Expanding the Lifestyle Medicine Inpatient Consultation Services at Loma Linda University Health: A Transformative Tool for Chronic Diseases Management in Tertiary Care Settings.

Lifestyle Medicine (LM) is an emerging field dedicated to the prevention, management, and reversal of chronic diseases by promoting healthy lifestyle choices. LM utilizes six pillars targeting the root causes of diseases to promote health, improve clinical outcomes and significantly enhance overall quality of life. They include plant-based nutrition, physical activity, sleep health, tobacco cessation/managing risky alcohol use, and spiritual/emotional well-being. LM holds great promise as an evidence-based solution for the rising rates of chronic diseases and healthcare costs in the United States. Loma Linda University Health (LLUH), a pioneer of LM, has successfully implemented a phased expansion of its novel LM inpatient consultation services to positively impact the trajectory of morbidity and mortality among patients with chronic conditions and/risk factors admitted to the hospital. This was achieved by boosting awareness, hiring LM-trained providers to meet growing demand, and making consultations accessible hospital-wide. The service has been very well received and saw a 50-fold increase in consultations between 2016 and 2022. It is also reimbursed by all major insurers. LLUH's experience shows that establishing and growing an inpatient LM consultation service is a viable clinical and cost-effective chronic care model that can be utilized in a tertiary care setting.

The Resulting Variation in Nutrient Intake With the Inclusion of Walnuts in the Diets of Adults at Risk for Type 2 Diabetes: A Randomized, Controlled, Crossover Trial.

PURPOSE: We previously demonstrated that including walnuts in the diets of adults at risk for type 2 diabetes mellitus (T2DM) led to improved overall diet quality. This report examines the specific changes in their nutrient intake. DESIGN: This was a randomized, controlled, modified Latin square parallel design trial with 2 treatment arms. Participants were randomized to walnut intake with, or without, dietary advice to regulate caloric intake. Within each treatment arm, they were further randomized to one of 2 sequence permutations (walnut-included/walnut-excluded or walnut-excluded/walnut-included diet), with a 3-month washout between treatment phases. SETTING: Community hospital in Lower Naugatuck Valley in Connecticut. PARTICIPANTS: Cohort of 112 participants (31 men and 81 women) at risk for T2DM. INTERVENTION: Participants included 56 g (366 kcal) of walnuts in their daily diets for 6 months. MEASURES: Nutrient intake was assessed using web-based Automated Self-Administered 24-Hour Dietary Assessment. ANALYSIS: Data were analyzed using generalized linear models. RESULTS: Walnut inclusion led to increased intake of total fat, calcium, magnesium, thiamin, total saturated fatty acids, and monounsaturated and polyunsaturated fatty acids (379.0 ± 90.3 g vs -136.5 ± 92.7 g, P < .01; 230.7 ± 114.2 mg vs -95.2 ± 117.4 mg, P = .05; 111.0 ± 33.9 mg vs -32.3 ± 34.9 mg, P < .01; 0.28 ± 0.2 mg vs -0.47 ± 0.2 mg, P = .02; 8.6 ± 3.4 g vs -1.1 ± 3.5 g, P =.05; 6.3 ± 3.9 g vs -6.3 ± 4.0 g, P = .03; and 25.4 ± 4.0 vs -6.6 ± 4.2 g, P < .01, respectively). Vitamin C intake decreased (-65.3 ± 55.3 mg vs 98.9 ± 56.8 mg, P = .04). Protein intake increased from baseline with the inclusion of walnuts (20.0 ± 8.8 g, P < .05). Walnut inclusion led to an increase in total calories consumed when caloric intake is not regulated. CONCLUSION: Including walnuts in the diets of these adults led to increased dietary intake of some nutrients associated with lower risk of developing T2DM and other cardiometabolic risk factors.

Which foods are displaced in the diets of adults with type 2 diabetes with the inclusion of eggs in their diets? A randomized, controlled, crossover trial.

BACKGROUND: The inclusion or exclusion of specific foods from the overall diet inevitably affects other food choices, and this matter is routinely neglected in dietary guidance and nutritional epidemiology. We examined how the inclusion of eggs in the diets of type 2 diabetics affected dietary pattern. METHODS: Randomized, controlled, single-blind, crossover trial of 34 adults (mean age 64.5 years; 14 women, 20 men) with type 2 diabetes assigned to one of two possible sequence permutations of two different 12-week treatments (two eggs/day or egg exclusion), with 6-week washout periods. For the egg inclusion phase, participants received advice from a dietitian on how to preserve an isocaloric condition relative to the egg exclusion phase. To assess changes in dietary pattern in the diets of our study participants, we analyzed the 12 components of the 2010 Healthy Eating Index. RESULTS: The inclusion of eggs was associated with reduced consumption of refined grains nearing statistical significance (-0.7±3.4 vs 0.7±2.2; p=0.0530). The consumption of total protein foods significantly increased from baseline (0.3±0.7; p=0.0153) with the inclusion of eggs for 12 weeks, while the consumption of dairy products significantly decreased with the exclusion of eggs from their diets (-1.3±2.9; p=0.0188). CONCLUSIONS: Eggs in the diets of type 2 diabetics may lead to increased consumption of some healthful foods and reduced consumption of some less healthful foods. TRIAL REGISTRATION NUMBER: NCT02052037; Post-results.

7-Hexagon Multifocal Electroretinography for an Objective Functional Assessment of the Macula in 14 Seconds.

PURPOSE: We present the multifocal electroretinogram (mfERG) with a 7-hexagon array as an objective test of macular function that can be recorded in 14 s. We provide normal values and investigate its reproducibility and validity. METHODS: Healthy participants underwent mfERG testing according to International Society for Clinical Electrophysiology of Vision (ISCEV) standards using the Espion Profile/D310 multifocal ERG system (Diagnosys, LLC, Lowell, MA, USA). One standard recording of a 61-hexagon array and 2 repeated recordings of a custom 7-hexagon array were obtained. RESULTS: A total of 13 subjects (mean age 46.9 years) were included. The median response densities were 12.5 nV/deg2 in the center and 5.2 nV/deg2 in the periphery. Intereye correlations were strong in both the center (ρCenter = 0.821; p < 0.0001) and the periphery (ρPeriphery = 0.862; p < 0.0001). Intraeye correlations were even stronger: ρCenter = 0.904 with p < 0.0001 and ρPeriphery = 0.955 with p < 0.0001. Bland-Altman plots demonstrated an acceptable retest mean difference in both the center and periphery, and narrow limits of agreement. We found strong correlations of the center (ρCenter = 0.826; p < 0.0001) and periphery (ρPeriphery = 0.848; p < 0.0001), with recordings obtained by the 61-hexagon method. CONCLUSIONS: The 7-hexagon mfERG provides reproducible results in agreement with results obtained according to the ISCEV standard.

Fixation Stability Measurement Using Two Types of Microperimetry Devices.

PURPOSE: We compared the fixation stability measurements obtained with two microperimeters, the Micro Perimeter 1 (MP-1) and the Spectral OCT/SLO (OCT/SLO), in subjects with and without maculopathies. METHODS: A total of 41 eyes with no known ocular diseases and 45 eyes with maculopathies were enrolled in the study. Both eyes of each participant had a 20-second fixation test using the MP-1 and OCT/SLO. The bivariate contour ellipse area (BCEA) was used for fixation stability evaluation. RESULTS: In the normal group, BCEA was 2.93 ± 0.32 log minarc2 on OCT/SLO and 2.89 ± 0.30 log minarc2 on MP-1. In the maculopathy group, BCEA was 3.05 ± 0.41 log minarc2 on OCT/SLO and 3.15 ± 0.46 log minarc2 on MP-1. There was no statistically significant difference between the BCEA measured by OCT/SLO and by MP-1 in both groups. A moderate correlation was found between the two devices (r = 0.45, P < 0.001). The sample size during the fixation test was 535.5 ± 14.6 pairs of coordinates in the normal group and 530.7 ± 14.9 pairs in the maculopathy group with MP-1, while it was 72.3 ± 6.9 and 59.9 ± 10.1, respectively, with OCT/SLO. This was due to different tracking frequencies between the two microperimeters. CONCLUSION: Fixation stability assessment yields similar results using the OCT/SLO and MP-1. A major difference in sampling rate between the two microperimeters does not significantly affect BCEA measurements. TRANSLATIONAL RELEVANCE: Fixation stability assessments are comparable and interchangeable between the OCT/SLO and the MP-1.

Assessment of oxygen saturation in retinal vessels of normal subjects and diabetic patients with and without retinopathy using Flow Oximetry System.

PURPOSE: To assess oxygen saturation (StO2) in retinal vessels of normal subjects and diabetic patients with and without retinopathy using the modified version of the Flow Oximetry System (FOS) and a novel assessment software. METHODS: The FOS and novel assessment software were used to determine StO2 levels in arteries and veins located between 1 and 2 mm from the margin of the optic disc and in the macular area. RESULTS: Eighteen normal subjects, 15 diabetics without diabetic retinopathy (DM no DR), and 11 with non-proliferative diabetic retinopathy (NPDR) were included in final analysis. The mean [± standard deviation (SD)] StO2 in retinal arteries was 96.9%±3.8% in normal subjects; 97.4%±3.7% in DM no DR; and 98.4%±2.0% in NPDR. The mean venous StO2 was 57.5%±6.8% in normal subjects; 57.4%±7.5% in DM no DR; and 51.8%±6.8% in NPDR. The mean arterial and venous StO2 across the three groups were not statistically different (P=0.498 and P=0.071, respectively). The arterio-venous differences between the three study groups, however, were found to be statistically significant (P=0.015). Pairwise comparisons have demonstrated significant differences when comparing the A-V difference in the NPDR group to either normal subjects (P=0.02) or diabetic patients without DR (P=0.04). CONCLUSIONS: The arterio-venous difference was greater, and statistically significant, in patients with NPDR when compared to normal subjects and to patients with diabetes and no retinopathy. The mean venous StO2 was lower, but not statistically significant, in NPDR compared with diabetics without retinopathy and with normal subjects.

Assessment of Central Retinal Sensitivity Employing Two Types of Microperimetry Devices.

PURPOSE: To compare the retinal sensitivity measurements obtained with two microperimeters, the Micro-Perimeter 1 (MP-1) and the Optos optical coherence tomography (OCT)/scanning laser ophthalmoscope (SLO) in subjects with and without maculopathies. METHODS: Forty-five eyes with no known ocular disease and 47 eyes with maculopathies were examined using both microperimeters. A contrast-adjusted scale was applied to resolve the different stimuli and background luminance existing between the two devices. RESULTS: There was a strong ceiling effect with the MP-1 in the healthy group, with 90.1% (1136 of 1260) test points clustered at 20 dB. The mean sensitivity for the corresponding points in the OCT/SLO was 25.8 ± 1.9 dB. A floor effect was also observed with the OCT/SLO in the maculopathy group with 9.7% (128 of 1316) points clustered at 9-dB values. The corresponding mean sensitivity in the MP-1 was 1.7 ± 3.9 dB. A regression equation between the two microperimeters was established in the common 10 to19 dB intervals as: OCT/SLO = 15.6 + 0.564 × MP-1 - 0.009 × MP-12 + k (k is an individual point constant; MP-1 coefficient P < 0.001; MP-12 coefficient P = 0.006). CONCLUSION: The OCT/SLO and the MP-1 provide two different ranges of contrasts for microperimetry examination. Broadening the dynamic range may minimize the constraint of the ceiling and floor effect. There is a significant mathematical relationship in the common interval of the contrast scale. TRANSLATIONAL RELEVANCE: Applying a unified and broadened dynamic range in different types of microperimeters will help to generate consistent clinical reference for measurements.

New treatment options for noninfectious uveitis.

Autoimmune uveitis is a group of sight-threatening inflammatory diseases associated with an exacerbated immunological response to ocular proteins. The Standardization of Uveitis Nomenclature Working Group Guidelines have recommended the use of corticosteroids as the first line of therapy for patients who present with active uveitis. However, long-term use of corticosteroids is associated with numerous adverse effects including cataract, glaucoma and metabolic disorders. In this context, new drugs developed to treat rheumatic diseases, and other autoimmune diseases, are being employed often as monotherapy or combined with other immunosuppressive drugs in order to decrease the corticosteroid burden on patients and to manage refractive uveitis. These drugs are currently being evaluated in the framework of uveitis and may open a new horizon with less side effects and more responsiveness for chronic cases. Among others, calcineurin inhibitor voclosporin, mammalian target of rapamycin inhibitor sirolimus, and the IL-1 trap rilonacept, are among these new agents and will be scrutinized in detail in this chapter. More efficient modes of drug delivery are also being employed to deliver high concentration of drug locally and to minimize systemic side effects. The new modes of drug delivery that we will describe in the index chapter include nanoparticles and iontophoresis.