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Total estimated usual nutrient intake and nutrient status biomarkers in women of childbearing age and women of menopausal age.
Devarshi, PP, Legette, LL, Grant, RW, Mitmesser, SH
The American journal of clinical nutrition. 2021;113(4):1042-1052
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Nutritional needs vary depending on the stage in a woman’s lifecycle. Women of child-bearing age (WCBA) and women of menopausal age (WMENO) are at high risk of not meeting required nutrient amounts, yet data is limited on nutrient intakes in these groups. This observational study of 4134 WCBA and 3438 WMENO aimed to determine any nutrient gaps and if associations exist between dietary intake and blood levels of key nutrients. The results showed that WCBA and WMENO had inadequate dietary intakes of calcium, magnesium, and vitamins A, C, D and E, which was allevaited by supplementation. Women who had lower levels of folate, vitamins D, B12 and essential fatty acids had lower dietary intakes of these nutrients, indicating a risk of deficiency. It was concluded that many women of WCBA and WMENO may have inadequate dietary nutrient intake and supplementation may improve this. This study could be used by healthcare professionals to understand that nutrient intakes may be inadequate in WCBA and WMENO. Dietary recommendations to increase nutrient intake would be advisable, however if individuals are still not meeting nutrient requirements, nutrient supplementation may be advisable.
Abstract
BACKGROUND Women of childbearing age (WCBA) and women of menopausal age (WMENO) have distinct nutritional needs. Understanding nutrient intake and status in these life stages is critical for tailoring dietary recommendations. OBJECTIVES The objectives of this study were to evaluate total estimated usual nutrient intakes from food and food plus supplements and to compare these to established recommendations for WCBA and WMENO life stages and examine associations between self-reported estimated usual intakes and nutrient status biomarkers. METHODS Twenty-four-hour dietary recall data from 2011-2016 NHANES were used to estimate usual intake of nutrients from food and food plus supplements for WCBA (aged 15-44 y, n = 4,134) and WMENO (aged 40-65 y, n = 3,438). Estimates of mean usual intake were derived and compared across clinically defined nutrient biomarker categories. RESULTS Both young (aged 15-30 y) and older (aged 31-44 y) WCBA had intakes from food below the Estimated Average Requirement (EAR) for calcium (49% and 44%, respectively), magnesium (62%, 44%), and vitamins A (50%, 44%), C (47%, 46%), D (>97%, >97%), and E (92%, 88%). Similarly, perimenopausal (aged 40-50 y) and menopausal (aged 51-65 y) women had intakes from food below the EAR for calcium (48% and 74%, respectively), magnesium (50%, 49%), and vitamins A (44%, 37%), C (44%, 41%), D (>97%, >97%), and E (88%, 86%). Nutrient gaps decreased with supplement usage. For folate, vitamins D and B-12, and DHA, women in the lowest biomarker category (indicating increased risk of deficiency) had significantly lower intake from food (315.2 ± 25.9 compared with 463.8 ± 5.2 µg dietary folate equivalents, 3.5 ± 0.1 compared with 4.2 ± 0.1 µg, 3.6 ± 0.2 compared with 4.3 ± 0.1 µg, and 0.037 ± 0.005 compared with 0.070 ± 0.006 g, respectively; P < 0.01) of the corresponding nutrient compared with the highest biomarker category. CONCLUSIONS Substantial percentages of WCBA and WMENO are not meeting recommendations for multiple nutrients, whereas supplement usage partially fills nutrient gaps. Dietary intake was positively associated with most nutrient status biomarkers. Specific guidance is needed to ensure adequate nutrient intakes and nutrient status during these critical life stages.
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Inadequacy of Immune Health Nutrients: Intakes in US Adults, the 2005-2016 NHANES.
Reider, CA, Chung, RY, Devarshi, PP, Grant, RW, Hazels Mitmesser, S
Nutrients. 2020;(6)
Abstract
A well-functioning immune system is essential for human health and well-being. Micronutrients such as vitamins A, C, D, E, and zinc have several functions throughout the immune system, yet inadequate nutrient intakes are pervasive in the US population. A large body of research shows that nutrient inadequacies can impair immune function and weaken the immune response. Here, we present a new analysis of micronutrient usual intake estimates based on nationally representative data in 26,282 adults (>19 years) from the 2005-2016 National Health and Nutrition Examination Surveys (NHANES). Overall, the prevalence of inadequacy (% of population below estimated average requirement [EAR]) in four out of five key immune nutrients is substantial. Specifically, 45% of the U.S. population had a prevalence of inadequacy for vitamin A, 46% for vitamin C, 95% for vitamin D, 84% for vitamin E, and 15% for zinc. Dietary supplements can help address nutrient inadequacy for these immune-support nutrients, demonstrated by a lower prevalence of individuals below the EAR. Given the long-term presence and widening of nutrient gaps in the U.S.-specifically in critical nutrients that support immune health-public health measures should adopt guidelines to ensure an adequate intake of these micronutrients. Future research is needed to better understand the interactions and complexities of multiple nutrient shortfalls on immune health and assess and identify optimal levels of intake in at-risk populations.
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Maternal Omega-3 Nutrition, Placental Transfer and Fetal Brain Development in Gestational Diabetes and Preeclampsia.
Devarshi, PP, Grant, RW, Ikonte, CJ, Hazels Mitmesser, S
Nutrients. 2019;(5)
Abstract
Omega-3 fatty acids, particularly docosahexaenoic fatty acid (DHA), are widely recognized to impact fetal and infant neurodevelopment. The impact of DHA on brain development, and its inefficient synthesis from the essential alpha-linolenic acid (ALA), has led to recommended DHA intakes of 250-375 mg eicosapentaenoic acid + DHA/day for pregnant and lactating women by the Dietary Guidelines for Americans. Despite these recommendations, the intake of omega-3s in women of child-bearing age in the US remains very low. The low maternal status of DHA prior to pregnancy could impair fetal neurodevelopment. This review focuses on maternal omega-3 status in conditions of gestational diabetes mellitus (GDM) and preeclampsia, and the subsequent impact on placental transfer and cord blood concentration of omega-3s. Both GDM and preeclampsia are associated with altered maternal omega-3 status, altered placental omega-3 metabolism, reduced cord blood omega-3 levels and have an impact on neurodevelopment in the infant and on brain health later in life. These findings indicate lower DHA exposure of the developing baby may be driven by lower placental transfer in both conditions. Thus, determining approaches which facilitate increased delivery of DHA during pregnancy and early development might positively impact brain development in infants born to mothers with these diseases.
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Changes in physical activity among adults with diabetes: a longitudinal cohort study of inactive patients with Type 2 diabetes who become physically active.
Palakodeti, S, Uratsu, CS, Schmittdiel, JA, Grant, RW
Diabetic medicine : a journal of the British Diabetic Association. 2015;(8):1051-7
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AIMS: To identify the predictors and clinical effects among inactive patients with diabetes who become physically active, in the setting of a large integrated health system. METHODS We studied adults with Type 2 diabetes with at least two clinic visits between December 2011 and November 2012 who reported being inactive at their first visit. The mean (±sd) interval between their first and last visit was 6.2 (±2.3) months. We analysed self-reported moderate-to-vigorous physical activity data collected using a structured intake form during routine clinical care. RESULTS The study cohort (N = 6853) had a mean age of 60.2 years; 51.4% were women and 53.6% were non-white. Nearly two-thirds (62.5%, n = 4280) reported remaining physically inactive, while 16.0% reported achieving the recommended moderate-to-vigorous physical activity levels (≥ 150 min/week) by the last visit of the study period. Female gender (odds ratio 0.77, 95% CI 0.67, 0.88), obesity (BMI 30-34.9 kg/m(2) : odds ratio 0.76, 95% CI 0.60, 0.97; BMI ≥ 35 kg/m(2) : odds ratio 0.55, 95% CI 0.42, 0.70), chronic kidney disease (odds ratio 0.78, 95% CI 0.65, 0.94) and depression (odds ratio 0.77, 95% CI 0.62, 0.96) were each independently associated with not achieving the recommended moderate-to-vigorous physical activity level, while physician referral to lifestyle education was a positive predictor (odds ratio 1.40, 95% CI 1.09, 1.85). Controlling for baseline differences, patients achieving the recommended moderate-to-vigorous physical activity target lost 1.0 kg more weight compared with patients remaining inactive (P < 0.001). CONCLUSIONS Patients with diabetes in a real-world clinical setting lost weight after becoming physically active; however, nearly two-thirds of patients remained inactive. Novel interventions to address physical inactivity in primary care should address barriers faced by older patients with medically complex disease.
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Adipose tissue as an immunological organ.
Grant, RW, Dixit, VD
Obesity (Silver Spring, Md.). 2015;(3):512-8
Abstract
OBJECTIVE This review will focus on the immunological aspects of adipose tissue and its potential role in development of chronic inflammation that instigates obesity-associated comorbidities. METHODS The review used PubMed searches of current literature to examine adipose tissue leukocytosis. RESULTS AND CONCLUSIONS The adipose tissue of obese subjects becomes inflamed and contributes to the development of insulin resistance, type 2 diabetes, and metabolic syndrome. Numerous immune cells including B cells, T cells, macrophages, and neutrophils have been identified in adipose tissue, and obesity influences both the quantity and the nature of immune cell subtypes, which emerges as an active immunological organ capable of modifying whole-body metabolism through paracrine and endocrine mechanisms. Adipose tissue is a large immunologically active organ during obesity and displays hallmarks of both and innate and adaptive immune response. Despite the presence of hematopoietic lineage cells in adipose tissue, it is unclear whether the adipose compartment has a direct role in immune surveillance or host defense. Understanding the interactions between leukocytes and adipocytes may reveal the clinically relevant pathways that control adipose tissue inflammation and is likely to reveal mechanisms by which obesity contributes to increased susceptibility to both metabolic and certain infectious diseases.
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The study to understand the genetics of the acute response to metformin and glipizide in humans (SUGAR-MGH): design of a pharmacogenetic resource for type 2 diabetes.
Walford, GA, Colomo, N, Todd, JN, Billings, LK, Fernandez, M, Chamarthi, B, Warner, AS, Davis, J, Littleton, KR, Hernandez, AM, et al
PloS one. 2015;(3):e0121553
Abstract
OBJECTIVE Genome-wide association studies have uncovered a large number of genetic variants associated with type 2 diabetes or related phenotypes. In many cases the causal gene or polymorphism has not been identified, and its impact on response to anti-hyperglycemic medications is unknown. The Study to Understand the Genetics of the Acute Response to Metformin and Glipizide in Humans (SUGAR-MGH, NCT01762046) is a novel resource of genetic and biochemical data following glipizide and metformin administration. We describe recruitment, enrollment, and phenotyping procedures and preliminary results for the first 668 of our planned 1,000 participants enriched for individuals at risk of requiring anti-diabetic therapy in the future. METHODS All individuals are challenged with 5 mg glipizide × 1; twice daily 500 mg metformin × 2 days; and 75-g oral glucose tolerance test following metformin. Genetic variants associated with glycemic traits and blood glucose, insulin, and other hormones at baseline and following each intervention are measured. RESULTS Approximately 50% of the cohort is female and 30% belong to an ethnic minority group. Following glipizide administration, peak insulin occurred at 60 minutes and trough glucose at 120 minutes. Thirty percent of participants experienced non-severe symptomatic hypoglycemia and required rescue with oral glucose. Following metformin administration, fasting glucose and insulin were reduced. Common genetic variants were associated with fasting glucose levels. CONCLUSIONS SUGAR-MGH represents a viable pharmacogenetic resource which, when completed, will serve to characterize genetic influences on pharmacological perturbations, and help establish the functional relevance of newly discovered genetic loci to therapy of type 2 diabetes. TRIAL REGISTRATION ClinicalTrials.gov NCT01762046.
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Patients who self-monitor blood glucose and their unused testing results.
Grant, RW, Huang, ES, Wexler, DJ, Laiteerapong, N, Warton, ME, Moffet, HH, Karter, AJ
The American journal of managed care. 2015;(2):e119-29
Abstract
OBJECTIVES To investigate the prevalence, predictors, and costs associated with unused results from self-monitoring of blood glucose (SMBG). STUDY DESIGN Observational cohort study. METHODS We studied 7320 patients with type 2 diabetes mellitus who were not prescribed insulin and who reported SMBG. Patients reported whether they used SMBG results to make adjustments to diet, exercise, or medicines; and whether their physician/provider reviewed their SMBG results. We categorized SMBG results as "used" (by patient and/or provider) or "unused" (not used by either patient or provider). RESULTS SMBG results were unused by patient and provider in 15.2% of patients. In separate models adjusted for demographic and clinical differences, major predictors of SMBG without patient or physician using the results included a patient reporting that diabetes was not a high priority (relative risk [RR], 1.81; 95% CI, 1.58-2.07); the physician not engaging in shared decision making (RR, 1.66; 95% CI, 1.46-1.90); and no healthcare professional teaching the patient how to adjust diet/medicines based on SMBG results in the past year (RR, 2.27; 95% CI, 2.00-2.57). Patients with unused results were dispensed 171 ± 191 test strips per year at an estimated annual cost of $168. CONCLUSIONS Nearly 1 in 6 non-insulin-treated patients practiced SMBG without either the patient or physician using the results. This represents a wasteful and ineffective practice for patients and health systems alike. Our results suggest that the decision to initiate and continue SMBG must be made in concert with the patient's own priorities, and, if prescribed, SMBG requires effective patient provider communication and patient education.
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Randomized trial of a health IT tool to support between-visit-based laboratory monitoring for chronic disease medication prescriptions.
Grant, RW, Ashburner, JM, Jernigan, MC, Chang, J, Borowsky, LH, Chang, Y, Atlas, SJ
Journal of general internal medicine. 2015;(5):619-25
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BACKGROUND Lack of timely medication intensification and inadequate medication safety monitoring are two prevalent and potentially modifiable barriers to effective and safe chronic care. Innovative applications of health information technology tools may help support chronic disease management. OBJECTIVE To examine the clinical impact of a novel health IT tool designed to facilitate between-visit ordering and tracking of future laboratory testing. DESIGN AND PARTICIPANTS Clinical trial randomized at the provider level (n = 44 primary care physicians); patient-level outcomes among 3,655 primary care patients prescribed 5,454 oral medicines for hyperlipidemia, diabetes, and/or hypertension management over a 12-month period. MAIN MEASURES Time from prescription to corresponding follow-up laboratory testing; proportion of follow-up time that patients achieved corresponding risk factor control (A1c, LDL); adverse event laboratory monitoring 4 weeks after medicine prescription. KEY RESULTS Patients whose physicians were allocated to the intervention (n = 1,143) had earlier LDL laboratory assessment compared to similar patients (n = 703) of control physicians [adjusted hazard ratio (aHR): 1.15 (1.01-1.32), p = 0.04]. Among patients with elevated LDL (486 intervention, 324 control), there was decreased time to LDL goal in the intervention group [aHR 1.26 (0.99-1.62)]. However, overall there were no significant differences between study arms in time spent at LDL or HbA1c goal. Follow-up safety monitoring (e.g., creatinine, potassium, or transaminases) was relatively infrequent (ranging from 7 % to 29 % at 4 weeks) and not statistically different between arms. Intervention physicians indicated that lack of reimbursement for non-visit-based care was a barrier to use of the tool. CONCLUSIONS A health IT tool to support between-visit laboratory monitoring improved the LDL testing interval but not LDL or HbA1c control, and it did not alter safety monitoring. Adoption of innovative tools to support physicians in non-visit-based chronic disease management may be limited by current visit-based financial and productivity incentives.
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Exercise as a vital sign: a quasi-experimental analysis of a health system intervention to collect patient-reported exercise levels.
Grant, RW, Schmittdiel, JA, Neugebauer, RS, Uratsu, CS, Sternfeld, B
Journal of general internal medicine. 2014;(2):341-8
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BACKGROUND Lack of regular physical activity is highly prevalent in U.S. adults and significantly increases mortality risk. OBJECTIVE To examine the clinical impact of a newly implemented program ("Exercise as a Vital Sign" [EVS]) designed to systematically ascertain patient-reported exercise levels at the beginning of each outpatient visit. DESIGN AND PARTICIPANTS The EVS program was implemented in four of 11 medical centers between April 2010 and October 2011 within a single health delivery system (Kaiser Permanente Northern California). We used a quasi-experimental analysis approach to compare visit-level and patient-level outcomes among practices with and without the EVS program. Our longitudinal observational cohort included over 1.5 million visits by 696,267 adults to 1,196 primary care providers. MAIN MEASURES Exercise documentation in physician progress notes; lifestyle-related referrals (e.g. exercise programs, nutrition and weight loss consultation); patient report of physician exercise counseling; weight change among overweight/obese patients; and HbA1c changes among patients with diabetes. KEY RESULTS EVS implementation was associated with greater exercise-related progress note documentation (26.2 % vs 23.7 % of visits, aOR 1.12 [95 % CI: 1.11-1.13], p < 0.001) and referrals (2.1 % vs 1.7 %; aOR 1.14 [1.11-1.18], p < 0.001) compared to visits without EVS. Surveyed patients (n = 6,880) were more likely to report physician exercise counseling (88 % vs. 76 %, p < 0.001). Overweight patients (BMI 25-29 kg/m(2), n = 230,326) had greater relative weight loss (0.20 [0.12 - 0.28] lbs, p < 0.001) and patients with diabetes and baseline HbA1c > 7.0 % (n = 30,487) had greater relative HbA1c decline (0.1 % [0.07 %-0.13 %], p < 0.001) in EVS practices compared to non-EVS practices. CONCLUSIONS Systematically collecting exercise information during outpatient visits is associated with small but significant changes in exercise-related clinical processes and outcomes, and represents a valuable first step towards addressing the problem of inadequate physical activity.
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Individualizing HbA1c targets for patients with diabetes: impact of an automated algorithm within a primary care network.
Berkowitz, SA, Atlas, SJ, Grant, RW, Wexler, DJ
Diabetic medicine : a journal of the British Diabetic Association. 2014;(7):839-46
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AIMS: To develop glycaemic goal individualization algorithms and assess potential impact on a healthcare system and different segments of the population with diabetes. METHODS A cross-sectional observational study of patients with diabetes in a primary care network age > 18 years with an HbA1c measured between 1 January and 31 December 2011. We applied diabetes guidelines to create targeted algorithms 1 and 2, which assigned HbA1c goals based on age, duration of diabetes (< 15 years or < 10 years), diabetes complications and Charlson co-morbidity score (< 6 or < 4) [targeted algorithm 2 was designed to assign more patients a goal < 64 mmol/mol (8.0%) than targeted algorithm 1]. Each patient's HbA1c was compared with these targeted goals and to the 'standard' goal < 53 mmol/mol (7.0%). Agreement was tested using McNemar's test. RESULTS Overall, 55.7% of 12 199 patients would be considered controlled under the 'standard' approach, 61.2% under targeted algorithm 1 and 67.5% under targeted algorithm 2. Targeted algorithm 1 reclassified 1213 (23.6%) patients considered uncontrolled under the standard approach to controlled, P < 0.001. Targeted algorithm 2 reclassified 1844 (35.2%) patients, P < 0.001. Compared with those controlled under the standard goal, there was no significant difference in the proportion of those controlled using targeted goals who had Medicaid, had less than a high school diploma or received primary care in a federally qualified health centre. CONCLUSIONS Two automated targeted algorithms would reclassify one quarter to one third of patients from uncontrolled to controlled within a primary care network without differentially affecting vulnerable patient subgroups.