GLP-1 RAs and SGLT2-Is to Lower Glucose and Reduce the Risk of Cardiovascular and Diabetic Kidney Disease.

The landscape of diabetes management has changed, such that the goal of pharmacotherapy extends beyond glucose-lowering to prioritize risk reduction of cardiovascular disease and diabetic kidney disease. Two newer classes of medications, glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT2-Is), have become first line therapies for many patients with type 2 diabetes to reduce cardiovascular and renal complications of type 2 diabetes. This review article will describe the mechanism of action, evidence for cardiovascular and kidney outcomes, contraindications, adverse effects, and risk mitigation strategies for the GLP-1 RA and SGLT2-I drug classes. In addition, we will provide a practical approach for primary care clinicians to prescribe, adjust, and combine these medication classes, while considering patient preference, tolerability, comorbidities, cost, and availability.

A Primary Care-Based Weight Navigation Program.

Importance: Evidence-based weight management treatments (WMTs) are underused; strategies are needed to increase WMT use and patients' weight loss. Objective: To evaluate the association of a primary care-based weight navigation program (WNP) with WMT use and weight loss. Design, Setting, and Participants: This cohort study comprised a retrospective evaluation of a quality improvement program conducted from October 1, 2020, to September 30, 2021. Data analysis was performed from August 2, 2022, to March 7, 2024. Adults with obesity and 1 or more weight-related condition from intervention and control sites in a large academic health system in the Midwestern US were propensity matched on sociodemographic and clinical factors. Exposure: WNP, in which American Board of Obesity Medicine-certified primary care physicians offered weight-focused visits and guided patients' selection of preference-sensitive WMTs. Main Outcomes and Measures: Primary outcomes were feasibility measures, including rates of referral to and engagement in the WNP. Secondary outcomes were mean weight loss, percentage of patients achieving 5% or more and 10% or more weight loss, referral to WMTs, and number of antiobesity medication prescriptions at 12 months. Results: Of 264 patients, 181 (68.6%) were female and mean (SD) age was 49.5 (13.0) years; there were no significant differences in demographic characteristics between WNP patients (n = 132) and matched controls (n = 132). Of 1159 WNP-eligible patients, 219 (18.9%) were referred to the WNP and 132 (11.4%) completed a visit. In a difference-in-differences analysis, WNP patients lost 4.9 kg more than matched controls (95% CI, 2.11-7.76; P < .001), had 4.4% greater weight loss (95% CI, 2.2%-6.4%; P < .001), and were more likely to achieve 5% or more weight loss (odds ratio [OR], 2.90; 95% CI, 1.54-5.58); average marginal effects, 21.2%; 95% CI, 8.8%-33.6%) and 10% or more weight loss (OR, 7.19; 95% CI, 2.55-25.9; average marginal effects, 17.4%; 95% CI, 8.7%-26.2%). Patients in the WNP group were referred at higher rates to WMTs, including bariatric surgery (18.9% vs 9.1%; P = .02), a low-calorie meal replacement program (16.7% vs 3.8%; P < .001), and a Mediterranean-style diet and activity program (10.6% vs 1.5%; P = .002). There were no between-group differences in antiobesity medication prescribing. Conclusions and Relevance: The findings of this cohort study suggest that WNP is feasible and associated with greater WMT use and weight loss than matched controls. The WNP warrants evaluation in a large-scale trial.

Supporting faculty development for obesity education: A National Survey of United States family medicine residency programme directors.

Obesity is the most common chronic condition in the United States (US), yet primary care physicians face barriers in providing obesity treatment. This study examines the prevalence of American Board of Obesity Medicine (ABOM) certified obesity specialists on the faculty of US Family Medicine residency training programmes, the preparedness of graduating resident physicians to treat obesity, and residency training programme director preferences for supporting faculty development to improve residency education in obesity management. This cross-sectional on-line survey of programme directors addressed the number of ABOM-certified faculty, perceived graduate preparedness to treat obesity, and priorities to improve faculty expertise and obesity curriculum. Of 672 eligible programme directors, 298 (44%) responded to our survey. Most programmes (76%) had no ABOM-certified faculty. The proportion of programme directors assessing their graduates as prepared to care for patients with obesity has significantly decreased in the last 5 years (2018: 74%, 2022: 58%, p = .016). Residents in programmes with ABOM-certified faculty member were more likely to be assessed as very prepared to provide medical care (18% vs. 7.8% p = .047). A majority (54%) of programme directors identified limited faculty training and expertise as the biggest faculty and resident-level barrier to quality obesity care. This study demonstrates an important trend towards increasing ABOM-certification among Family Medicine residency programme faculty and an urgent need to prioritise faculty development to improve faculty expertise and resident training to address the obesity epidemic.

Developing weight navigation program to support personalized and effective obesity management in primary care settings: protocol for a quality improvement program with an embedded single-arm pilot study.

BACKGROUND: Primary care providers (PCPs) are expected to help patients with obesity to lose weight through behavior change counseling and patient-centered use of available weight management resources. Yet, many PCPs face knowledge gaps and clinical time constraints that hinder their ability to successfully support patients' weight loss. Fortunately, a small and growing number of physicians are now certified in obesity medicine through the American Board of Obesity Medicine (ABOM) and can provide personalized and effective obesity treatment to individual patients. Little is known, however, about how to extend the expertise of ABOM-certified physicians to support PCPs and their many patients with obesity. AIM: To develop and pilot test an innovative care model - the Weight Navigation Program (WNP) - to integrate ABOM-certified physicians into primary care settings and to enhance the delivery of personalized, effective obesity care. METHODS: Quality improvement program with an embedded, 12-month, single-arm pilot study. Patients with obesity and ≥1 weight-related co-morbidity may be referred to the WNP by PCPs. All patients seen within the WNP during the first 12 months of clinical operations will be compared to a matched cohort of patients from another primary care site. We will recruit a subset of WNP patients (n = 30) to participate in a remote weight monitoring pilot program, which will include surveys at 0, 6, and 12 months, qualitative interviews at 0 and 6 months, and use of an electronic health record (EHR)-based text messaging program for remote weight monitoring. DISCUSSION: Obesity is a complex chronic condition that requires evidence-based, personalized, and longitudinal care. To deliver such care in general practice, the WNP leverages the expertise of ABOM-certified physicians, health system and community weight management resources, and EHR-based population health management tools. The WNP is an innovative model with the potential to be implemented, scaled, and sustained in diverse primary care settings.

"It's Better in a Group Anyway": Patient Experiences of Group and Individual Acupuncture.

OBJECTIVES: Chronic pain is prevalent, burdensome, and costly, and there are ethnic and racial disparities in treatment. Acupuncture is effective and safe, but access is limited. Group acupuncture can decrease cost and increase capacity by decreasing clinic space needs and increasing patient volume per acupuncturist; however, the effectiveness and patient acceptability of group and individual session acupuncture have never been directly compared. DESIGN: The Acupuncture Approaches to Decrease Disparities in Pain Treatment (AADDOPT-2) study is a randomized comparative effectiveness trial of acupuncture for chronic pain. Semistructured in-depth interviews were conducted with a subset of patients enrolled in the trial. SETTINGS/LOCATION: Outpatient clinics in an urban, low income area serving a primarily black and Hispanic population. SUBJECTS: Qualitative interviews were conducted with 46 patients; 23 in each arm of the AADDOPT-2 study. INTERVENTIONS: Patients were randomized to receive either individual acupuncture or acupuncture delivered in a small group. OUTCOME MEASURES: Transcripts of the interviews were analyzed using an inductive thematic framework to explore and compare the patient experience in group and individual settings. RESULTS: Patients in both study arms valued the pain relief, improved quality of life, and relaxation experienced during acupuncture. Privacy and mixed-sex groups were cited as a concern by a minority of patients; however, most of those randomized to the group setting noted that these concerns abated after initiating treatment. Differences between arms included the depth of the relationship with the acupuncturist and misgivings related to the treatment space. Group dynamics varied; some groups fostered a supportive, therapeutic interaction, while others were more reserved. CONCLUSIONS: Patients in both arms valued their acupuncture experience. Participants described both positive and negative aspects of the group setting.

Facilitators and Barriers to the Integration of Mind-Body Medicine into Primary Care.

PURPOSE: To improve understanding of the facilitators and barriers affecting the integration of mind-body medicine (MBM) into primary care and describe the experiences of mind-body primary care providers. METHODS: The authors conducted a qualitative analysis of semi-structured telephone interviews with mind-body primary care providers selected via a maximum variation sampling strategy. RESULTS: Four main themes emerged: (1) MBM is an approach to patient care as well as a set of modalities, (2) time and reimbursement pose significant challenges to MBM, (3) support for MBM in one's practice setting is a key facilitator, and (4) commitment to MBM comes from personal experience. "Insufficient time" was the most highly ranked barrier among survey respondents. Interviewees described innovative strategies to overcome barriers, including customized intake forms, MBM training for staff, MBM group visits, and discounted referrals for low-income patients. CONCLUSIONS: While increased MBM and self-care training for providers may facilitate the integration of MBM into primary care, systematic changes are needed to decrease time pressures on providers and incentivize patient wellness. Despite barriers, providers are using innovative strategies to provide mind-body primary care in diverse practice settings.

"I Felt Like It Was God's Hands Putting the Needles In": A Qualitative Analysis of the Experience of Acupuncture for Chronic Pain in a Low-Income, Ethnically Diverse, and Medically Underserved Patient Population.

OBJECTIVES: To examine the experience of patients from a low-income, ethnically diverse medically underserved population receiving acupuncture for chronic pain. DESIGN: Qualitative analysis using inductive thematic analysis of interviews with participants from an acupuncture trial. SETTINGS/LOCATION: Four community health centers in the Bronx, New York. PARTICIPANTS: Thirty-seven adults with chronic neck or back pain or osteoarthritis who participated in a previous acupuncture trial. INTERVENTIONS: Up to 14 weekly acupuncture treatments. OUTCOME MEASURES: Pain and quality of life were examined in the original trial; this study examines qualitative outcomes. RESULTS: The themes grouped naturally into three domains of the acupuncture experience: the decision-making process, the treatment experience, and the effect of acupuncture on health. Regarding decision-making, important factors were a willingness to try something new even if you do not necessarily "believe" in it or have specifically positive expectations; a sense that medications were not working for their pain, that they also caused significant adverse effects, and that natural strategies might be preferable; and a feeling of desperation. Cost and access were significant barriers to acupuncture treatment. Regarding the process of acupuncture, the open and personal communication with the acupuncturist was an important factor, as were the sense that the process of acupuncture related to a natural process of healing or correction within the body and that part of making acupuncture successful required being open to the power of the mind to generate a positive outcome. Regarding the effect of treatment, notable aspects were the deep sense of rest and relaxation participants reported during treatment as well as the benefit they experienced for conditions other than pain. CONCLUSIONS: The themes that emerged in this ethnically diverse, low-income population were very similar to those that have emerged over the past decade of qualitative research on the acupuncture experience in other patient populations.

Trinucleotide repeat deletion via a unique hairpin bypass by DNA polymerase ß and alternate flap cleavage by flap endonuclease 1.

Trinucleotide repeat (TNR) expansions and deletions are associated with human neurodegenerative diseases and prostate cancer. Recent studies have pointed to a linkage between oxidative DNA damage, base excision repair (BER) and TNR expansion, which is demonstrated by the observation that DNA polymerase ß (pol ß) gap-filling synthesis acts in concert with alternate flap cleavage by flap endonuclease 1 (FEN1) to mediate CAG repeat expansions. In this study, we provide the first evidence that the repair of a DNA base lesion can also contribute to CAG repeat deletions that were initiated by the formation of hairpins on both the template and the damaged strand of a continuous run of (CAG)(20) or (CAG)(25) repeats. Most important, we found that pol ß not only bypassed one part of the large template hairpin but also managed to pass through almost the entire length of small hairpin. The unique hairpin bypass of pol ß resulted in large and small deletions in coordination with FEN1 alternate flap cleavage. Our results provide new insight into the role of BER in modulating genome stability that is associated with human diseases.