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Lifestyle medicine interventions that emphasize healthy behavior changes are growing in popularity in U.S. health systems. Safety-net healthcare settings that serve low-income and uninsured populations most at risk for lifestyle-related disease are ideal venues for lifestyle medicine interventions. Patient-reported outcomes are important indicators of the efficacy of lifestyle medicine interventions. Past research on patient-reported outcomes of lifestyle medicine interventions has occurred outside of traditional healthcare care settings. In this study, we aimed to assess patient-reported outcomes on nutrition knowledge, barriers to adopting a plant-based diet, food and beverage consumption, lifestyle behaviors, self-rated health, and quality-of-life of participants in a pilot plant-based lifestyle medicine program in an urban safety-net healthcare system. We surveyed participants at three time points (baseline, 3 months, 6 months) to measure change over time. After 6 months of participation in the program, nutrition knowledge increased by 7.2 percentage points, participants reported an average of 2.4 fewer barriers to adopting a plant-based diet, the score on a modified healthful plant-based diet index increased by 5.3 points, physical activity increased by 0.7 days per week while hours of media consumption declined by 0.7 h per day, and the percentage of participants who reported that their quality of sleep was “good” or “very good” increased by 12.2 percentage points. Our findings demonstrate that a lifestyle medicine intervention in a safety-net healthcare setting can achieve significant improvements in patient-reported outcomes. Key lessons for other lifestyle medicine interventions include using a multidisciplinary team; addressing all pillars of lifestyle medicine; and the ability for patients to improve knowledge, barriers, skills, and behaviors with adequate support.

BackgroundLifestyle interventions that optimize nutrition, physical activity, sleep health, social connections, and stress management, and address substance use can reduce cardiometabolic risk. Despite substantial evidence that healthful plant-based diets are beneficial for long-term cardiometabolic health and longevity, uncertainty lies in how to implement plant-based lifestyle programs in traditional clinical settings, especially in safety-net contexts with finite resources.MethodsIn this mixed-methods implementation evaluation of the Plant-Based Lifestyle Medicine Program piloted in a large public healthcare system, we surveyed participants and conducted qualitative interviews and focus groups with stakeholders to assess program demand in the eligible population, and feasibility of implementation within the safety-net setting.FindingsProgram demand was high and exceeded capacity. Participants’ main motivations for joining the program included gaining more control over life, reducing medication, and losing weight. The program team, approach, and resources were successful facilitators. However, the program faced administrative and payor-related challenges within the safety-net setting, and participants reported barriers to access.ConclusionsStakeholders found the program to be valuable, despite challenges in program delivery and access. Findings provide guidance for replication. Future research should focus on randomized controlled trials to assess clinical outcomes as a result of program participation.

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.

Objective To determine whether participation in a lifestyle medicine intervention is associated with improved nutrition behaviors. Use of Theory or Research Past research has demonstrated the effectiveness of plant-based diets in improving health. Target Audience Adults in New York City (NYC) with type 2 diabetes, prediabetes, high blood pressure, high cholesterol, excess weight, and/or heart disease. Program Description The Plant-Based Lifestyle Medicine (PBLM) Program is a pilot program designed to help individuals reduce their cardiometabolic risk through lifestyle changes. Providers with expertise in plant-based nutrition (physicians, registered dietician, health coach) educate and support patients in adopting a whole-foods plant-based diet and other healthful lifestyle changes. Patients meet individually with each provider to set goals and monitor progress. Group visits supplement one-on-one visits, include education and skills building, and foster peer-to-peer support. Evaluation Methods All PBLM participants were invited to participate in the evaluation; 131 agreed to be contacted; 85% provided consent. Data came from surveys of participants at baseline, 3-months, and 6-months (83%, 85%, 80% response rates respectively). Surveys measured nutrition knowledge, dietary intake, self-rated health, barriers to adopting a plant-based diet, and motivation and confidence in adhering to a plant-based diet. Results Participants were on average 53 years old, mostly female, roughly two-thirds were Black or White, and the majority completed college or more. Participants demonstrated statistically significant short-term improvements and maintained longer-term improvements in all domains of interest including nutrition knowledge; barriers to adopting a plant-based diet; motivation and confidence in plant-based diet adherence; increased consumption of non-animal protein and fruits/vegetables; decreased consumption of animal protein, sweets, and oil; and self-rated health. Consumption of whole grains was the only food category to not show improvements longer-term. Conclusions PBLM shows promise in improving participants’ nutrition behaviors within a healthcare setting. Additional studies are needed to demonstrate the effectiveness of changing nutrition behaviors and achieving positive clinical outcomes through participation in a lifestyle medicine intervention. Funding NYC Health and Hospitals Corporation.

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

Background: Type 2 diabetes (T2D) has long been identified as an incurable chronic disease based on traditional means of treatment. Research now exists that suggests reversal is possible through other means that have only recently been embraced in the guidelines. This narrative review examines the evidence for T2D reversal using each of the three methods, including advantages and limitations for each. Methods: A literature search was performed, and a total of 99 original articles containing information pertaining to diabetes reversal or remission were included. Results: Evidence exists that T2D reversal is achievable using bariatric surgery, low-calorie diets (LCD), or carbohydrate restriction (LC). Bariatric surgery has been recommended for the treatment of T2D since 2016 by an international diabetes consensus group. Both the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) now recommend a LC eating pattern and support the short-term use of LCD for weight loss. However, only T2D treatment, not reversal, is discussed in their guidelines. Conclusion: Given the state of evidence for T2D reversal, healthcare providers need to be educated on reversal options so they can actively engage in counseling patients who may desire this approach to their disease.

We report the case of a 41-year-old male with severe obesity, hypertension, and an 8-year history of type 2 diabetes mellitus who achieved dramatic glycemic improvement following a 10-week low-fat, whole-food, plant based diet. Improvements in weight, blood pressure, and lipid values were noted as well.

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.

Physicians must effectively evaluate and treat obesity. To design a needs-driven curriculum intended to improve patient outcomes, physicians were surveyed about their self-perceived knowledge and skills.The objective of this study was to determine the expressed needs of residents and faculty regarding obesity care training across three specialties.The study used a survey given to faculty and residents in General Internal Medicine, Pediatrics, and Psychiatry.Survey questions were generated from comprehensive nutrition curriculum and clinical recommendations, administered online, and then organized around a validated behavioral health framework-the 5As (assess, advise, agree, assist, arrange). Analyses were conducted to evaluate differences in perceived knowledge and skills between specialties and across training levels.From an overall response rate of 65% (65 residents and 250 faculty members), nearly 20% reported inadequate competency in every item with 48% of respondents reporting an inability to adequately counsel patients about common treatment options. Internists reported the lowest competency in arranging referrals and follow-up. Psychiatrists reported the lowest competency in assessment skills.This survey demonstrated a critical need for training in specific areas of obesity care. The proposed curriculum targets these areas taking into consideration observed differences across specialties.

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.