Impact of a Participatory Wellness Continuing Medical Education Program on Physician Burnout and Well-Being.

OBJECTIVE: Examine the impact of a participatory wellness continuing medical education (CME) program on physician burnout, wellness, and well-being. METHODS: Physicians attending a three-day wellness CME program. Self-reported questionnaires at baseline with paired analyses at 26-week follow-up. RESULTS: Compared to baseline, at 26 weeks there were decreases in burnout (P < .001, ES -0.68), red meat consumption (P = .02, ES -0.29), and current stress levels (P < .001, ES -0.50). There were increases in fruit/vegetable consumption (P < .001, ES 0.55), energy levels at work (P < .001, ES 0.60) and at home (P < .001, ES 0.66), quality of life (P < .001, ES 0.53), and confidence (P < .001, ES 0.89) and frequency (P = .01, ES 0.32) of counseling patients on wellness. CONCLUSION: Attendance at this participatory wellness CME program was associated with improved physician burnout, health behaviors in diet, stress, energy, quality of life, and wellness counseling.

Unraveling the Variability of Human Satiation: Implications for Precision Obesity Management.

Satiation is the physiologic process that regulates meal size and termination, and it is quantified by the calories consumed to reach satiation. Given its role in energy intake, changes in satiation contribute to obesity's pathogenesis. Our study employed a protocolized approach to study the components of food intake regulation including a standardized breakfast, a gastric emptying study, appetite sensation testing, and a satiation measurement by an ad libitummeal test. These studies revealed that satiation is highly variable among individuals, and while baseline characteristics, anthropometrics, body composition and hormones, contribute to this variability, these factors do not fully account for it. To address this gap, we explored the role of a germline polygenic risk score, which demonstrated a robust association with satiation. Furthermore, we developed a machine-learning-assisted gene risk score to predict satiation and leveraged this prediction to anticipate responses to anti-obesity medications. Our findings underscore the significance of satiation, its inherent variability, and the potential of a genetic risk score to forecast it, ultimately allowing us to predict responses to different anti-obesity interventions.

Phenotype tailored lifestyle intervention on weight loss and cardiometabolic risk factors in adults with obesity: a single-centre, non-randomised, proof-of-concept study.

Background: Lifestyle interventions for weight loss are currently not individualised to underlying pathophysiology and behavioral traits in obesity. We aim to compare the outcome of a standard lifestyle intervention (SLI) to phenotype-tailored lifestyle interventions (PLI) on weight loss, cardiometabolic risk factors and physiologic variables contributing to obesity. Methods: This 12-week, single-centre non-randomised proof-of-concept clinical trial including men and women aged 18-65 years with a body mass index (BMI) greater than 30 without history of any bariatric procedure, and current use of any medication known to affect weight. Participants lived anywhere in the United States, and underwent in-person testing in Rochester, MN at a teaching hospital. All participants completed in-person phenotype testing at baseline and after 12 weeks. Participants were assigned to their intervention based on their period of enrollment. In the first phase, participants were assigned to SLI with a low-calorie diet (LCD), moderate physical activity, and weekly behavioral therapy sessions. In the second phase, other participants were assigned to PLI according to phenotype: abnormal satiation (time-restricted volumetric LCD); abnormal postprandial satiety (LCD with pre-meal protein supplementation); emotional eating (LCD with intensive behavioral therapy); and abnormal resting energy expenditure (LCD with post-workout protein supplementation and high-intensity interval training). The primary outcome was total body weight loss in kg at 12 weeks using multiple imputation for missing data. Linear models estimated the association of study group allocation and study endpoints adjusting for age, sex, and baseline weight. This study was registered with ClinicalTrials.gov, NCT04073394. Findings: Between July 2020 and August 2021, 211 participants were screened, and 165 were assigned to one of the two treatments in the two phases: 81 SLI (mean [SD] age 42.9 [12] years; 79% women; BMI 38.0 [6.0]) and 84 PLI (age 44.8 [12.2] years; 83% women; BMI 38.7 [6.9]); 146 completed the 12-week programs. The weight loss was -7.4 kg (95%CI, -8.8, -6.0) with PLI vs. -4.3 kg (95%CI, -5.8, -2.7) with SLI (difference, -3.1 kg [95%CI, -5.1 to -1.1]; P = 0.004). No adverse events were reported in any group. Interpretation: Phenotype-tailored lifestyle interventions may result in significant weight loss, but a randomised controlled trial is required to confirm causality. Funding: Mayo Clinic; NIH (K23-DK114460).

Sex as an independent variable in the measurement of satiation: a retrospective cohort study.

BACKGROUND: Satiation is a key component of food intake regulation as it brings an eating episode to an end. The effect of sex on satiation measurement has not been characterized. OBJECTIVE: To assess the effects of biological variables on satiation. DESIGN: Retrospective cohort study. We included 959 participants (mean age 39 [SD 12] years; 70.7% female, and BMI 33 kg/m2 [8]) who had measurements of satiation with a nutrient-drink test to assess volume to fullness (VTF) and maximum tolerated volume (MTV), and/or an ad libitum meal test to assess calories consumed to fullness (CTF). We performed univariate and multiple regression analyses to estimate the contribution of sex to VTF, MTV, and CTF, compared to other biological variables, such as age, weight, height, BMI, waist-to-hip circumference (W/H), and lean mass percentage (LM%), that are known to affect these parameters. RESULTS: Females had higher BMI, W/H, and LM%. VTF, MTV, and CTF were lower in females: 704 [323] vs. 783 [328] mL, p = 0.001; 1226 [384] vs. 1419 [410] mL, p < 0.001; and 871 [291] vs. 1086 [326] kcal, p < 0.001; respectively. Sex was a strong and independent predictor of VTF, MTF and CTF: parameter estimate [PE] = -80.8, p = 0.006; PE = -124.2, p = 0.0007; and PE = -110, p = 0.001; respectively. CONCLUSIONS: Sex has a strong effect on satiation measured by VTF, MTV, and CTF, even after adjusting for other biological factors known to affect these parameters. Females seem to integrate intra-meal inhibition signals to consume fewer calories unrelated to body size or composition. CLINICAL TRIAL REGISTRATION: None.

Effects of Heterozygous Variants in the Leptin-Melanocortin Pathway on Roux-en-Y Gastric Bypass Outcomes: a 15-Year Case-Control Study.

INTRODUCTION: Heterozygous variants in the leptin-melanocortin pathway are associated with obesity. However, their effect on the long-term outcomes after Roux-en-Y gastric bypass (RYGB) is still unknown. METHODS: In this matched case-control study, 701 participants from the Mayo Clinic Biobank with a history of RYGB were genotyped. Sixty-three patients had a heterozygous variant in the leptin-melanocortin pathway. After excluding patients with potential confounders, carriers were randomly matched (on sex, age, body mass index [BMI], and years since surgery) with two non-carrier controls. The electronic medical record of carriers and matched non-carriers was reviewed for up to 15 years after RYGB. RESULTS: A total of 50 carriers and 100 matched non-carriers with a history of RYGB were included in the study. Seven different genes (LEPR, PCSK1, POMC, SH2B1, SRC1, MC4R, and SIM1) in the leptin-melanocortin pathway were identified. At the time of surgery, the mean age was 50.8 ± 10.6 years, BMI 45.6 ± 7.3 kg/m2, and 79% women. There were no differences in postoperative years of follow-up, Roux limb length, or gastric pouch size between groups. Fifteen years after RYGB, the percentage of total body weight loss (%TBWL) in carriers was - 16.6 ± 10.7 compared with - 28.7 ± 12.9 in non-carriers (diff = 12.1%; 95% CI, 4.8 to 19.3) and the percentage of weight regain after maximum weight loss was 52.7 ± 29.7 in carriers compared with 29.8 ± 20.7 in non-carriers (diff = 22.9%; 95% CI, 5.3 to 40.5). The nadir %TBWL was lower - 32.1 ± 8.1 in carriers compared with - 36.8 ± 10.4 in non-carriers (diff = 4.8%; 95% CI 1.8 to 7.8). CONCLUSIONS: Carriers of a heterozygous variant in the leptin-melanocortin pathway have a progressive and significant weight regain in the mid- and long-term after RYGB. Genotyping patients experiencing significant weight regain after RYGB could help implement multidisciplinary and individualized weight loss interventions to improve weight maintenance after surgery.

Association between anxiety and eating behaviors in patients with obesity.

Background: Given the link between eating behavior and obesity, it is critical to identify individuals who have eating behaviors which contribute to obesity etiology. This study aimed to investigate the potential relationship between symptoms of anxiety and eating behaviors in patients with obesity. Methods: This was a cross-sectional study analyzing baseline characteristics of 438 patients with obesity (BMI>30). Patients completed the Hospital Anxiety and Depression Scale (HADS) questionnaire, the Three-Factor Eating Questionnaire R21 (TFEQ-R21), and the Weight Efficacy Lifestyle Questionnaire (WEL). Pearson correlation coefficients were used to evaluate the association between questionnaires. Two-sample independent t-test were conducted to examine differences in the TFEQ-R21 and WEL between low and moderate to severe levels of symptoms of anxiety. Results: Anxiety scores (HADS-A) positively correlated with two factors of the TFEQ, emotional eating (r = 0.36) and uncontrolled eating (r = 0.27). The HADS-A score was negatively correlated with self-efficacy to resist eating in all five situational factors on the WEL (p < 0.01). Patients with symptoms of anxiety additionally showed higher mean scores for emotional eating and uncontrolled eating (p < 0.001, respectively),and lower levels of cognitive restraint (p = 0.04)) on the TFEQ-R21. Conclusion: Patients with obesity who reported having anxiety symptoms had lower self-confidence to manage their eating and more emotional eating than patients with low anxiety symptoms. Clearly more needs to be learned about symtoms of anxiety and eating behaviors.

The effect of culinary interventions (cooking classes) on dietary intake and behavioral change: a systematic review and evidence map.

BACKGROUND: Culinary interventions (cooking classes) have been used to improve the quality of dietary intake and change behavior. The aim of this systematic review is to investigate the effects of culinary interventions on dietary intake and behavioral and cardiometabolic outcomes. METHODS: We conducted a systematic review of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus for comparative studies that evaluated culinary interventions to a control group or baseline values. The intervention was defined as a cooking class regardless of its length or delivery approach. Studies included populations of children, healthy adults or adults with morbidities. The risk of bias was assessed using the Cochrane Risk of Bias tool and the Newcastle-Ottawa Scale. Outcomes were pooled using the random-effects model and descriptive statistics and depicted in an evidence map. Simple logistic regression was used to evaluate factors associated with intervention success. RESULTS: We included 30 studies (6 were randomized, 7381 patients, average follow up 25 weeks). Culinary interventions were not associated with a significant change in body mass index (- 0.07 kg/m2, 95% CI: -1.53, 1.40), systolic (- 5.31 mmHg, 95% CI: -34.2, 23.58) or diastolic blood pressure (- 3.1 mmHg, 95% CI: -23.82, 17.62) or LDL cholesterol (- 8.09 mg/dL, 95% CI: -84.43, 68.25). Culinary interventions were associated with improved attitudes, self-efficacy and healthy dietary intake in adults and children. We were unable to demonstrate whether the effect of a culinary intervention was modified by various characteristics of the intervention such as its delivery or intensity. Interventions with additional components such as education on nutrition, physical activity or gardening were particularly effective. CONCLUSIONS: Culinary interventions were not associated with a significant change in cardiometabolic risk factors, but were associated with improved attitudes, self-efficacy and a healthier dietary intake in adults and children.

Health Habits of Employees in a Large Medical Center: Time Trends and Impact of a Worksite Wellness Facility.

Worksite health interventions are not novel but their effect remains subject of debate. We examined employer-based wellness program to determine health habits trends, and compare prevalence estimates to national data. We conducted serial surveys (1996 and 2007-10) to employees of a large medical center that included questions measuring outcomes, including obesity, regular exercise, cardiovascular activity, and smoking status. Logistic regression models were estimated to compare data by membership across years, considering p-values ≤ 0.01 as statistically significant. 3,206 employees responded (Response rates 59-68%). Obesity prevalence increased over time in members and nonmembers of the wellness facility, consistent with national trends. Members had a lower prevalence of cigarette smoking compared to nonmembers (overall year-adjusted odds ratio 0.66, P < 0.001). Further, employees had a lower prevalence of cigarette smoking (9.7 vs. 17.3% in 2010, P < 0.001) compared with national data. Wellness facility membership was associated with increased regular exercise and cardiovascular exercise (P < 0.001) compared to nonmembers. In summary, working in a medical center was associated with a decreased prevalence of cigarette smoking, but not with lower prevalence of obesity. Worksite wellness facility membership was associated with increased exercise and decreased cigarette smoking. Employer-based interventions may be effective in improving some health behaviors.

The effect of coffee consumption on blood pressure and the development of hypertension: a systematic review and meta-analysis.

CONTEXT: Coffee is one of the most widely consumed beverages worldwide and is known to acutely raise blood pressure (BP), but the effects of chronic consumption on BP is unclear. OBJECTIVES: To conduct a systematic review and meta-analysis of available randomized controlled trials (RCTs) and cohort studies to assess the effect of chronic coffee consumption on BP and the development of hypertension. DATA SOURCES: Ovid, MEDLINE (from 1948), EMBASE (from 1988), and all of Web of Science and Scopus. STUDY SELECTION: RCTs and cohort studies of at least 1-week duration that assessed BP and/or the incidence of hypertension in coffee consumers compared with a control group that consumed less or no coffee. DATA EXTRACTION: Two authors independently reviewed abstracts and full-text articles for inclusion. Data were abstracted using standardized forms. Risk of bias in the RCTs was examined using the method described in the Cochrane Handbook for Systematic Reviews of Interventions. Quality of the cohort studies were assessed using the Newcastle-Ottawa quality assessment scale for cohort studies. DATA SYNTHESIS: Six hundred and ten articles were retrieved and a total of 15 (10 RCTs and five cohort studies) met inclusion criteria. Meta-analysis of RCTs demonstrated a pooled weighted difference in mean change in SBP of -0.55 mmHg [95% confidence interval (CI) -2.46 to 1.36) and DBP -0.45 mmHg (95% CI -1.52 to 0.61). Meta-analysis of the cohort studies demonstrated a pooled risk ratio for developing hypertension of 1.03 (95% CI 0.98-1.08). CONCLUSION: Low-quality evidence did not show any statistically significant effect of coffee consumption on BP or the risk of hypertension. Given the quality of the currently available evidence, no recommendation can be made for or against coffee consumption as it relates to BP and hypertension.

The diagnostic yield of the first episode of a periodic health evaluation: a descriptive epidemiology study.

BACKGROUND: The benefits of a periodic health evaluation remain debatable. The incremental value added by such evaluations beyond the delivery of age appropriate screening and preventive medicine recommendations is unclear. METHODS: We retrospectively collected data on a cohort of consecutive patients presenting for their first episode of a comprehensive periodic health evaluation. We abstracted data on new diagnoses that were identified during this single episode of care and that were not trivial (i.e., required additional testing or intervention). RESULTS: The cohort consisted of 491 patients. The rate of new diagnoses per this single episode of care was 0.9 diagnoses per patient. The majority of these diagnoses was not prompted by patients' complaints (71%) and would not have been identified by screening guidelines (51%). Men (odds ratio 2.67; 95% CI, 1.76, 4.03) and those with multiple complaints at presentation (odds ratio 1.12; 95% CI, 1.05, 1.19) were more likely to receive a clinically relevant diagnosis at the conclusion of the visit. Age was not a predictor of receiving a diagnosis in this cohort. CONCLUSION: The first episode of a comprehensive periodic health evaluation may reveal numerous important diagnoses or risk factors that are not always identified through routine screening.

Clinical review: The effect of vitamin D on falls: a systematic review and meta-analysis.

CONTEXT: Vitamin D affects bone and muscle health and likely reduces the risk of falls in the elderly. OBJECTIVE: The aim of this systematic review is to summarize the existing evidence on vitamin D use and the risk of falls. DATA SOURCES: We searched electronic databases from inception through August 2010. STUDY SELECTION: Eligible studies were randomized controlled trials in which the intervention was vitamin D and the incidence of falls was reported. DATA EXTRACTION: Reviewers working in duplicate and independently extracted study characteristics, quality, and outcomes data. DATA SYNTHESIS: Odds ratio and associated 95% confidence interval were estimated from each study and pooled using the random effects model. RESULTS: We found 26 eligible trials of moderate quality that enrolled 45,782 participants, the majority of which were elderly and female. Vitamin D use was associated with statistically significant reduction in the risk of falls (odds ratio for suffering at least one fall, 0.86; 95% confidence interval, 0.77-0.96). This effect was more prominent in patients who were vitamin D deficient at baseline and in studies in which calcium was coadministered with vitamin D. The quality of evidence was low to moderate because of heterogeneity and publication bias. CONCLUSIONS: Vitamin D combined with calcium reduces the risk of falls. The reduction in studies without calcium coadministration did not reach statistical significance. The majority of the evidence is derived from trials enrolling elderly women.

Vitamin D and cardiovascular outcomes: a systematic review and meta-analysis.

CONTEXT: Several studies found association between vitamin D levels and hypertension, coronary artery calcification, and heart disease. OBJECTIVE: The aim of this study was to summarize the evidence on the effect of vitamin D on cardiovascular outcomes. DESIGN AND METHODS: We searched electronic databases from inception through August 2010 for randomized trials. Reviewers working in duplicate and independently extracted study characteristics, quality, and the outcomes of interest. Random-effects meta-analysis was used to pool the relative risks (RR) and the weighted mean differences across trials. RESULTS: We found 51 eligible trials with moderate quality. Vitamin D was associated with nonsignificant effects on the patient-important outcomes of death [RR, 0.96; 95% confidence interval (CI), 0.93, 1.00; P = 0.08], myocardial infarction (RR, 1.02; 95% CI, 0.93, 1.13; P = 0.64), and stroke (RR, 1.05; 95% CI, 0.88, 1.25; P = 0.59). These analyses were associated with minimal heterogeneity. There were no significant changes in the surrogate outcomes of lipid fractions, glucose, or diastolic or systolic blood pressure. The latter analyses were associated with significant heterogeneity, and the pooled estimates were trivial in absolute terms. CONCLUSIONS: Trial data available to date are unable to demonstrate a statistically significant reduction in mortality and cardiovascular risk associated with vitamin D. The quality of the available evidence is low to moderate at best.

Physician diagnosis of overweight status predicts attempted and successful weight loss in patients with cardiovascular disease and central obesity.

INTRODUCTION: Despite the association of central obesity with adverse outcomes, most patients with cardiovascular disease (CVD) are unable to successfully lose weight. We undertook this analysis to evaluate the effect of motivational factors, and clinical factors, including physician diagnosis of overweight, on weight loss in patients with CVD and central obesity in the United States. METHODS AND RESULTS: We used data from the National Health and Nutrition Examination Survey 1999 to 2004. Waist circumference ≥ 102 cm in men and ≥ 88 cm in women were used to classify central obesity. We examined demographic, motivational and clinical determinants of attempted and successful weight loss using multivariable logistic regression. Successful weight loss was defined as ≥ 5% weight loss in the preceding year. There were 907 respondents with CVD and central obesity of which 78% were aware of their overweight status and 80% were desirous to weigh less. Despite this awareness and desire, only 49% of centrally obese adults had attempted weight loss in the last year. Only 62% (n = 584) reported that they had been informed that they were overweight by a physician. On multivariable analysis, physician diagnosis of overweight was a significant predictor of weight loss attempts (OR 2.42, 95% CI 1.44-4.09, P = .006) and successful weight loss (OR 2.70, 95% CI 1.40-5.19, P = .001). CONCLUSION: In a nationally representative sample of adults with CVD and central obesity, physician diagnosis of overweight status emerged as a significant predictor of attempted and successful weight loss.

Vitamin D deficiency an important, common, and easily treatable cardiovascular risk factor?

Vitamin D deficiency is a highly prevalent condition, present in approximately 30% to 50% of the general population. A growing body of data suggests that low 25-hydroxyvitamin D levels may adversely affect cardiovascular health. Vitamin D deficiency activates the renin-angiotensin-aldosterone system and can predispose to hypertension and left ventricular hypertrophy. Additionally, vitamin D deficiency causes an increase in parathyroid hormone, which increases insulin resistance and is associated with diabetes, hypertension, inflammation, and increased cardiovascular risk. Epidemiologic studies have associated low 25-hydroxyvitamin D levels with coronary risk factors and adverse cardiovascular outcomes. Vitamin D supplementation is simple, safe, and inexpensive. Large randomized controlled trials are needed to firmly establish the relevance of vitamin D status to cardiovascular health. In the meanwhile, monitoring serum 25-hydroxyvitamin D levels and correction of vitamin D deficiency is indicated for optimization of musculoskeletal and general health.

The influence of sex and obesity phenotype on meal fatty acid metabolism before and after weight loss.

BACKGROUND: Regional differences in meal fat storage may explain the preservation of fat accumulation in obese persons. OBJECTIVE: The objective was to determine whether meal fatty acid (FA) metabolism differs by sex and obesity phenotypes before and after weight loss. DESIGN: A [(3)H]triolein-containing meal was given to trace meal FA oxidation ((3)H(2)O generation) and adipose tissue uptake (abdominal subcutaneous and gluteal biopsy samples) in 13 upper-body obese (UOb) men, 9 UOb women, and 8 lower-body obese (LOb) women (study 1). Dual-energy X-ray absorptiometry and abdominal computed tomography were used to measure fat distribution. The subjects participated in a diet and exercise weight-loss program, after which 23 subjects returned for an identical study (study 2). RESULTS: In study 1, the storage of meal FA (mg meal fat/g adipose lipid) was greater in gluteal than in abdominal fat (P = 0.022) in LOb women, but not in UOb women or UOb men. UOb men stored a lesser percentage of meal FAs in both upper- and lower-body subcutaneous fat than did the LOb and UOb women (P = 0.001 and P = 0.044, respectively). The participants who returned for study 2 had lost 14.1 +/- 1.1 kg. Changes in the uptake of meal FAs followed a pattern indicative of obesity phenotype maintenance by group. The uptake of meal FAs increased in upper-body subcutaneous fat (P = 0.028) in weight-reduced UOb women and UOb men (P = 0.046) and decreased in lower-body fat (P = 0.025) in UOb men. CONCLUSION: The differences in meal FA trafficking by obesity phenotype suggest that meal FA storage may play a role in regulating body fat distribution in obese persons.

The impact of a quality improvement program on employee satisfaction in an academic microsystem.

Quality improvement is a potential method to enhance employee satisfaction. This study describes the impact of a program instituted to enhance employee satisfaction using the principles of high-performing microsystems. A shared leadership committee, participatory meetings, suggestion boxes, and quality improvement projects were implemented as part of the program. A follow-up survey 1 year after implementation of the program demonstrated an increase in employee perception of the division's desire to improve service (16%), opportunities to expand skills (17%), involvement in work decisions (25%), and the institution's interest in employee well-being (17%). Key drivers of discretionary effort (4 of 5), job satisfaction (2 of 6), and overall satisfaction (1 of 8) with the institution showed statistically significant improvement in the study division as compared with the other divisions in which no such program was implemented. Further research is needed to study systems changes that enhance employee satisfaction and their impact on patient and financial outcomes.

An office-place stepping device to promote workplace physical activity.

OBJECTIVE: It was proposed that an office-place stepping device is associated with significant and substantial increases in energy expenditure compared to sitting energy expenditure. The objective was to assess the effect of using an office-place stepping device on the energy expenditure of lean and obese office workers. METHODS: The office-place stepping device is an inexpensive, near-silent, low-impact device that can be housed under a standard desk and plugged into an office PC for self-monitoring. Energy expenditure was measured in lean and obese subjects using the stepping device and during rest, sitting and walking. 19 subjects (27+/-9 years, 85+/-23 kg): 9 lean (BMI<25 kg/m2) and 10 obese (BMI>29 kg/m2) attended the experimental office facility. Energy expenditure was measured at rest, while seated in an office chair, standing, walking on a treadmill and while using the office-place stepping device. RESULTS: The office-place stepping device was associated with an increase in energy expenditure above sitting in an office chair by 289+/-102 kcal/hour (p<0.001). The increase in energy expenditure was greater for obese (335+/-99 kcal/hour) than for lean subjects (235+/-80 kcal/hour; p = 0.03). The increments in energy expenditure were similar to exercise-style walking. CONCLUSION: The office-place stepping device could be an approach for office workers to increase their energy expenditure. If the stepping device was used to replace sitting by 2 hours per day and if other components of energy balance were constant, weight loss of 20 kg/year could occur.