It is time to talk about people: a human-centered healthcare system

Examining vulnerabilities within our current healthcare system we propose borrowing two tools from the fields of engineering and design: a) Reason's system approach [1] and b) User-centered design [2,3]. Both approaches are human-centered in that they consider common patterns of human behavior when analyzing systems to identify problems and generate solutions. This paper examines these two human-centered approaches in the context of healthcare. We argue that maintaining a human-centered orientation in clinical care, research, training, and governance is critical to the evolution of an effective and sustainable healthcare system

Long-Term Intake of Animal Flesh, Fruits and Vegetables and the Incidence of Hypertension in Three Prospective Cohort Studies

Vegetarian and vegan diets are associated with a lower prevalence of hypertension when compared with animal-based diets. Small, short-term interventional studies showed that replacing an omnivorous diet with a vegetarian diet lowered blood pressure. The potential mechanisms by which plant-based food intake is linked to a reduced risk of hypertension are not well understood. However, proposed effects include systemic inflammation, endothelial dysfunction, and the activation of the renin-angiotensin system (RAS) among those eating animal-based foods. We propose the VEGIE-BP (VEGetarian Initiative on the Endpoint of Blood Pressure) study, a prospective longitudinal study examining the incidence of hypertension in three large-scale, ongoing prospective cohorts with decades of follow-up: the Nurses’ Health Study 1 (NHS1), the Nurses’ Health Study 2 (NHS2), and the Health Professionals Follow-up Study (HPFS). These cohorts have validated information about health outcomes, as well as longitudinal and repeated measures of diet using detailed food-frequency questionnaires. Biomarkers of inflammation and endothelial function have also been measured on many of these participants, and at several time points in some participants. These cohorts therefore represent a unique resource to analyze the longitudinal associations of vegetarian/vegan diets and specific foods with the incidence of hypertension as well as associations with inflammation and endothelial dysfunction. In addition, we will explore the possible mechanisms of vegetarian diets, using not only these pre-existing inflammatory and endothelial biomarkers from the three cohorts, but also by examining the associations of diet with gold-standard measurements of endothelial function and RAS activation in 225 individuals enrolled the Modifiable Effectors of Renin System Activation Treatment Evaluation (MODERATE) trial. VEGIE-BP is the first prospective, longitudinal study examining the relation of vegetarian/vegan diets and specific foods on the incidence of hypertension and its potential mechanisms. From a public health perspective, this study will advance the understanding of how vegetarian diets are related to blood pressure and will help patients to avoid hypertension, chronic kidney disease and cardiovascular disease

Plant-Based Dietary Patterns and Incidence of Type 2 Diabetes in US Men and Women: Results from Three Prospective Cohort Studies

Background: Plant-based diets have been recommended to reduce the risk of type 2 diabetes (T2D). However, not all plant foods are necessarily beneficial. We examined the association of an overall plant-based diet and hypothesized healthful and unhealthful versions of a plant-based diet with T2D incidence in three prospective cohort studies in the US. Methods and Findings: We included 69,949 women from the Nurses’ Health Study (1984–2012), 90,239 women from the Nurses’ Health Study 2 (1991–2011), and 40,539 men from the Health Professionals Follow-Up Study (1986–2010), free of chronic diseases at baseline. Dietary data were collected every 2–4 y using a semi-quantitative food frequency questionnaire. Using these data, we created an overall plant-based diet index (PDI), where plant foods received positive scores, while animal foods (animal fats, dairy, eggs, fish/seafood, poultry/red meat, miscellaneous animal-based foods) received reverse scores. We also created a healthful plant-based diet index (hPDI), where healthy plant foods (whole grains, fruits, vegetables, nuts, legumes, vegetable oils, tea/coffee) received positive scores, while less healthy plant foods (fruit juices, sweetened beverages, refined grains, potatoes, sweets/desserts) and animal foods received reverse scores. Lastly, we created an unhealthful plant-based diet index (uPDI) by assigning positive scores to less healthy plant foods and reverse scores to healthy plant foods and animal foods. We documented 16,162 incident T2D cases during 4,102,369 person-years of follow-up. In pooled multivariable-adjusted analysis, both PDI and hPDI were inversely associated with T2D (PDI: hazard ratio [HR] for extreme deciles 0.51, 95% CI 0.47–0.55, p trend < 0.001; hPDI: HR for extreme deciles 0.55, 95% CI 0.51–0.59, p trend < 0.001). The association of T2D with PDI was considerably attenuated when we additionally adjusted for body mass index (BMI) categories (HR 0.80, 95% CI 0.74–0.87, p trend < 0.001), while that with hPDI remained largely unchanged (HR 0.66, 95% CI 0.61–0.72, p trend < 0.001). uPDI was positively associated with T2D even after BMI adjustment (HR for extreme deciles 1.16, 95% CI 1.08–1.25, p trend < 0.001). Limitations of the study include self-reported diet assessment, with the possibility of measurement error, and the potential for residual or unmeasured confounding given the observational nature of the study design. Conclusions: Our study suggests that plant-based diets, especially when rich in high-quality plant foods, are associated with substantially lower risk of developing T2D. This supports current recommendations to shift to diets rich in healthy plant foods, with lower intake of less healthy plant and animal foods

Hazard ratios (95% CI) for type 2 diabetes according to deciles of the healthful plant-based diet index.

<p>Hazard ratios (95% CI) for type 2 diabetes according to deciles of the healthful plant-based diet index.</p

Age-standardized baseline characteristics by deciles of the healthful plant-based diet index.

<p>Age-standardized baseline characteristics by deciles of the healthful plant-based diet index.</p

Pooled hazard ratios (95% CI) for type 2 diabetes comparing extreme deciles of the plant-based diet indices, stratified by selected characteristics.

<p>Results were pooled across the three cohorts using a fixed-effects model. Adjusted for age (years), smoking status (never, past, current [1–14, 15–24, or ≥25 cigarettes/day]), physical activity (<3, 3–8.9, 9–17.9, 18–26.9, or ≥27 MET-h/wk), alcohol intake (0, 0.1–4.9, 5–9.9, 10–14.9, or ≥15 g/d), multivitamin use (yes or no), family history of diabetes (yes or no), margarine intake (quintiles), energy intake (quintiles), baseline hypertension (yes or no), baseline hypercholesterolemia (yes or no), and BMI (<21, 21–22.9, 23–24.9, 25–26.9, 27–29.9, 30–32.9, 33–34.9, 35–39.9, or ≥40 kg/m²). Also adjusted for menopause status and postmenopausal hormone use in NHS and NHS2 (premenopausal or, if postmenopausal, current, past, or never postmenopausal hormone use) and for oral contraceptive use in NHS2 (never, past, or current use). <i>p</i> trend < 0.001 for both indices across all strata. <i>p</i>-Value obtained by assigning the median value to each decile and entering this as a continuous variable in the model.</p

Hazard ratios (95% CIs) for type 2 diabetes according to deciles of the overall plant-based diet Index.

<p>Hazard ratios (95% CIs) for type 2 diabetes according to deciles of the overall plant-based diet Index.</p

Pooled hazard ratios (95% CIs) for type 2 diabetes according to deciles of the overall, healthful, and unhealthful plant-based diet indices.

<p>Results were pooled across the three cohorts using a fixed-effects model. Adjusted for age (years), smoking status (never, past, current [1–14, 15–24, or ≥25 cigarettes/day]), physical activity (<3, 3–8.9, 9–17.9, 18–26.9, or ≥27 MET-h/wk), alcohol intake (0, 0.1–4.9, 5–9.9, 10–14.9, or ≥15 g/d), multivitamin use (yes or no), family history of diabetes (yes or no), margarine intake (quintiles), energy intake (quintiles), baseline hypertension (yes or no), baseline hypercholesterolemia (yes or no), and BMI (<21, 21–22.9, 23–24.9, 25–26.9, 27–29.9, 30–32.9, 33–34.9, 35–39.9, or ≥40 kg/m²). Also adjusted for menopausal status and postmenopausal hormone use in NHS and NHS2 (premenopausal or, if postmenopausal, current, past, or never postmenopausal hormone use) and for oral contraceptive use in NHS2 (never, past, or current use). <i>p</i> trend < 0.001 for all indices. <i>p</i>-Value obtained by assigning the median value to each decile and entering this as a continuous variable in the model.</p