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Poor dietary quality is a leading contributor to mortality in the United States, and to most cardiovascular risk factors. By providing education on lifestyle changes and, specifically, dietary changes, hospitals have the opportunity to use the patient experience as a "teachable moment." The food options provided to inpatients and outpatients can be a paradigm for patients to follow upon discharge from the hospital. There are hospitals in the United States that are showcasing novel ways to increase awareness of optimal dietary patterns and can serve as a model for hospitals nationwide.

In recent years, a growing body of evidence has emerged on the benefits of plant-based diets for the prevention and treatment of lifestyle diseases. In parallel, data now exist regarding the treatment of chronic kidney disease and its most common complications with this dietary pattern. Improving the nutrient quality of foods consumed by patients by including a higher proportion of plant-based foods while reducing total and animal protein intake may reduce the need for or complement nephroprotective medications, improve kidney disease complications, and perhaps favorably affect disease progression and patient survival. In this In Practice article, we review the available evidence on plant-dominant fiber-rich diet as it relates to kidney disease prevention, chronic kidney disease incidence and progression, metabolic acidosis, hyperphosphatemia, hypertension, uremic toxins, need for kidney replacement therapy including dialysis, patient satisfaction and quality of life, and mortality. Further, concerns of hyperkalemia and protein inadequacy, which are often associated with plant-based diets, are also reviewed in the context of available evidence. It is likely that the risks for both issues may not have been as significant as previously thought, while the advantages are vast. In conclusion, the risk to benefit ratio of plant-based diets appears to be tilting in favor of their more prevalent use.

Hallberg et al. provide a limited literature review on the reversal of type 2 diabetes mellitus (T2DM) [...]

Patients with type 2 diabetes mellitus (T2DM) and a body mass index (BMI) >35 kg/m are currently eligible for bariatric surgery, according to the 1991 NIH Consensus Criteria for bariatric surgery. Up to 78% of patients with T2DM experience diabetes remission within 2 years after bariatric surgery. Evidence exists that changes in the gut hormonal milieu after gastric bypass can improve insulin resistance immediately after surgery and preceding substantial weight loss. In 2007, the American Society of Bariatric Surgery added “Metabolic Surgery” to its name. Patients with T2DM and BMI

Many insurance payors mandate that bariatric surgery candidates undergo a medically supervised weight management (MSWM) program as a prerequisite for surgery. However, there is little evidence to support this requirement. We evaluated in a randomized controlled trial the hypothesis that participation in a MSWM program does not predict outcomes after laparoscopic adjustable gastric banding (LAGB) in a publicly insured population. This pilot randomized trial was conducted in a large academic urban public hospital. Patients who met NIH consensus criteria for bariatric surgery and whose insurance did not require a mandatory 6-month MSWM program were randomized to a MSWM program with monthly visits over 6 months (individual or group) or usual care for 6 months and then followed for bariatric surgery outcomes postoperatively. Demographics, weight, and patient behavior scores, including patient adherence, eating behavior, patient activation, and physical activity, were collected at baseline and at 6 months (immediately preoperatively and postoperatively). A total of 55 patients were enrolled in the study with complete follow-up on 23 patients. Participants randomized to a MSWM program attended an average of 2 sessions preoperatively. The majority of participants were female and non-Caucasian, mean age was 46 years, average income was less than $20,000/year, and most had Medicaid as their primary insurer, consistent with the demographics of the hospital’s bariatric surgery program. Data analysis included both intention-to-treat and completers’ analyses. No significant differences in weight loss and most patient behaviors were found between the two groups postoperatively, suggesting that participation in a MSWM program did not improve weight loss outcomes for LAGB. Participation in a MSWM program did appear to have a positive effect on physical activity postoperatively. MSWM does not appear to confer additional benefit as compared to the standard preoperative bariatric surgery protocol in terms of weight loss and most behavioral outcomes after LAGB in our patient population.

Up to 78% of patients with type 2 diabetes mellitus (T2DM) may experience diabetes remission within two years after bariatric surgery.1 Currently, only patients with T2DM and body mass index (BMI) above 35 kg/m2 are eligible for bariatric surgery. This is based on the 1991 National Institutes of Health (NIH) Guidelines and has been endorsed by the Center for Medicare and Medicaid Services.2 Patients with T2DM and BMI < 35 are primarily offered intensive medical weight management (MWM), including pharmacotherapy and nonsurgical weight loss strategies. Millions of patients with T2DM have BMI < 35—yet metabolic surgery is not an option for them.3 There is emerging evidence supporting the use of bariatric surgery to treat diabetes in less obese (BMI < 35) patients. However, there are very few randomized trials. The Agency for Healthcare Research and Quality (AHRQ) recently identified this area as a research priority for comparative effectiveness research.4 The NIH is unlikely to change the bariatric surgery guidelines for patients with T2DM without additional evidence to support such a change.5 There is also an overall lack of treatment data in underrepresented minorities (especially Hispanics and non-Hispanic African-Americans) with T2DM, who are disproportionately affected by diabetes-related complications and mortality. Our municipal health care system serves a substantial number of these “hard-to-reach” minorities. The receptor for advanced glycation end-products (RAGE) binds multiple ligand families linked to hyperglycemia. Activation of RAGE plays a major role in the pathogenesis of diabetic vascular complications via activation of the nuclear factor κ β pathway.6 Recent data indicate that mice devoid of RAGE who are fed high fat diet are protected from diet-induced obesity and that the treatment of diabetic mice with a soluble form of RAGE (sRAGE) results in significantly reduced body weight gain vs. vehicle-treated animals.7 Interestingly, sRAGE already circulate in human plasma. sRAGE acts as a decoy to prevent an interaction between advanced glycation end-products and RAGE and subsequent RAGE ligand-mediated effects on obesity and diabetes complications.8 Therefore, levels of sRAGE may be innate biomarkers of vulnerability to obesity and diabetes and/or their severity.9 The purpose of this study was two-fold: 1) to conduct a pilot randomized trial to compare bariatric surgery to MWM in patients with T2DM and BMI 30–35 who otherwise met NIH criteria for surgery, and 2) to assess the role of sRAGE as a biomarker for predictor of success after surgery. Due to the fact that insurance companies typically cover bariatric surgery in patients with T2DM and BMI > 35, we partnered with our municipal healthcare system’s primary insurer, who agreed to cover the costs of the surgery as part of this research project.

Genitourinary tuberculosis (TB) is infrequently reported in the United States, but is a common form of extrapulmonary TB that often goes unnoticed due to its insidious and sometimes asymptomatic presentation. Prostate involvement and the development of tuberculous prostatic abscesses have been reported in the literature largely in association with human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS). We report a case of disseminated TB involving tuberculous prostatic abscesses in a patient without HIV/AIDS, presenting with sepsis and urinary symptoms. This patient had simultaneous prostatic, peritoneal, pulmonary, and likely renal TB, serving as a reminder to clinicians that multi-organ presentations of TB do occur in patients without overt immunosuppressive conditions. This case also highlights the importance of considering the diagnosis of genitourinary TB in patients with risk factors for TB presenting with vague, long-standing urinary symptoms.

Background Physicians frequently report negative attitudes about obesity which is thought to affect patient care. However, little is known about how attitudes toward treating obese patients are formed. We conducted a cross-sectional survey of physicians in order to better characterize their attitudes and explore the relationships among attitudes, perceived competency in obesity care, including report of weight loss in patients, and other key physician, training, and practice characteristics. Methods We surveyed all 399 physicians from internal medicine, pediatrics, and psychiatry specialties at one institution regarding obesity care attitudes, competency, including physician report of percent of their patients who lose weight. We performed a factor analysis on the attitude items and used hierarchical regression analysis to explore the degree to which competency, reported weight loss, physician, training and practice characteristics explained the variance in each attitude factor. Results The overall response rate was 63%. More than 40% of physicians had a negative reaction towards obese patients, 56% felt qualified to treat obesity, and 46% felt successful in this realm. The factor analysis revealed 4 factors–Physician Discomfort/Bias, Physician Success/Self Efficacy, Positive Outcome Expectancy, and Negative Outcome Expectancy. Competency and reported percent of patients who lose weight were most strongly associated with the Physician Success/Self Efficacy attitude factor. Greater skill in patient assessment was associated with less Physician Discomfort/Bias. Training characteristics were associated with outcome expectancies with newer physicians reporting more positive treatment expectancies. Pediatric faculty was more positive and psychiatry faculty less negative in their treatment expectancies than internal medicine faculty. Conclusion Physician attitudes towards obesity are associated with competency, specialty, and years since postgraduate training. Further study is necessary to determine the direction of influence and to explore the impact of these attitudes on patient care.