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By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is a consultant for GlaxoSmithKline and is on the speaker's bureau of GlaxoSmithKline, 3M, Wyeth-Ayerst, Pfizer, Novartis, Bristol-Myers Squibb, AstraZeneca, Jones Pharma, and Boehringer Ingelheim.
Dietary Intervention for Fatty Liver Disease: Fat or Carbohydrate Restriction?
The spectrum of nonalcoholic fatty liver disease (NAFLD) can range from asymptomatic accumulation of fat in the liver without inflammation, to non-alcoholic Steatohepatitis (NASH). Because NASH is an inflammatory condition, it ultimately leads to fibrosis and even end-stage liver disease in some. Increasing numbers of obese and diabetic individuals result in clinicians encountering NAFLD regularly.
Initial treatment recommended for NASH is weight loss. Major consensus groups (eg, American Heart Association, American Diabetes Association) have advocated a diet with less than 30% fat. Typically, however, fat restriction is compensated by an increase in dietary carbohydrate, which can induce deleterious metabolic consequences to insulin levels and triglycerides.
To study the impact of fat vs carbohydrate restriction, 52 obese individuals were given a calorie-restricted diet containing 15% protein. The remainder of calories was then divided as either 60% carbohydrate/25% fat or 40% carbohydrate/45% fat.
The amount of weight loss was equal in the two groups over 16 weeks. Serum alanine aminotransferase levels decreased significantly more in the group assigned to low carbohydrate, suggesting reduced fat-induced hepatic inflammation. The authors suggest that a carbohydrate restricted, moderately fat enhanced diet provides physiologic benefits for obese individuals compared to dietary advice currently recommended.
Ryan MC, et al. Diabetes Care. 2007;30(5):1075-1080.
Motivational Interviewing to Enhance Weight Control in Diabetic Women
Motivational Interviewing (M-INT) is not a generic term, but rather a specific process of techniques that have proven successful in diverse health issues; fundamentally, it is based upon an exploration of a person's rationale for change, coupled with elucidation of their own ambivalence, looking into discrepancies between current behavior and core values/personal goals.
Overweight diabetic women (n = 217) were enrolled in an 18 month randomized controlled trial. All subjects participated in an intensive behavioral weight control program with guidance by a multidisciplinary team including psychologists, dietitians, exercise counselors, and diabetes educators to assist with caloric restriction (1200-1500 kcal/day). Half the group also received M-INT, administered as five individual sessions (45 minutes) at baseline, 3, 6, 9, and 12 months.
Both groups experienced weight loss, but the M-INT group lost more weight at each measurement point (eg, 4.8 kg vs 2.7 kg at 12 months). Although the A1c improvement seen in the M-INT group was superior at six months, by eighteen months, the groups were similar. The results of this data should have wide generalizability, because the study subjects were ethnically diverse (eg, 38% African American). Whether male subjects would enjoy similar benefits has not yet been studied.
West DS, et al. Diabetes Care. 2007;30(5):1081-1087.
One-stop Shopping for Osteoporosis Treatment
Management of osteoporosis (OSPS) has evolved from daily treatment with bisphosphonates, to weekly or even monthly administration. There is some support for the concept that every step towards dosing parsimony improves likelihood of compliance, keeping in mind, however, that with treatment regimens employing infrequent dosing, each omissive error is also more consequential!
Zoledronic acid (ZDA) is a parenteral bisphosphonate (BIS), and is felt to work by similar mechanism to oral BIS (ie, alendronate, ibandronate, risedronate). The notoriously poor bioavailability of oral BIS requires strict administration techniques, without which absorption is severely compromised. As many as 50% of persons prescribed oral BIS have been documented to be non-adherent after a single year of use.
A double-blind placebo-controlled trial of ZDA in postmenopausal women with OSPS (n = 7,765) monitored new vertebral fractures and hip fractures over 36 months. ZDA was administered as a one-time 15-minute intravenous infusion of 5 mg each year for 3 years.
Over 3 years, ZDA reduced vertebral fractures by 70%, and hip fracture by 41%. Bone mineral density was improved. Markers of bone turnover were improved. The results attained equal or surpass those shown in clinical trials of oral BIS. One case of osteonecrosis was seen in the treatment group, but one was also seen in the placebo group. Although atrial fibrillation was seen more often in the ZDA group (mechanism unknown), adverse events associated with atrial fibrillation such as stroke were similar in both groups.
Black DM, et al. N Engl J Med. 2007;356:1809-1822.