Low carbohydrate diets in family practice: what can we learn from an internet-based support group

The Active Low-Carber Forums (ALCF) is an on-line support group started in 2000 which currently has more than 86,000 members. Data collected from posts to the forum and from an on-line survey were used to determine the behavior and attitudes of people on low carbohydrate diets. Members were asked to complete a voluntary 27-item questionnaire over the internet. Our major findings are as follows: survey respondents, like the membership at large, were mostly women and mostly significantly overweight, a significant number intending to and, in many cases, succeeding at losing more than 100 lbs. The great majority of members of ALCF identify themselves as following the Atkins diet or some variation of it. Although individual posts on the forum and in the narrative part of our survey are critical of professional help, we found that more than half of respondents saw a physician before or during dieting and, of those who did, about half received support from the physician. Another 28 % found the physician initially neutral but supportive after positive results were produced. Using the same criteria as the National Weight Registry (without follow-up) – 30 lbs or more lost and maintained for more than one year – it was found that more than 1400 people had successfully used low carb methods. In terms of food consumed, the perception of more than half of respondents were that they ate less than before the diet and whereas high protein, high fat sources replaced carbohydrate to some extent, the major change indicated by survey-takers is a large increase in green vegetables and a large decrease in fruit intake. Government or health agencies were not sources of information for dieters in this group and a collection of narrative comments indicates a high level of satisfaction, indeed enthusiasm for low carbohydrate dieting. The results provide both a tabulation of the perceived behavior of a significant number of dieters using low carbohydrate strategies as well as a collection of narratives that provide a human perspective on what it is like to be on such a diet. An important conclusion for the family physician is that it becomes possible to identify a diet that is used by many people where the primary principle is replacement of starch and sugar-containing foods with non-starchy vegetables, with little addition of fat or protein. Used by many people who identify themselves as being on the Atkins diet, such a strategy provides the advantages of carbohydrate-restricted diets but is less iconoclastic than the popular perception and therefore more acceptable to traditional nutritionists. It is reasonable for family practitioners to turn this observation into a recommendation for patients for weight control and other health problems

A low-carbohydrate, ketogenic diet to treat type 2 diabetes

BACKGROUND: The low-carbohydrate, ketogenic diet (LCKD) may be effective for improving glycemia and reducing medications in patients with type 2 diabetes. METHODS: From an outpatient clinic, we recruited 28 overweight participants with type 2 diabetes for a 16-week single-arm pilot diet intervention trial. We provided LCKD counseling, with an initial goal of <20 g carbohydrate/day, while reducing diabetes medication dosages at diet initiation. Participants returned every other week for measurements, counseling, and further medication adjustment. The primary outcome was hemoglobin A(1c). RESULTS: Twenty-one of the 28 participants who were enrolled completed the study. Twenty participants were men; 13 were White, 8 were African-American. The mean [± SD] age was 56.0 ± 7.9 years and BMI was 42.2 ± 5.8 kg/m(2). Hemoglobin A(1c )decreased by 16% from 7.5 ± 1.4% to 6.3 ± 1.0% (p < 0.001) from baseline to week 16. Diabetes medications were discontinued in 7 participants, reduced in 10 participants, and unchanged in 4 participants. The mean body weight decreased by 6.6% from 131.4 ± 18.3 kg to 122.7 ± 18.9 kg (p < 0.001). In linear regression analyses, weight change at 16 weeks did not predict change in hemoglobin A(1c). Fasting serum triglyceride decreased 42% from 2.69 ± 2.87 mmol/L to 1.57 ± 1.38 mmol/L (p = 0.001) while other serum lipid measurements did not change significantly. CONCLUSION: The LCKD improved glycemic control in patients with type 2 diabetes such that diabetes medications were discontinued or reduced in most participants. Because the LCKD can be very effective at lowering blood glucose, patients on diabetes medication who use this diet should be under close medical supervision or capable of adjusting their medication

Implementation costs of a multi-component program to increase human papillomavirus (HPV) vaccination in a network of pediatric clinics

Introduction: HPV vaccination is both a clinically and cost-effective way to prevent HPV-related cancers. Increased focus on preventing HPV infection and HPV-related cancers has motivated development of strategies to increase adolescent vaccination rates. This analysis estimates the average cost associated with implementing programs aimed at increasing HPV vaccination from the perspective of the clinic decision makers. As providers and healthcare organizations consider vaccination initiatives, it is important for them to understand the costs associated with implementing these programs. Methods: Healthcare provider assessment and feedback, reminders, and education; and parent education/reminder strategies were implemented in a large pediatric clinic network between October 2015 and February 2018 to improve HPV vaccination rates. A micro-costing method was used in 2018 to prospectively estimate program implementation costs with the clinic as the unit of analysis. A sensitivity analysis assessed the effects of variability in levels of participation. Results: Assessment and feedback reports and provider education were implemented among 51 clinics at average per clinic cost of $786 and$368 respectively. Electronic vaccination reminders were delivered to providers and parents at a per clinic cost of $824. The parent education implementation cost was$2,126 per clinic. Conclusion: The four complimentary HPV evidence-based strategies were delivered at a total cost of $157,534 or$4,749 per clinic, including staff training and participant recruitment, reaching 155,000 HPV vaccine eligible adolescents

Comparison of a reduced carbohydrate and reduced fat diet for LDL, HDL, and VLDL subclasses during 9-months of weight maintenance subsequent to weight loss

Objectives: This study compared LDL, HDL, and VLDL subclasses in overweight or obese adults consuming either a reduced carbohydrate (RC) or reduced fat (RF) weight maintenance diet for 9 months following significant weight loss. Methods: Thirty-five (21 RC; 14 RF) overweight or obese middle-aged adults completed a 1-year weight management clinic. Participants met weekly for the first six months and bi-weekly thereafter. Meetings included instruction for diet, physical activity, and behavior change related to weight management. Additionally, participants followed a liquid very low-energy diet of ~2092 kJ per day for the first three months of the study. Subsequently, participants followed a dietary plan for nine months that targeted a reduced percentage of carbohydrate (~20%) or fat (~30%) intake and an energy intake level calculated to maintain weight loss. Lipid subclasses using NMR spectroscopy were analyzed prior to weight loss and at multiple intervals during weight maintenance. Results: Body weight change was not significantly different within or between groups during weight maintenance (p > 0.05). The RC group showed significant increases in mean LDL size, large LDL, total HDL, large and small HDL, mean VLDL size, and large VLDL during weight maintenance while the RF group showed increases in total HDL, large and small HDL, total VLDL, and large, medium, and small VLDL (p 0.05). Conclusion: Some individual lipid subclasses improved in both dietary groups. Large and medium VLDL subclasses increased to a greater extent across weight maintenance in the RF group

Using Intervention Mapping to Develop an Efficacious Multicomponent Systems-Based Intervention to Increase Human Papillomavirus (HPV) Vaccination in a Large Urban Pediatric Clinic Network

Background: The CDC recommends HPV vaccine for all adolescents to prevent cervical, anal, oropharyngeal, vaginal, vulvar, and penile cancers, and genital warts. HPV vaccine rates currently fall short of national vaccination goals. Despite evidence-based strategies with demonstrated efficacy to increase HPV vaccination rates, adoption and implementation of these strategies within clinics is lacking. The Adolescent Vaccination Program (AVP) is a multicomponent systems-based intervention designed to implement five evidence-based strategies within primary care pediatric practices. The AVP has demonstrated efficacy in increasing HPV vaccine initiation and completion among adolescents 10-17 years of age. The purpose of this paper is to describe the application of Intervention Mapping (IM) toward the development, implementation, and formative evaluation of the clinic-based AVP prototype. Methods: Intervention Mapping (IM) guided the development of the Adolescent Vaccination Program (AVP). Deliverables comprised: a logic model of the problem (IM Step 1); matrices of behavior change objectives (IM Step 2); a program planning document comprising scope, sequence, theory-based methods, and practical strategies (IM Step 3); functional AVP component prototypes (IM Step 4); and plans for implementation (IM Step 5) and evaluation (IM Step 6). Results: The AVP consists of six evidence-based strategies implemented in a successful sequenced roll-out that (1) established immunization champions in each clinic, (2) disseminated provider assessment and feedback reports with data-informed vaccination goals, (3) provided continued medical and nursing education (with ethics credit) on HPV, HPV vaccination, message bundling, and responding to parent hesitancy, (4) electronic health record cues to providers on patient eligibility, and (5) patient reminders for HPV vaccine initiation and completion. Conclusions: IM provided a logical and systematic approach to developing and evaluating a multicomponent systems-based intervention to increase HPV vaccination rates among adolescents in pediatric clinics

Has carbohydrate-restriction been forgotten as a treatment for diabetes mellitus? A perspective on the ACCORD study design

Prior to the discovery of medical treatment for diabetes, carbohydrate-restriction was the predominant treatment recommendation to treat diabetes mellitus. In this commentary we argue that carbohydrate-restriction should be reincorporated into contemporary treatment studies for diabetes mellitus

The Lantern Vol. 6, No. 2, March 1938

• Among Our Contributors • Of Special Interest To You! • Jenny Lee • The Arguments Against Isolation • The Note • Visit of the Grandchildren • One Finds God • To The North Lies New Hampshire • The Two Camps in Washington • Substitutes • At Times It Seems So Very Strange • Episode on a Lake Shore • My Campus Song • Irony • A Chinese Mysteryhttps://digitalcommons.ursinus.edu/lantern/1017/thumbnail.jp

Increasing HPV Vaccination in a Network of Pediatric Clinics using a Multi-component Approach

Background: Despite continued public health efforts to increase human papillomavirus (HPV) vaccination among adolescents, initiation remains below the level needed to reach the Healthy People 2020 goal of 80% series completion by age 13. Methods: We developed, implemented, and evaluated a multi-component program that used evidence-based strategies to increase HPV vaccine initiation in a network of 51 pediatric clinics in Houston, Texas. Our target populations were the clinic network, healthcare providers, male and female patients ages 11-17, and their parents. The program, called the Adolescent Vaccination Program (AVP), was conducted from March 2016 through March 2019 and contained strategies to increase vaccination including: HPV immunization champions; provider assessment and feedback; provider continuing education; provider reminders; and patient reminders. We used a single group pre/post design with an external comparison – NIS-Teen. Our primary outcome was initiation of the HPV vaccine based on the electronic health record. We used interrupted time series analysis (ITSA) to measure change in initiation over time. We calculated monthly, quarterly, and annual rates of initiation for each physician, clinic, and the network. We examined patterns of initiation by patient age, sex, race/ethnicity, and type of insurance. Results: By the end of the project, the 51 clinics averaged 77.4% initiation. Rates increased annually from September 2015 through March 2019. ITSA analysis over 75 months showed an increase in vaccine initiation of 0.396% per month from the introduction of the program in March 2016. Average individual clinic improvement was 0.37% per month ranging from -0.04% to 0.68% through March 2019. Data for the 11-12 year olds, the target age group for initiating the vaccine, showed a greater percentage increase (54.2%) compared with the 13-17 year olds (29.6%). Hispanics and African Americans had the highest initiation rates in all years while non-Hispanic whites had the lowest. Families without insurance had the lowest rates while those with Medicaid/Medicare had the highest. Conclusions: We observed a secular trend upward in both the network and NIS-Teen data; however, the network showed a steeper increase. The AVP is a promising program of strategies to increase HPV vaccination in a clinic setting

Impact of cryopreservation on tetramer, cytokine flow cytometry, and ELISPOT

BACKGROUND: Cryopreservation of PBMC and/or overnight shipping of samples are required for many clinical trials, despite their potentially adverse effects upon immune monitoring assays such as MHC-peptide tetramer staining, cytokine flow cytometry (CFC), and ELISPOT. In this study, we compared the performance of these assays on leukapheresed PBMC shipped overnight in medium versus cryopreserved PBMC from matched donors. RESULTS: Using CMV pp65 peptide pool stimulation or pp65 HLA-A2 tetramer staining, there was significant correlation between shipped and cryopreserved samples for each assay (p ≤ 0.001). The differences in response magnitude between cryopreserved and shipped PBMC specimens were not significant for most antigens and assays. There was significant correlation between CFC and ELISPOT assay using pp65 peptide pool stimulation, in both shipped and cryopreserved samples (p ≤ 0.001). Strong correlation was observed between CFC (using HLA-A2-restricted pp65 peptide stimulation) and tetramer staining (p < 0.001). Roughly similar sensitivity and specificity were observed between the three assays and between shipped and cryopreserved samples for each assay. CONCLUSION: We conclude that all three assays show concordant results on shipped versus cryopreserved specimens, when using a peptide-based readout. The assays are also concordant with each other in pair wise comparisons using equivalent antigen systems