Timothy S. Harlan

Medical school-based teaching kitchen improves HbA1c, blood pressure, and cholesterol for patients with type 2 diabetes: Results from a novel randomized controlled trial

AIMS A medical school-based teaching kitchen sought to establish proof-of-principle for its hands-on Mediterranean diet (MD)-based cooking and nutrition curriculum for patients with type 2 diabetes (T2D). METHODS This pilot randomized controlled trial (RCT) allocated 27 patients with T2D between the control and GCCM arms. Mixed effects linear regression with repeated measures was used to investigate differences from baseline to 6 months. The primary and secondary endpoints were HbA1c -0.3% (-27 mmol/mol) and diastolic blood pressure (DBP) -10 mmHg and a 25% improved responses in dietary habits and attitudes and competencies in healthy nutrition. RESULTS Compared to the control group, the GCCM group had superior HbA1c reduction (-0.4% vs. -0.3%, p = 0.575) that was not statistically significant. There were significantly greater reductions in the GCCM vs. control group for DBP (-4 vs. 7 mmHg, p=0.037) and total cholesterol (-14 vs. 17 mg/dL, p = 0.044). There was a greater proportion increase though not significant of GCCM subjects compared to controls who mostly believed they could eat correct portions (18% vs. -11%, p = 0.124), and who used nutrition panels to make food choices (34% vs. 0%, p = 0.745). CONCLUSION This is the first known RCT demonstrating improved biometrics using a novel MD-based hands on cooking and nutrition curriculum for patients with T2D. These results suggest subsequent clinical trials are warranted on the grounds of documented feasibility and clinical efficacy.

Novel Longitudinal and Propensity Score Matched Analysis of Hands-On Cooking and Nutrition Education versus Traditional Clinical Education among 627 Medical Students.

Background. Physicians are inadequately equipped to respond to the global obesity and nutrition-associated chronic disease epidemics. We investigated superiority of simulation-based medical education with deliberate practice (SBME-DP) hands-on cooking and nutrition elective in a medical school-based teaching kitchen versus traditional clinical education for medical students. Materials and Methods. A 59-question panel survey was distributed to an entire medical school twice annually from September 2012 to May 2014. Student diet and attitudes and competencies (DACs) counseling patients on nutrition were compared using conditional multivariate logistic regression, propensity score-weighted, and longitudinal panel analyses. Inverse-variance weighted meta-analysis (IVWM) was used for planned subgroup analysis by year and treatment estimates across the three methods. Results. Of the available 954 students, 65.72% (n = 627) unique students were followed to produce 963 responses. 11.32% (n = 109) of responses were from 84 subjects who participated in the elective. SBME-DP versus traditional education significantly improved fruit and vegetable diet (OR = 1.38, 95% CI: 1.07–1.79, p = 0.013) and attitudes (OR = 1.81, 95% CI: 1.40–2.35, p < 0.001) and competencies (OR = 1.72, 95% CI: 1.54–1.92, p < 0.001). Conclusions. This study reports for the first time superiority longitudinally for SBME-DP style nutrition education for medical students which has since expanded to 13 schools.

Letter by Kasprowicz et al Regarding Article, “Reducing Sodium Intake to Prevent Stroke: Time for Action, Not Hesitation”

The article by Appel1 entitled “Reducing Sodium Intake to Prevent Stroke: Time for Action, Not Hesitation” provides a call to action that diet modification is a cost effective and clinically relevant component of our prevention and management of chronic disease and stroke. The author notes a potential profound impact of widespread nutrition intervention and that a 4% annual reduction in sodium intake for 10 years could prevent 30 000 to 83 000 stroke-related deaths. We agree with Appel’s conclusion and offer 1 concrete step to move the American medical community from hesitation to action. There is a larger problem limiting the ability of providers to offer effective nutrition counseling that patients can easily integrate into their …

Harmony in discord

Almost twenty years ago the National Academy of Medicine defined primary care as “the provision of integrated, accessible health care services byclinicianswhoareaccountable foraddressinga largemajorityofpersonal health care needs, developing a sustained partnership with patients and practicingwithin the context of family and community” (Donaldson, Yordy, Lohr,&Vanselow, 1996). It is this breadthof responsibility and thedegreeof illness that challenges us in patient care and it is crucial that we develop tools that allow us to quickly recognize opportunities for improving the quality of care for our patients, especially those with multiple co-morbid conditions. Such tools will allow for a true intersection of population health management and the day-to-day care of patients. It is at this intersection that the work by Dr. Magnan and her colleagues provides an intriguing and potentially excitingway to view our patients both collectively and individually. Their paper published in this journal (Magnan et al., 2014) indicates that our diabetic patientswho havemore conditions concordant with their diabetes are more likely to achieve care goal than those patients who have diseases that are discordant with their diabetes. While there is a great deal of work to be done in clarifying specific conditions that are significantly concordant with diabetes this line of research does have the promise of helping shape public health policy and daily practice. We have numerous tools now that risk stratify and seek to predict our patients outcomes. These range from condition specific tools such as the TIMI Risk Score to more complex algorithms based on claims and clinical data (3M® APR-DRG Software & Johns Hopkins ACG® System). Such tools are being used near and in some cases at the point of care and by incorporating the significant but very simple layer of a patients disease concordance we could easily predict those diabetics who may actually need more attention due to their disparate disease in the same way that we have focused on the low hanging fruit of our patients with similar co-morbid conditions. There are clear areas for further research to refine these exciting concepts, however. Perfecting the dataset to reflect the degrees of severity contributed by concordant and discordant conditions will be key to understanding potential outcomes. At the same time itwill be important to considerwhether there is an impact on outcomes as a result of the number andfrequencyofphysicianvisits inbothcohorts. Ifweare followingpatients with multiple concordant diseases more frequently than those with discordant issues, the very simple intervention of increasing appointments with thosepatientswemightotherwisebelievearedoingwell because they are in our minds not as sick could have a tremendous impact. Lastly, the factor of specialty vs. primary care visits is a critical variable. If patients with more concordant conditions are receiving the preponderance of their care from specialists and are having improved outcomes, the number of conditions could be a guideline for referral by