Publications by authors named "Laura R Saslow"

21 Publications

  • Page 1 of 1

Intervention Enhancement Strategies Among Adults With Type 2 Diabetes in a Very Low-Carbohydrate Web-Based Program: Evaluating the Impact With a Randomized Trial.

JMIR Diabetes 2020 Sep 9;5(3):e15835. Epub 2020 Sep 9.

Osher Center for Integrative Medicine, University of California San Francisco, San Francisco, CA, United States.

Background: Adults with type 2 diabetes may experience health benefits, including glycemic control and weight loss, from following a very low-carbohydrate, ketogenic (VLC) diet. However, it is unclear which ancillary strategies may enhance these effects.

Objective: This pilot study aims to estimate the effect sizes of 3 intervention enhancement strategies (text messages, gifts, and breath vs urine ketone self-monitoring) that may improve outcomes of a 12-month web-based ad libitum VLC diet and lifestyle intervention for adults with type 2 diabetes. The primary intervention also included other components to improve adherence and well-being, including positive affect and mindfulness as well as coaching.

Methods: Overweight or obese adults (n=44; BMI 25-45 kg/m) with type 2 diabetes (glycated hemoglobin [HbA] ≥6.5%), who had been prescribed either no glucose-lowering medications or metformin alone, participated in a 12-month web-based intervention. Using a 2×2×2 randomized factorial design, we compared 3 enhancement strategies: (1) near-daily text messages about the intervention's recommended behaviors (texts n=22 vs no texts n=22), (2) mailed gifts of diet-relevant foods and cookbooks (6 rounds of mailed gifts n=21 vs no gifts n=23), and (3) urine- or breath-based ketone self-monitoring (urine n=21 vs breath n=23). We assessed HbA and weight at baseline and at 4, 8, and 12 months. We evaluated whether each strategy exerted a differential impact on HbA and weight at 12 months against an a priori threshold of Cohen d of 0.5 or greater.

Results: We retained 73% (32/44) of the participants at 12 months. The intervention, across all conditions, led to improvements in glucose control and reductions in body weight at the 12-month follow-up. In intent-to-treat (ITT) analyses, the mean HbA reduction was 1.0% (SD 1.6) and the mean weight reduction was 5.3% (SD 6.0), whereas among study completers, these reductions were 1.2% (SD 1.7) and 6.3% (SD 6.4), respectively, all with a P value of less than .001. In ITT analyses, no enhancement strategy met the effect size threshold. Considering only study completers, 2 strategies showed a differential effect size of at least a d value of 0.5 or greater.

Conclusions: Text messages, gifts of food and cookbooks, and urine-based ketone self-monitoring may potentially enhance the glycemic or weight loss benefits of a web-based VLC diet and lifestyle intervention for individuals with type 2 diabetes. Future research could investigate other enhancement strategies to help create even more effective solutions for the treatment of type 2 diabetes.

Trial Registration: ClinicalTrials.gov NCT02676648; http://clinicaltrials.gov/ct2/show/NCT02676648.
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http://dx.doi.org/10.2196/15835DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7511867PMC
September 2020

Lifestyle Interventions for Polycystic Ovary Syndrome: Cross-Sectional Survey to Assess Women's Treatment and Outcome Preferences.

JMIR Form Res 2020 Sep 2;4(9):e17126. Epub 2020 Sep 2.

Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States.

Background: Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age. Diet and lifestyle programs improve health, but women's preferences for these programs have not been formally explored.

Objective: The aim of our study was to examine diet and lifestyle program preferences among women with PCOS.

Methods: We conducted a cross-sectional online survey of women with PCOS.

Results: At least half of the 197 respondents expressed strong interest in programs addressing energy level, anxiety, depression, weight, diabetes prevention, menstrual period regulation, and hirsutism. Similarly, at least half reported willingness to modify their sleep, stress, and physical activity; and slightly less than half reported willingness to adopt a very low-carbohydrate, paleo, or low-glycemic index diet. At least half reported interest in online or mobile programs and email-based mentoring. Younger age was associated with interest in help with acne and fertility; higher body mass index was associated with wanting help with weight loss, energy, and anxiety; and greater stress eating was associated with wanting help with depression, anxiety, and menstrual period regulation.

Conclusions: To our knowledge, this is the first study to examine attitudes and preferences of women with PCOS toward such programs. Future online and mobile diet and lifestyle programs may be able to capitalize on this information to better target this population's expressed preferences.
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http://dx.doi.org/10.2196/17126DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7495256PMC
September 2020

Treating binge eating and food addiction symptoms with low-carbohydrate Ketogenic diets: a case series.

J Eat Disord 2020 29;8. Epub 2020 Jan 29.

2Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305 - 5723 USA.

Background: Many patients with obesity and comorbid binge eating symptoms present with the desire to lose weight. Although some studies suggest that dietary restriction can exacerbate binge eating, others show dietary restriction is associated with significant reductions in binge eating. The effect of a particular type of dieting on binge eating, the ketogenic diet (a high fat, moderate protein, very low carbohydrate diet), is not known.

Case Presentations: We report on the feasibility of a low-carbohydrate ketogenic diet initiated by three patients (age 54, 34, and 63) with obesity (average BMI 43.5 kg/m) with comorbid binge eating and food addiction symptoms. All patients tolerated following the ketogenic diet (macronutrient proportion 10% carbohydrate, 30% protein, and 60% fat; at least 5040 kJ) for the prescribed period (e.g., 6-7 months) and none reported any major adverse effects. Patients reported significant reductions in binge eating episodes and food addiction symptoms including cravings and lack of control as measured by the Binge-Eating Scale, Yale Food Addiction Scale, or Yale-Brown Obsessive-Compulsive Scale modified for Binge Eating, depending on the case. Additionally, the patients lost a range of 10-24% of their body weight. Participants reported maintenance of treatment gains (with respect to weight, binge eating, and food addiction symptoms) to date of up to 9-17 months after initiation and continued adherence to diet.

Conclusions: Although the absence of control cases precludes conclusions regarding the specific role of ketogenic diets versus other forms of dietary restriction, this is the first report to demonstrate the feasibility of prescribing a ketogenic diet for patients with obesity who report binge eating and food addiction symptoms. Further research should seek to reproduce the observed effects in controlled trials as well as to explore potential etiologies.
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http://dx.doi.org/10.1186/s40337-020-0278-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6988301PMC
January 2020

Correction to: Lipid findings from the Diabetes Education to Lower Insulin, Sugars, and Hunger (DELISH) Study.

Nutr Metab (Lond) 2019;16:91. Epub 2019 Dec 30.

2UCSF Osher Center for Integrative Medicine, 1545 Divisadero Street, Suite 301, San Francisco, CA 94115 USA.

[This corrects the article DOI: 10.1186/s12986-019-0383-2.].
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http://dx.doi.org/10.1186/s12986-019-0416-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6936057PMC
December 2019

Feasibility study of automated interactive voice response telephone calls with community health nurse follow-up to improve glycaemic control in patients with type 2 diabetes.

Int J Nurs Pract 2019 Dec 18;25(6):e12781. Epub 2019 Sep 18.

Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan.

Background: Thailand has a shortage of community health nurses for supporting the self-management of type 2 diabetes, which is prevalent and poorly controlled.

Aim: This study examined the feasibility and acceptability of a self-care assistance programme for poorly controlled type 2 diabetes mellitus. The SukapapNet programme consisted of automated interactive voice response calls to patients and automated follow-up email notifications to their nurses.

Design: Single-arm pre-post trial.

Methods: Six nurses and 35 type 2 diabetes patients were recruited from primary care settings in suburban provinces in Thailand. The study was conducted from June 2017 to November 2017. We assessed patients before and after 12 weeks of the SukapapNet intervention.

Results: Mean glycated haemoglobin decreased by 0.9%. Patients reported reduced carbohydrate consumption, increased physical activity, increased medication adherence, improved sleep quality, and more frequent foot care. Patients and nurses both recommended using the intervention, although nurses expressed concerns regarding increased workload.

Conclusions: The study programme could improve outcomes in Thai type 2 diabetes patients. Further study of the impact of technology upon nurses' workload is warranted.
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http://dx.doi.org/10.1111/ijn.12781DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6898746PMC
December 2019

Lipid findings from the Diabetes Education to Lower Insulin, Sugars, and Hunger (DELISH) Study.

Nutr Metab (Lond) 2019 27;16:58. Epub 2019 Aug 27.

2UCSF Osher Center for Integrative Medicine, 1545 Divisadero Street, Suite 301, San Francisco, CA 94115 USA.

Background: A carbohydrate-restricted (CR) diet can improve glycemic control in people with type 2 diabetes mellitus (T2DM). There are concerns, however, that the high dietary fat content of CR diets can increase low-density lipoprotein cholesterol (LDL-C), thus increasing cardiovascular disease (CVD) risk. Quantifying CVD risk associated with changes in LDL-C in the context of CR diets is complicated by the fact that LDL-C reflects heterogeneous lipids. For example, small LDL particle number (sLDL-P) is more closely associated with CVD risk than is total LDL-C, and CR diets tend to decrease the proportion of sLDL-C in LDL-C, which standard lipid measures do not indicate. Advanced lipoprotein assays, such as nuclear magnetic resonance (NMR) testing, can subfractionate lipoproteins by size and density and may better depict the effects of CR diets on CVD risk.

Methods: Adults ( = 58) with T2DM ( = 37 women; baseline HbA1c ≥ 6.5%) completed a 6-month group-based CR diet intervention. We obtained a standard lipid panel, advanced lipoprotein assays (NMR testing), and two 24-h diet recalls at baseline and post-intervention (6 months). Participants also completed home-based blood ketone testing (a biological index of dietary adherence) during the final five weeks of the intervention.

Results: From baseline to post-intervention, participants had increased mean HDL-C, decreased triglycerides and triglyceride/HDL ratio, decreased mean sLDL-P, and increased LDL size, which reflect reductions in CVD risk (s < 0.05). Participants did not have statistically significant changes in total cholesterol, non-HDL-C cholesterol, LDL-P, or HDL-P. Twelve participants (23.1%) had a ≥ 5% increase in sLDL-P. Exploratory analyses revealed that participants with sLDL-P increases of ≥ 5% reported larger increases in servings of red meat than participants without sLDL-P increases of ≥ 5% (+ 0.69 vs - 0.29 servings;  = 0.033). Changes in saturated fat intake were not associated with changes in sLDL-P.

Conclusions: Among most participants, we observed changes in several lipid measures consistent with decreased CVD risk. Approximately one in four participants evidenced increases in sLDL-P. Further research should clarify whether individuals with increased sLDL-P after implementing a CR diet can reverse observed increases by limiting red meat consumption.

Trial Registration: ClinicalTrials.gov, NCT03207711, Registered 6/11/2017. Retrospectively registered.
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http://dx.doi.org/10.1186/s12986-019-0383-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6712717PMC
August 2019

The MARIGOLD study: Feasibility and enhancement of an online intervention to improve emotion regulation in people with elevated depressive symptoms.

J Affect Disord 2019 10 5;257:352-364. Epub 2019 Jul 5.

Department of Medical Social Sciences, Osher Center for Integrative Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

Background: This manuscript describes the first two phases of pilot testing MARIGOLD, an online self-guided positive emotion skills intervention for adults with elevated depressive symptoms, along with enhancements to overcome retention and adherence problems reported in previous research.

Methods: Adults with elevated depressive symptoms were recruited online and assessed at baseline, post-intervention, 1- and 3-month follow-up. Phase 1 participants (n = 58) were randomized to MARIGOLD, daily emotion reporting, or waitlist. Phase 2 participants (n = 79) were randomized to MARIGOLD plus one enhancement: online discussion board (ODB), virtual badges (VB), or facilitator contact (FC). Post-intervention interviews assessed acceptability. Intention-to-treat analyses examined retention, adherence, and preliminary efficacy.

Results: In both phases, retention and adherence did not differ between groups. MARIGOLD skills were highly acceptable, but qualitative results indicate web-based features (e.g., log-in, ODB, VB) require refinement prior to larger testing. Neither phase demonstrated between-group differences in preliminary efficacy. In Phase 1 within-group analyses, MARIGOLD and emotion reporting control demonstrated a similar pattern of findings (stable depressive symptoms, increased positive emotion, decreased negative emotion and stress), whereas the waitlist group significantly increased in depressive mood. Most Phase 2 within-group analyses demonstrated the expected pattern of results (i.e., decreases in PHQ-8 and negative emotion, increases in positive emotion). However, CES-D scores were stable in FC; perceived stress was stable in FC and ODB.

Limitations: This pilot study is not powered to evaluate efficacy.

Conclusion: Positive emotion skills, plus enhancements for web-based, self-guided delivery, warrant additional study in people with elevated depressive symptoms.
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http://dx.doi.org/10.1016/j.jad.2019.07.049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6711819PMC
October 2019

Measuring moral politics: How strict and nurturant family values explain individual differences in conservatism, liberalism, and the political middle.

J Pers Soc Psychol 2020 Apr 27;118(4):777-804. Epub 2019 Jun 27.

Department of Social Science Research Institute.

Individuals' political stances tend to place them into the conservative "right," the liberal "left," or the moderate "middle." What might explain this pattern of division? Moral Politics Theory (Lakoff, 1996) holds that political attitudes arise from moral worldviews that are conceptually anchored in contrasting family models-the strict-father and nurturant-parent models-while the political middle is morally "biconceptual," endorsing both models simultaneously. The present research examined these postulations empirically. Studies 1 and 2 tested the conceptual and predictive validity of the theorized models by developing an instrument assessing strict and nurturant parenting beliefs (the Moral Politics Scale [MPT]), and examining its power to predict political stances on issues seemingly unrelated to parenting attitudes (e.g., abortion, taxes, and same-sex marriage). Studies 3a and 3b explored construct validity while testing whether the family models translate into more general moral worldviews, which then serve as a foundation of political attitudes. Studies 4a through 4c tested generalizability, examining the relationship between the family models and political stances across different countries, data-collection modalities, and a representative American sample. Finally, Studies 5-7 explored biconceptualism and the tendency for these individuals to shift political attitudes as a consequence of situational factors, particularly moral framing, such that strict-father frames lead to increased support for conservative stances while nurturant-parent frames lead to increased support for liberal stances. Overall, we found support for each of MPT's assertions, suggesting that an important aspect of the conceptual and experiential basis of people's political attitudes lies in the strict-father and nurturant-parent family models. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/pspp0000255DOI Listing
April 2020

A Mobile Phone-Based Program to Promote Healthy Behaviors Among Adults With Prediabetes Who Declined Participation in Free Diabetes Prevention Programs: Mixed-Methods Pilot Randomized Controlled Trial.

JMIR Mhealth Uhealth 2019 01 9;7(1):e11267. Epub 2019 Jan 9.

University of Michigan Medical School, Ann Arbor, MI, United States.

Background: Despite evidence that Diabetes Prevention Programs (DPPs) can delay or prevent progression to type 2 diabetes mellitus (T2DM), few individuals with prediabetes enroll in offered programs. This may be in part because many individuals with prediabetes have low levels of autonomous motivation (ie, motivation that arises from internal sources) to prevent T2DM.

Objective: This study aims to examine the feasibility and acceptability of a mobile health (mHealth) intervention designed to increase autonomous motivation and healthy behaviors among adults with prediabetes who previously declined participation free DPPs. In addition, the study aims to examine changes in autonomous motivation among adults offered 2 versions of the mHealth program compared with an information-only control group.

Methods: In this 12-week, parallel, 3-arm, mixed-methods pilot randomized controlled trial, participants were randomized to (1) a group that received information about prediabetes and strategies to prevent T2DM (control); (2) a group that received a mHealth app that aims to increase autonomous motivation among users (app-only); or (3) a group that received the app plus a physical activity tracker and wireless-enabled digital scale for self-monitoring (app-plus). Primary outcome measures included rates of intervention uptake (number of individuals enrolled/number of individuals assessed for eligibility), retention (number of 12-week survey completers/number of participants), and adherence (number of device-usage days). The secondary outcome measure was change in autonomous motivation (measured using the Treatment Self-Regulation Questionnaire), which was examined using difference-in-difference analysis. Furthermore, we conducted postintervention qualitative interviews with participants.

Results: Overall, 28% (69/244) of eligible individuals were randomized; of these, 80% (55/69) completed the 12-week survey. Retention rates were significantly higher among app-plus participants than participants in the other 2 study arms combined (P=.004, χ). No significant differences were observed in adherence rates between app-only and app-plus participants (43 days vs 37 days; P=.34). Among all participants, mean autonomous motivation measures were relatively high at baseline (6.0 of 7.0 scale), with no statistically significant within- or between-group differences in follow-up scores. In qualitative interviews (n=15), participants identified reasons that they enjoyed using the app (eg, encouraged self-reflection), reasons that they did not enjoy using the app (eg, did not consider personal circumstances), and strategies to improve the intervention (eg, increased interpersonal contact).

Conclusions: Among individuals with prediabetes who did not engage in free DPPs, this mHealth intervention was feasible and acceptable. Future work should (1) examine the effectiveness of a refined intervention on clinically relevant outcomes (eg, weight loss) among a larger population of DPP nonenrollees with low baseline autonomous motivation and (2) identify other factors associated with DPP nonenrollment, which may serve as additional potential targets for interventions.

Trial Registration: ClinicalTrials.gov NCT03025607; https://clinicaltrials.gov/ct2/show/NCT03025607 (Archived by WebCite at http://www.webcitation.org/73cvaSAie).
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http://dx.doi.org/10.2196/11267DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6329413PMC
January 2019

Outcomes of a Digitally Delivered Low-Carbohydrate Type 2 Diabetes Self-Management Program: 1-Year Results of a Single-Arm Longitudinal Study.

JMIR Diabetes 2018 Aug 3;3(3):e12. Epub 2018 Aug 3.

Principal in General Practice, The Norwood Surgery, Southport, United Kingdom.

Background: Type 2 diabetes mellitus has serious health consequences, including blindness, amputation, stroke, and dementia, and its annual global costs are more than US $800 billion. Although typically considered a progressive, nonreversible disease, some researchers and clinicians now argue that type 2 diabetes may be effectively treated with a carbohydrate-reduced diet.

Objective: Our objective was to evaluate the 1-year outcomes of the digitally delivered Low-Carb Program, a nutritionally focused, 10-session educational intervention for glycemic control and weight loss for adults with type 2 diabetes. The program reinforces carbohydrate restriction using behavioral techniques including goal setting, peer support, and behavioral self-monitoring.

Methods: The study used a quasi-experimental research design comprised of an open-label, single-arm, pre-post intervention using a sample of convenience. From adults with type 2 diabetes who had joined the program and had a complete baseline dataset, we randomly selected participants to be followed for 1 year (N=1000; mean age 56.1, SD 15.7 years; 59.30% (593/1000) women; mean glycated hemoglobin A (HbA) 7.8%, SD 2.1%; mean body weight 89.6 kg, SD 23.1 kg; taking mean 1.2, SD 1.01 diabetes medications).

Results: Of the 1000 study participants, 708 (70.80%) individuals reported outcomes at 12 months, 672 (67.20%) completed at least 40% of the lessons, and 528 (52.80%) completed all lessons of the program. Of the 743 participants with a starting HbA at or above the type 2 diabetes threshold of 6.5%, 195 (26.2%) reduced their HbA to below the threshold while taking no glucose-lowering medications or just metformin. Of the participants who were taking at least one hypoglycemic medication at baseline, 40.4% (289/714) reduced one or more of these medications. Almost half (46.40%, 464/1000) of all participants lost at least 5% of their body weight. Overall, glycemic control and weight loss improved, especially for participants who completed all 10 modules of the program. For example, participants with elevated baseline HbA (≥7.5%) who engaged with all 10 weekly modules reduced their HbA from 9.2% to 7.1% (P<.001) and lost an average of 6.9% of their body weight (P<.001).

Conclusions: Especially for participants who fully engage, an online program that teaches a carbohydrate-reduced diet to adults with type 2 diabetes can be effective for glycemic control, weight loss, and reducing hypoglycemic medications.
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http://dx.doi.org/10.2196/diabetes.9333DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6238840PMC
August 2018

A Self-Paced, Web-Based, Positive Emotion Skills Intervention for Reducing Symptoms of Depression: Protocol for Development and Pilot Testing of MARIGOLD.

JMIR Res Protoc 2018 Jun 5;7(6):e10494. Epub 2018 Jun 5.

Department of Medical Social Sciences, Osher Center for Integrative Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.

Background: Living with elevated symptoms of depression can have debilitating consequences for an individual's psychosocial and physical functioning, quality of life, and health care utilization. A growing body of evidence demonstrates that skills for increasing positive emotion can be helpful to individuals with depression. Although Web-based interventions to reduce negative emotion in individuals with depression are available, these interventions frequently suffer from poor retention and adherence and do not capitalize on the potential benefits of increasing positive emotion.

Objective: The aim of this study was to develop and test a Web-based positive emotion skills intervention tailored for individuals living with elevated depressive symptoms, as well as to develop and test enhancement strategies for increasing retention and adherence to that intervention.

Methods: This study protocol describes the development and testing for Mobile Affect Regulation Intervention with the Goal of Lowering Depression (MARIGOLD), a Web-based positive emotion skills intervention, adapted for individuals with elevated depressive symptomatology. The intervention development is taking place in three phases. In phase 1, we are tailoring an existing positive emotion skills intervention for individuals with elevated symptoms of depression and are pilot testing the tailored version of the intervention in a randomized controlled trial with two control conditions (N=60). In phase 2, we are developing and testing three enhancements aimed at boosting retention and adherence to the Web-based intervention (N=75): facilitator contact, an online discussion board, and virtual badges. In phase 3, we are conducting a multifactorial, nine-arm pilot trial (N=600) to systematically test these enhancement strategies, individually and in combination. The primary outcome is depressive symptom severity. Secondary outcomes include positive and negative emotion, psychological well-being, and coping resources.

Results: The project was funded in August 2014, and data collection was completed in May 2018. Data analysis is currently under way, and the first results are expected to be submitted for publication in 2018.

Conclusions: Findings from this investigation will enable us to develop an optimal package of intervention content and enhancement strategies for individuals with elevated symptoms of depression. If this intervention proves to be effective, it will provide a cost-effective, anonymous, appealing, and flexible approach for reducing symptoms of depression and improving psychological adjustment through increasing positive emotion.

Trial Registration: ClinicalTrials.gov NCT01964820 (Phase 1); https://clinicaltrials.gov/ct2/show/NCT01964820 (Archived by WebCite at http://www.webcitation.org/6zpmKBcyX). ClinicalTrials.gov NCT02861755 (Phase 2); https://clinicaltrials.gov/ct2/show/NCT02861755 (Archived by WebCite at http://www.webcitation.org/6zpmLmy8k).

Registered Report Identifier: RR1-10.2196/10494.
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http://dx.doi.org/10.2196/10494DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6008514PMC
June 2018

Twelve-month outcomes of a randomized trial of a moderate-carbohydrate versus very low-carbohydrate diet in overweight adults with type 2 diabetes mellitus or prediabetes.

Nutr Diabetes 2017 12 21;7(12):304. Epub 2017 Dec 21.

University of California, San Francisco, CA, USA.

Dietary treatment is important in management of type 2 diabetes or prediabetes, but uncertainty exists about the optimal diet. We randomized adults (n = 34) with glycated hemoglobin (HbA1c) > 6.0% and elevated body weight (BMI > 25) to a very low-carbohydrate ketogenic (LCK) diet (n = 16) or a moderate-carbohydrate, calorie-restricted, low-fat (MCCR) diet (n = 18). All participants were encouraged to be physically active, get sufficient sleep, and practice behavioral adherence strategies based on positive affect and mindful eating. At 12 months, participants in the LCK group had greater reductions in HbA1c levels (estimated marginal mean (EMM) at baseline = 6.6%, at 12 mos = 6.1%) than participants in MCCR group (EMM at baseline = 6.9%, at 12 mos = 6.7%), p = .007. Participants in the LCK group lost more weight (EMM at baseline = 99.9 kg, at 12 mos = 92.0 kg) than participants in the MCCR group (EMM at baseline = 97.5 kg, at 12 mos = 95.8 kg), p < .001. The LCK participants experienced larger reductions in diabetes-related medication use; of participants who took sulfonylureas or dipeptidyl peptidase-4 inhibitors at baseline, 6/10 in the LCK group discontinued these medications compared with 0/6 in the MCCR group (p = .005). In a 12-month trial, adults with elevated HbA1c and body weight assigned to an LCK diet had greater reductions in HbA1c, lost more weight, and reduced more medications than those instructed to follow an MCCR diet.
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http://dx.doi.org/10.1038/s41387-017-0006-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5865541PMC
December 2017

An Online Intervention Comparing a Very Low-Carbohydrate Ketogenic Diet and Lifestyle Recommendations Versus a Plate Method Diet in Overweight Individuals With Type 2 Diabetes: A Randomized Controlled Trial.

J Med Internet Res 2017 02 13;19(2):e36. Epub 2017 Feb 13.

Feinberg School of Medicine, Northwestern University, Chicago, IL, United States.

Background: Type 2 diabetes is a prevalent, chronic disease for which diet is an integral aspect of treatment. In our previous trial, we found that recommendations to follow a very low-carbohydrate ketogenic diet and to change lifestyle factors (physical activity, sleep, positive affect, mindfulness) helped overweight people with type 2 diabetes or prediabetes improve glycemic control and lose weight. This was an in-person intervention, which could be a barrier for people without the time, flexibility, transportation, social support, and/or financial resources to attend.

Objective: The aim was to determine whether an online intervention based on our previous recommendations (an ad libitum very low-carbohydrate ketogenic diet with lifestyle factors; "intervention") or an online diet program based on the American Diabetes Associations' "Create Your Plate" diet ("control") would improve glycemic control and other health outcomes among overweight individuals with type 2 diabetes.

Methods: In this pilot feasibility study, we randomized overweight adults (body mass index ≥25) with type 2 diabetes (glycated hemoglobin [HbA] 6.5%-9.0%) to a 32-week online intervention based on our previous recommendations (n=12) or an online diet program based around a plate method diet (n=13) to assess the impact of each intervention on glycemic control and other health outcomes. Primary and secondary outcomes were analyzed by mixed-effects linear regression to compare outcomes by group.

Results: At 32 weeks, participants in the intervention group reduced their HbA levels more (estimated marginal mean [EMM] -0.8%, 95% CI -1.1% to -0.6%) than participants in the control group (EMM -0.3%, 95% CI -0.6% to 0.0%; P=.002). More than half of the participants in the intervention group (6/11, 55%) lowered their HbA to less than 6.5% versus 0% (0/8) in the control group (P=.02). Participants in the intervention group lost more weight (EMM -12.7 kg, 95% CI -16.1 to -9.2 kg) than participants in the control group (EMM -3.0 kg, 95% CI -7.3 to 1.3 kg; P<.001). A greater percentage of participants lost at least 5% of their body weight in the intervention (10/11, 90%) versus the control group (2/8, 29%; P=.01). Participants in the intervention group lowered their triglyceride levels (EMM -60.1 mg/dL, 95% CI -91.3 to -28.9 mg/dL) more than participants in the control group (EMM -6.2 mg/dL, 95% CI -46.0 to 33.6 mg/dL; P=.01). Dropout was 8% (1/12) and 46% (6/13) for the intervention and control groups, respectively (P=.07).

Conclusions: Individuals with type 2 diabetes improved their glycemic control and lost more weight after being randomized to a very low-carbohydrate ketogenic diet and lifestyle online program rather than a conventional, low-fat diabetes diet online program. Thus, the online delivery of these very low-carbohydrate ketogenic diet and lifestyle recommendations may allow them to have a wider reach in the successful self-management of type 2 diabetes.

Trial Registration: ClinicalTrials.gov NCT01967992; https://clinicaltrials.gov/ct2/show/NCT01967992 (Archived by WebCite at http://www.webcitation.org/6o0fI9Mkq).
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http://dx.doi.org/10.2196/jmir.5806DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5329646PMC
February 2017

Short alleles, bigger smiles? The effect of 5-HTTLPR on positive emotional expressions.

Emotion 2015 Aug 1;15(4):438-48. Epub 2015 Jun 1.

Department of Psychology and Institute for Personality and Social Research, University of California, Berkeley.

The present research examined the effect of the 5-HTTLPR polymorphism in the serotonin transporter gene on objectively coded positive emotional expressions (i.e., laughing and smiling behavior objectively coded using the Facial Action Coding System). Three studies with independent samples of participants were conducted. Study 1 examined young adults watching still cartoons. Study 2 examined young, middle-aged, and older adults watching a thematically ambiguous yet subtly amusing film clip. Study 3 examined middle-aged and older spouses discussing an area of marital conflict (that typically produces both positive and negative emotion). Aggregating data across studies, results showed that the short allele of 5-HTTLPR predicted heightened positive emotional expressions. Results remained stable when controlling for age, gender, ethnicity, and depressive symptoms. These findings are consistent with the notion that the short allele of 5-HTTLPR functions as an emotion amplifier, which may confer heightened susceptibility to environmental conditions.
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http://dx.doi.org/10.1037/emo0000074DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4861141PMC
August 2015

Autonomic and prefrontal events during moral elevation.

Biol Psychol 2015 May 23;108:51-5. Epub 2015 Mar 23.

School of Psychological Science, Oregon State University, Corvallis, OR, United States. Electronic address:

Moral elevation, or elevation, is a specific emotional state triggered by witnessing displays of profound virtue and moral beauty. This study set out to characterize the physiology underlying elevation with measurements of heart rate (HR), respiratory sinus arrhythmia (RSA), and medial prefrontal cortex (mPFC) activity. During elevation, HR and RSA increased. These findings illustrate that elevation involves an uncommon combination of both sympathetic and parasympathetic activation, which is present in circumstances where arousal and social engagement are both required. In addition, we show evidence of content-dependent alterations of mPFC activity during elevation peaks. Altogether, this study shows that the induction of moral elevation recruits an uncommon autonomic and neural pattern that is consistent with previous understanding of socioemotional-induced allostasis.
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http://dx.doi.org/10.1016/j.biopsycho.2015.03.004DOI Listing
May 2015

An online positive affect skills intervention reduces depression in adults with type 2 diabetes.

J Posit Psychol 2014 Jan;9(6):523-534

Osher Center for Integrative Medicine, University of California, San Francisco, San Francisco, CA, USA.

Positive affect predicts improved glycemic control and longevity in adults with type 2 diabetes. We tested DAHLIA, a self-paced online intervention for type 2 diabetes that teaches positive affect skills such as savoring, gratitude, and acts of kindness. Participants (n=49) were randomized to the 5-week DAHLIA course or an emotion-reporting waitlist control. DAHLIA was understood and accepted by participants and showed good retention (78%). At post-intervention, DAHLIA participants showed a significantly greater decrease in depression than controls (-4.3 vs. +0.6 points on the CES-D, =.05). Secondary analyses found that this effect was considerably stronger in intervention recipients recruited online than those recruited in person. Intervention recipients recruited online also showed significantly increased positive affect, reduced negative affect, and reduced perceived stress. There were no effects on measures of diabetes-specific efficacy or sense of burden, or preliminary measures of health behaviors. This successful feasibility and efficacy trial provides support for a larger trial focusing more specifically on health behavior.
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http://dx.doi.org/10.1080/17439760.2014.920410DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4157680PMC
January 2014

A randomized pilot trial of a moderate carbohydrate diet compared to a very low carbohydrate diet in overweight or obese individuals with type 2 diabetes mellitus or prediabetes.

PLoS One 2014 9;9(4):e91027. Epub 2014 Apr 9.

University of California San Francisco, San Francisco, California, United States of America.

We compared the effects of two diets on glycated hemoglobin (HbA1c) and other health-related outcomes in overweight or obese adults with type 2 diabetes or prediabetes (HbA1c>6%). We randomized participants to either a medium carbohydrate, low fat, calorie-restricted, carbohydrate counting diet (MCCR) consistent with guidelines from the American Diabetes Association (n = 18) or a very low carbohydrate, high fat, non calorie-restricted diet whose goal was to induce nutritional ketosis (LCK, n = 16). We excluded participants receiving insulin; 74% were taking oral diabetes medications. Groups met for 13 sessions over 3 months and were taught diet information and psychological skills to promote behavior change and maintenance. At 3 months, mean HbA1c level was unchanged from baseline in the MCCR diet group, while it decreased 0.6% in the LCK group; there was a significant between group difference in HbA1c change favoring the LCK group (-0.6%, 95% CI, -1.1% to -0.03%, p = 0.04). Forty-four percent of the LCK group discontinued one or more diabetes medications, compared to 11% of the MCCR group (p = 0.03); 31% discontinued sulfonylureas in the LCK group, compared to 5% in the MCCR group (p = 0.05). The LCK group lost 5.5 kg vs. 2.6 kg lost in MCCR group (p = 0.09). Our results suggest that a very low carbohydrate diet coupled with skills to promote behavior change may improve glycemic control in type 2 diabetes while allowing decreases in diabetes medications. This clinical trial was registered with ClinicalTrials.gov, number NCT01713764.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0091027PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3981696PMC
January 2015

Speaking under pressure: low linguistic complexity is linked to high physiological and emotional stress reactivity.

Psychophysiology 2014 Mar 20;51(3):257-66. Epub 2013 Dec 20.

Osher Center for Integrative Medicine, University of California, San Francisco, California, USA.

What can a speech reveal about someone's state? We tested the idea that greater stress reactivity would relate to lower linguistic cognitive complexity while speaking. In Study 1, we tested whether heart rate and emotional stress reactivity to a stressful discussion would relate to lower linguistic complexity. In Studies 2 and 3, we tested whether a greater cortisol response to a standardized stressful task including a speech (Trier Social Stress Test) would be linked to speaking with less linguistic complexity during the task. We found evidence that measures of stress responsivity (emotional and physiological) and chronic stress are tied to variability in the cognitive complexity of speech. Taken together, these results provide evidence that our individual experiences of stress or "stress signatures"-how our body and mind react to stress both in the moment and over the longer term-are linked to how complex our speech under stress.
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http://dx.doi.org/10.1111/psyp.12171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4059522PMC
March 2014

The 5-HTTLPR polymorphism in the serotonin transporter gene moderates the association between emotional behavior and changes in marital satisfaction over time.

Emotion 2013 Dec 7;13(6):1068-79. Epub 2013 Oct 7.

Department of Psychology.

Why do some individuals become dissatisfied with their marriages when levels of negative emotion are high and levels of positive emotions are low, whereas others remain unaffected? Using data from a 13-year longitudinal study of middle-aged and older adults in long-term marriages, we examined whether the 5-HTTLPR polymorphism in the serotonin transporter gene moderates the association between negative and positive emotional behavior (objectively measured during marital conflict) and changes in marital satisfaction over time. For individuals with two short alleles of 5-HTTLPR, higher negative and lower positive emotional behavior at Time 1 predicted declines in marital satisfaction over time (even after controlling for depression and other covariates). For individuals with one or two long alleles, emotional behavior did not predict changes in marital satisfaction. We also found evidence for a crossover interaction (individuals with two short alleles of 5-HTTLPR and low levels of negative or high levels of positive emotion had the highest levels of marital satisfaction). These findings provide the first evidence of a specific genetic polymorphism that moderates the association between emotional behavior and changes in marital satisfaction over time and are consistent with increasing evidence that the short allele of this polymorphism serves as a susceptibility factor that amplifies sensitivity to both negative and positive emotional influences.
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http://dx.doi.org/10.1037/a0033761DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4067734PMC
December 2013

Thin-slicing study of the oxytocin receptor (OXTR) gene and the evaluation and expression of the prosocial disposition.

Proc Natl Acad Sci U S A 2011 Nov 14;108(48):19189-92. Epub 2011 Nov 14.

Department of Psychology, University of Toronto, Mississauga, ON, Canada L5L 1C6.

Individuals who are homozygous for the G allele of the rs53576 SNP of the oxytocin receptor (OXTR) gene tend to be more prosocial than carriers of the A allele. However, little is known about how these differences manifest behaviorally and whether they are readily detectable by outside observers, both critical questions in theoretical accounts of prosociality. In the present study, we used thin-slicing methodology to test the hypotheses that (i) individual differences in rs53576 genotype predict how prosocial observers judge target individuals to be on the basis of brief observations of behavior, and (ii) that variation in targets' nonverbal displays of affiliative cues would account for these judgment differences. In line with predictions, we found that individuals homozygous for the G allele were judged to be more prosocial than carriers of the A allele. These differences were completely accounted for by variations in the expression of affiliative cues. Thus, individual differences in rs53576 are associated with behavioral manifestations of prosociality, which ultimately guide the judgments others make about the individual.
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http://dx.doi.org/10.1073/pnas.1112658108DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3228468PMC
November 2011

Oxytocin receptor genetic variation relates to empathy and stress reactivity in humans.

Proc Natl Acad Sci U S A 2009 Dec 23;106(50):21437-41. Epub 2009 Nov 23.

Institute of Personality and Social Research, University of California, Berkeley, CA 94720, USA.

Oxytocin, a peptide that functions as both a hormone and neurotransmitter, has broad influences on social and emotional processing throughout the body and the brain. In this study, we tested how a polymorphism (rs53576) of the oxytocin receptor relates to two key social processes related to oxytocin: empathy and stress reactivity. Compared with individuals homozygous for the G allele of rs53576 (GG), individuals with one or two copies of the A allele (AG/AA) exhibited lower behavioral and dispositional empathy, as measured by the "Reading the Mind in the Eyes" Test and an other-oriented empathy scale. Furthermore, AA/AG individuals displayed higher physiological and dispositional stress reactivity than GG individuals, as determined by heart rate response during a startle anticipation task and an affective reactivity scale. Our results provide evidence of how a naturally occurring genetic variation of the oxytocin receptor relates to both empathy and stress profiles.
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http://dx.doi.org/10.1073/pnas.0909579106DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2795557PMC
December 2009