Performance Medicine: a novel and needed paradigm for proactive health care.

Performance Medicine is an emerging clinical practice that holds immense promise for advancing preventive health. To date, however, the concept remains imprecise, disorganized, and commercialized. The purpose of this perspective article is to define characteristics, core tenets, and practice standards to help build a common framework. We define performance broadly as "one's capacity to bring energy and attention to what matters most in a given moment". Performance Medicine, therefore, is predicated on the thesis that the critical practices that enhance one's daily wellbeing simultaneously increase both lifespan and healthspan. As a clinical practice, Performance Medicine is proactive and preventive. It focuses on the immediate and actionable strategies to address one's physical, mental, and emotional capabilities every day. The practice employs a values-centered approach that begins with a discovery process to elucidate the client's deeply held beliefs about their health status, life mission and goals, vision for optimal wellbeing, and motivations for change. Subsequent diagnostics and therapies combine evidence-based practices from multiple medical specialties including internal medicine, sports medicine, obesity medicine, integrative medicine, and others. This is complemented by the most recent scientific advancements in nutrition, exercise physiology, sleep, and recovery. The Performance Medicine prescription incorporates a personalized combination of lifestyle-based behavior change practices, evidence-based diagnostics and risk reduction therapies, ongoing monitoring, and community support. Finally, the iterative and incremental process towards enhanced and sustained health is guided and supported by a trusted partnership between the client and a team of expert practitioners and coaches.

Vitamin D deficiency associated with risk of prediabetes among older adults: Data from the National Health and Nutrition Examination Survey (NHANES), 2007-2012.

AIM: To examine the association between vitamin D (25(OH)D) deficiency and risk of prediabetes in Americans 50+ years of age. MATERIALS AND METHODS: This was a cross-sectional analysis of NHANES (2007-2012) subjects aged 50+ years, free of kidney/liver diseases and diabetes. Prediabetes was defined as: HbA1c level 5.7%-6.4%, or fasting plasma glucose level 100-125 mg/dL, or Oral Glucose Tolerance Test result 140-199 mg/dL, with no laboratory value in the diabetic range. The comparison group had normal glucose tolerance (NGT) with no marker in the prediabetes/diabetes range. Total serum 25(OH)D levels were deficient at <50 nmol/L, insufficient 50-75 nmol/L, and sufficient >75 nmol/L. Logistic regression included strata, cluster and weight variables. Models were adjusted for body mass index (BMI), ethnicity, age and gender. RESULTS: The final sample was 2286 adults, predominantly White (80.4%) and female (56.6%), with a mean age of 62.3 years. Within the sample, 1387 had prediabetes (59.1%) and 899 were NGT (40.9%). Individuals classified within a lower serum vitamin D category were more likely to have prediabetes (p = 0.03). Those with 25(OH)D deficiency were more likely to have prediabetes compared to 25(OH)D sufficient individuals (crude OR = 1.48, 95% CI 1.15-1.91), and this association remained significant after adjustment for ethnicity, BMI, age and gender (aOR = 1.39, 95% CI 1.02-1.89). There was no effect modification by BMI, gender or ethnicity. CONCLUSIONS: Vitamin D status was associated with risk of prediabetes in this sample of Americans 50+ years of age. Future research should seek to understand the potential mechanistic relationship between vitamin D and prediabetes.

Improved Access to and Impact of Registered Dietitian Nutritionist Services Associated with an Integrated Care Model in a High-Risk, Minority Population.

BACKGROUND: Integrated health care models create opportunities for registered dietitian nutritionists (RDNs) to provide nutrition-related care and engage in multidisciplinary teams to improve clinical outcomes. While benefits of integrated care (IC) have been reported, little is known about the impact of the RDN within an IC model. OBJECTIVE: Our primary objective was to identify whether IC vs traditional care (TC) increases the number of RDN patient visits. Our secondary objective was to evaluate clinical outcomes of patients seeing an RDN vs not, regardless of care model. DESIGN: This was a retrospective cohort study. PARTICIPANTS/SETTING: Patients were aged 3 to 94 years and from a patient-centered medical home in Boston, MA. MAIN OUTCOME MEASURES: We measured 3-month total and average number of patients seen by the RDN in TC vs IC. Changes in adult hemoglobin A1c, weight, and pediatric body mass index (measured as kg/m2) among high-risk patients seen by an RDN compared to patients not seen by an RDN. STATISTICAL ANALYSIS: Data were obtained from electronic medical records and analyzed utilizing Mann-Whitney U test, analysis of covariance, and paired sample t tests. RESULTS: The RDN saw 145 patients (137 adult, 8 pediatric) in the TC model compared to 185 patients (135 adult, 50 pediatric) in the IC model. Mean number of patients seen per session was 3.20 in the TC model vs 4.63 in the IC model (P=0.004). Adult hemoglobin A1c within-group differences decreased by 0.42%±1.49% (P=0.007) for patients seen by an RDN and decreased 0.15%±1.47% (P=0.012) for patients not seen by an RDN. Adult weight within-group differences decreased 1.0±7.2 kg (P=0.15) for patients seen by a RDN and increased 0.1±5.6 kg (P=0.70) for patients not seen by a RDN. Pediatric BMI showed no change between or within groups. CONCLUSIONS: The IC model increased 3-month total number of patients seen by an RDN. High-risk patients who saw an RDN had a significant decrease in hemoglobin A1c.

Practice patterns, counseling and promotion of physical activity by sports medicine physicians.

OBJECTIVES: This study examined sports medicine physicians with an established interest in physical activity to investigate attitudes surrounding exercise, physical activity and patient-counseling behavior. The degree to which physicians' personal knowledge of physical activity and related resources, involvement with common activities, and perceived barriers were assessed. DESIGN: An internet survey was designed in four domains: (1) counseling behavior, (2) tools and resources, (3) appropriateness of common physical activities for patients and (4) barriers. METHODS: The survey was sent to 3570 members of two electronic mailing lists - Institute of Lifestyle Medicine, Boston, MA and The American College of Sports Medicine. Surveys were emailed during 2011-2012 and analyzed in 2013-2014. Each survey contained 39 questions. RESULTS: The response rate of the surveys was 16%. Of 412 physicians, 74% regularly recommended physical activity, 66% talked about exercise with patients, and 49% included as a vital sign. Only 26% of physicians provided a written exercise prescription. ACSM's Exercise is Medicine® (37%) was the most popular resource. Walking, followed by aerobic activity, strength training and cycling were the most recommended forms of activity and were associated with physicians' personal experiences. The most potent inhibitor was time. CONCLUSIONS: Physicians with an interest in exercise and physical activity recognize the importance of recommending and counseling patients on exercise and physical activity. Physician counseling was associated with personal familiarity with physical activity. Increasing knowledge and experience with exercise, physical activity and counseling behavior is an important component to encourage physical activity assessment and promotion by sports medicine physicians.

Lifestyle Medicine Education.

The actual causes of premature adult deaths, the preponderance of noncommunicable chronic diseases, and their associated costs are related to unhealthy behaviors, such as poor nutrition, physical inactivity, and tobacco use. Although recommended as the first line of prevention and management, providers often do not provide behavioral change counseling in their care. Medical education in lifestyle medicine is, therefore, proposed as a necessary intervention to allow all health providers to learn how to effectively and efficiently counsel their patients toward adopting and sustaining healthier behaviors. Lifestyle medicine curricula, including exercise, nutrition, behavioral change, and self-care, have recently evolved in all levels of medical education, together with implementation initiatives like Exercise is Medicine and the Lifestyle Medicine Education (LMEd) Collaborative. The goal of this review is to summarize the existing literature and to provide knowledge and tools to deans, administrators, faculty members, and students interested in pursuing lifestyle medicine training or establishing and improving an LMEd program within their institution.

Vitamin D receptor protein is associated with interleukin-6 in human skeletal muscle.

Vitamin D is associated with skeletal muscle physiology and function and may play a role in intramuscular inflammation, possibly via the vitamin D receptor (VDR). We conducted two studies to examine (1) whether serum 25-hydroxyvitamin D (25OHD) and/or intramuscular VDR protein concentrations are associated with intramuscular interleukin-6 (IL-6) and/or tumor necrosis factor-α (TNFα); and (2) whether 16-week supplementation with vitamin D3 alters intramuscular IL-6 and/or TNFα. Potential-related signaling pathways were also examined. Muscle biopsies of 30 older, mobility-limited adults were obtained at baseline. A subset of 12 women were supplemented with either 4,000 IU/day of vitamin D3 (N = 5) or placebo (N = 7), and biopsies were repeated at 16 weeks. Serum 25OHD was measured, and intramuscular VDR, IL-6, and TNFα gene expressions and protein concentrations were analyzed. Baseline serum 25OHD was not associated with intramuscular IL-6 or TNFα gene expression or protein concentration. Baseline intramuscular VDR protein concentration, adjusted for baseline serum 25OHD, was positively associated with intramuscular IL-6 gene expression (n = 28; p = 0.04), but negatively associated with intramuscular IL-6 protein (n = 18; p = 0.03). Neither intramuscular IL-6 nor TNFα gene expression was different between placebo (n = 7) or vitamin D3 supplementation groups (n = 5) after 16 weeks (p = 0.57, p = 0.11, respectively). These data suggest that VDR is a better predictor than serum 25OHD concentration of intramuscular IL-6 gene and protein expressions. A similar relationship was not observed for TNFα expression. Further, supplementation with 4,000 IU vitamin D3 per day does not appear to affect intramuscular IL-6 or TNFα gene expression after 16 weeks.

Effects of 1,25-dihydroxyvitamin D3 and vitamin D3 on the expression of the vitamin d receptor in human skeletal muscle cells.

Vitamin D receptor (VDR) expression and action in non-human skeletal muscle have recently been reported in several studies, yet data on the activity and expression of VDR in human muscle cells are scarce. We conducted a series of studies to examine the (1) effect of 1,25-dihydroxyvitamin D3 (1,25(OH)2D3) on VDR gene expression in human primary myoblasts, (2) effect of 16-week supplementation with vitamin D3 on intramuscular VDR gene expression in older women, and (3) association between serum 25-hydroxyvitamin D (25OHD) and intramuscular VDR protein concentration in older adults. Human primary myoblasts were treated with increasing concentrations of 1,25(OH)2D3 for 18 h. A dose-dependent treatment effect was noted with 1 nmol/L of 1,25OH2D3 increasing intramuscular VDR mRNA expression (mean fold change±SD 1.36±0.33; P=0.05). Muscle biopsies were obtained at baseline and 16 weeks after vitamin D3 supplementation (4,000 IU/day) in older adults. Intramuscular VDR mRNA was significantly different from placebo after 16 weeks of vitamin D3 (1.2±0.99; -3.2±1.7, respectively; P=0.04). Serum 25OHD and intramuscular VDR protein expression were examined by immunoblot. 25OHD was associated with intramuscular VDR protein concentration (R=0.67; P=0.0028). In summary, our study found VDR gene expression increases following treatment with 1,25OH2D3 in human myoblasts. 25OHD is associated with VDR protein and 16 weeks of supplementation with vitamin D3 resulted in a persistent increase in VDR gene expression of vitamin D3 in muscle tissue biopsies. These findings suggest treatment with vitamin D compounds results in sustained increases in VDR in human skeletal muscle.

The emerging biomolecular role of vitamin D in skeletal muscle.

In this review, we summarize current evidence for a direct effect of vitamin D on skeletal muscle. A number of studies identify the receptor for 1,25-dihydroxyvitamin-D3 (vitamin D receptor (VDR)) and the enzyme CYP27B1 (1-α-hydroxylase) in muscle. We hypothesize that vitamin D acts on myocytes via the VDR, and we examine proposed effects on myocyte proliferation, differentiation, growth, and inflammation.

Innovation in diabetes care: improving consumption of healthy food through a "chef coaching" program: a case report.

Nutrition therapy as part of lifestyle care is recommended for people with type 2 diabetes. However, most people with diabetes do not follow this guideline. Changing eating habits involves obtaining knowledge and building practical skills such as shopping, meal preparation, and food storage. Just as fitness coaches use their specific knowledge base in fitness to enhance the effectiveness of their coaching, credentialed chefs trained as health coaches might combine their culinary expertise with coaching in order to improve clients' food choices and lifestyles. This report documents the case of a 55-year-old white male physician, single and living alone, who was recently diagnosed with type 2 diabetes and reported chronic stress, sedentary behavior, and unhealthy eating habits. He participated in a chef coaching program of 8 weekly one-on-one 30-minute coaching sessions via Skype delivered by a chef trained as a health coach. During the first five meetings, the patient's goals were primarily culinary; however, with his success in accomplishing these goals, the patient progressed and expanded his goals to include other lifestyle domains, specifically exercise and work-life balance. At the end of the program, the patient had improved both his nutritional and exercise habits, his confidence in further self-care improvement, and his health parameters such as HgA1c (8.8% to 6.7%; normal <6.5%). We conclude that chef coaching has the potential to help people with diabetes improve their practical culinary skills and implement them so that they eat better and, further, has the potential to help them improve their overall self-care. We intend to further develop chef coaching and assess its potential as we learn from its implementation.

Se recomienda un tratamiento nutricional como parte de un estilo de vida saludable para las personas con diabetes de tipo 2. No obstante, la mayoría de las personas con diabetes no siguen esta pauta. Cambiar los hábitos de alimentación implica obtener conocimientos y desarrollar habilidades prácticas, como ir de compras, preparar comidas y almacenar los alimentos. De la misma forma que los entrenadores personales usan sus conocimientos específicos del mantenimiento físico, para mejorar la efectividad de los entrenamientos, los acreditados chefs, que se han formado como entrenadores de la salud, podrían combinar su experiencia culinaria con el entrenamiento especializado en la salud, para mejorar las elecciones alimentarias y los estilos de vida de sus clientes.Este informe documenta el caso de un médico de 55 años, blanco, soltero y que vive solo, a quien se le diagnosticó recientemente diabetes de tipo 2 y que presentaba estrés crónico, comportamiento sedentario y hábitos dietéticos insanos. Participó en un programa de entrenamiento con un chef durante 8 sesiones individuales de 30 minutos por semana a través de Skype, impartido por un chef con formación específica en la salud. Durante las primeras cinco reuniones, los objetivos del paciente fueron principalmente culinarios; no obstante, al haber conseguido con éxito estos objetivos, el paciente avanzó y amplió los objetivos e incluyó otros ámbitos respecto al estilo de vida, en concreto, el equilibrio entre el ejercicio y el trabajo. Al final del programa, el paciente había mejorado los hábitos alimenticios y los hábitos de ejercicio, la confianza en sí mismo para seguir mejorando el cuidado personal y los parámetros médicos, como la HbA1c (de 8,8 % a 6,7 %; normal <6,5 %).La conclusión es que el entrenamiento con chef ayuda potencialmente a las personas con diabetes a la hora de mejorar sus habilidades culinarias y de ponerlas en práctica para comer mejor. Además, tiene potencial para ayudarles a mejorar el cuidado personal en general. Tenemos intención de desarrollar el entrenamiento con chef y valorar su potencial, al mismo tiempo que vamos aprendiendo de su implementación.

Longitudinal decline of neuromuscular activation and power in healthy older adults.

BACKGROUND: Weakness contributes to the decline of physical function that occurs with aging. Contradictory findings have been reported as to whether neuromuscular activation is impaired with aging, and the extent to which it contributes to weakness. The present study uses a longitudinal design to assess how potential age-related change of neuromuscular activation affects strength, power, and mobility function. METHODS: Participants included 16 healthy older adults who were healthy and high functioning at baseline. Strength was measured by leg press one repetition maximum. Power production was measured during a maximal effort rapid leg press movement with resistance set to 70% of the one repetition maximum. During the same movement, neuromuscular activation was quantified as the rate of rise of the quadriceps surface electromyogram (rate of electromyogram rise). Thigh muscle cross-sectional area was measured by computed tomography. Mobility function was assessed by the Short Physical Performance Battery. RESULTS: The time between baseline and follow-up testing was almost 3 years. Between these time points, rate of electromyogram rise decreased 28% (p = .004) and power decreased 16.5% (p = .01). There was a trend for reduced anterior thigh muscle cross-sectional area (3%, p = .05), but no change in posterior thigh muscle cross-sectional area (p = .84), one repetition maximum strength (p = .72), or Short Physical Performance Battery score (p = .17). Loss of power was strongly associated with reduction in the rate of electromyogram rise (R (2) = .61, p < .001), but not with reduction of anterior thigh muscle cross-sectional area (p = .83). CONCLUSIONS: The present findings suggest that voluntary neuromuscular activation declines with advancing age, contributes to a reduction in power production, and precedes the decline of mobility function.

Effects of alkali supplementation and vitamin D insufficiency on rat skeletal muscle.

Data on the independent and potential combined effects of acid-base balance and vitamin D status on muscle mass and metabolism are lacking. We investigated whether alkali supplementation with potassium bicarbonate (KHCO3), with or without vitamin D3 (± VD3), alters urinary nitrogen (indicator of muscle proteolysis), muscle fiber cross-sectional area (FCSA), fiber number (FN), and anabolic (IGF-1, Akt, p70s6k) and catabolic (FOXO3a, MURF1, MAFbx) signaling pathways regulating muscle mass. Thirty-six, 20-month-old, Fischer 344/Brown-Norway rats were randomly assigned in a 2 × 2 factorial design to one of two KHCO3-supplemented diets (± VD3) or diets without KHCO3 (± VD3) for 12 weeks. Soleus, extensor digitorum longus (EDL), and plantaris muscles were harvested at 12 weeks. Independent of VD3 group, KHCO3 supplementation resulted in 35 % lower mean urinary nitrogen to creatinine ratio, 10 % higher mean type I FCSA (adjusted to muscle weight), but no statistically different mean type II FCSA (adjusted to muscle weight) or FN compared to no KHCO3. Among VD3-replete rats, phosphorylated-Akt protein expression was twofold higher in the KHCO3 compared to no KHCO3 groups, but this effect was blunted in rats on VD3-deficient diets. Neither intervention significantly affected serum or intramuscular IGF-1 expression, p70s6k or FOXO3a activation, or MURF1 and MAFbx gene expression. These findings provide support for alkali supplementation as a promising intervention to promote preservation of skeletal muscle mass, particularly in the setting of higher vitamin D status. Additional research is needed in defining the muscle biological pathways that are being targeted by alkali and vitamin D supplementation.

The specific contributions of force and velocity to muscle power in older adults.

The purpose of this study is to examine the relative importance of the force-based and velocity-based measures of muscle performance to explain inter-individual differences in power production capability and functional task performance. Participants included seventy-nine men and women: middle-aged healthy adults (MH: 40-55years), older healthy adults (OH: 70-85years), and older adults with mobility limitations (OML: 70-85years). Muscle power at 180°/s, isometric maximal torque, and maximal contraction velocity at 40% 1RM were measured during unilateral leg extension. The Short Physical Performance Battery (SPPB) was used to differentiate between healthy and mobility limited older adults. Functional task performance was assessed using multiple chair rise and stair climb tests. Leg extensor force (torque), but not maximal contraction velocity, was significantly associated with muscle power in MH. Both torque and velocity were significantly associated with muscle power in OH. Maximal velocity, but not torque, was associated with power in OML. Maximal velocity demonstrated an association with multiple chair rise time and stair climb time in OML, but not MH or OH. It is concluded that movement velocity is an increasingly important determinant of maximal power output with advancing age. Furthermore, movement velocity is also a critical component of functional task performance with aging and may contribute to functional deficits. These findings help to explain why the rate-dependent variable power has emerged as a critical component of both assessment and rehabilitation of muscular performance and physical function in older adults.