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1.
Contemp Clin Trials ; 109: 106539, 2021 Aug 13.
Artigo em Inglês | MEDLINE | ID: mdl-34400362

RESUMO

INTRODUCTION: Over 100 million adults in the United States have hypertension. The DASH (Dietary Approaches to Stop Hypertension) eating pattern is an evidence-based first-line treatment option for hypertension; however, adherence to the DASH eating pattern at a population level remains low. To address this gap, we will implement Nourish, a randomized controlled efficacy trial that will leverage a commercially-available smartphone application and evidence-based behavior change principles to improve adherence to the DASH eating pattern among adults with hypertension. METHODS: The Nourish trial is a two-arm, 12-month randomized control trial that will enroll adults (N = 300) with hypertension, defined as a systolic blood pressure of 120-159 mmHg; a diastolic blood pressure of 80-99 mmHg; and/or adults on blood pressure-lowering medication. Nourish will test the efficacy of a digital health intervention, as compared to the attention control arm, on DASH eating pattern adherence and blood pressure. Intervention components will include skills training, self-monitoring, personalized feedback, and responsive coaching. The primary outcome of the trial is 6-month changes in adherence to the DASH eating pattern, as measured by 24-h dietary recalls. DISCUSSION: Millions of Americans remain in need of effective behavioral interventions to manage and improve their hypertension and its adverse consequences. The ubiquity of smartphones offers a promising approach to disseminate the DASH eating pattern. By leveraging these widely used smartphone applications, combined with evidence-based behavior change principles and the DASH eating plan, Nourish will demonstrate the effectiveness of a digital health intervention to improve DASH adherence, and ultimately, to reduce blood pressure. Trial Number: NCT03875.

2.
Nutrients ; 13(6)2021 May 22.
Artigo em Inglês | MEDLINE | ID: mdl-34067295

RESUMO

We aimed to identify plasma and urine metabolites altered by the Dietary Approaches to Stop Hypertension (DASH) diet in a post-hoc analysis of a pilot feeding trial. Twenty adult participants with un-medicated hypertension consumed a Control diet for one week followed by 2 weeks of random assignment to either Control or DASH diet. Non-missing fasting plasma (n = 56) and 24-h urine (n = 40) were used to profile metabolites using untargeted gas chromatography/mass spectrometry. Linear models were used to compare metabolite levels between the groups. In urine, 19 identifiable untargeted metabolites differed between groups at p < 0.05. These included a variety of phenolic acids and their microbial metabolites that were higher during the DASH diet, with many at false discovery rate (FDR) adjusted p < 0.2. In plasma, eight identifiable untargeted metabolites were different at p < 0.05, but only gamma-tocopherol was significantly lower on DASH at FDR adjusted p < 0.2. The results provide insights into the mechanisms of benefit of the DASH diet.


Assuntos
Abordagens Dietéticas para Conter a Hipertensão/métodos , Hipertensão/sangue , Hipertensão/urina , Metabolômica/métodos , Adulto , Pressão Sanguínea , Feminino , Cromatografia Gasosa-Espectrometria de Massas/métodos , Humanos , Hipertensão/dietoterapia , Modelos Lineares , Masculino , Metaboloma , Pessoa de Meia-Idade , Projetos Piloto , Resultado do Tratamento
3.
Acad Med ; 96(6): 836-841, 2021 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-34031305

RESUMO

The National Institutes of Health (NIH) has prioritized efforts to increase diversity in the biomedical research workforce. NIH-funded institutional career development awards may serve as one mechanism to facilitate these efforts. In 2013, the Duke University KL2 program, an internal career development program funded by the National Center for Advancing Translational Sciences, set a goal to increase the number of investigators from underrepresented racial and ethnic groups (UREGs) to ≥ 50% of KL2 awardees. From 2013 to 2019, 133 KL2 applications were received, 38% from UREG investigators. Of the 21 scholars selected, 10 (47.6%) were UREG investigators; all were Black/African American. This represents a threefold increase in the proportion of UREG applications and a sixfold increase in the proportion of UREG KL2 scholars compared with Duke's previous KL2 cycles (2003-2012), during which only 13% of applicants and 8.3% of funded scholars were UREGs. Of the 12 KL2 scholars (7 UREG) who completed the program, 5 have received NIH funding as principal investigators of an external K award or R01, and 4 of them are UREG investigators; this constitutes a post-KL2 NIH funding success rate of 57% (4/7) for UREG scholars. Achieving this programmatic priority was facilitated by institutional support, clear communication of goals to increase the proportion of UREG KL2 awardees, and intentional strategies to identify and support applicants. Strategies included targeted outreach to UREG investigators, partnerships with other institutional entities, structured assistance for investigators with preparing their applications, and a KL2 program structure addressing common barriers to success for UREG investigators, such as lack of consistent mentorship, protected research time, and peer support. The authors' experience suggests that KL2 and other internal career development programs may represent a scalable, national strategy to increase diversity in the biomedical research workforce.


Assuntos
Distinções e Prêmios , Diversidade Cultural , Grupos Étnicos , Pesquisadores/economia , Apoio à Pesquisa como Assunto , Pesquisa Médica Translacional/economia , Humanos , National Institutes of Health (U.S.) , North Carolina , Estados Unidos , Universidades
4.
PLoS One ; 16(5): e0240764, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34043632

RESUMO

Obesity is an epidemic internationally. While weight loss interventions are efficacious, they are compounded by heterogeneity with regards to clinically relevant metabolic responses. Thus, we sought to identify metabolic biomarkers that are associated with beneficial metabolic changes to weight loss and which distinguish individuals with obesity who would most benefit from a given type of intervention. Liquid chromatography mass spectrometry-based profiling was used to measure 765 metabolites in baseline plasma from three different weight loss studies: WLM (behavioral intervention, N = 443), STRRIDE-PD (exercise intervention, N = 163), and CBD (surgical cohort, N = 125). The primary outcome was percent change in insulin resistance (as measured by the Homeostatic Model Assessment of Insulin Resistance [%ΔHOMA-IR]) over the intervention. Overall, 92 individual metabolites were associated with %ΔHOMA-IR after adjustment for multiple comparisons. Concordantly, the most significant metabolites were triacylglycerols (TAGs; p = 2.3e-5) and diacylglycerols (DAGs; p = 1.6e-4), with higher baseline TAG and DAG levels associated with a greater improvement in insulin resistance with weight loss. In tests of heterogeneity, 50 metabolites changed differently between weight loss interventions; we found amino acids, peptides, and their analogues to be most significant (4.7e-3) in this category. Our results highlight novel metabolic pathways associated with heterogeneity in response to weight loss interventions, and related biomarkers which could be used in future studies of personalized approaches to weight loss interventions.


Assuntos
Biomarcadores/sangue , Metabolômica , Obesidade/sangue , Perda de Peso/fisiologia , Adulto , Índice de Massa Corporal , Diglicerídeos/sangue , Feminino , Humanos , Resistência à Insulina/fisiologia , Metabolismo dos Lipídeos/fisiologia , Lipídeos/sangue , Masculino , Espectrometria de Massas , Pessoa de Meia-Idade , Obesidade/metabolismo , Obesidade/cirurgia , Obesidade/terapia , Triglicerídeos/sangue
5.
J Am Coll Cardiol ; 77(21): 2635-2637, 2021 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-34045019
6.
Am J Kidney Dis ; 78(1): 38-47, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33810868

RESUMO

RATIONALE & OBJECTIVE: Patients with CKD are at elevated risk of metabolic acidosis due to impaired net acid excretion (NAE). Identifying early markers of acidosis may guide prevention in chronic kidney disease (CKD). This study compared NAE in participants with and without CKD, as well as the NAE, blood pressure (BP), and metabolomic response to bicarbonate supplementation. STUDY DESIGN: Randomized order, cross-over study with controlled feeding. SETTING & PARTICIPANTS: Participants consisted of 8 patients with CKD (estimated glomerular filtration rate 30-59mL/min/1.73m2 or 60-70mL/min/1.73m2 with albuminuria) and 6 patients without CKD. All participants had baseline serum bicarbonate concentrations between 20 and 28 mEq/L; they did not have diabetes mellitus and did not use alkali supplements at baseline. INTERVENTION: Participants were fed a fixed-acid-load diet with bicarbonate supplementation (7 days) and with sodium chloride control (7 days) in a randomized order, cross-over fashion. OUTCOMES: Urine NAE, 24-hour ambulatory BP, and 24-hour urine and plasma metabolomic profiles were measured after each period. RESULTS: During the control period, mean NAE was 28.3±10.2 mEq/d overall without differences across groups (P=0.5). Urine pH, ammonium, and citrate were significantly lower in CKD than in non-CKD (P<0.05 for each). Bicarbonate supplementation reduced NAE and urine ammonium in the CKD group, increased urine pH in both groups (but more in patients with CKD than in those without), and increased; urine citrate in the CKD group (P< 0.2 for interaction for each). Metabolomic analysis revealed several urine organic anions were increased with bicarbonate in CKD, including 3-indoleacetate, citrate/isocitrate, and glutarate. BP was not significantly changed. LIMITATIONS: Small sample size and short feeding duration. CONCLUSIONS: Compared to patients without CKD, those with CKD had lower acid excretion in the form of ammonium but also lower base excretion such as citrate and other organic anions, a potential compensation to preserve acid-base homeostasis. In CKD, acid excretion decreased further, but base excretion (eg, citrate) increased in response to alkali. Urine citrate should be evaluated as an early and responsive marker of impaired acid-base homeostasis. FUNDING: National Institute of Diabetes and Digestive and Kidney Diseases and the Duke O'Brien Center for Kidney Research. TRIAL REGISTRATION: Registered at ClinicalTrials.gov with study number NCT02427594.


Assuntos
Equilíbrio Ácido-Base , Bicarbonatos/administração & dosagem , Pressão Sanguínea , Dieta , Insuficiência Renal Crônica/metabolismo , Insuficiência Renal Crônica/fisiopatologia , Idoso , Estudos Cross-Over , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência Renal Crônica/terapia
7.
Patient Educ Couns ; 104(8): 1993-2003, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33579569

RESUMO

OBJECTIVES: Examine the association of patient perceptions of care with hemoglobin A1c (HbA1c), medication adherence, and missed appointments in non-Hispanic Black (NHB) and White (NHW) patients with type 2 diabetes (T2DM). METHODS: We used linear and logistic regression models to analyze the association of the Interpersonal Processes of Care survey (IPC) with HbA1c, medication adherence, and missed appointments. We then examined how these associations differed by race. RESULTS: There was no overall association between IPC subdomains and HbA1c in our sample (N = 221). NHB patients perceiving their provider always explained results and medications had a HbA1c on average 0.59 (-1.13, -0.04; p = 0.04) points lower than those perceiving their provider sometimes explained results and medications. No effect was observed in NHWs. Never perceiving disrespect from office staff was associated with an average 0.67 (-1.1, -0.24; p = 0.002) point improvement in medication adherence for all patients. Never perceiving discrimination from providers was associated with a 0.44 (-0.63, -0.25; p < 0.0001) decrease in the probability of missing an appointment for NHB patients. CONCLUSIONS: These results demonstrate that particular aspects of communication in the patient-provider interaction may contribute to racial disparities in T2DM. PRACTICE IMPLICATIONS: Communication training for both providers and staff may reduce disparities in T2DM.


Assuntos
Diabetes Mellitus Tipo 2 , Relações Profissional-Paciente , Fatores Raciais , Grupo com Ancestrais do Continente Africano , Diabetes Mellitus Tipo 2/terapia , Grupo com Ancestrais do Continente Europeu , Hemoglobina A Glicada/análise , Humanos , Avaliação de Resultados em Cuidados de Saúde , Percepção
8.
JMIR Mhealth Uhealth ; 8(12): e17536, 2020 12 07.
Artigo em Inglês | MEDLINE | ID: mdl-33284116

RESUMO

BACKGROUND: Over 100 million individuals have high blood pressure, and more than half of them are women. The Dietary Approaches to Stop Hypertension (DASH) dietary pattern is a proven lifestyle approach to lower blood pressure, yet population-level adherence is poor. Innovative strategies that promote DASH are needed. OBJECTIVE: This paper aims to improve adherence to the DASH diet among women with hypertension or prehypertension. METHODS: We conducted a 3-month randomized controlled feasibility trial comparing app-based diet tracking (active comparator) to app-based diet tracking plus feedback on DASH adherence via text message (intervention). The intervention platform extracted nutrient data from the app, compared it to DASH recommendations, and sent tailored feedback text messages. Outcomes included the number of days participants tracked their diet, changes in their DASH adherence score, and blood pressure. RESULTS: The women (N=59) had a mean age of 49.9 (SD 11.9) years and were primarily non-Hispanic White (41/59, 69%) and college educated (49/59, 83%). The mean baseline DASH score was 2.3 (SD 1.3). At 3 months, the intervention and active comparator participants had similar mean days tracked per week (4.2, SD 2.1 days vs 4.6, SD 2.7 days; P=.54) and mean changes in their DASH score (0.8, 95% CI 0.2-1.5 vs 0.8, 95% CI 0.4-1.2; P=.75). Intervention participants had lower systolic (mean difference: -2.8 mmHg, 95% CI -1.8 to 7.4; P=.23) and diastolic (mean difference: -3.6 mmHg, 95% CI -0.2 to 7.3; P=.07) blood pressure compared with active comparator participants. Most intervention participants (23/29, 79%) said they would recommend the DASH Cloud intervention to a friend or family member. However, only 34% (10/59) indicated that the feedback text messages helped them reach their diet goals. CONCLUSIONS: A digital health intervention to improve DASH adherence is feasible and produces moderately high engagement among women with elevated blood pressure. The intervention did not enhance DASH adherence over diet tracking alone but resulted in greater reductions in blood pressure. Larger studies are needed to determine how digital health interventions can improve population-level adherence to DASH. TRIAL REGISTRATION: ClinicalTrials.gov NCT03215472; https://clinicaltrials.gov/ct2/show/study/NCT03215472.


Assuntos
Hipertensão , Envio de Mensagens de Texto , Pressão Sanguínea , Dieta , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
9.
Resuscitation ; 156: 42-50, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32860854

RESUMO

BACKGROUND: Cardiac arrest is the leading cause of death among patients receiving hemodialysis. Despite guidelines recommending CPR training and AED presence in dialysis clinics, rates of CPR and AED use by dialysis staff are suboptimal. Given that racial disparities exist in bystander CPR administration in non-healthcare settings, we examined the relationship between patient race/ethnicity and staff-initiated CPR and AED application within dialysis clinics. METHODS: We analyzed data prospectively collected in the Cardiac Arrest Registry to Enhance Survival across the U.S. from 2013 to 2017 and the Centers for Medicare & Medicaid Services dialysis facility database to identify outpatient dialysis clinic cardiac arrest events. Using multivariable logistic regression models, we examined relationships between patient race/ethnicity and dialysis staff-initiated CPR and AED application. RESULTS: We identified 1568 cardiac arrests occurring in 809 hemodialysis clinics. The racial/ethnic composition of patients was 31.3% white, 32.9% Black, 10.7% Hispanic/Latinx, 2.7% Asian, and 22.5% other/unknown. Overall, 88.0% of patients received CPR initiated by dialysis staff, but rates differed by race: 91% of white patients, 85% of black patients, and 77% of Asian patients (p = 0.005). After adjusting for differences in patient and clinic characteristics, black (OR = 0.41, 95% CI 0.25-0.68) and Asian patients (OR = 0.28, 95% CI 0.12-0.65) were significantly less likely than white patients to receive staff-initiated CPR. No significant difference between staff-initiated CPR rates among white, Hispanic/Latinx, and other/unknown patients was observed. An AED was applied by dialysis staff in 62% of patients. In adjusted models, there was no relationship between patient race/ethnicity and staff AED application. CONCLUSIONS: Black and Asian patients are significantly less likely than white patients to receive CPR from dialysis staff. Further understanding of practices in dialysis clinics and increased awareness of this disparity are necessary to improve resuscitation practices.


Assuntos
Reanimação Cardiopulmonar , Parada Cardíaca Extra-Hospitalar , Idoso , Humanos , Medicare , Parada Cardíaca Extra-Hospitalar/terapia , Pacientes Ambulatoriais , Diálise Renal , Estados Unidos/epidemiologia
10.
Metabolomics ; 16(7): 75, 2020 06 18.
Artigo em Inglês | MEDLINE | ID: mdl-32556595

RESUMO

INTRODUCTION: Low potassium intake can affect cardiovascular disease (CVD) risk and cardiometabolic risk factors. OBJECTIVE: We hypothesize that potassium chloride (KCl) supplementation can improve cardiovascular risk metabolomic profile. METHODS: In this secondary analysis of a pilot randomized clinical trial (RCT) of 26 participants with prediabetes randomized to KCl or placebo, we performed targeted mass-spectrometry-based metabolomic profiling on baseline and 12-week (end-of-study) plasma samples. Principal component analysis (PCA) was used to reduce the many correlated metabolites into fewer, independent factors that retain most of the information in the original data. RESULTS: Those taking KCl had significant reductions (corresponding to lower cardiovascular risk) in the branched-chain amino acids (BCAA) factor (P = 0.004) and in valine levels (P = 0.02); and non-significant reductions in short-chain acylcarnitines (SCA) factor (P = 0.11). CONCLUSIONS: KCl supplementation may improve circulating BCAA levels, which may reflect improvements in overall cardiometabolic risk profile. CLINICAL TRIALS REGISTRY: Clinicaltrials.gov identifier: NCT02236598; https://clinicaltrials.gov/ct2/show/NCT02236598.

11.
Clin J Am Soc Nephrol ; 15(2): 219-227, 2020 02 07.
Artigo em Inglês | MEDLINE | ID: mdl-31911423

RESUMO

BACKGROUND AND OBJECTIVES: Patients on maintenance dialysis with in-hospital cardiac arrest have been reported to have worse outcomes relative to those not on dialysis; however, it is unknown if poor outcomes are related to the quality of resuscitation. Using the Get With The Guidelines-Resuscitation (GWTG-R) registry, we examined processes of care and outcomes of in-hospital cardiac arrest for patients on maintenance dialysis compared with nondialysis patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We used GWTG-R data linked to Centers for Medicare and Medicaid data to identify patients with ESKD receiving maintenance dialysis from 2000 to 2012. We then case-matched adult patients on maintenance dialysis to nondialysis patients in a 1:3 ratio on the basis of age, sex, race, hospital, and year of arrest. Logistic regression models with generalized estimating equations were used to assess the association of in-hospital cardiac arrest and outcomes by dialysis status. RESULTS: After matching, there were a total of 31,144 GWTG-R patients from 372 sites, of which 8498 (27%) were on maintenance dialysis. Patients on maintenance dialysis were less likely to have a shockable initial rhythm (20% versus 21%) and less likely to be within the intensive care unit at the time of arrest (46% versus 47%) compared with nondialysis patients; they also had lower composite scores for resuscitation quality (89% versus 90%) and were less likely to have defibrillation within 2 minutes (54% versus 58%). After adjustment, patients on maintenance dialysis had similar adjusted odds of survival to discharge (odds ratio [OR], 1.05; 95% confidence interval [95% CI], 0.97 to 1.13), better acute survival (OR, 1.33; 95% CI, 1.26 to 1.40), and were more likely to have favorable neurologic status (OR, 1.12; 95% CI, 1.04 to 1.22) compared with nondialysis patients. CONCLUSIONS: Although there appears to be opportunities to improve the quality of in-hospital cardiac arrest care for among those on maintenance dialysis, survival to discharge was similar for these patients compared with nondialysis patients.


Assuntos
Parada Cardíaca/terapia , Falência Renal Crônica/terapia , Avaliação de Processos e Resultados em Cuidados de Saúde , Diálise Renal/efeitos adversos , Ressuscitação , Idoso , Centers for Medicare and Medicaid Services, U.S. , Bases de Dados Factuais , Feminino , Parada Cardíaca/diagnóstico , Parada Cardíaca/mortalidade , Mortalidade Hospitalar , Humanos , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/mortalidade , Masculino , Alta do Paciente , Melhoria de Qualidade , Indicadores de Qualidade em Assistência à Saúde , Sistema de Registros , Diálise Renal/mortalidade , Ressuscitação/efeitos adversos , Ressuscitação/mortalidade , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
12.
Am J Hypertens ; 32(10): 975-982, 2019 09 24.
Artigo em Inglês | MEDLINE | ID: mdl-31187128

RESUMO

BACKGROUND: The Dietary Approaches to Stop Hypertension (DASH) diet lowers blood pressure (BP) more effectively in blacks compared to other US racial subgroups. Considering chronic kidney disease (CKD) raises BP through complex mechanisms, DASH may affect BP differently among blacks with and without CKD. We compared the association of DASH accordance to BP and prevalent hypertension among blacks with and without CKD. METHODS: Our study involved 3,135 black Americans enrolled in the Jackson Heart Study (2000-2004) with diet and office BP data. Using linear models adjusted for demographics, health behaviors, and clinical factors, we determined the association of a modified DASH score (excluding sodium intake, ranging from 0 to 8 with increasing DASH accordance) with BP. We performed tests for interaction between DASH score and CKD status. RESULTS: Among participants (mean age: 55 years; hypertension: 60%; CKD: 19%), the median DASH score was similar among participants with and without CKD (1.0 [interquartile range (IQR): 0.5-2] and 1.0 [IQR: 0.5-1.5]). CKD status modified the association of the DASH score with systolic BP (SBP) and diastolic BP (DBP; P interactions were 0.06 and <0.01). Among participants without CKD, SBP and DBP were not associated with the DASH score (-0.4 [95% confidence interval: -1.0, 0.1] mm Hg and -0.1 [-0.4, 0.2] mm Hg per one unit higher DASH score). Among participants with CKD, one unit higher DASH score was associated with lower SBP by 1.6 (0.5, 2.6) mm Hg and lower DBP by 0.9 (0.3, 1.5) mm Hg. CONCLUSIONS: Despite low DASH scores overall, better DASH accordance was associated with lower BP among Black Americans with CKD.


Assuntos
Afro-Americanos , Pressão Sanguínea , Abordagens Dietéticas para Conter a Hipertensão , Hipertensão/dietoterapia , Rim/fisiopatologia , Insuficiência Renal Crônica/etnologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Humanos , Hipertensão/diagnóstico , Hipertensão/etnologia , Hipertensão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Mississippi/epidemiologia , Prevalência , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/fisiopatologia , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
13.
Obesity (Silver Spring) ; 27(7): 1085-1098, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31135102

RESUMO

OBJECTIVE: The goal of the present study was to deconstruct the 17 treatment arms used in the Early Adult Reduction of weight through LifestYle (EARLY) weight management trials. METHODS: Intervention materials were coded to reflect behavioral domains and behavior change techniques (BCTs) within those domains planned for each treatment arm. The analytical hierarchy process was employed to determine an emphasis profile of domains in each intervention. RESULTS: The intervention arms used BCTs from all of the 16 domains, with an average of 29.3 BCTs per intervention arm. All 12 of the interventions included BCTs from the six domains of Goals and Planning, Feedback and Monitoring, Social Support, Shaping Knowledge, Natural Consequences, and Comparison of Outcomes; 11 of the 12 interventions shared 15 BCTs in common across those six domains. CONCLUSIONS: Weight management interventions are complex. The shared set of BCTs used in the EARLY trials may represent a core intervention that could be studied to determine the required emphases of BCTs and whether additional BCTs add to or detract from efficacy. Deconstructing interventions will aid in reproducibility and understanding of active ingredients.


Assuntos
Terapia Comportamental/métodos , Manutenção do Peso Corporal/fisiologia , Adolescente , Adulto , Feminino , Humanos , Estilo de Vida , Masculino , Adulto Jovem
14.
J Acad Nutr Diet ; 119(4): 574-584, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30905430

RESUMO

BACKGROUND: Obesity treatment focuses primarily on reducing overall caloric intake with limited focus on improving diet quality. The Dietary Approaches to Stop Hypertension (DASH) dietary pattern is effective in managing hypertension and other chronic conditions, yet it is not clear whether behavioral weight control interventions improve DASH adherence. We conducted a post hoc analysis of a behavioral weight loss intervention that did not emphasize diet quality and examined whether the intervention impacted DASH adherence in medically vulnerable community health center patients. METHODS: Participants (n=306) were enrolled in Track, a randomized controlled weight loss intervention for patients with elevated cardiovascular risk. The trial compared usual care to an intervention with weekly self-monitoring, tailored feedback on diet and exercise goals, and dietitian and provider counseling in community health centers. Dietary intake was measured using the Block Food Frequency Questionnaires collected at baseline and 12 months. DASH adherence was determined using previously validated scoring indices that assessed adherence based on recommended nutrient or food group targets. Total scores for both indices ranged from 0 to 9, with higher scores indicating greater DASH adherence. RESULTS: The mean (and standard deviation [SD]) age of participants was 51.1 (SD=8.8) years and the mean body mass index was 35.9 (SD=3.9). Most were female (69%) and black (51%); 13% were Hispanic. Half (51%) had an annual income <$25,000 and 33% had both diabetes and hypertension. At baseline, the mean DASH nutrient score was 1.81 (SD=1.42) with 6% achieving at least a score of 4.5. Similar scores were seen for the DASH foods index. The intervention group saw significantly greater, albeit small, improvements in mean DASH nutrient score (intervention: 1.28 [SD=1.5] vs control: 0.20 [SD=1.3]; P<0.001), and there was no difference in DASH food score between study arms. There were no significant predictors of change in DASH score and no association between DASH adherence and changes in blood pressure. Within the intervention arm, improvements in DASH nutrient score were associated with greater weight loss (r=-0.28; P=0.003). CONCLUSION: Although the intervention was not designed to increase adoption of DASH, the Track intervention produced significant weight loss and small improvements in DASH adherence. Despite these small improvements, overall adoption of DASH was poor among the medically vulnerable patients enrolled in Track. To further reduce chronic disease burden, weight loss interventions should include a focus on both caloric restriction and increasing diet quality.


Assuntos
Terapia Comportamental/métodos , Abordagens Dietéticas para Conter a Hipertensão/psicologia , Obesidade/terapia , Cooperação do Paciente/psicologia , Populações Vulneráveis/psicologia , Índice de Massa Corporal , Aconselhamento , Inquéritos sobre Dietas , Dieta Saudável , Abordagens Dietéticas para Conter a Hipertensão/métodos , Feminino , Comportamentos Relacionados com a Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade/psicologia , Atenção Primária à Saúde , Resultado do Tratamento , Perda de Peso , Programas de Redução de Peso/métodos
15.
J Am Soc Nephrol ; 2019 Feb 07.
Artigo em Inglês | MEDLINE | ID: mdl-30733235

RESUMO

BACKGROUND: Out-of-hospital cardiac arrest, the leading cause of death among patients on hemodialysis, occurs frequently within outpatient dialysis centers. Practice guidelines recommend resuscitation training for all dialysis clinic staff and on-site defibrillator availability, but the extent of staff involvement in cardiopulmonary resuscitation (CPR) efforts and its association with outcomes is unknown. METHODS: We used data from the Cardiac Arrest Registry to Enhance Survival and the Centers for Medicare & Medicaid Services dialysis facility database to identify patients who had cardiac arrest within outpatient dialysis clinics between 2010 and 2016 in the southeastern United States. We compared outcomes of patients who received dialysis staff-initiated CPR with those who did not until the arrival of emergency medical services (EMS). RESULTS: Among 398 OHCA events in dialysis clinics, 66% of all patients presented with a nonshockable initial rhythm. Dialysis staff initiated CPR in 81.4% of events and applied defibrillators before EMS arrival in 52.3%. Staff were more likely to initiate CPR among men and witness cardiac arrests, and were more likely to provide CPR within larger dialysis clinics. Staff-initiated CPR was associated with a three-fold increase in the odds of hospital discharge and favorable neurologic status on discharge. There was no overall association between staff-initiated defibrillator use and outcomes, but there was a nonsignificant trend toward improved survival to hospital discharge in the subgroup with shockable initial cardiac arrest rhythms. CONCLUSIONS: Dialysis staff-initiated CPR was associated with a large increase in survival but was only performed in 81% of cardiac arrest events. Further investigations should focus on understanding the potential facilitators and barriers to CPR in the dialysis setting.

16.
Am J Prev Med ; 55(6): 777-786, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30361140

RESUMO

INTRODUCTION: Obesity treatment is less successful for socioeconomically disadvantaged populations, particularly when delivered in primary care. Digital health strategies can extend the reach of clinical obesity treatments to care settings serving patients at highest risk. METHODS: Track was an effectiveness RCT of a 12-month digital weight-loss intervention, embedded within a community health center system. Participants were 351 adult patients (aged 21-65 years) with obesity and hypertension, diabetes, and hyperlipidemia. Patients were randomized to usual care (n=175) or an intervention (n=176) comprising app-based self-monitoring of behavior change goals with tailored feedback, a smart scale, dietitian-delivered counseling calls, and clinician counseling informed by app-generated recommendations, delivered via electronic health record. The primary outcome was 12-month weight change. Randomization began on June 18, 2013, final assessments were completed on September 10, 2015. Data analysis was conducted in 2016 and 2017. The trial retained 92% of usual care and 96% of intervention participants at 12 months. RESULTS: The Track intervention produced larger weight losses relative to usual care at 6 months (net effect: -4.4 kg, 95% CI= -5.5, -3.3, p<0.001) and 12 months (net effect: -3.8 kg, 95% CI= -5.0, -2.5, p<0.001). Intervention participants were more likely to lose ≥5% of their baseline weight at 6 months (43% vs 6%, p<0.001) and 12 months (40% vs 17%, p<0.001). Intervention participants completing ≥80% of expected self-monitoring episodes (-3.5 kg); counseling calls (-3.0 kg); or self-weighing days (-4.4 kg) lost significantly more weight than less engaged intervention participants (all p<0.01). CONCLUSIONS: A digital obesity treatment, integrated with health system resources, can produce clinically meaningful weight-loss outcomes among socioeconomically disadvantaged primary care patients with elevated cardiovascular disease risk. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT01827800.


Assuntos
Aconselhamento , Aplicativos Móveis , Obesidade/terapia , Perda de Peso , Programas de Redução de Peso/métodos , Adulto , Idoso , Diabetes Mellitus , Registros Eletrônicos de Saúde , Feminino , Humanos , Hiperlipidemias , Hipertensão , Masculino , Pessoa de Meia-Idade , Atenção Primária à Saúde , Adulto Jovem
17.
J Natl Med Assoc ; 110(4): 305-313, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30126554

RESUMO

BACKGROUND: Disparities in health and healthcare are widely documented for underrepresented racial and ethnic populations across a spectrum of diseases and care settings. An evidence base for addressing racial and ethnic disparities in health and healthcare requires investigators trained to conduct health disparities research. OBJECTIVE: To increase knowledge, stimulate interest, teach skills to evaluate and conduct, and foster collaborations in health disparities research. DESIGN: We designed, implemented and evaluated a Health Disparities Research Curriculum (HDRC). Participants were early-stage investigators. INTERVENTION: HDRC included twelve monthly sessions during 2015-2016. Instructors were mostly HDR investigators. Sessions combined didactic presentations, discussions, small group activities, and participant presentations. MEASURES: Pre- and post-surveys to assess participants' perceptions of knowledge and skills. RESULTS: Of 21 enrollees, 13 were from under-represented groups and 14 were women. Four reported some prior training in HDR, and 12 reported currently conducting HDR. Among the 12 participants who completed both the pre and post HDRC survey, initially the most commonly cited barriers to pursuing HDR were lack of knowledge (N = 6) and funding (N = 7). In the post-survey, the number citing lack of knowledge decreased (N = 2) and the number listing lack of funding increased (N = 9). There were increases in the number of participants reporting increased knowledge of HDR methods (pre-post: 4 vs. 8) and competence to design (3 vs. 7) and implement (2 vs. 9) HDR research. CONCLUSIONS: The Duke HDRC augments efforts to reduce health disparities by providing training in HDR for young investigators. Our data indicate that the course was feasible, well-received, and increased perceived knowledge and competence. HDRC and similar courses may increase the quantity, quality and scope of HDR and thus move us closer to health equity.


Assuntos
Currículo , Docentes de Medicina/educação , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde , Projetos de Pesquisa , Pesquisadores/educação , Centros Médicos Acadêmicos , North Carolina
18.
Surg Obes Relat Dis ; 14(8): 1126-1132, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29805089

RESUMO

BACKGROUND: Gastric bypass surgery for weight reduction often corrects dysglycemia in diabetic patients, but a full understanding of the underlying biochemical pathways continues to be investigated. OBJECTIVES: To explore the effects of weight loss by surgical and dietary interventions on plasma metabolites using both targeted and discovery-oriented metabolomics platforms. SETTING: An academic medical center in the United States. METHODS: Improvement in homeostatic model assessment for insulin resistance (HOMA-IR), as an index of insulin resistance, was compared at 6 months in 11 patients that underwent Roux-en-Y gastric bypass against 11 patients that were matched for weight loss in the Weight Loss Maintenance (WLM) program. Metabolites in plasma were evaluated by nontargeted gas chromatography/mass spectrometry for the potential detection of >1100 biochemical markers. RESULTS: Among multiple metabolites detected, 2-hydroxybutyric acid (2-HBA) declined most significantly after 6 months in comparing patients that underwent Roux-en-Y gastric bypass with those in WLM (P < .001), corresponding with declines in HOMA-IR (P = .025). Baseline levels of 2-HBA for all patients were correlated with preintervention levels of HOMA-IR (R2 = .565, P < .001). Moreover, the changes in 2-HBA after 6 months were correlated with changes in HOMA-IR (R2 = .399, P = .0016). CONCLUSIONS: Correlation between insulin resistance and 2-HBA suggests the utility of the latter as an excellent biomarker for tracking glycemic improvement, and offers further insight into the pathways that control diabetes. This is the first report of a decline in 2-HBA in response to bariatric surgery.


Assuntos
Derivação Gástrica/estatística & dados numéricos , Hidroxibutiratos/sangue , Resistência à Insulina/fisiologia , Adulto , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
19.
J Clin Hypertens (Greenwich) ; 20(2): 308-314, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29384243

RESUMO

We evaluated whether low-grade albuminuria or black race modulates ambulatory blood pressure (BP) or nocturnal BP response to the DASH diet. Among 202 adults enrolled in the DASH multicenter trial who were fed the DASH or control diet for 8 weeks, reductions in 24-hour daytime and nighttime SBP and DBP were significantly larger for DASH compared to control. Median changes in nocturnal BP dipping were not significant. Compared to urine albumin excretion of <7 mg/d, ≥7 mg/d was associated with larger significant median reductions in 24-hour SBP (-7.3 vs -3.1 mm Hg), all measures of DBP (24-hour: -5.9 vs -1.8 mm Hg; daytime: -9.9 vs -4.0 mm Hg; nighttime -9.0 vs -2.0 mm Hg), and with increased nocturnal SBP dipping (2.3% vs -0.5%). Black race was associated with larger median reduction in 24-hour SBP only (-5.5 vs -2.4 mm Hg). This analysis suggests greater effect of DASH on ambulatory BP in the presence of low-grade albuminuria.


Assuntos
Albuminúria , Anti-Hipertensivos/uso terapêutico , Abordagens Dietéticas para Conter a Hipertensão , Hipertensão , Adulto , Afro-Americanos/estatística & dados numéricos , Albuminúria/diagnóstico , Albuminúria/dietoterapia , Albuminúria/etnologia , Albuminúria/etiologia , Pressão Sanguínea/fisiologia , Monitorização Ambulatorial da Pressão Arterial/métodos , Abordagens Dietéticas para Conter a Hipertensão/etnologia , Abordagens Dietéticas para Conter a Hipertensão/métodos , Feminino , Humanos , Hipertensão/diagnóstico , Hipertensão/dietoterapia , Hipertensão/etnologia , Hipertensão/fisiopatologia , Testes de Função Renal/métodos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Gravidade do Paciente , Estados Unidos
20.
Kidney Int Rep ; 2(6): 1122-1131, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-29270520

RESUMO

Introduction: Chronic kidney disease (CKD) patients have increased risks of sudden cardiac arrest and sudden cardiac death (SCA/SCD) that are not explained by traditional risk factors. We examined associations between serum potassium and SCA/SCD in a large cohort of patients with coronary artery disease (CAD) and moderate CKD. Methods: Among 22,009 patients who underwent cardiac catheterization at our institution between 1999 and 2011, 6181 patients had an estimated glomerular filtration rate of ≤60 ml/min per 1.73 m2 and were not receiving renal replacement therapy. The risk of SCA/SCD and all-cause mortality associated with potassium concentration was evaluated at the time of cardiac catheterization (baseline) and most proximate to SCA/SCD events. Covariate-adjusted Cox models were used to examine relationships between baseline potassium measurements and outcomes. A propensity score-matched, case-control design was used to assess risk associations of potassium measurements obtained proximate to SCA events. Results: In the baseline potassium analysis, compared with levels in the normal range, there was no significant risk association between hyperkalemia (>5 mEq/l) or hypokalemia (<3.5 mEq/l) and SCA/SCD or all-cause death after covariate adjustment. In the proximate potassium analysis, hyperkalemia occurred more frequently than hypokalemia (16.7% vs. 3%), and was associated with a doubling in SCA/SCD risk (adjusted odd ratio: 2.37; 95% confidence interval: 1.33-4.23) whereas there was no significant relationship between hypokalemia and outcome. Discussion: Among CKD patients with significant CAD, elevated serum potassium levels >5.0 mEq/l are common and are associated with an increased short-term risk of SCA/SCD. Early detection and treatment of hyperkalemia may reduce the high risk of SCD among CKD patients.

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