Kevin O. Hwang

A Silent Response to the Obesity Epidemic Decline in US Physician Weight Counseling

Background:Guidelines recommend that physicians screen all adults for obesity and offer an intensive counseling and behavioral interventions for weight loss for obese adults. Current trends of weight-related counseling are unknown in the setting of the US obesity epidemic. Objectives:To describe primary care physician (PCP) weight-related counseling, comparing counseling rates in 1995–1996 and 2007–2008. Research Design:Data analysis of outpatient PCP visits in 1995–1996 and 2007–2008, as reported in the National Ambulatory Medical Care Survey. Subjects:A total of 32,519 adult primary care visits with PCPs. Measures:Rates of counseling for weight, diet, exercise, and a composite variable, weight-related counseling (defined as counseling for weight, diet, or exercise) between survey years. Adjusted analyses controlled for patient and visit characteristics. Results:Weight counseling declined from 7.8% of visits in 1995–1996 to 6.2% of visits in 2007–2008 [adjusted odds ratios, 0.64; 95% confidence intervals, 0.53, 0.79]. Rates of receipt of diet, exercise, and weight-related counseling similarly declined. Greater declines in odds of weight-counseling receipt were observed among those with hypertension (47%), diabetes (59%), and obesity (41%), patients who stand the most to gain from losing weight. Conclusions:Rates of weight counseling in primary care have significantly declined despite increased rates of overweight and obesity in the United States. Further, these declines are even more marked in patients with obesity and weight-related comorbidities, despite expectations to provide such care by both patients and policymakers. These findings have implications for determining deliverable, novel ways to engage PCPs in addressing the obesity epidemic.

Butyrate-induced differentiation of Caco-2 cells is associated with apoptosis and early induction of p21Waf1/Cip1 and p27Kip1 ☆ ☆☆ ★

BACKGROUND Intestinal mucosal turnover is a process of proliferation, differentiation, and apoptosis; the mechanisms remain largely undefined. The purpose of our study was to (1) assess the relationship between apoptosis and enterocyte differentiation and (2) determine whether the cell-cycle inhibitors, p21Waf1/Cip1 and p27Kip1, or the apoptosis inhibitors, Bcl-2 and Bcl-XL, may be involved. METHODS Gut-derived Caco-2 cells were treated with sodium butyrate. Apoptosis was assessed by Hoechst stain, DNA laddering, and annexin V assay; differentiation was determined by alkaline phosphatase and sucrase activity. RNA and protein were analyzed for expression of p21Waf1/Cip1, p27Kip1, and members of the Bcl-2 family. RESULTS Treatment of Caco-2 cells with sodium butyrate resulted in the concomitant induction of both differentiation (increased alkaline phosphatase and sucrase activity) and apoptosis. Increased levels of p21Waf1/Cip1 and p27Kip1 mRNA and protein were detected at 24 hours, occurring before apoptosis or differentiation; decreased mRNA levels of Bcl-2 and Bcl-XL were noted at 24 hours. CONCLUSIONS Differentiation and apoptosis occurred simultaneously in Caco-2 cells, suggesting that apoptosis may be linked to enterocyte differentiation. The induction of p21Waf1/Cip1 and p27Kip1 and the down-regulation of Bcl-2 and Bcl-XL further suggest a link between the cell-cycle mechanisms regulating enterocyte differentiation and apoptosis.

Glutamine deprivation induces apoptosis in intestinal epithelial cells

BACKGROUND Glutamine is the most abundant amino acid in the blood, and its deprivation leads to gut mucosal atrophy. The small intestinal mucosa is maintained by a balance between cell proliferation and cell death by apoptosis. We reported that glutamine is required for nitrogen-stimulated proliferation in intestinal epithelial cells. We do not know whether glutamine regulates apoptosis in the gut. The purpose of this study is to determine whether glutamine deprivation induces apoptosis in rat intestinal epithelial (RIE-1) cells and to compare the effect of glutamine starvation with that of methionine and cysteine (Met/Cys) starvation. METHODS RIE-1 cells were deprived of either glutamine or Met/Cys for 24 hours. Cell numbers were determined by cell counting and tetrazolium enzymatic assay. Apoptosis was quantified by Annexin V assay and confirmed by DNA gel electrophoresis and Hoecsht nuclear staining. RESULTS Deprivation of glutamine or Met/Cys resulted in decreased cell numbers. However, only the glutamine-deprived group showed significant induction of apoptosis with increased Annexin V staining, DNA laddering, and nuclear condensation. CONCLUSIONS This study provides biochemical and morphologic evidence that glutamine deprivation induces apoptosis in rat intestinal epithelial cells. In contrast, Met/Cys starvation suppresses cell number without induction of apoptosis. These results suggest that glutamine serves as a specific survival factor in enterocytes.

Practices Associated with Weight Loss Versus Weight-Loss Maintenance Results of a National Survey

BACKGROUND Few studies have examined the weight-control practices that promote weight loss and weight-loss maintenance in the same sample. PURPOSE To examine whether the weight control practices associated with weight loss differ from those associated with weight-loss maintenance. METHODS Cross-sectional survey of a random sample of 1165 U.S. adults. The adjusted associations of the use of 36 weight-control practices in the past week with success in weight loss (≥10% lost in the past year) and success in weight-loss maintenance (≥10% lost and maintained for ≥1 year) were examined. RESULTS Of the 36 practices, only 8 (22%) were associated with both weight loss and weight-loss maintenance. Overall, there was poor agreement (kappa=0.22) between the practices associated with weight loss and/or weight-loss maintenance. For example, those who reported more often following a consistent exercise routine or eating plenty of low-fat sources of protein were 1.97 (95% CI=1.33, 2.94) and 1.76 (95% CI=1.25, 2.50) times more likely, respectively, to report weight-loss maintenance but not weight loss. Alternatively, those who reported more often doing different kinds of exercises or planning meals ahead of time were 2.56 (95% CI=1.44, 4.55) and 1.68 (95% CI=1.03, 2.74) times more likely, respectively, to report weight loss but not weight-loss maintenance. CONCLUSIONS Successful weight loss and weight-loss maintenance may require two different sets of practices. Designing interventions with this premise may inform the design of more effective weight-loss maintenance interventions.

Website Usage and Weight Loss in a Free Commercial Online Weight Loss Program: Retrospective Cohort Study

Background Online weight loss programs are increasingly popular. However, little is known about outcomes and associations with website usage among members of free online weight loss programs. Objective This retrospective cohort study examined the association between website usage and weight loss among members of a free commercial online weight loss program (SparkPeople). Methods We conducted a retrospective analysis of a systematic random sample of members who joined the program during February 1 to April 30, 2008, and included follow-up data through May 10, 2010. The main outcome was net weight change based on self-reported weight. Measures of website usage included log-ins, self-monitoring entries (weight, food, exercise), and use of social support tools (discussion forums, friendships). Results The main sample included 1258 members with at least 2 weight entries. They were 90.7% female, with mean (SD) age 33.6 (11.0) and mean (SD) BMI 31.6 (7.7). Members with at least one forum post lost an additional 1.55 kg (95% CI 0.55 kg to 2.55 kg) relative to those with no forum posts. Having at least 4 log-in days, weight entry days, or food entry days per 30 days was significantly associated with weight loss. In the multiple regression analysis, members with at least 4 weight entry days per 30 days reported 5.09 kg (95% CI 3.29 kg to 6.88 kg) more weight loss per 30 days than those with fewer weight entry days. After controlling for weight entry days, the other website usage variables were not associated with weight change. Conclusions Weekly or more frequent self-monitoring of weight is associated with greater weight loss among members of this free online weight loss program.

The impact of physician weight discussion on weight loss in US adults.

PROBLEM The increasing prevalence of overweight and obesity in the United States and worldwide is at epidemic levels. Physicians may play a vital role in addressing this epidemic. We aimed to examine the association of a physicians discussion of patients’ weight status with self-reported weight loss. We hypothesized that physician discussion of patients’ being overweight is associated with increased weight loss in patients with overweight and obesity. METHODS Data analysis of participants (n = 5054) in the National Health and Nutritional Examination Survey (NHANES) in 2005-2008. The main outcome was rates of self-reported weight loss and the association with physicians’ discussion of their patients’ weight status. RESULTS Overweight and obese participants were significantly more likely to report a 5% weight loss in the past year if their doctor had told them they were overweight (adjusted OR (AOR) 1.88; 95% CI 1.45-2.44; AOR 1.79; 95% CI 1.30-2.46, respectively). CONCLUSIONS Physicians’ direct discussion of their patients’ weight status is associated with clinically significant patient weight loss and may be a targetable intervention. Further studies are needed to determine if increasing physician discussion of patients’ weight status leads to significant weight loss.

Structural social support predicts functional social support in an online weight loss programme

Background  Online weight loss programmes allow members to use social media tools to give and receive social support for weight loss. However, little is known about the relationship between the use of social media tools and the perception of specific types of support.

Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication: a randomized trial.

BACKGROUND After-hours telephone communications are common in patient management. Patterns of communication of key information during after-hours phone calls were evaluated, and the utility of problem-specific Situation, Background, Assessment, Recommendation (SBAR) forms in improving this communication was assessed. METHODS In a randomized trial using a simulated on-call setting, 20 nurses called physicians regarding six cases adapted from inpatient records and based on the six most common reasons for after-hours nurse-physician communication. Three of the cases were handled without the SBAR forms (control cases), and three cases were handled with the forms (SBAR cases). Two cue types of communication were evaluated: situation cues, which conveyed the patients situation (for example, a patient is confused), and background cues, which conveyed problem-specific data indicated on the SBAR forms (for example, the patient has a low sodium level). RESULTS Ninety-two phone calls were analyzed (43 SBAR/49 controls). Most of the nurses reported the situation cues (SBAR 88%, control 84%, p = .60) but not the background cues. There was a trend toward fewer background cues communicated in the SBAR cases (14% versus 31%, p = .08). In 14% of the cases, on average, nurses omitted information or reported wrong information regarding the background cue. Physicians asked questions that resulted in the communication of the cues in a minority of the cases when the background cues were not originally provided by the nurses (SBAR 6%, control 16%, p = .39). CONCLUSIONS In after-hours phone communication between physicians and nurses, significant information was often not communicated and physicians did not elicit the necessary information. Simply providing an SBAR-based form did not ensure complete communication of key information.

Primary Care Providers’ Perspectives on Online Weight-Loss Programs: A Big Wish List

Background Integrating online weight-loss programs into the primary care setting could yield substantial public health benefit. Little is known about primary care providers’ perspectives on online weight-loss programs. Objective To assess primary care providers’ perspectives on online weight-loss programs. Methods We conducted focus group discussions with providers in family medicine, internal medicine, and combined internal medicine/pediatrics in Texas and Pennsylvania, USA. Open-ended questions addressed their experience with and attitudes toward online weight-loss programs; useful characteristics of existing online weight-loss programs; barriers to referring patients to online weight-loss programs; and preferred characteristics of an ideal online weight-loss program. Transcripts were analyzed with the grounded theory approach to identify major themes. Results A total of 44 primary care providers participated in 9 focus groups. The mean age was 45 (SD 9) years. Providers had limited experience with structured online weight-loss programs and were uncertain about their safety and efficacy. They thought motivated, younger patients would be more likely than others to respond to an online weight-loss program. According to primary care providers, an ideal online weight-loss program would provide—at no cost to the patient—a structured curriculum addressing motivation, psychological issues, and problem solving; tools for tracking diet, exercise, and weight loss; and peer support monitored by experts. Primary care providers were interested in receiving reports about patients from the online weight-loss programs, but were concerned about the time required to review and act on the reports. Conclusions Primary care providers have high expectations for how online weight-loss programs should deliver services to patients and fit into the clinical workflow. Efforts to integrate online weight-loss programs into the primary care setting should address efficacy and safety of online weight-loss programs in clinic-based populations; acceptable methods of sending reports to primary care providers about their patients’ progress; and elimination or reduction of costs to patients.

Inhibition of gastric cancer by camptothecin involves apoptosis and multiple cellular pathways

BACKGROUND The prognosis for gastric cancer remains dismal; novel agents that target specific molecular pathways are needed as adjuvant therapy. Camptothecin (CPT), on inhibitor of topoisomerase I, is effective in the treatment of certain solid tumors; its effects on gastric cancer are largely undefined. The purpose of this study was to (1) characterize the effects of CPT on the growth of a human gastric cancer and (2) assess potential cellular mechanisms responsible for CPT-mediated growth inhibition. METHODS The human gastric cancer SIIA was transplanted subcutaneously into athymic nude mice. After tumors reached approximately 100 mm2, mice were randomized into 3 groups to receive either CPT (5 or 10 mg/kg) or vehicle (control) intraperitoneally 3 days per week for 3 weeks; tumor size was measured biweekly. To assess potential mechanisms of CPT-mediated inhibition, SIIA cells were treated with CPT (20 mumol/L) and cells were counted over a time course; apoptosis was assessed by Hoechst stain and DNA laddering. Expression of p53 (a tumor suppressor), p21Waf1 and p27Kip1 (cell cycle inhibitors), and Bcl-2 and Bcl-XL (antiapoptotic proteins) was determined. RESULTS CPT (5 and 10 mg/kg) significantly inhibited tumor growth of SIIA gastric cancers compared with controls. CPT-mediated inhibition of SIIA cell proliferation was associated with an increase in apoptosis. Moreover, CPT treatment resulted in induction of p53, p21Waf1, and p27Kip1 and a decrease in Bcl-2 and Bcl-XL RNA and protein levels. CONCLUSIONS Treatment with CPT effectively inhibited the growth of the human gastric cancer SIIA; the mechanism involved was induction of apoptosis mediated by up-regulation of p53, p21Waf1/Cip1, and p27Kip1 and the down-regulation of Bcl-2 and Bcl-XL. Novel agents such as CPT, which target specific molecular pathways, may prove clinically useful in the adjuvant treatment of gastric cancers.