Mindfulness in Undergraduate Medical Education: Where We Are Now and Where We Go Next

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Obesity : novel and unusual predisposing factors

To tackle the complexity of the global obesity epidemic, it is important to consider the many predisposing factors that underlie progressive and sustained weight gain. Some of the biological drivers for weight gain following initial weight loss include persistent changes in appetite hormones [including ghrelin and postprandial plasma peptide YY (PYY)], and ‘persistent metabolic adaptation’. However, many factors within our busy, stressful modern-day environment seem to conspire towards promotion of weight gain. These include the effects of sleep deprivation on appetite regulation, and the effects of modern-day technology on ‘attention competition’. These factors, combined with cultural and societal factors can result in a ‘mindless’ attitude regarding eating-related behaviour that is likely to predispose to weight gain. In addition to the external environment, our internal environment within the gut has also changed radically within the last few decades, resulting from changes in fibre intake, and increased ingestion of highly refined, sterilised and processed foods. Although contentious, these dietary changes have implications for our gut microbiota, and possible downstream effects on control of appetite and metabolism. In this brief review, we consider some of the novel predisposing factors for weight gain within our modern-day 21st century environments (both external and internal), and explore how legal terminology can help to conceptualise the numerous factors that contribute towards weight gain, and, ultimately the global obesity epidemic

Exploring appetitive, metabolic and ketotic effects and weight-loss potential of Dapagliflozin in patients with Type 2 Diabetes Mellitus and Obesity, with concomitant dietary intervention

Background: Type 2 Diabetes Mellitus (T2DM) is closely associated with obesity and increased metabolic risk. Dapagliflozin, the first-in-class of the Sodium Glucose-Like Co-Transporter 2 (SGLT2) inhibitor agents, licensed for use in patients with T2DM, has been demonstrated both on evidence from randomized controlled trials and real-world studies, to be associated with secondary weight-loss and improved cardiovascular outcomes. There have been relatively few studies exploring the metabolic effects of Dapagliflozin and how they relate to weight loss. Moreover, the long-term metabolic adaptations to SGLT2 inhibitors are unknown. Aims: Our primary objective was to execute detailed phenotyping (metabolic changes, glycosuric response, natriuretic response, changes to appetite, and body composition) in participants with T2DM and obesity, treated with Dapagliflozin therapy and concomitant dietary intervention. We also explored the ketotic potential of Dapagliflozin. Methodology: Participants underwent detailed metabolic studies, including indirect calorimetry (energy expenditure measurements), quantification of body fat, blood and urine samples analyses and appetite assessments in Metabolic Research Unit located at University Hospitals of Coventry and Warwickshire (UHCW), before, during and after 12-month therapy with Dapagliflozin. Results: Dapagliflozin therapy resulted in a significant weight loss at 12 months (8.4 kg, p<0.001) driven by a fat loss (8.9 kg, p<0.001), reduction in leptin and insulin levels and reduction in insulin resistance, increase in glucagon levels, glycosuria and urinary volume. There were no changes in appetite, basal metabolic rate, adiponectin levels, fasting glucose and natriuresis. The rise in ketone levels was significant numerically but not clinically, indicating that SGLT2 inhibitor therapy alone does not cause significant ketosis. Conclusion: Long term treatment with Dapagliflozin leads to significant metabolic changes in patients with T2DM and obesity which are sustained over 12 months and represent mechanisms that could reverse metabolic syndrome

Effect of an online mindfulness course for hospital doctors during COVID-19 pandemic on resilience and coping

Introduction: Physicians’ wellbeing is a priority to prevent increasing rates of poor mental health and burnout, exacerbated by caregiving during the COVID-19 pandemic. Structured mindfulness courses have been shown to be beneficial, but face-to-face delivery is not always feasible in the context of busy health services. Remotely delivered structured mindfulness courses could enable wider participation, particularly at time when social distancing to prevent infection transmission is necessary. Our objective was to test the feasibility of a remotely delivered structured mindfulness course for hospital doctors during the COVID-19 pandemic. Methods: This was a feasibility study run at one English hospital between January and March 2021, when COVID-19 admissions were at a high. Interested doctors participated in a 6-session remotely delivered mindfulness course. Sessions lasted 90 min and could be attended on-line or the recording watched at later time. Main outcome measures were data on interest, course attendance and engagement, together with validated psychological outcome measures at baseline and follow-up after course completion. Results: 20 doctors expressed interest to participate and 16 started the course. Of these, 12 completed at least 3 sessions (median = 4); difficulty attending resulted from conflicting clinical commitments and rosters. Twelve participants completed the follow-up survey. They rated the course highly and all perceived it to have been useful, with statistically significant ( P &lt; .01) improvements in wellbeing and mindfulness scores. They all stated that they would recommend this course to their colleagues and most (10/12) were interested in follow-up mindfulness sessions. Conclusion: Remotely delivered structured mindfulness training for hospital doctors was feasible, but there is a need to address the difficulties that affected attendance in order to optimize accessibility and completion of such programs

The low-carbohydrate diet : short-term metabolic efficacy versus longer-term

Background: Diets have been a central component of lifestyle modification for decades. The Low-Carbohydrate Diet (LCD), originally conceived as a treatment strategy for intractable epilepsy (due to its association with ketogenesis), became popular in the 1970s and since then has risen to prominence as a weight loss strategy. Objective: To explore the efficacy, limitations and potential safety concerns of the LCD. Data Sources: We performed a narrative review, based on relevant articles written in English from a Pubmed search, using the terms ‘low carbohydrate diet and metabolic health’. Results: Evidence supports the efficacy of the LCD in the short-term (up to 6-months) for reduction in fat mass and remission of Type 2 Diabetes Mellitus (T2D). However, the longer-term efficacy of the LCD is disappointing, with diminishment of weight loss potential and metabolic benefits of the LCD beyond 6-months of its adoption. Furthermore, practical limitations of the LCD include the associated restriction of food choices that restrict the acceptability of the LCD for the individual, particularly over the longer term. There are also safety concerns of the LCD that stem from nutritional imbalances (with a relative excess of dietary fat and protein intake with associated dyslipidaemia and increased risk of insulin resistance and T2D development) and ketotic effects. Finally, the LCD often results in a reduction in dietary fibre intake, with potentially serious adverse consequences for overall health and the gut microbiota. Conclusions: Although widely adopted, the LCD usually has short-lived metabolic benefits, with limited efficacy and practicality over the longer term. Dietary modification needs tailoring to the individual, with careful a priori assessments of food preferences to ensure acceptability and adherence over the longer term, with avoidance of dietary imbalances and optimization of dietary fibre intake (primarily from plant-based fruit and vegetables), and with a posteriori assessments of the highly individual responses to the LCD. Finally, we need to change our view of diets from simply an excipient for weight loss to an essential component of a healthy lifestyle. View Full-Tex

Low Carb Program health app within a hospital-based obesity setting : cluster randomised service evaluation

Background: Obesity underlies much chronic disease. Digitalization of obesity management provides an opportunity to innovate our traditional model of health care delivery within this setting, and to transform its scalability potentially to the population level. Objective: The objective was to assess the feasibility and effectiveness of the Low Carb Program app for weight loss, applied within our hospital-based (tier 3) obesity service. Due to the disrupting effects of the COVID-19 pandemic on our obesity service, we compared the clinical outcomes from the Low Carb Program app applied in the context of remote patient appointments over the telephone with the prepandemic traditional standard of care. Methods: We invited patients who attended our hospital-based obesity service to engage with the Low Carb Program smartphone app. We combined this approach with remote delivery (over the telephone) of obesity management from medical and psychology members of our obesity team during the COVID-19 pandemic. Outcome variables included changes in body weight and changes in HbA1c as a marker of glycemic control. We compared data from the Low Carb Program group with a retrospective control group (n=126) that had received traditional face-to-face obesity management from our team without concomitant use of the Low Carb Program app in the pre–COVID-19 era. T test comparisons were employed, with P<.05 considered significant. Results: The mean weight of participants (n=105) was 130.2 kg, with 59% (n=62) females and a mean age of 48.8 years. Most participants (90/105, 86%) completed the Low Carb Program app registration process and engaged with the Low Carb Program app program; at follow-up, most participants (88/105, 84%) had actively engaged with the Low Carb Program app within the prior 30 days. The majority of participants (58/105, 55%) self-reported outcomes within the app. Mean duration of clinical follow-up for recruited participants who received the app was 7.4 months. Paired data were available for 48 participants for body weight and 41 participants for HbA1c. Paired sample t test analysis revealed a statistically significant mean loss of body weight of 2.7 kg (P=.001) and improvement in HbA1c of 3.3 mmol/mol (P=.01). The mean weight of control group patients (n=126) was 137.1 kg, with 74% (93/126) females and a mean age of 44.4 years. The mean follow-up for this group was 6 months. Data comparisons between the app user group and the pre–COVID-19 retrospective control group revealed equivalence for loss of body weight and change in HbA1c between the two groups. Conclusions: We provide evidence to support the feasibility of implementing the Low Carb Program app combined with remote management; this is the first proof of concept for digitalized management within a hospital-based (tier 3) obesity service. We demonstrate the potential clinical efficacy of the approach in terms of improvements in body weight and glycemic control

Dietary Influences on the Microbiota–Gut–Brain Axis

Over unimaginable expanses of evolutionary time, our gut microbiota have co-evolved with us, creating a symbiotic relationship in which each is utterly dependent upon the other. Far from confined to the recesses of the alimentary tract, our gut microbiota engage in complex and bi-directional communication with their host, which have far-reaching implications for overall health, wellbeing and normal physiological functioning. Amongst such communication streams, the microbiota–gut–brain axis predominates. Numerous complex mechanisms involve direct effects of the microbiota, or indirect effects through the release and absorption of the metabolic by-products of the gut microbiota. Proposed mechanisms implicate mitochondrial function, the hypothalamus–pituitary–adrenal axis, and autonomic, neuro-humeral, entero-endocrine and immunomodulatory pathways. Furthermore, dietary composition influences the relative abundance of gut microbiota species. Recent human-based data reveal that dietary effects on the gut microbiota can occur rapidly, and that our gut microbiota reflect our diet at any given time, although much inter-individual variation pertains. Although most studies on the effects of dietary macronutrients on the gut microbiota report on associations with relative changes in the abundance of particular species of bacteria, in broad terms, our modern-day animal-based Westernized diets are relatively high in fats and proteins and impoverished in fibres. This creates a perfect storm within the gut in which dysbiosis promotes localized inflammation, enhanced gut wall permeability, increased production of lipopolysaccharides, chronic endotoxemia and a resultant low-grade systemic inflammatory milieu, a harbinger of metabolic dysfunction and many modern-day chronic illnesses. Research should further focus on the colony effects of the gut microbiota on health and wellbeing, and dysbiotic effects on pathogenic pathways. Finally, we should revise our view of the gut microbiota from that of a seething mass of microbes to one of organ-status, on which our health and wellbeing utterly depends. Future guidelines on lifestyle strategies for wellbeing should integrate advice on the optimal establishment and maintenance of a healthy gut microbiota through dietary and other means. Although we are what we eat, perhaps more importantly, we are what our gut microbiota thrive on and they thrive on what we eat

Systematic review and meta-analysis of the metabolic effects of modified-release hydrocortisone versus standard glucocorticoid replacement therapy in adults with adrenal insufficiency

Context Published studies exploring the metabolic effects of Modified‐Release Hydrocortisone (MR‐HC) replacement in patients with adrenal insufficiency (AI). Objective To compare metabolic effects of MR‐HC with Standard Glucocorticoid (SG) replacement in adults with AI. Randomised control trials (RCTs) were meta‐analysed; non‐RCT studies described narratively with critical appraisal. Data sources PubMed/Medline, EMBASE, CINAHL and CENTRAL were searched to identify relevant articles, published before Aug 2019. Study selection All study types that reported metabolic profile (including anthropometric, glucose and lipid‐related parameters), on patients switched from SG to MR‐HC replacement. Following independent screening from two reviewers, 390 studies were identified, of which 9 studies were included for review (RCT, n=2; non‐RCT, n=7). Data extraction Two independent reviewers assessed each paper for bias and data extraction. Results Meta‐analysis from RCTs (n=2), 104 patients were switched from SG to MR‐HC replacement. Combining treatment effects, at 3‐months post‐therapy switch there was significant reduction in body weight (‐0.82kg; 95% CI: ‐1.24kg to ‐0.40kg; p<0.001) and HbA1c (‐0.13%; 95% CI: ‐0.214% to ‐0.045%; p=0.003). In the sub‐group with Diabetes Mellitus (DM), reduction in HbA1C was more pronounced (‐0.52%; 95% CI: ‐0.82% to ‐0.23%; p<0.001). Non‐RCT studies showed improved anthropometric measures and glucose metabolism up to 48‐months following switch from SG to MR‐HC replacement. Conclusions In adults with AI, replacement with MR‐HC associates with significant improvements in anthropometric measurements and HbA1c compared with SG replacement, particularly those with DM

Sodium in the dermis colocates to glycosaminoglycan scaffold, with diminishment in type 2 diabetes mellitus

BACKGROUND. Dietary sodium intake mismatches urinary sodium excretion over prolonged periods. Our aims were to localize and quantify electrostatically bound sodium within human skin using triple-quantum–filtered (TQF) protocols for MRI and magnetic resonance spectroscopy (MRS) and to explore dermal sodium in type 2 diabetes mellitus (T2D). METHODS. We recruited adult participants with T2D (n = 9) and euglycemic participants with no history of diabetes mellitus (n = 8). All had undergone lower limb amputations or abdominal skin reduction surgery for clinical purposes. We used 20 μm in-plane resolution 1H MRI to visualize anatomical skin regions ex vivo from skin biopsies taken intraoperatively, 23Na TQF MRI/MRS to explore distribution and quantification of freely dissolved and bound sodium, and inductively coupled plasma mass spectrometry to quantify sodium in selected skin samples. RESULTS. Human dermis has a preponderance (>90%) of bound sodium that colocalizes with the glycosaminoglycan (GAG) scaffold. Bound and free sodium have similar anatomical locations. T2D associates with a severely reduced dermal bound sodium capacity. CONCLUSION. We provide the first evidence to our knowledge for high levels of bound sodium within human dermis, colocating to the GAG scaffold, consistent with a dermal “third space repository” for sodium. T2D associates with diminished dermal electrostatic binding capacity for sodium