in 1, 2, or 3 core activities were 1.55 (CI 1.2-2.03), 2.34 (1.76-3.11), and 3.5 (2.21-5.53), respectively. Conclusion: effectiveness parallels degree of engagement in the recommended activities of VS. A characterization of a program´s participation rate is crucial for improving its effectiveness.

INTRODUCCIÓN: Introducción: el objetivo del programa chileno Vida Sana (VS) es reducir los factores de riesgo de enfermedades crónicas en personas de 2-64 años con sobrepeso/obesidad (SP/OB). Objetivo: determinar la efectividad del programa VS en mujeres SP/OB (20-44 años) a través de su participación en cada una de las actividades recomendadas (consultas con psicólogo, talleres y actividad física) durante 6 meses, para lograr perder un 5 % de peso y mejorar la condición física (CF). Métodos: estudio retrospectivo con análisis secundario de la base de datos VS de 2017 (n = 5179 mujeres SP/OB). Se determinó la efectividad: a) comparando los cambios en el peso y la CF de las participantes que lograron uno o ambos resultados, usando el test de la "t" y el de proporciones; b) evaluando la probabilidad de lograr el objetivo de acuerdo con la participación en 1, 2 o 3 actividades, de manera individual y conjunta, calculando los OR (IC 95 %) y el análisis de tendencias. Resultados: el 32 %, 88 % y 29 % de las mujeres perdieron un 5 % de peso, mejoraron la CF o consiguieron ambas cosas, respectivamente. El alto porcentaje que mejoró la CF se debió a un criterio permisivo. Aunque el 20 % de las mujeres lograron el objetivo del programa con una participación "0", los OR (IC del 95 %) de lograr el objetivo al participar en 1, 2 o 3 de las actividades fueron de 1,55 (IC: 1,2-2,03), 2,34 (IC: 1,76-3,11) y 3,5 (IC: 2,21-5,53), respectivamente. Conclusión: la efectividad del programa VS se asocia directamente con el grado de participación en las actividades. Caracterizar la participación de un programa es clave para mejorar su efectividad.

Outpatient metformin use is associated with reduced severity of COVID-19 disease in adults with overweight or obesity.

Observational studies suggest outpatient metformin use is associated with reduced mortality from coronavirus disease-2019 (COVID-19). Metformin is known to decrease interleukin-6 and tumor-necrosis factor-α, which appear to contribute to morbidity in COVID-19. We sought to understand whether outpatient metformin use was associated with reduced odds of severe COVID-19 disease in a large US healthcare data set. Retrospective cohort analysis of electronic health record (EHR) data that was pooled across multiple EHR systems from 12 hospitals and 60 primary care clinics in the Midwest between March 4, 2020 and December 4, 2020. Inclusion criteria: data for body mass index (BMI) > 25 kg/m2 and a positive SARS-CoV-2 polymerase chain reaction test; age ≥ 30 and ≤85 years. Exclusion criteria: patient opt-out of research. Metformin is the exposure of interest, and death, admission, and intensive care unit admission are the outcomes of interest. Metformin was associated with a decrease in mortality from COVID-19, OR 0.32 (0.15, 0.66; p = .002), and in the propensity-matched cohorts, OR 0.38 (0.16, 0.91; p = .030). Metformin was associated with a nonsignificant decrease in hospital admission for COVID-19 in the overall cohort, OR 0.78 (0.58-1.04, p = .087). Among the subgroup with a hemoglobin HbA1c available (n = 1193), the adjusted odds of hospitalization (including adjustment for HbA1c) for metformin users was OR 0.75 (0.53-1.06, p = .105). Outpatient metformin use was associated with lower mortality and a trend towards decreased admission for COVID-19. Given metformin's low cost, established safety, and the mounting evidence of reduced severity of COVID-19 disease, metformin should be prospectively assessed for outpatient treatment of COVID-19.

Continuous Engagement in a Weight-Loss Program Promotes Sustained Significant Weight Loss.

BACKGROUND: Significant weight loss improves health but regain is common. OBJECTIVE: The objective of the study was to determine if 2,346 members of Take Off Pounds Sensibly-a national, low-cost, peer-led weight-loss program-achieved and maintained significant weight loss with 7 consecutive annual renewals. METHODS: This study was a retrospective cohort design. For each renewal, the cumulative change from baseline weight was calculated. Weight change was placed into 1 of 3 categories: significant weight loss, loss ≥ 5%; weight stable, loss of 0 to < 5%; or weight gain, any amount above baseline weight. RESULTS: The cohort included 2,346 individuals. Fifty-one percent (n=740) of participants were in the significant weight-loss category all 7 years; 256 (18%) were in the significant weight-loss category at year 1 but moved into at least 1 other category during years 2 through 6; 359 (25%) were in the weight stable category at year 1; and 98 (7%) were in the weight gain category at year 1. CONCLUSIONS: Over 60% of the population achieved significant weight loss by year 7. Since continuous, long-term engagement in a weight-loss program can lead to significant weight loss, even if significant weight loss is not initially achieved, participation should be encouraged.

Are low-carbohydrate diets safe in diabetic and nondiabetic chronic kidney disease?

Diabetes mellitus and obesity both contribute to chronic kidney disease (CKD) and diabetic kidney disease (DKD), and they can accelerate the loss of kidney function. Dietary intake can potentially have wide-reaching effects on the risk of CKD/DKD and their progression by reducing weight and blood pressure, improving glycemic control, reducing hyperfiltration, and modulating inflammation. Low-carbohydrate (LC) diets can reduce weight and improve glycemic control, but the relatively higher protein content also raises concern in CKD/DKD. Empiric evidence supporting the kidney-related benefits or risks of LC diets is needed to understand the balance of these potential harms and benefits for patients with DKD and is the subject of our review.