Nichola J. Davis

Impact of Adherence, Knowledge, and Quality of Life on Anticoagulation Control

BACKGROUND: Patients receiving chronic warfarin therapy who have poor anticoagulation control are at increased risk for adverse events. However, it is unknown how adherence to warfarin, patient demographics, patient knowledge about therapy, and perceived impact of warfarin therapy on quality of life are associated with anticoagulation control. OBJECTIVE: To determine the association between these patient factors and anticoagulation control in patients attending 2 anticoagulation clinics in the Bronx, New York City. METHODS: A cross-sectional survey of 52 patients was conducted. The 4-item Morisky survey was used to assess self-reported adherence. Patient knowledge about warfarin therapy and the perceived impact of warfarin therapy on quality of life were determined by self-administered questionnaires. Associations between adherence, patient knowledge, impact of warfarin therapy on quality of life, and anticoagulation control were determined with t-tests, χ2 analysis, and logistic regression. RESULTS: Only 14% of patients had good anticoagulation control. Adequate adherence was reported by 50% of patients and was significantly associated with good anticoagulation control (p = 0.01). Thirty-seven percent of participants had good knowledge of anticoagulation, and 19% of participants reported that warfarin negatively impacted their quality of life. Knowledge about warfarin therapy and impact of warfarin on quality of life were not significantly associated with anticoagulation control. CONCLUSIONS: Adherence is one of many factors that contribute to anticoagulation control. Adequate adherence, as determined by the Morisky survey, was significantly associated with anticoagulation control. Patient demographic characteristics, knowledge about warfarin therapy, and perceived impact of warfarin on quality of life were not associated with anticoagulation control.

The Effect of Diet on Endothelial Function

Endothelial dysfunction is an early precursor to atherosclerosis. Lifestyle interventions, including diet, have been shown to affect endothelial function. High-fat diets have been shown to impair endothelial function, and diets such as the Mediterranean diet have been associated with improved endothelial function. This review discusses the effects of diet, dietary supplements such as folic acid, polyphenols, and antioxidant vitamins on endothelial function. We provide a summary of the current data linking diet with endothelial function and explore controversies within this field.

Differential effects of low-carbohydrate and low-fat diets on inflammation and endothelial function in 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 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.

Nutritional Strategies in Type 2 Diabetes Mellitus

Weight loss is a key goal in the management of patients with type 2 diabetes mellitus. There are conflicting weight-loss strategies, including low-carbohydrate diets, low glycemic-index diets, low-fat vegan diets, conventional low-fat diets, and high-protein and high-monounsaturated fat diets. There is no evidence to suggest that 1 nutritional strategy is clearly the best. The most successful strategy is one that the patient can adopt and follow in the long term.

Telephone Intervention to Improve Diabetes Control: A Randomized Trial in the New York City A1c Registry

INTRODUCTION Scalable self-management interventions are necessary to address suboptimal diabetes control, especially among minority populations. The study tested the effectiveness of a telephone behavioral intervention in improving glycemic control among adults with diabetes in the New York City A1c Registry. DESIGN RCT comparing a telephone intervention to print-only intervention in the context of the A1c Registry program. SETTING/PARTICIPANTS Nine hundred forty-one adults with diabetes and hemoglobin A1c (A1c) >7% from a low-income, predominantly Latino population in the South Bronx were recruited from the A1c Registry. INTERVENTION All study participants were mailed print diabetes self-management materials at baseline and modest lifestyle incentives quarterly. Only the telephone participants received four calls from health educators evenly spaced over 1 year if baseline A1c was >7%-9%, or eight calls if baseline A1c was >9%. Medication adherence was the main behavioral focus and, secondarily, nutrition and exercise. MAIN OUTCOME MEASURES Primary outcome was difference between two study arms in change in A1c from baseline to 1 year. Secondary outcomes included diabetes self-care activities, including self-reported medication adherence. Data were collected in 2008-2012 and analyzed in 2012-2014. RESULTS Participants were predominantly Latino (67.7%) or non-Latino black (28%), with 69.7% foreign-born and 55.1% Spanish-speaking. Among 694 (74%) participants with follow-up A1c, mean A1c decreased by 0.9 (SD=0.1) among the telephone group compared with 0.5 (SD=0.1) among the print-only group, a difference of 0.4 (95% CI=0.09, 0.74, p=0.01). The intervention had significant effect when baseline A1c was >9%. Both groups experienced similar improvements in self-care activities, medication adherence, and intensification. CONCLUSIONS A telephone intervention delivered by health educators can be a clinically effective tool to improve diabetes control in diverse populations, specifically for those with worse metabolic control identified using a registry. This public health approach could be adopted by health systems supported by electronic record capabilities. CLINICALTRIALS. GOV REGISTRATION NCT00797888.

Trends and Disparities in Provider Diagnosis of Overweight Analysis of NHANES 1999–2004

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 ≥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.

Impact of a Focused Nutrition Educational Intervention Coupled With Improved Access to Fresh Produce on Purchasing Behavior and Consumption of Fruits and Vegetables in Overweight Patients With Diabetes Mellitus

Purpose The purpose of this study was to test the impact of distributing coupons redeemable at farmers markets plus an educational intervention on fruit and vegetable (F&V) purchase and consumption in overweight patients with type 2 diabetes (T2DM). Methods Seventy-eight participants with T2DM being followed at Jacobi Medical Center, a large public hospital in the Bronx, New York, were randomized to receive the standard of care or a 1-hour session focused on benefits of F&V consumption and

Death to carbohydrate counting

6 in coupons. Questionnaires assessed demographics, F&V intake, and farmers market purchasing at baseline and 12 weeks. Clinical parameters were obtained through chart review at baseline and at 12 weeks. Results Participants were predominantly Latino, females, and low income. At 12 weeks, there was a statistically significant increase in the number of participants in the intervention arm who reported purchasing from a farmers market. In addition, there was a minimal increase in fresh fruit intake in the intervention arm at 12 weeks. Conclusion Focused education combined with a small economic incentive resulted in an increase in purchasing behavior and fresh fruit intake per day. A more intense behavioral intervention combined with increased access may result in a significant impact on obesity and diabetes, particularly among low-income and racially diverse communities.

Dietary patterns in blacks and Hispanics with diagnosed diabetes in New York City's South Bronx

Insulin therapy is an effective strategy for achieving glycemic control in patients with type 2 diabetes. Although often neglected, it is important to use an appropriate diet strategy to complement the insulin. Furthermore, a basic tenet of such therapy is that insulin dosage and administration should be appropriate to balance diet and physical activity in order to maintain normoglycemia. In this issue of Diabetes Car e, Bergenstal et al. (1) evaluated two strategies for determining the appropriate dosage of mealtime bolus insulin. A simple algorithm that adjusted bolus insulin dose based on weekly average of premeal glucose was compared with an algorithm based on mealtime carbohydrate counting. The authors demonstrated the equivalence of both the simple strategy and the more elaborate carbohydrate-counting strategy in achieving glycemic control; almost one-half the participants in both groups achieved an A1C <6.5%. Can patients with type 2 diabetes treated with basal:bolus insulin succeed without adding the complexity of carbohydrate counting? Carbohydrate counting has been around since the 1920s and became integral in managing patients with type 1 diabetes after the landmark findings of the Diabetes Control and Complications …

Revised 2005 Diabetes Quality Improvement Checklist

BACKGROUND An understanding of dietary patterns in diverse populations may guide the development of food-based, rather than nutrient-based, recommendations. OBJECTIVE We identified and determined predictors of dietary patterns in low-income black and Hispanic adults with diagnosed diabetes. DESIGN A food-frequency questionnaire was used to assess dietary intake in 235 adults living in the South Bronx, New York City, NY. We used principal factor analysis with promax rotation to identify dietary patterns. Multivariate linear regression models were used to test associations between demographic variables and dietary pattern scores. RESULTS The following 5 dietary patterns were identified: pizza and sweets, meats, fried foods, fruit and vegetables, and Caribbean starch. The Caribbean starch and fruit and vegetables patterns were high in fruit and vegetables and low in trans fats. In multivariate analyses, sex, language spoken, years living in the United States, and region of birth were significant predictors of dietary patterns. Compared with English speakers, Spanish speakers were less likely to have high scores in pizza and sweets (P = 0.001), meat (P = 0.004), and fried food (P = 0.001) patterns. Participants who lived longer in the United States were less likely to have a meat (P = 0.024) or Caribbean starch pattern (P < 0.001). In Hispanics, the consumption of foods in the Caribbean starch pattern declined for each year that they lived in the United States. CONCLUSIONS In adults with diagnosed diabetes who were living in the South Bronx, a Caribbean starch pattern, which included traditional Hispanic and Caribbean foods, was consistent with a healthier dietary pattern. In developing dietary interventions for this population, one goal may be to maintain healthy aspects of traditional diets. This trial was registered at clinicaltrials.gov as NCT00797888.