Four-year longitudinal culinary and lifestyle medicine track for undergraduate medical students: development and implementation.

The importance of culinary and lifestyle medicine education to combat the growing burden of chronic disease is gaining recognition in the United States. However, few medical schools offer in-depth training with a 4-year longitudinal track. The Culinary and Lifestyle Medicine Track (CLMT) is a 4-year curriculum thread created at West Virginia University School of Medicine to address the need for comprehensive culinary and lifestyle medicine education. CLMT teaches concepts of healthy nutrition, physical activity, stress management, and restorative sleep. CLMT students complete approximately 300 h of in-person and virtual culinary and lifestyle medicine education, including hands-on teaching kitchens, distributed over the preclinical and clinical years. Students are selected into the track prior to matriculation after an application and interview process. The students have exceeded expectations for scholarly and community activity. Track graduates have entered into primary care as well as specialty and surgical residencies, demonstrating that lifestyle education plays a role for students interested in a wide range of careers. Exit survey responses from learners reflected tangible and intangible benefits of participation and offered constructive feedback for improvement. Presented here are the components of the curricular design, implementation, and initial outcomes.

Effect of High-Deductible Insurance on High-Acuity Outcomes in Diabetes: A Natural Experiment for Translation in Diabetes (NEXT-D) Study.

OBJECTIVE: High-deductible health plans (HDHPs) are now the predominant commercial health insurance benefit in the U.S. We sought to determine the effects of HDHPs on emergency department and hospital care, adverse outcomes, and total health care expenditures among patients with diabetes. RESEARCH DESIGN AND METHODS: We applied a controlled interrupted time-series design to study 23,493 HDHP members with diabetes, aged 12-64, insured through a large national health insurer from 2003 to 2012. HDHP members were enrolled for 1 year in a low-deductible (≤$500) plan, followed by 1 year in an HDHP (≥$1,000 deductible) after an employer-mandated switch. Patients transitioning to HDHPs were matched to 192,842 contemporaneous patients whose employers offered only low-deductible coverage. HDHP members from low-income neighborhoods (n = 8,453) were a subgroup of interest. Utilization measures included emergency department visits, hospitalizations, and total (health plan plus member out-of-pocket) health care expenditures. Proxy health outcome measures comprised high-severity emergency department visit expenditures and high-severity hospitalization days. RESULTS: After the HDHP transition, emergency department visits declined by 4.0% (95% CI -7.8, -0.1), hospitalizations fell by 5.6% (-10.8, -0.5), direct (nonemergency department-based) hospitalizations declined by 11.1% (-16.6, -5.6), and total health care expenditures dropped by 3.8% (-4.3, -3.4). Adverse outcomes did not change in the overall HDHP cohort, but members from low-income neighborhoods experienced 23.5% higher (18.3, 28.7) high-severity emergency department visit expenditures and 27.4% higher (15.5, 39.2) high-severity hospitalization days. CONCLUSIONS: After an HDHP switch, direct hospitalizations declined by 11.1% among patients with diabetes, likely driving 3.8% lower total health care expenditures. Proxy adverse outcomes were unchanged in the overall HDHP population with diabetes, but members from low-income neighborhoods experienced large, concerning increases in high-severity emergency department visit expenditures and hospitalization days.

Diabetes Outpatient Care and Acute Complications Before and After High-Deductible Insurance Enrollment: A Natural Experiment for Translation in Diabetes (NEXT-D) Study.

Importance: High-deductible health plans (HDHPs) have expanded under the Affordable Care Act and are expected to play a major role in the future of US health policy. The effects of modern HDHPs on chronically ill patients and adverse outcomes are unknown. Objective: To determine the association of HDHP with high-priority diabetes outpatient care and preventable acute complications. Design, Setting, and Participants: Controlled interrupted-time-series study using a large national health insurer database from January 1, 2003, to December 31, 2012. A total of 12 084 HDHP members with diabetes, aged 12 to 64 years, who were enrolled for 1 year in a low-deductible (≤$500) plan followed by 2 years in an HDHP (≥$1000) after an employer-mandated switch were included. Patients transitioning to HDHPs were propensity-score matched with contemporaneous patients whose employers offered only low-deductible coverage. Low-income (n = 4121) and health savings account (HSA)-eligible (n = 1899) patients with diabetes were subgroups of interest. Data analysis was performed from February 23, 2015, to September 11, 2016. Exposures: Employer-mandated HDHP transition. Main Outcomes and Measures: High-priority outpatient visits, disease monitoring tests, and outpatient and emergency department visits for preventable acute diabetes complications. Results: In the 12 084 HDHP members included after the propensity score match, the mean (SD) age was 50.4 (10.0) years; 5410 of the group (44.8%) were women. The overall, low-income, and HSA-eligible diabetes HDHP groups experienced increases in out-of-pocket medical expenditures of 49.4% (95% CI, 40.3% to 58.4%), 51.7% (95% CI, 38.6% to 64.7%), and 67.8% (95% CI, 47.9% to 87.8%), respectively, compared with controls in the year after transitioning to HDHPs. High-priority primary care visits and disease monitoring tests did not change significantly in the overall HDHP cohort; however, high-priority specialist visits declined by 5.5% (95% CI, -9.6% to -1.5%) in follow-up year 1 and 7.1% (95% CI, -11.5% to -2.7%) in follow-up year 2 vs baseline. Outpatient acute diabetes complication visits were delayed in the overall and low-income HDHP cohorts at follow-up (adjusted hazard ratios, 0.94 [95% CI, 0.88 to 0.99] for the overall cohort and 0.89 [95% CI, 0.81 to 0.98] for the low-income cohort). Annual emergency department acute complication visits among HDHP members increased by 8.0% (95% CI, 4.6% to 11.4%) in the overall group, 21.7% (95% CI, 14.5% to 28.9%) in the low-income group, and 15.5% (95% CI, 10.5% to 20.6%) in the HSA-eligible group. Conclusions and Relevance: Patients with diabetes experienced minimal changes in outpatient visits and disease monitoring after an HDHP switch, but low-income and HSA-eligible HDHP members experienced major increases in emergency department visits for preventable acute diabetes complications.

Understanding why some women with a history of gestational diabetes do not get tested for diabetes.

BACKGROUND: The proportion of women with previous gestational diabetes mellitus (GDM) receiving postpartum diabetes testing is far less than desired. Even in health care systems with high testing rates, some women remain untested. We explored what helps and what hinders women to obtain recommended testing. METHODS: In this mixed methods study, we recruited 139 patients with a history of GDM in their most recent pregnancy (6 months to 4.5 years before study enrollment) from a delivery system that had instituted a quality improvement program to increase postpartum diabetes testing rates. We determined whether they had received a postpartum diabetes test according to American Diabetes Association guidelines. Using survey data, we ran logistic regression models to assess correlates of testing status, and we conducted in-depth interviews with 22 women to provide greater context to their survey responses. RESULTS: Of the 139 women, 21 women (15%) did not complete recommended diabetes testing. From the survey data, women who visited a primary care provider had 72% (95% CI, 0.09-0.83) lesser odds of not having been tested. From the qualitative interviews, difficulty fitting testing around work and caregiver demands were the most common reasons for not testing. Untested women interpreted providers' reassurances that diabetes would resolve after delivery and lack of reminders to reschedule missed appointments and to complete diabetes testing as indicators that their physicians were not concerned about their diabetes risk. CONCLUSIONS: Among hard-to-reach women, multiple demands on their time were common explanations for not receiving a postpartum diabetes test. Consistent messages regarding long-term diabetes risk during pregnancy, access to postpartum primary care and convenient lab appointments, and systematic reminders to providers and patients are approaches that, in combination, may influence more resistant women to test.

Rational use of electronic health records for diabetes population management.

Population management is increasingly invoked as an approach to improve the quality and value of diabetes care. Recent emphasis is driven by increased focus on both costs and measures of care as the US moves from fee for service to payment models in which providers are responsible for costs incurred, and outcomes achieved, for their entire patient population. The capacity of electronic health records (EHRs) to create patient registries, apply analytic tools, and facilitate provider- and patient-level interventions has allowed rapid evolution in the scope of population management initiatives. However, findings on the efficacy of these efforts for diabetes are mixed, and work remains to achieve the full potential of an-EHR based population approach. Here we seek to clarify definitions and key domains, provide an overview of evidence for EHR-based diabetes population management, and recommend future directions for applying the considerable power of EHRs to diabetes care and prevention.

Innovative uses of electronic health records and social media for public health surveillance.

Electronic health records (EHRs) and social media have the potential to enrich public health surveillance of diabetes. Clinical and patient-facing data sources for diabetes surveillance are needed given its profound public health impact, opportunity for primary and secondary prevention, persistent disparities, and requirement for self-management. Initiatives to employ data from EHRs and social media for diabetes surveillance are in their infancy. With their transformative potential come practical limitations and ethical considerations. We explore applications of EHR and social media for diabetes surveillance, limitations to approaches, and steps for moving forward in this partnership between patients, health systems, and public health.

Participatory surveillance of diabetes device safety: a social media-based complement to traditional FDA reporting.

BACKGROUND AND OBJECTIVE: Malfunctions or poor usability of devices measuring glucose or delivering insulin are reportable to the FDA. Manufacturers submit 99.9% of these reports. We test online social networks as a complementary source to traditional FDA reporting of device-related adverse events. METHODS: Participatory surveillance of members of a non-profit online social network, TuDiabetes.org, from October 2011 to September 2012. Subjects were volunteers from a group within TuDiabetes, actively engaged online in participatory surveillance. They used the free TuAnalyze app, a privacy-preserving method to report detailed clinical information, available through the network. Network members were polled about finger-stick blood glucose monitors, continuous glucose monitors, and insulin delivery devices, including insulin pumps and insulin pens. RESULTS: Of 549 participants, 75 reported device-related adverse events, nearly half (48.0%) requiring intervention from another person to manage the event. Only three (4.0%) of these were reported by participants to the FDA. All TuAnalyze reports contained outcome information compared with 22% of reports to the FDA. Hypoglycemia and hyperglycemia were experienced by 48.0% and 49.3% of participants, respectively. DISCUSSION: Members of an online community readily engaged in participatory surveillance. While polling distributed online populations does not yield generalizable, denominator-based rates, this approach can characterize risk within online communities using a bidirectional communication channel that enables reach-back and intervention. CONCLUSIONS: Engagement of distributed communities in social networks is a viable complementary approach to traditional public health surveillance for adverse events related to medical devices.

Participatory surveillance of hypoglycemia and harms in an online social network.

IMPORTANCE: Surveillance systems for elucidating the burden of hypoglycemia are limited. OBJECTIVE: To quantify experiences of hypoglycemia and related harms, members of an international online diabetes social network with insulin-dependent diabetes mellitus were polled through a software application ("app"). Aggregate results were returned to participants through network channels. DESIGN: The study period was from March 2011 through April 2012, during which time retrospective reports about experiences with hypoglycemia and related harms were collected from participants using the app. SETTING: The study was undertaken within the TuDiabetes.org international online diabetes social network. PARTICIPANTS: Eligibility criteria included TuDiabetes membership, age 13 years or older, a self-reported diagnosis of diabetes mellitus, ability to read and write English, and Internet access. Of 2827 app users, 687 (response rate, 24.3%) opted in to the volunteer sample. MAIN OUTCOME MEASURES: Primary outcomes included the following: frequency of "going low" (having a low glucose value in the past 2 weeks) and episodes of severe hypoglycemia (in the past 12 months), and, for respondents reporting recent and/or severe hypoglycemia, lifetime experience of vehicle crashes or severe medical injury, daily debilitating worry, and withdrawal from driving, exercise, sex, and going outside of the home to avoid hypoglycemia and consequences. Secondary outcomes included measures of research engagement. RESULTS: Of 613 respondents (24.3% of app users), 49.1% reported more than 4 episodes of "going low" in the past 2 weeks and 29.2% reported 1 or more severe low in the past year; 16.6% reported both more than 4 recent low episodes and 1 or more severe event in the past year. Harms were common, including daily debilitating worry (45.8%), vehicle crash or injury (15.0%), and withdrawal from exercise, driving, leaving home, and having sex (54.0%, 37.4%, 24.8%, and 22.7%, respectively). Of all respondents, 54.2% reported multiple harms, the risks for which were highest (73.7%) among respondents with a past-year severe event (odds ratio, 2.39; 95% CI, 1.60-3.58; P < .001 controlling for frequent recent low episodes and demographic and disease factors). Engagement was high, with 96.6% of the sample permitting recontact for research and 31.7% posting personal study data on their app profile page; 40.5% of 2825 unique page views of research-related materials published on the community site involved views of returned research results. CONCLUSIONS AND RELEVANCE: Participatory surveillance of hypoglycemia in an online diabetes social network enables characterization of patient-centered harms in a community sample and bidirectional communication with affected persons, augmenting traditional surveillance.

Early microvascular recruitment modulates subsequent insulin-mediated skeletal muscle glucose metabolism during lipid infusion.

OBJECTIVE: To test whether early, insulin-mediated microvascular recruitment in skeletal muscle predicts steady-state glucose metabolism in the setting of physiological elevation of free fatty acid concentrations. RESEARCH DESIGN AND METHODS: We measured insulin's microvascular and metabolic effects in 14 healthy young adults during a 2-h euglycemic insulin clamp. Plasma free fatty acid concentrations were raised (Intralipid and heparin infusion) for 3 h before the clamp and maintained at postprandial concentrations during the clamp. Microvascular blood volume (MBV) was measured by contrast-enhanced ultrasound (CEU) continuously from baseline through the first 30 min of the insulin clamp. Muscle glucose and insulin uptake were measured by the forearm balance method. RESULTS: The glucose infusion rate (GIR) necessary to maintain euglycemia during the clamp varied by fivefold across subjects (2.5-12.5 mg/min/kg). The early MBV responses to insulin, as indicated by CEU video intensity, ranged widely, from a 39% decline to a 69% increase. During the clamp, steady state forearm muscle glucose uptake and GIR each correlated significantly with the change in forearm MBV (P < 0.01). To explore the basis for the wide range of vascular and metabolic insulin sensitivity observed, we also measured V(O(2max)) in a subset of eight subjects. Fitness (V(O(2max))) correlated significantly with the GIR, the forearm glucose uptake, and the percentage change in MBV during the insulin clamp (P < 0.05 for each). CONCLUSIONS: Early microvascular responses to insulin strongly associate with steady state skeletal muscle insulin-mediated glucose uptake. Physical fitness predicts both metabolic and vascular insulin responsiveness.

Hyperinsulinemia rapidly increases human muscle microvascular perfusion but fails to increase muscle insulin clearance: evidence that a saturable process mediates muscle insulin uptake.

OBJECTIVE: Transport of insulin from the central circulation into muscle is rate limiting for the stimulation of glucose metabolism. By recruiting muscle microvasculature, insulin may promote its own movement into muscle interstitium. We tested whether in humans, as in the rat, insulin exerts an early action to recruit microvasculature within skeletal muscle. We further hypothesized that expansion of the microvascular volume of muscle would enhance muscle insulin clearance. RESEARCH DESIGN AND METHODS: Microvascular volume, total blood flow, and muscle insulin and glucose uptake (forearm balance method) were measured in 14 lean, healthy volunteers before and during a 2-h hyperinsulinemic-euglycemic clamp (1 mU x kg(-1) x min(-1)). Microvascular volume was measured using contrast-enhanced ultrasound. RESULTS: Forearm muscle microvascular volume increased within 20 min of insulin infusion (P < 0.01), whereas an effect to increase total forearm flow was not observed until 100 min. Forearm insulin uptake increased with physiological hyperinsulinemia (15 +/- 3 and 87 +/- 13 fmol x min(-1) x 100 ml(-1) basal vs. last 40 min of clamp, P < 0.001). However, the extraction fraction and clearance of insulin declined (P = 0.02, for each), indicating saturability of muscle insulin uptake at physiological hyperinsulinemia. CONCLUSIONS: Skeletal muscle contributes to peripheral insulin clearance both in the basal state and with physiological hyperinsulinemia. Insulin promptly expands human muscle microvascular volume but only slowly increases blood flow. Despite increased microvascular volume available for insulin uptake, muscle insulin clearance decreases significantly. These findings are consistent with the presence of a saturable transport mechanism facilitating the transendothelial transport of insulin into human muscle.