New system promising as novel treatment for post-bariatric hypoglycemia

Gastric bypass vastly improves the health of the patients who elect to receive the surgery. Post-bariatric hypoglycemia, however, can be a severe complication experienced by 10 to 30 percent of patients.

Researchers at Joslin Diabetes Center and Harvard John A. Paulson School of Engineering and Applied Sciences have developed a closed-loop system that automatically provides patients with an appropriate, as-needed dose of liquid glucagon to treat this condition. The system, comprised of a continuous glucose monitor (CGM) and a glucagon pump that communicate via an algorithm-controlled application, would allow patients to go about their daily activities without the fear of dipping into dangerous low blood sugar levels. The success of the system was reported on Nov. 13 in The Journal of Clinical Endocrinology & Metabolism.

“Post-bariatric hypoglycemia is a profoundly life-altering condition for patients. Having unpredictable hypoglycemia that people can’t detect is really an unsafe situation,” says Mary Elizabeth Patti, M.D., Associate Professor of Medicine at Harvard Medical School, Investigator at Joslin, and senior author on the paper. “This system provides a way to help individuals keep their glucose in a safe range.”

Over two hundred thousand people in the United States have bariatric surgery each year. Some types of these surgeries not only shrink the size of the stomach, but also change the way food travels through the intestines. As a result, high levels of certain hormones are released from the intestine after eating, and these hormones increase insulin production. These changes, in part, account for the reduction in obesity-associated problems, including type 2 diabetes. But in some patients, the surgery can trigger the body to over-produce insulin, leading to sharp drops in blood glucose levels.

“Hypoglycemia can be very disabling,” says Dr. Patti. “Since it is not predictable, people can’t plan in advance for it. And if it happens repeatedly, people can become unaware that their glucose is low. And if the glucose is severely low, they may have alterations in brain function and may not be able to think clearly. With more severe hypoglycemia, they may have loss of consciousness and may require the assistance of someone else. It becomes quite a dangerous situation.”

Current treatments for post-bariatric hypoglycemia include strictly regulated meal plans, and medications to reduce insulin production after meals. Once a low blood glucose develops, patients have to consume sugar. If the patient has lost consciousness, a family member may have to administer an emergency dose of glucagon, a medication that increases glucose. These treatments, however, are frequently not sufficient on their own and may lead to unhealthy swings in blood sugar.

“This new automated glucagon delivery system is an important development because it helps protect these patients from developing undetected or difficult to treat low blood sugars,” says Christopher Mulla, MD, first author on the study. “Glucagon provides patients with a treatment that doesn’t involve eating, which they’re often afraid of doing, and it does not cause rebound high blood sugars, which can then trigger another low blood sugar.”

The system grew from a collaboration between clinical and computational scientists at Joslin Diabetes Center and Harvard John A. Paulson School of Engineering and Applied Sciences. Work on this system began about four years ago, when Dr. Patti realized that artificial pancreas algorithms which had been developed to treat diabetes by study co-senior author Dr. Eyal Dassau, Director, Biomedical Systems Engineering Research Group at the Harvard John A. Paulson School of Engineering and Applied Sciences and his team, could similarly be developed to detect, treat, and prevent severe hypoglycemia.

The team tested whether a glucagon pump and CGM could communicate to provide an adequate dose of glucagon to treat an impending low. During this first phase, glucagon doses were administered by the study physicians. In this newly published paper, the team closed the loop and allowed Dr. Dassau’s algorithm to sense impending low blood sugar levels and automatically deliver an appropriate glucagon dose under supervision by the medical team.

“The way that we look at it, it is very similar to how in your car, you have an airbag,” says Dr. Dassau. “You don’t use that airbag every time that you stop at a traffic light, but when there is a severe event and there’s a need to prevent catastrophe, the airbag will be deployed. We employing the same idea for the glucagon system: we detect, we analyze and then we deliver automatically a mini dose of glucagon.”

Twelve patients participated in the study, which took place at Joslin’s Clinical Research Center on two separate days. Upon arrival at Joslin, patients were hooked into a CGM and a pump that was filled either with glucagon or a placebo. The study was double-blind, meaning neither the study team nor the patients knew which medication was being delivered which day until the conclusion of the study . The team then induced hypoglycemia in each patient and allowed the algorithm to predict impending or detect current low blood sugar and deliver either glucagon or placebo. The results from each day were analyzed and compared.

“I was very pleased that the system was able to detect hypoglycemia consistently, that the patients were able to tolerate the small dose of glucagon that we used, and that it was effective,” says Dr. Patti. “We used about a third of the usual emergency rescue glucagon dose, and that was sufficient to raise the glucose without causing a high glucose level.”

Too high a dose of glucagon can lead to vomiting and other symptoms of hyperglycemia, which often occurs in patients given emergency-level doses for hypoglycemia. This new, closed-loop system significantly reduced the risk of over-treating. “That’s one of the benefits of automation and running a closed loop. You can start with a very low dose of glucagon as it’s needed, and add an additional small dose if indicated without overdosing,” says Dr. Dassau.

The team has already started to adapt the algorithm from a computer application to a cell phone in preparation for the next phase of a clinical trial, which will send the entire system home with study participants to test in a real-world setting.

“We believe that it will provide a particularly helpful therapeutic option,” says Dr. Patti. “Using the system to detect an upcoming severe low and treat it before it gets unsafe would be so important to improve safety and quality of life of patients with this type of hypoglycemia.”

---

Story Source:

Materials provided by Joslin Diabetes Center. Note: Content may be edited for style and length.

---

Journal Reference:

1. Christopher M Mulla, Stamatina Zavitsanou, Alejandro Jose Laguna Sanz, David Pober, Lauren Richardson, Pamela Walcott, Ipsa Arora, Brett Newswanger, Martin J Cummins, Steve J Prestrelski, Francis J Doyle, Eyal Dassau, Mary Elizabeth Patti. A Randomized, Placebo-Controlled Double-Blind Trial of a Closed-Loop Glucagon System for Post-Bariatric Hypoglycemia. The Journal of Clinical Endocrinology & Metabolism, 2019; DOI: 10.1210/clinem/dgz197

https://www.sciencedaily.com/releases/2020/01/200109130152.htm

Cancer: Giving entire course of radiation treatment in less than a second is feasible

Cancer patients may one day be able to get their entire course of radiation therapy in less than a second rather than coming in for treatment over the course of several weeks, and researchers in the Abramson Cancer Center of the University of Pennsylvania have taken the first steps toward making it a reality. In a new report published today in the International Journal of Radiation Oncology, Biology, and Physics, researchers detail how they used proton radiation to generate the dosage needed to theoretically give a cancer patient their entire course of radiotherapy in one rapid treatment. It’s known as FLASH radiotherapy, and it’s an experimental paradigm that could represent a sea change for the world of oncology in the future. In this study, researchers also found FLASH demonstrated the same effect on tumors as traditional photon radiation while sparing healthy tissue due to the shorter exposure time.

“This is the first time anyone has published findings that demonstrate the feasibility of using protons — rather than electrons — to generate FLASH doses, with an accelerator currently used for clinical treatments,” said the study’s co-senior author James M. Metz, MD, director of the Roberts Proton Therapy Center and chair of Radiation Oncology. The co-senior authors on the study are Constantinos Koumenis, PhD, the Richard H. Chamberlain Professor of Research Oncology, and Keith A. Cengel, MD, PhD, an associate professor of Radiation Oncology, both in Penn’s Perelman School of Medicine.

Metz noted that other research teams have generated similar doses using electrons, which do not penetrate deep enough into the body to be clinically useful as a cancer treatment for internal tumors. Other groups have tried the approach with conventional photons, but currently available treatment devices do not have the ability to generate the necessary dosage. This study shows, that with technical modifications, the currently available accelerators for protons can achieve FLASH doses with the biologic effects today.

The key for the Penn team was the ability to generate the dose with protons, and even in that setting, researchers had to specially develop the tools needed to effectively and accurately measure radiation doses, since the standard detectors were quickly saturated due to the high levels of radiation. The Roberts Proton Therapy Center includes a dedicated research room to run experiments like these, allowing investigators to use photon and proton radiation side-by-side just feet from the clinic. It’s one of the few facilities in the world with those unique features, and Metz said this infrastructure is what made Penn’s FLASH experiments possible.

“We’ve been able to develop specialized systems in the research room to generate FLASH doses, demonstrate that we can control the proton beam, and perform a large number of experiments to help us understand the implications of FLASH radiation that we simply could not have done with a more traditional research setup,” Metz said.

Researchers said they are already beginning to optimize how they would use this down the road for clinical trials, including taking the necessary steps to translate the ability from the research room to a clinical space, as well as designing a delivery system for FLASH in humans.

---

Story Source:

Materials provided by University of Pennsylvania School of Medicine. Note: Content may be edited for style and length.

https://www.sciencedaily.com/releases/2020/01/200109130225.htm

Gene network helps to turn white fat into beneficial calorie-burning fat

Our fat cells, technically referred to as adipocytes, play an essential role in regulating energy balance in our body. “Adipocytes are not merely an energy storage for times of deprivation, but they also release hormones into the blood, regulating our metabolism as well as feelings of hunger and satiety through the brain and other organs. Nevertheless, too much of a good thing causes harm.” explained Professor Klingenspor, Chair of Molecular Nutritional Science at the TUM Else Kröner-Fresenius Center.

White, beige or brown — the color of fat cells affects our health

There are different types of fat tissue in our body, which can be categorized according to color. White fat cells are primarily responsible for energy storage. Brown and beige fat cells can convert nutritional energy into heat. This process is referred to as non-shivering thermogenesis — a principle that small mammals and human newborns use to maintain a stable body temperature.

The occurrence and activity of brown and beige fat cells vary among individuals. There is some evidence suggesting that people with a high number of thermogenic fat cells possess a lower risk to develop obesity and associated metabolic disorders. Especially the growth of beige fat cells within white fat tissue may have particular health benefits.

Browning ability of white fat is genetically determined

“We want to understand how thermogenic fat cells develop; so how beige fat cells grow inside white fat tissue,” stated Klingenspor. By “browning” the white fat tissue, an energy-storing organ could be partially transformed into an energy-dissipating organ, thereby improving metabolic health.

The development of beige fat cells is controlled by a still largely unknown genetic program. Mouse strains with divergent genetic backgrounds largely differ in their ability to brown the white fat tissue. “By systematically comparing fat cells among these different strains of mice, we were able to discover which genes or regulators might explain the variation in beige cell differentiation — in other words, the growth of beige fat cells,” indicated Klingenspor.

New possibilities due to transcriptomics and network analyses

By sequencing all transcripts of a cell using Next Generation Sequencing technology, all gene activities across the entire genome can be registered in a snap-shot.

For the current study, the joint TUM/EPFL team performed a comparative analysis of the transcriptomics of fat cells from genetically divergent mouse strains. The study goes beyond other work in this field in that it not only identifies important individual factors but also relates them to each other in a molecular network.

With this approach, the team could provide a systematic overview over the network of cell-intrinsic regulatory mechanisms that represent the underlying principle for the development of beige fat cells, making them the first team of scientists to achieve this.

“Now we have gathered a unique insight into the genetic architecture driving the molecular mechanisms of beige fat cell development. What we managed to confirm in a cell culture is now to be examined ‘in vivo’ — so inside a living organism — as our next step,” said Klingenspor with respect to avenues for future research.

---

Story Source:

Materials provided by Technical University of Munich (TUM). Note: Content may be edited for style and length.

---

Journal Reference:

1. Yongguo Li, Petra C. Schwalie, Andrea Bast-Habersbrunner, Sabine Mocek, Julie Russeil, Tobias Fromme, Bart Deplancke, Martin Klingenspor. Systems-Genetics-Based Inference of a Core Regulatory Network Underlying White Fat Browning. Cell Reports, 2019; 29 (12): 4099 DOI: 10.1016/j.celrep.2019.11.053

https://www.sciencedaily.com/releases/2020/01/200109105541.htm

Cancer mortality continues decline, driven by progress against lung cancer

The cancer death rate declined by 29% from 1991 to 2017, including a 2.2% drop from 2016 to 2017, the largest single-year drop in cancer mortality ever reported. The news comes from Cancer Statistics, 2020, the latest edition of the American Cancer Society’s annual report on cancer rates and trends.

The steady 26-year decline in overall cancer mortality is driven by long-term drops in death rates for the four major cancers — lung, colorectal, breast, and prostate, although recent trends are mixed. The pace of mortality reductions for lung cancer — the leading cause of cancer death — accelerated in recent years (from 2% per year to 4% overall) spurring the record one-year drop in overall cancer mortality. In contrast, progress slowed for colorectal, breast, and prostate cancers. The article appears early online in CA: A Cancer Journal for Clinicians, and is accompanied by a consumer version, Cancer Facts & Figures 2020.

Overall cancer death rates dropped by an average of 1.5% per year during the most recent decade of data (2008-2017), continuing a trend that began in the early 1990s and resulting in the 29% drop in cancer mortality in that time. The drop translates to approximately 2.9 million fewer cancer deaths than would have occurred had mortality rates remained at their peak. Continuing declines in cancer mortality contrast with a stable trend for all other causes of death combined, reflecting a slowing decline for heart disease, stabilizing rates for cerebrovascular disease, and an increasing trend for accidents and Alzheimer disease.

Lung cancer death rates have dropped by 51% (since 1990) in men and by 26% (since 2002) in women, with the most rapid progress in recent years. For example, reductions in mortality accelerated from 3% per year during 2008-2013 to 5% per year during 2013-2017 in men and from 2% to almost 4% in women. However, lung cancer still accounts for almost one-quarter of all cancer deaths, more than breast, prostate, and colorectal cancers combined.

The most rapid declines in mortality occurred for melanoma of the skin, on the heels of breakthrough treatments approved in 2011 that pushed one-year survival for patients diagnosed with metastatic disease from 42% during 2008-2010 to 55% during 2013-2015. This progress is likewise reflected in the overall melanoma death rate, which dropped by 7% per year during 2013-2017 in people ages 20 to 64, compared to declines during 2006-2010 (prior to FDA approval of ipilimumab and vemurafenib) of 2%-3% per year in those ages 20 to 49 and 1% per year in those ages 50 to 64. Even more striking are the mortality declines of 5% to 6% in individuals 65 and older, among whom rates were previously increasing.

“The news this year is mixed,” said Rebecca Siegel, MPH, lead author of the report. “The exciting gains in reducing mortality for melanoma and lung cancer are tempered by slowing progress for colorectal, breast, and prostate cancers, which are amenable to early detection. It’s a reminder that increasing our investment in the equitable application of existing cancer control interventions, as well as basic and clinical research to further advance treatment, would undoubtedly accelerate progress against cancer.”

Highlights from the report:

• The death rate for breast cancer dropped by 40% from 1989 to 2017.
• The death rate for prostate cancer dropped by 52% from 1993 to 2017.
• The death rate for colorectal cancer dropped by 53% from 1980 to 2017 among males and by 57% from 1969 to 2017 among females.
• Decades-long rapid increases in liver cancer mortality appear to be abating in both men and women.
• Cervical cancer, which is almost completely preventable, caused ten premature deaths per week in women ages 20-39 in 2017.

Other highlights:

• In 2020, 1,806,590 new cancer cases and 606,520 cancer deaths are projected to occur in the United States.*
• Progress for hematopoietic and lymphoid malignancies (leukemias and lymphomas) has been especially rapid due to improvements in treatment protocols, including the development of targeted therapies. The 5-year relative survival rate for chronic myeloid leukemia increased from 22% in the mid-1970s to 70% for those diagnosed during 2009 through 2015, and most patients treated with tyrosine kinase inhibitors now experience nearly normal life expectancy.
• The overall cancer incidence rate in men declined rapidly from 2007 to 2014, but stabilized through 2016, reflecting slowing declines for colorectal cancer and stabilizing rates for prostate cancer.
• The overall cancer incidence rate in women has remained generally stable over the past few decades because lung cancer declines have been offset by a tapering decline for colorectal cancer and increasing or stable rates for other common cancers in women.
• The slight rise in breast cancer incidence rates (by approximately 0.3% per year) since 2004 has been attributed at least in part to continued declines in the fertility rate and increased obesity, factors that may also contribute to increasing incidence for uterine cancer (1.3% per year from 2007-2016).
• Lung cancer incidence continues to decline twice as fast in men as in women, reflecting historical differences in tobacco uptake and cessation.
• In contrast, colorectal cancer incidence patterns are generally similar in men and women, with the rapid declines noted during the 2000s in the wake of widespread colonoscopy uptake appearing to taper in more recent years.
• Incidence continues to increase for cancers of the kidney, pancreas, liver, and oral cavity and pharynx (among non-Hispanic whites) and melanoma of the skin. Liver cancer is increasing most rapidly, by 2% to 3% annually during 2007 through 2016, although the pace has slowed from previous years.
• The 5-year relative survival rate for all cancers combined diagnosed during 2009 through 2015 was 67% overall, 68% in whites, and 62% in blacks.
• Cancer survival has improved since the mid-1970s for all of the most common cancers except cervical and uterine cancers. Stagnant survival rates for these cancers largely reflect a lack of major treatment advances for patients with recurrent and metastatic disease.

“The accelerated drops in lung cancer mortality as well as in melanoma that we’re seeing are likely due at least in part to advances in cancer treatment over the past decade, such as immunotherapy,” said William G. Cance, M.D., chief medical and scientific officer for the American Cancer Society. “They are a profound reminder of how rapidly this area of research is expanding, and now leading to real hope for cancer patients.”

Note:

*Estimates should not be compared year-to year. They are based on computer models of cancer trends and population and may vary considerably. Cancer trends should be based on age-adjusted cancer incidence and death rates (expressed as the number of cancer deaths per 100,000 people).

---

Story Source:

Materials provided by American Cancer Society. Note: Content may be edited for style and length.

---

Journal Reference:

1. Rebecca L. Siegel, Kimberly D. Miller, Ahmedin Jemal. Cancer statistics, 2020. CA: A Cancer Journal for Clinicians, 2020; DOI: 10.3322/caac.21590

https://www.sciencedaily.com/releases/2020/01/200108074809.htm

Consider Vitamin D in Alzheimer’s Prevention and Management

I’m Richard Isaacson, director of the Alzheimer’s Prevention Clinic at Weill Cornell Medicine and NewYork-Presbyterian.

Over the years, evolving evidence has helped our understanding of whether vitamin D has any potential neuroprotective or therapeutic effect when it comes to Alzheimer’s disease. During that time, we’ve learned more and more about the relationship between vitamin D and other neurologic conditions, such as multiple sclerosis, and its potential protective effects and mechanisms. But from a practical clinical perspective, what is the real story with vitamin D and Alzheimer’s prevention and treatment?

When you look at epidemiologic data, it does appear that vitamin D potentially has a protective effect when it comes to Alzheimer’s disease. Does that mean that vitamin D should be utilized when trying to reduce a person’s risk for Alzheimer’s? Well, it depends. If a person’s vitamin D level is 25 (nmol/L), 20, or lower, then maybe it makes some practical sense that we should, at a minimum, try to target a vitamin D level above 30. However, an important 2014 study in the journal Neurology^[1] investigating the optimal target level for vitamin D suggests that aiming toward 50 nmol/L may have a better therapeutic effect when it comes to prevention and risk reduction for dementia.

What about when it comes to treatment? Should patients who are already diagnosed with Alzheimer’s disease be on vitamin D supplementation? Again, this may not be one-size-fits-all. It could be that we need to consider levels, or that different people with different genes need different therapies.

A recent study^[2] from China suggests that there actually may be a role for vitamin D supplementation in this area. Investigators randomized 210 people (105 in each arm) with Alzheimer’s disease to 800 IU/day of vitamin D or placebo for 12 months. They looked not only at the potential beneficial effects of vitamin D supplementation on cognitive function, but also at its impact on Alzheimer’s disease biomarkers like amyloid beta. Although the study was small and conducted at only one center, it was nonetheless positive in showing that vitamin D supplementation not only improved various measures of cognitive function in people already diagnosed with the earliest phases of Alzheimer’s, but it also had a positive impact on Alzheimer’s disease biomarkers. The question is, did the vitamin D actually have a disease-modifying or potentially direct beneficial effect on disease pathophysiology?

Although more studies are definitely needed, vitamin D is a relatively safe intervention. We need to realize that 800 IU is not a super-high dose. However, various doses and forms of vitamin D have been investigated in other studies, and we really don’t have all the answers just yet.

When it comes to risk reduction for Alzheimer’s disease, I also think there may be a genetic contribution, as shown in the emerging fields of pharmacogenomics and nutrigenomics. A study published several years ago in the European Journal of Clinical Nutrition^[3] helped us fine-tune our potential suggestions by showing that people with two APOE ɛ4 alleles may have had a preferential benefit from vitamin D supplementation.

In conclusion, I would say that vitamin D is generally safe and that it is potentially effective as well. When it comes to risk reduction, as well as for treatment of patients with early Alzheimer’s disease, vitamin D may very well be one of our new therapeutic paradigms.

Richard Isaacson is an associate professor in the Department of Neurology at Weill Cornell Medicine in New York City. In 2013 he founded the first Alzheimer’s disease prevention clinic in the United States and is a leading advocate for the idea that cognitive decline can be prevented or slowed through lifestyle interventions.

https://www.medscape.com/viewarticle/917452

Obesity Epidemic and Junk Food Consumption Go Hand in Hand

Mounting evidence shows that the obesity epidemic — and rise of related chronic conditions — corresponds with the increased intake of ultra-processed food, particularly in lower socioeconomic classes, but clinicians can play a role in turning the tide by using key strategies to help patients curb their consumption, according to a new review.

“The epidemic of obesity correlates directly with the pervasiveness of chronic diseases,” the US authors write.

“Rather than simple secondary treatment of diseases with medications alone, we must transition our efforts to food as medicine as well,” they add.

The review, published in Current Treatment Options in Gastroenterology, notes alarming data from the Centers for Disease Control and Prevention showing the prevalence of obesity in the United States in 2015-2016 to be more than a third of the population — 39.8%.

Of the multitude of issues in grappling with the epidemic is the question of food quality versus quantity, and whether “the food source of calories matter — or are all calories created equal?” write the authors, Janese Laster, MD, and Leigh A. Frame, PhD, of The George Washington School of Medicine & Health Sciences, in Washington, DC.

“It is essential to study the trends in types of food consumed to determine the major contributors to the obesity epidemic and chronic disease states,” they add.

“Food as Medicine”; Processed Food Intake Leads to Fiber Deficits

In looking at the changes in food consumption that have paralleled the rising obesity prevalence, one indisputable trend is the increase in the consumption of ultra-processed or “junk” foods, and evidence supports a link between the two.

In mice and in vitro trials, emulsifiers, found in highly processed foods, have been shown to alter microbiome compositions, elevate fasting blood glucose, cause hyperphagia, increase weight gain and adiposity, and induce hepatic steatosis.

And recent human trials have found ultra-processed foods contribute to decreased satiety, increased meal eating rates, worsening biochemical markers, and more weight gain.

Notable research includes a study of three cohorts of healthy volunteers who were prospectively followed from 1986 to 2006 and from 1991 to 2003.

With an average weight gain among all participants over 20 years of 16.8 pounds, the study showed weight gain was positively associated with increased consumption of processed foods such as potato chips, sugar-sweetened beverages, refined grains, and processed meats.

Meanwhile, there was an inverse association with weight gain and increased intake of minimally processed foods such as vegetables, grains, nuts, and yogurt.

Additional studies have shown differing trends according to socioeconomic class, with small incremental improvements in dietary quality in higher socioeconomic groups; however, even in those groups, increases in servings of processed foods have been observed, say the review authors.

Ultra-processed food consumption is also linked to deficits in dietary fiber, which may explain notably insufficient fiber intake rates in the US population overall, the authors note.

Although the recommended daily fiber intake is 14 g/1000 calories, or approximately 25 g for women and 38 g for men, data from the National Health and Nutrition Examination Survey (NHANES) showed the average daily fiber consumption in 2009-2010 was just 17 g/day, with substantially higher consumption among men than women.

Lower fiber consumption has also been reported among black adults and those with lower family income.

Fiber deficits have important implications, as high fiber diets are linked to health benefits including the prevention of precancerous lesions, cancer, cardiovascular disease, type 2 diabetes, and Crohn’s disease, as well as reductions in mortality, the authors note.

Lessons From the “Blue Zones” and Advice for Clinicians

Lessons from the so-called “Blue Zones” — five regions where populations consistently live over the age of 100 without chronic disease, such as indigenous South Americans and Mediterranean populations — provide insight. These populations, who have low meat intake, high fiber intake, and eat minimally processed foods, have far less chronic disease and obesity, and live longer disease-free, compared with the typical US population.

This offers insights into the dietary and lifestyle practices that appear most beneficial, say Laster and Frame.

In addition to showing better fitness, social interaction, and relatively lower stress, these populations have dietary commonalities of eating until 80% full, eating mostly plant-based proteins including beans (meat up to five times per month), and moderate daily drinking with friends, the authors write.

For the vast majority of individuals who reside outside of Blue Zones, the authors recommend key strategies for clinicians to help steer individuals towards the evidence-based improved dietary practices, underscoring the need to consider the key factors of socioeconomic status, potentially restricted access to fresh food, transportation, and work schedules.

When counseling patients on weight loss and improved nutrition, the authors recommend starting patients with a 2-week food journal of their typical diet.

“Then make small changes such as counseling on reducing, then eliminating, sodas and sugar-sweetened beverages and increasing daily water intake,” they suggest.

“Encourage decreasing the frequency of fast food consumption with the ultimate goal of avoidance,” they add.

Patients can then be encouraged to gradually change one meal per day for the subsequent month, substituting healthier options based on personal preferences.

Solutions such as baking rather than frying or substituting quinoa or cauliflower rice for white rice can be offered in addition to handouts, recipes, and brands of foods to purchase.

Regularly follow-up with patients, report progress on measures such as weight, and continue to reinforce and encourage them as they develop new tastes and habits, they advise.

“Reassure that over time these improved dietary choices become easier and unhealthy cravings lessen,” the authors recommend.

“But also remind them to allow some pleasurable treats as well and to never punish themselves or feel guilty. A special food upon occasion and in small amounts may be the key to success, as they will not feel deprived or that it is a forbidden fruit,” they conclude.

The authors have reported no relevant financial relationships.

Curr Treat Options Gastroenterol. 2019;17:577-586. Abstract

https://www.medscape.com/viewarticle/923632#vp_1

#CES20: Healthcare Picks Up Tips From Retailers About How to Connect

About 80% of people seek information online before they become our patients, said Nancy Howell Agee, president and chief executive officer of Carilion Clinic, a nonprofit integrated health system serving about a million patients in Virginia.

“That’s a consumer,” she told Medscape Medical News.

“I struggle with ‘consumer’ versus ‘patient’, as that implies a patronizing relationship,” she said. “But when we say they are consumers, we need to own those words and not shy away from them. The fact is, our patients are consumers who can — and need — to use information to engage in their own health.”

And lessons from the retail guidebook for engaging consumers are leading to a paradigm shift in patient engagement, said Agee, who took to the stage at the Digital Health Conference and Consumer Electronics Show 2020 in Las Vegas to explain how she is embracing retail digital “front door” strategies to engage patients and improve health outcomes.

The fact is, our patients are consumers who can – and need – to use information to engage in their own health.

For most health centers, adding a digital front door has been synonymous with offering patients the ability to schedule an appointment or fill out a form online. But that’s just the tip of the iceberg, said Agee. The Carilion Clinic is taking the concept and running with it “in more of a strategic direction.”

That “door” starts the whole journey of care. “Our overall philosophy is that engaging patients is about being transparent with information, and trying to do things in a way that is consumer friendly,” she explained.

That means making information available when somebody wants and needs it, not just when a provider offers it. And it means providing practical health-education content and payer information in a way that is accessible and easy to use.

“One of the things we don’t want is a series of apps so our consumers have to remember a whole slew of passwords,” she said.

When users log in to the Carilion Clinic portal, they can view lab results and billing information, request prescription renewals, schedule appointments, and communicate with their care team.

They can also access videos tailored to their diagnosis so that they better understand their condition, can make decisions about whether to undergo a procedure, prepare for surgery, and take actions to help them recover.

People who are going to have a knee replacement, for example, can watch videos to learn what exercises they should do to prepare for the procedure. And “they can watch them over and over again,” any time of the day or night, Agee said.

We know people are becoming accustomed to using devices. “Having information readily available on any device — just like Netflix on our phones and TVs — is what they expect,” she added.

The Carilion Clinic is focused on ensuring that the digital front door meets three criteria.

First, Agee explained, it has to be accessible, meaning it is “easy to use and agnostic to any device, anytime.” Second, it has to be instructive, so that “you’re actually giving patients something they can use from a trusted source.” And third, it has to be motivating, and give users “something to do with that information, whether it be preparing for a procedure or sharing with family and friends.”

Netflix for Healthcare

Mytonomy, the video streaming platform and content provider that manages the video component of the Carilion Clinic portal, integrates streaming technology with personalized options related to diagnoses and electronic medical records.

The platform is “Netflix for healthcare,” said Anjali Kataria, cofounder and chief executive officer of Mytonomy, who served as Senior Technology Advisor and Entrepreneur in Residence in the Obama administration,

It fills a void by giving users a controlled, curated environment in which to gather health information, she explained.

Consumers are accustomed to online learning. “We can look up a new banana bread recipe,” she said, but challenges arise when healthcare is the subject being searched.

Conflicting information can confuse people and give them false information. For example, a patient with a genetic condition might find information related to the nongenetic version of that condition.

“Our system is data-driven; we learn who the patients are, administer surveys, access the electronic health record, and then offer content,” Kataria said. “We offer a ‘short bites’ playlist to help them prepare for procedures so they can see the entire care journey.”

And “we make videos with providers from their own healthacare system, their own doctors,” she added.

Currently, about 1000 videos have been created.

According to statistics reports, consumers of Mytonomy content watch an average of 42 minutes, clicking through a list of videos tailored to their needs. “We have an 85% viewing rate,” Kataria told Medscape Medical News. And her team is getting feedback that patients are “more likely to show up, are easier to manage, and come in happier and less worried.”

“This is a digital front door that is enabling them to participate in their healthcare journey, to do things on their own,” she pointed out.

What’s more, clients who live in remote areas can access diagnosis-specific videos that can save them hours of driving to and from the clinic. “A series of 30 second to 3 minute videos can provide information that will help users better manage lifestyle choices, take medications, or learn to use a new device,” Agee said.

“We know that patients who are more informed about their health have better health outcomes,” she added. “We’re pretty excited about this process.”

Digital Health Conference and Consumer Electronics Show (CES) 2020. Presented January 7, 2020.

https://www.medscape.com/viewarticle/923648#vp_1