Faculty Bibliography

PURPOSE:The purpose of the study was to examine the impact of a 12-month weight loss intervention with either a low-carbohydrate or a low-fat diet on quality of life (QOL) among obese patients with type 2 diabetes. METHODS:Participants were enrolled in a randomized trial comparing a low-carbohydrate to a low-fat diet in type 2 diabetes. QOL was assessed with the Diabetes-39 questionnaire, which measures QOL within 5 distinct scales: anxiety and worry, diabetes control, energy and mobility, social burden, and sexual functioning. Repeated measures ANOVA compared change in QOL scales at baseline and 6 and 12 months. RESULTS:Forty-six participants completed all measures. Following 12 months, there was a significant reduction in the scores related to sexual function and energy and mobility, suggesting improvement in QOL related to these domains. These changes were not significantly different between dietary arms. Changes in weight, A1C, and dietary composition were not significantly correlated with changes in QOL. CONCLUSIONS:Participants with diabetes have various options for weight loss. Dietary interventions with either low-carbohydrate or low-fat diets may lead to some improvements in QOL in patients with type 2 diabetes.

OBJECTIVE:To characterize acute (postprandial) and chronic (after a 6-month period of weight loss) effects of a low-carbohydrate vs. a low-fat diet on subclinical markers of cardiovascular disease (CVD) in adults with type 2 diabetes. DESIGN/METHODS:At baseline and 6 months, measures of C-reactive protein (CRP), interleukin-6 (IL-6), soluble intercellular adhesion molecule (sICAM) and soluble E-selectin were obtained from archived samples (n = 51) of participants randomized in a clinical trial comparing a low-carbohydrate and a low-fat diet. In a subset of participants (n = 27), postprandial measures of these markers were obtained 3 h after a low-carbohydrate or low-fat liquid meal. Endothelial function was also measured by reactive hyperemic peripheral arterial tonometry during the meal test. Paired t tests and unpaired t tests compared within- and between-group changes. RESULTS:There were no significant differences observed in postprandial measures of inflammation or endothelial function. After 6 months, CRP (mean ± S.E.) decreased in the low-fat arm from 4.0 ± 0.77 to 3.0 ± 0.77 (P = .01). In the low-carbohydrate arm, sICAM decreased from 234 ± 22 to 199 ± 23 (P = .001), and soluble E-selectin decreased from 93 ± 10 to 82 ± 10 (P = .05.) A significant correlation between change in high-density lipoprotein and change in soluble E-selectin (r = -0.33, P = .04) and with the change in ICAM (r = -0.43, P = .01) was observed. CONCLUSIONS:Low-carbohydrate and low-fat diets both have beneficial effects on CVD markers. There may be different mechanisms through which weight loss with these diets potentially reduces CVD risk.

BACKGROUND:The US Preventive Services Task Force and the American Academy of Pediatrics recommend that physicians screen patients for obesity and practice counseling interventions to achieve modest (4%-8%) weight loss. Despite this, physicians frequently do not document obesity and/or counsel on weight loss. Our goal was to develop an innovative, easily disseminated workshop to improve resident physicians' skills and confidence in weight-loss counseling. METHODS:We developed a tailored 3-hour interactive Obesity Counseling Workshop. The approach incorporates principles of motivational interviewing, a set of listening and counseling skills designed to enhance patient centeredness and promote behavior change. Adult learning theory served as the foundation for program delivery. The half-day session is administered monthly to internal medicine and pediatric residents on outpatient rotations. KEY RESULTS/RESULTS:To date 77 residents (44 internal medicine and 33 pediatric) have completed the workshop, with approximately even distribution of postgraduate year (PGY)-1, PGY-2, and PGY-3 level residents. Forty-two were women and less than half planned to pursue a primary care-oriented career. Residents completed a 10-item workshop evaluation, with each category scoring an average of 3.5 or greater on a 4-point Likert scale. Residents reported the workshop was well organized and addressed an important topic; they enjoyed the role-playing with observation and feedback. CONCLUSIONS:Residents welcomed the opportunity to participate in an interactive workshop focused on obesity counseling and behavior change, and particularly liked putting new skills into practice with role-playing and receiving real-time feedback. Future analyses will determine the workshop's effect on knowledge, skills, and self-efficacy.

Rates of overweight and obesity are disproportionately high within minority populations. This study examined the trends in provider diagnosis of overweight from 1999 to 2004 and examined whether there were differences in provider diagnosis based on race/ethnicity. We examined data from 4,071 adults with BMI >or=30 who participated in the National Health and Nutrition Examination Surveys (NHANES) (1999-2004). Provider diagnosis was determined by self-report. From 1999 to 2004, the provider diagnosis of overweight decreased from 71 to 64% (P = 0.003). After controlling for potential confounders, non-Hispanic blacks and Mexican Americans were less likely to report a provider diagnosis of overweight compared to non-Hispanic whites. Odds ratio (OR) (95% confidence interval (CI)) for non-Hispanic blacks was 0.6 (95% CI, 0.4-0.8) and for Mexican Americans was 0.7 (95% CI, 0.4-1.0) compared to non-Hispanic whites. Reasons for this disparity warrant further investigation.

The diabetes and obesity epidemics have stimulated research to assess the benefits and potential risks of low-carbohydrate diets. Carbohydrate comprises less than 45% of calories in carbohydrate-restricted diets, but very low carbohydrate ketogenic diets may restrict carbohydrate to 20 g initially with variability in the carbohydrate level subsequently. Some research suggests that low-carbohydrate diets may achieve better early weight loss than comparison diets higher in carbohydrate. Studies of up to 1 year suggest that weight loss on low-carbohydrate diet is comparable with fat-restricted diets with higher carbohydrate content. Limited research has been conducted to evaluate low-carbohydrate diets in managing type 2 diabetes. Although science continues to advance in this field, current research suggests that low-carbohydrate diets can be a viable option for achieving weight loss and may have beneficial effects on glycemic control, triglyceride levels, and high-density lipoprotein cholesterol levels in some patients.

OBJECTIVE:To compare the effects of a 1-year intervention with a low-carbohydrate and a low-fat diet on weight loss and glycemic control in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS/METHODS:This study is a randomized clinical trial of 105 overweight adults with type 2 diabetes. Primary outcomes were weight and A1C. Secondary outcomes included blood pressure and lipids. Outcome measures were obtained at 3, 6, and 12 months. RESULTS:The greatest reduction in weight and A1C occurred within the first 3 months. Weight loss occurred faster in the low-carbohydrate group than in the low-fat group (P = 0.005), but at 1 year a similar 3.4% weight reduction was seen in both dietary groups. There was no significant change in A1C in either group at 1 year. There was no change in blood pressure, but a greater increase in HDL was observed in the low-carbohydrate group (P = 0.002). CONCLUSIONS:Among patients with type 2 diabetes, after 1 year a low-carbohydrate diet had effects on weight and A1C similar to those seen with a low-fat diet. There was no significant effect on blood pressure, but the low-carbohydrate diet produced a greater increase in HDL cholesterol.

BACKGROUND:Obesity is a common problem in primary care, but little is known about Internal Medicine residents' attitudes towards obesity treatment. OBJECTIVE:To describe resident attitudes about obesity treatment. METHODS:Cross-sectional survey of 101 Internal Medicine residents in Philadelphia, PA, and Bronx, NY. Responses to 18 items on a Likert scale assessed resident attitudes. Weight loss goals were assessed with open-ended questions to a clinical scenario. ANOVA with trend analysis compared questionnaire responses to resident postgraduate year (PGY) level. Associations between clinic site, PGY level, and dichotomized Likert responses were tested with chi-square analysis. RESULTS:19% of residents felt competent in prescribing weight loss programs. Few residents (18%) considered the current recommendations of a 5-10% reduction in body weight to be successful in an obese hypothetical patient. Third-year residents reported greater feelings of negativity towards obese patients than first- and second year residents (p<.05) CONCLUSIONS:Resident physicians do not feel competent in treating obesity and have unrealistic weight loss goals; third-year residents had more negative attitudes about obese patients compared to residents in their 1(st) or 2(nd) year of training. These areas are targets for further resident education about obesity management.

OBJECTIVE:To evaluate the change in potassium after initiating a low-carbohydrate or low-fat weight loss diet. METHODS:Participants randomized to a low-carbohydrate (low-CHO) or a low-fat diet had serum potassium measured at baseline, 3 days, 1 week, 2 weeks, and 1 month after dietary initiation. Paired t tests and repeated measure analysis of variance (ANOVA) compared changes within each subject and between groups. RESULTS:Mean potassium (4.29 mmol/L + 0.41) was similar in both groups at baseline. The low-CHO arm (n = 48) had a mean decrease of 0.16 mmol/L +/- 0.49 (P = 0.03) over one month, and the low-fat arm (n = 47) had a reduction of 0.19 +/- 0.45 (P = 0.006). Serum potassium decreased within 3 days of diet initiation in the low-CHO arm, and at one week in the low-fat arm. Five participants (3 in low-CHO arm) required potassium supplementation for serum potassium <3.5 mmol/L. CONCLUSIONS:Minor decreases in potassium occurred after initiating both diets, and was more rapid after the low-CHO diet. These decreases may be clinically meaningful in some patients.