Thomas M. Campbell

Introduction: Persistent inflammation and features of the tumor microenvironment are linked to poorer prognosis in breast cancer. This study examined the effects of a whole food, plant-based (WFPB) diet on serum biomarkers of proliferation, apoptosis, angiogenesis, and inflammation in women with metastatic breast cancer. Methods: Women with stage 4 breast cancer undergoing treatment were randomized to either a WFPB diet (n = 20) or usual care (n = 10) for 8 weeks. Blood samples collected at baseline, 4, and 8 weeks were analyzed for disease progression and inflammation markers, including IL-1β, IL-6, IL-8, IL-12, MCP-1, PDGF-AB/BB, FGF-2, MIF, sFasL, TNF-α, TRAIL, CA15-3, HGF, leptin, VEGF-A, VEGF-C, VEGF-D, and angiopoietin-2. Data were evaluated using t-tests, ANCOVA, and Pearson’s correlations. Results: While no statistically significant between-group differences were found—likely due to the small control group—several within-group changes were observed in the WFPB group. TNF-α decreased significantly by week 8 (P < .05), as did leptin at both weeks 4 and 8 (P < .001). Novel findings include significant decline in CA15-3 and VEGF-C levels by week 8 (both P < .05). CA15-3 positively correlated with sFasL (R = 0.72, P < .001), TRAIL (R = 0.58, P < .05), and TNF-α (R = 0.52, P < .01). Conclusion: This randomized trial is among the first to assess dietary intervention effects on progression-related biomarkers in metastatic breast cancer. The WFPB diet was associated with reductions in inflammatory and tumor markers, suggesting potential to reduce inflammation and slow disease progression. Further research is warranted.

Background/Objectives: Whole-food plant-based diets (WFPBDs) are beneficial in managing hypertension in the general population but have not been well studied in chronic kidney disease (CKD), potentially due to concerns about hyperkalemia. We hypothesized that individuals with CKD 3 or 4 attending a 15-day WFPBD education program would achieve lower blood pressure compared to those who did not, without an increased risk of hyperkalemia. Methods: This was a pilot trial of 40 subjects with mild-to-moderate CKD and hypertension but without diabetes or proteinuria from a single academic center. The subjects were randomized to the 15-day education program or the control group. The changes in blood pressure, serum potassium, and other anthropometric and biochemical values were assessed. Results: Systolic blood pressure decreased from the baseline to day 15 in the intervention group by 8 mm Hg and increased in the control group by 2.7 mm Hg, although the difference in the blood pressure change did not reach statistical significance (p = 0.12). Diastolic blood pressure was not different between the two groups. Potassium changed by 0.01 mEq/L in the intervention group and −0.07 mEq/L in the control group (p = 0.52). The intervention subjects had significant decreases in body mass (−3.0 vs. −0.12 kg, p < 0.0001), total cholesterol (−39.4 vs. −5.0 mg/dL, p < 0.0001), low-density lipoprotein (−28.4 vs. −0.6 mg/dL, p < 0.0001), and high-density lipoprotein (−8.6 vs. −0.4 mg/dL, p = 0.006) compared to the controls. The changes in albumin and phosphorus were not different between the two groups. Conclusions: The subjects with mild-to-moderate CKD attending a 15-day WFPBD education program had a non-statistically significant reduction in systolic blood pressure without an increased risk of hyperkalemia compared to those who did not attend. The intervention subjects achieved significantly greater reductions in body mass and cholesterol without adverse effects on albumin or phosphorus. Larger and longer-duration trials using this approach in a diverse group of CKD patients are warranted.

Purpose: Quality of life (QOL) is among the most important outcomes for women with metastatic breast cancer (MBC), and it predicts survival. QOL is negatively impacted by cognitive impairment, fatigue, and weight gain. We assessed whether a whole food, plant-based (WFPB) diet-promoting weight loss is feasible and might improve QOL. Methods: Women with MBC on stable systemic treatments were randomized 2:1 to 1) WFPB dietary intervention (n = 21) or 2) usual care (n = 11) for 8 weeks. Participants attended weekly education visits and consumed an ad libitum WFPB diet (3 prepared meals/day provided). Patient-reported outcomes and 3-day food records were assessed at baseline and 8 weeks. The effects of WFPB diet on changes in outcomes were assessed by analysis of covariance model controlling for baseline. Results: 20 intervention and 10 control participants completed the trial. Intervention participants were highly adherent to the WFPB diet (94.3 % total calories on-plan). Intervention group nutrient intakes changed significantly including dietary fat (35.8 % to 20.4 % percent calories from fat, p < 0.001) and fiber content (12.7 to 30.8 g fiber/1000 kcal, p < 0.001). Perceived cognitive function (FACT-Cog total + 16.1; 95 % confidence interval [CI] = 0.8–31.7; p = 0.040) and emotional well-being (FACT-B emotional well-being subscale + 2.3; CI = 0.5–4.1; p = 0.016) improved in the WFPB versus the control group. Fatigue, measured by the BFI, improved within the WFPB group for fatigue severity (M = 4.7 ± 2.5[SD] to 3.7 ± 2.3, p = 0.047) and fatigue at its worst (5.8 ± 2.8 to 4.4 ± 2.4, p = 0.011). Conclusions: Significant dietary changes in this population are feasible and may improve QOL by improving treatment-related symptoms. Additional study is warranted. Trial Registration: ClinicalTrials.gov identifier: NCT03045289. Registered 7 February 2017.

Purpose: Breast cancer treatment is associated with weight gain, and obesity and its related cardiometabolic and hormonal risk factors have been associated with poorer outcomes. Dietary intervention may address these risk factors, but limited research has been done in the setting of metastatic breast cancer requiring systemic therapy. Methods: Women with metastatic breast cancer on stable treatment were randomized 2:1 to an 8-week intervention (n = 21) or control (n = 11). The intervention included weekly assessment visits and an ad libitum whole-food, plant-based (WFPB) diet with provided meals. Cardiometabolic, hormonal, and cancer markers were assessed at baseline, 4 weeks, and 8 weeks. Results: Within the intervention group, mean weight decreased by 6.6% (p < 0.01) after 8 weeks. Fasting insulin decreased from 16.8 uIU/L to 11.2 uIU/L (p < 0.01), concurrent with significantly reduced insulin resistance. Total cholesterol decreased from 193.6 mg/dL to 159 mg/dL (p < 0.01), and low-density lipoprotein (LDL) cholesterol decreased from 104.6 mg/dL to 82.2 mg/dL (p < 0.01). Total testosterone was unchanged, but free testosterone trended lower within the intervention group (p = 0.08) as sex hormone binding globulin increased from 74.3 nmol/L to 98.2 nmol/L (p < 0.01). There were no significant differences in cancer progression markers at week 8, although mean CA 15-3, CA 27.29, and CEA were lower in the intervention group (p = 0.53, p = 0.23, and p = 0.54, respectively) compared to control, when adjusted for baseline. Conclusion: WFPB dietary changes during treatment for metastatic breast cancer are well tolerated and significantly improve weight, cardiometabolic and hormonal parameters. Longer studies are warranted to assess the durability of changes. Trial registration First registered at Clinicaltrials.gov (NCT03045289) on February 7, 2017.

Purpose Breast cancer treatment is associated with weight gain, and obesity and its related cardiometabolic and hormonal risk factors have been associated with poorer outcomes. Dietary intervention may address these risk factors, but limited research has been done in the setting of metastatic breast cancer requiring systemic therapy. Methods Women with metastatic breast cancer on stable treatment were randomized 2:1 to an 8-week intervention (n = 21) or control (n = 11). The intervention included weekly assessment visits and an ad libitum whole food, plant-based (WFPB) diet with provided meals. Cardiometabolic, hormonal, and cancer markers were assessed at baseline, 4 weeks, and 8 weeks. Results Within the intervention group, mean weight decreased by 6.6% (p < 0.01) after 8 weeks. Fasting insulin decreased from 16.8 uIU/L to 11.2 uIU/L (p < 0.01), concurrent with significantly reduced insulin resistance. Total cholesterol decreased from 193.6 mg/dL to 159 mg/dL (p < 0.01) and low-density lipoprotein (LDL) cholesterol decreased from 104.6 mg/dL to 82.2 mg/dL (p < 0.01). Total testosterone was unchanged, but free testosterone trended lower within the intervention group (p = 0.08) as sex hormone binding globulin increased from 74.3 nmol/L to 98.2 nmol/L (p < 0.01). There were no significant differences in cancer progression markers at week 8, although mean CA 15 − 3, CA 27.29, and CEA were lower in the intervention group (p = 0.53, p = 0.23, and p = 0.54, respectively) compared to control, when adjusted for baseline. Conclusion WFPB dietary changes during treatment for metastatic breast cancer are well tolerated and significantly improve weight and cardiometabolic and hormonal parameters. Longer studies are warranted to assess the durability of changes. Trial registration First registered at Clinicaltrials.gov (NCT03045289) on February 7, 2017.

Lifestyle medicine (LM) is a rapidly emerging clinical discipline that focuses on intensive therapeutic lifestyle changes to treat chronic disease, often producing dramatic health benefits. In spite of these well-documented benefits of LM approaches to provide evidence-based care that follows current clinical guidelines, LM practitioners have found reimbursement challenging. The objectives of this paper are to present the results of a cross-sectional survey of LM practitioners regarding lifestyle medicine reimbursement and to propose policy priorities related to the ability of practitioners to implement and achieve reimbursement for these necessary services. Results from a closed, online survey in 2019 were analyzed, with a total of n = 857 included in this analysis. Results were descriptively analyzed. This manuscript articulates policy proposals informed by the survey results. The study sample was 58% female, with median age of 51. A minority of the sample (17%) reported that all their practice was LM, while 56% reported that some of their practice was LM. A total of 55% of practitioners reported not being able to receive reimbursement for LM practice. Of those survey respondents who provided an answer to the question of what would make the practice of LM easier (n = 471), the following suggestions were offered: reimbursement overall (18%), reimbursement for more time spent with patients (17%), more support from leadership (16%), policy measures to incentivize health (13%), education in LM for practitioners (11%), LM-specific billing codes and billing knowledge along with better electronic medical record (EMR) capabilities and streamlined reporting/paperwork (11%), and reimbursement for the extended care team (10%). Proposed policy changes focus on three areas of focus: (1) support for the care process using a LM approach, (2) reimbursement emphasizing outcomes of health, patient experience, and delivering person-centered care, and (3) incentivizing treatment that produces disease remission/reversal. Rectifying reimbursement barriers to lifestyle medicine practice will require a sustained effort from health systems and policy makers. The urgency of this transition towards lifestyle medicine interventions to effectively address the epidemic of chronic diseases in a way that can significantly improve outcomes is being hindered by current reimbursement policies and models.

Chronic disease places an enormous economic burden on both individuals and the healthcare system, and existing fee-for-service models of healthcare prioritize symptom management, medications, and procedures over treating the root causes of disease through changing health behaviors. Value-based care is gaining traction, and there is a need for value-based care models that achieve the quadruple aim of (1) improved population health, (2) enhanced patient experience, (3) reduced healthcare costs, and (4) improved work life and decreased burnout of healthcare providers. Lifestyle medicine (LM) has the potential to achieve these four aims, including promoting health and wellness and reducing healthcare costs; however, the economic outcomes of LM approaches need to be better quantified in research. This paper demonstrates proof of concept by detailing four cases that utilized an intensive, therapeutic lifestyle intervention change (ITLC) to dramatically reverse disease and reduce healthcare costs. In addition, priorities for lifestyle medicine economic research related to the components of quadruple aim are proposed, including conducting rigorously designed research studies to adequately measure the effects of ITLC interventions, modeling the potential economic cost savings enabled by health improvements following lifestyle interventions as compared to usual disease progression and management, and examining the effects of lifestyle medicine implementation upon different payment models.

A 69-year-old man with type 2 diabetes, hypertension and stage 3 chronic kidney disease (CKD), hyperphosphataemia and borderline hyperkalaemia presented to an office visit interested in changing his diet to improve his medical conditions. He adopted a strict whole-foods, plant-based diet, without calorie or portion restriction or mandated exercise, and rapidly reduced his insulin requirements by >50%, and subsequently saw improvements in weight, blood pressure and cholesterol. His estimated glomerular filtration rate (eGFR) increased from 45 to 74 mL/min after 4.5 months on the diet and his microalbumin/creatinine ratio decreased from 414.3 to 26.8 mg/g. His phosphorus level returned to the normal range. For individuals with CKD, especially those with obesity, hypertension, or diabetes, a strict, ad libitum whole-food, plant-based diet may confer significant benefit, although one must consider potential limitations of a creatinine-based GFR equation in the face of significant weight loss.