- Researchers Put Kids on Course to Healthy Eating
- The HPV Vaccine
- Geisinger Researchers Investigate Obesity and Diet in the Elderly
- Morgan Remembered for Gifts to Science, Medicine and Education
- New Weis Center Scientist Explores the Genetics of Obesity
- New Ofﬁces Help Prepare Grants and Oversee Research
- Recent External Awards
- Staff Publications March - May 2009
A new program may help children who are overweight improve their eating habits and reduce their weight. Researchers in the Geisinger “Garden Gang” are testing the Stop Light Diet, a positive behavior-modiﬁcation program designed to appeal to kids. If successful, the program will help kids develop and maintain a healthy diet. “It’s not a weight-loss study,” said co-investigator Margaret Rukstalis, M.D. “It’s teaching eating and activity habits so that kids will maintain a healthy weight as they grow.”
In the United States today, 1 in 3 children is overweight. These children are at greater risk for a variety of physical and mental disorders, including obesity in adulthood. Often, the behaviors of entire families contribute to children’s weight problems, noted Dr. Rukstalis, a clinician-investigator at Geisinger’s Center for Health Research. American families now eat more than 50% of their meals in restaurants, where deep-fried foods and oversized portions are the norm. Babies as young as 4 to 6 months of age are drinking soda, Dr. Rukstalis said, and french fries are more pervasive in young people’s diets than vegetables.
The Stop Light Diet has shown effectiveness in research settings, but has not yet been tested in a primary care setting. Designed to be intuitive, the diet classiﬁes foods as red-, yellow-, or green-light meals. At home, families use color-coded stickers to keep track of their food intake. Red represents deep-fried, high-fat, and high-sugar foods. Yellow foods, such as bananas, are healthy but high in calories, requiring limits on daily consumption. Finally, green foods are mostly low-fat, nutritious vegetables. Weekly group counseling sessions teach parents techniques and behaviors to help their children lose weight, and afford kids an opportunity to try new vegetables. Typically, Dr. Rukstalis said, children must try a vegetable about 10 times before they start to like it.
The diet was designed by Faith Miles, PhD, assistant professor of psychology at the University of Pennsylvania, and Leonard Epstein, PhD, professor of behavioral medicine at the University of Buffalo, New York.
Funded by the National Institutes of Health, this study will enroll families with children 4 to 8 years old who are overweight, and is a collaboration between Geisinger and the University of Pennsylvania. The researchers aim to increase children’s intake of green-light foods to 5 to 9 servings per day and restrict red-light foods to once per week. This often requires all family members to make substantial changes to their diets. “Some kids eat 7 to 10 red-light foods a day, and no vegetables,” Dr. Rukstalis said.
In order to quantify the program’s effectiveness, researchers at Geisinger will recruit 60 families whom they will randomize either to participate in the full program, with 8 weekly sessions, or to receive handouts discussing nutrition and exercise. The primary end point is fruit and vegetable consumption 5 months after the study’s start, and 3 months after the end of the diet program.
If the program works, Dr. Rukstalis hopes that it will be adopted by other primary care facilities. She added, “I grew up on a farm, and my grandmother had a garden. This is how I ate growing up, and I hope this becomes how we all eat.”
The number of teenage girls receiving the human papillomavirus (HPV) vaccination has remained relatively low since the vaccine was ﬁrst approved in 2006. Now, investigators at Geisinger and the University of Pennsylvania are talking to young women and their parents in both rural and urban healthcare systems to understand what they know and believe about the HPV vaccine and what factors could encourage them to seek the vaccine when appropriate.
“Ideally young women would be vaccinated against HPV at the same rate as they receive vaccinations for other preventable health conditions, but we are not there yet,” noted coinvestigator Sharon Larson, Ph.D. “Eventually we hope to develop primary HPV story jump what they need to know about the vaccine,” explained Dr. Larson.
In Geisinger’s rural setting, only about 35% of girls under the age of 18 have chosen to get vaccinated, Dr. Larson explained, whereas the urban population served by the University of Pennsylvania has even lower vaccination rates, at about 15%.
An intervention in primary care settings could be an effective incentive and educational tool, noted Dr. Larson, a research investigator at the Geisinger Center for Health Research. “If a trusted physician makes a recommendation, people are much more likely to take it.” Investigating the attitudes of clinicians, parents, and teens toward the vaccine is a ﬁrst step, and will “help us understand what kinds of strategies will be useful in motivating [parents and children] to get the vaccine,” Dr. Larson said. Once developed, investigators intend to test the intervention in a group of parent–teenager dyads, and will record differences in vaccination rates between this group and girls who received standard care.
The interventions under development likely will target two issues that seem to play signiﬁcant roles in suppressing vaccination rates: parental attitudes and rural–urban differences in health care access. For instance, some parents are concerned about the vaccine’s effects on their children’s sexual behavior and health. For these parents, Dr. Larson explained, an intervention should demonstrate to parents that “the vaccine doesn’t promote increased sexual activity and that the risks associated with it are similar to those you might ﬁnd with, say, the tetanus shot.”
It is likely that differences in how patients access health care across rural and urban settings also will play a role in the content of interventions. Teens in urban areas can obtain the vaccine without parental consent by going to family planning clinics. In rural areas, by contrast, women tend to undergo routine gynecologic procedures less often than those living in a city.
Researchers also take into account rural–urban differences in framing their interventions. In Philadelphia, University of Pennsylvania researchers are planning a three-pronged approach, targeting parents only, teens only, and both together. But in rural Pennsylvania, where the population is smaller and statistical power is thus achieved with a smaller sample, clinicians will target only two groups — teens alone and teens and parents together — Dr. Larson said.
At present, researchers are still recruiting for focus groups to investigate the concerns of parents and teenagers. At Geisinger, Dr. Larson plans to enroll 50 parents and about 75 teenage girls. Once they reach the trial stage, she expects they will enroll 150 girls and another 150 parent–child dyads.
A signiﬁcant portion of the rural elderly population is affected by obesity and a poor diet, according to researchers at Geisinger. The GRAS (Geisinger Rural Aging Study) investigation is currently examining the prevalence and consequences of diet and weight in a substantial sample of elderly citizens in a rural area. GRAS co-investigator Christopher Still, D.O. explained, “People think that older individuals are frail—at least in central Pennsylvania, that’s far from the truth. They tend to be heavier, with a signiﬁcant disease burden.” GRAS researchers are seeking to elucidate how obesity and poor diet affect long-term health in this population.
Few studies have examined the quality of older individuals’ diets, explained Dr. Still, director of the Geisinger’s Nutrition and Weight Management Clinic and director of the Geisinger Obesity Institute. In order to clarify the prevalence of obesity and nutritional deﬁciency in a rural elderly population, GRAS researchers enrolled all patients eligible for Medicare who entered the clinic between 1994 and 1999. Using self-reported surveys, the researchers compiled information on diet, weight, and vitamin and protein intake for 21,645 patients, the largest longitudinal sample of older individuals in a rural setting. Researchers veriﬁed the results by studying fasting serology obtained from 200 subjects during comprehensive home visits.
Pennsylvania is an ideal state in which to investigate the effects of aging, Dr. Still said, because the elderly population is large and stable. The state “has one of the highest proportions of older adults in the United States, and there isn’t a lot of migration out of the state.” About 25% of Pennsylvanians are over age 60 and 70% of this population is native to Pennsylvania.
To date, results have highlighted the signiﬁcant health burdens associated with weight issues. In the initial survey, 45% of the cohort was overweight, whereas another 30% was obese, with a body mass index greater than 30 kg/m2. Study results show that women who live alone, require assistance with regular chores, and have functional limitations are at greatest risk for dietary deﬁciencies and increased morbidity, according to Dr. Still. Both overweight and obese individuals are more likely than subjects of normal weight to have inadequate intake of folate, zinc, calcium, and vitamins B6, D, and E. Results also showed greater functional decline, more frequent use of health resources, and increased chronic disease comorbidity in the overweight, the overweight, elderly population.
The U.S. Department of Agriculture is funding the study, a collaboration among researchers from Geisinger, the University of Pennsylvania, the Agricultural Research Service and Tufts University.
Future efforts will continue to explore correlations between diet and chronic disease, Dr. Still said, and will also investigate differences in outcomes based on race and ethnicity. Investigators also have developed two instruments designed to assess diet speciﬁcally in elderly, rural populations: the Population-Speciﬁc Food Frequency Questionnaire and the Diet Quality Screening Questionnaire. They plan to validate both tools in additional ethnic and racial groups.
Ultimately, Dr. Still hopes to develop clinical interventions to encourage healthy weight loss in the elderly. Currently, clinicians shy away from suggesting that individuals over age 60 or 65 should slim down. “Usually, when people at that age lose weight, it connotes a higher mortality,” he explained. But external factors, such as underlying illness or an occult disease pro¬cess, may account for this correlation, and well-developed clinical interventions may improve health.
An indelible legacy
Geisinger staff and leaders recently celebrated the life and achievements of Howard Morgan, M.D., who died on March 2. One of the nation’s foremost cardiology researchers, Dr. Morgan led a program that focused on the molecular and cellular mechanism of cardiovascular disease. As senior vice president for research and director of the Sigfried and Janet Weis Center for Research, Dr. Morgan recruited a strong cadre of scientists and established the standards and policies for a flourishing research program.
The tribute was organized by Janet Robishaw, Ph.D., senior researcher and associate director, Weis Center for Research; David Carey, Ph.D., associate chief research ofﬁcer, chief administrator and director, Weis Center for Research; and Cathy Beinlich, Ph.D., associate vice president, Weis Center for Research. Geisinger President and CEO Glenn Steele Jr., M.D., Ph.D., delivered the opening remarks.
Special guest speakers representing the worlds of research, education and health administration reﬂected on Dr. Morgan’s life as a physician, researcher, educator and healthcare thought leader. Robert B. Jennings, M.D., James B. Duke professor, Emeritus, Department of Pathology, Duke University Medical Center, referred to Dr. Morgan as “the leading experimental cardiologist of the 20th century.”
Edwards Park, Ph.D., professor of Pharmacology, University of Tennessee, remarked, “Dr. Morgan made a better person of everyone who came in contact with him.”
To make a gift to the Howard E. Morgan, M.D. Endowment for Research Education, visit www.geisingerfoundation.org. Or, send your gift via mail to: Geisinger Health System Foundation, M.C – 40-00
George Argyropoulos, Ph.D., a molecular biologist, has recently joined the Weis Center for Research as a staff scientist. The main focus of Dr. Argyropoulos’ research is obesity — more speciﬁcally, the regulation of genes that affect feeding behavior.
Dr. Argyropoulos, who had been an associate professor at Pennington Biomedical Research Center at Louisiana State University, has concentrated on the complicated, multifactorial conundrum of obesity. “My role in this effort is to understand the etiology of obesity by focusing on the hypothalamic control of food intake. Most genes affecting food intake are expressed in the hypothalamus. One of the genes that I have been studying extensively over the past few years is called the agouti-related protein (AgRP), which when over-expressed in the hypothalamus makes you eat more — what’s called being hyperphagic. This consequently leads to the development of obesity and type 2 diabetes.”
Dr. Argyropoulos was attracted to Geisinger’s advanced and extensive electronic health records system, which will help him undertake his human genetic studies, as well as Geisinger’s extensive bariatric surgery program. “The only cure for obesity nowadays is bariatric surgery,” Dr. Argyropoulos noted, “and diabetes can be completely alleviated by bariatric surgery. But no one really understands why that is so, so another question I have is why does bariatric surgery work so well.” Dr. Argyropoulos said that Pennsylvania is well known for having higher-than-average rates of obesity, a situation he hopes to positively affect with his research.
The Geisinger Health System recently has welcomed two experienced research administrators whose duties include the oversight of research compliance and the submission of proposals and acceptance of awards for research and non-research projects throughout the system. Both administrators have decades of experience in this area, the importance of which is growing as the Geisinger community continues to increase its research commitments. Gregg R. Bloomquist, MS, director of sponsored project administration, explained that his ofﬁce processes all proposals and awards, regardless of the source of funding, with the exception of clinical trials and industry-sponsored studies that are overseen by the Center for Health Research. Bloomquist comes to Geisinger from Vanderbilt University School of Medicine, where he was the director of research administration in the Department of Pediatrics. He previously held a similar position at Children’s Hospital of Pittsburgh.
Dorothy Sellers, the director of research compliance and training, had been the director of regulatory compliance for human subject research at the University of Chicago, where she was also responsible for “the research component of HIPAA implementation,” she explained. Whereas Bloomquist’s job is to focus on getting grants written, submitted, and awarded, Sellers’ ofﬁce takes over at that point to ensure that the project will be completed to the highest ethical standards. This includes, but is not limited to, the training of the staff, helping respond to external audits, developing processes for billing patient care costs on trials, managing the conﬂict of interest disclosure process, the consent process, the data collection and the compliance with applicable laws, rules and regulations. Sellers and Cathy Betz, Compliance Coordinator, work closely with the Human Research Protection Program, the Center for Clinical Studies, Legal and other ofﬁces.
The establishment of these ofﬁces is part of the development of a more robust research administration. Sellers and Bloomquist welcomed the level of collegiality they have found at Geisinger, and both have noted a signiﬁcant demand for their services, which speaks of the institution’s growing emphasis on research.
“I am looking forward to developing a program that beneﬁts this entire institution — it is a very exciting time to be at Geisinger.” said Sellers. “I think Geisinger’s reputation is very good,” added Bloomquist. “It is an emerging research institution and a very large, well-respected health system, and given the leadership and the resources here, I think it is poised to do great things.”
This list includes new awards and competitive renewals from external agencies and Geisinger’s Clinical Research Fund from March through May 2009. To protect sponsors’ conﬁdential information, we omit dollar amounts for clinical trials and industry-sponsored agreements and some clinical trial listings. If an award is overlooked, please forward the information to Shawna Seger (email@example.com) for inclusion in the next issue.
Eric Beiber, MD
Whole Genome-wide Association Analysis of Endometriosis
James Blankenship, MD
“Lifesaver” Health Screenings
David Carey, PhD
Genomic Medicine Investigator Recruitment
Commonwealth of Pennsylvania Ben Franklin Fund
David Carey, PhD
Genomics of Pregnancy-Related Complications
Department of Health
Ronald Harris, MD
The Effect of Insulin Determin in Combination with Liraglutide and Metformin Compared to Liraglutide and Metformin in Subjects with Type 2 Diabetes, a 26-week Random Open-Label Parallel Group Multicenter Multinational Trial, with a 26-week Extension
Sharon Larsen, PhD
Community Needs Assessment
Nava Nawaz, MD
A Study of C-KIT, PVHL, KI67 and P16 as a Panel of Useful Markers in Differentiating High Grade Lung Neuroendocrine Carcinoma from Low Grade Neuroendocrine Carcinomas
Steve Paolucci, MD
Reaching Rural Veterans Initiative Pennsylvania
Department of Health
Azadeh Stark, PhD
Just in Time Accession of Clinically Annotated Pathology Specimens for Molecular Marker Research
National Institutes of Health
Walter Stewart, PhD, MPH
A Prospective Study of NTproBNP, Self-reported Symptoms and EHR Data as Predictors of Health Failure Diagnosis
These publications feature Geisinger employees as authors with publication dates from March to May 2009. Publications with a Geisinger employee as the sole author have no special markings. But, when the publication is jointly authored by a Geisinger employee and employee of other institutions, an asterisk follows the Geisinger employee’s name. The listings below follow National Library of Medicine format and were compiled using RefWorks.
1. Boctor F*, Luban N. Transfusion medicine. In: Ahmed AA, Przygodzki RM, editors. Pathology exam review. Philadelphia, Wolters Kluwer; Lippincott Williams & Wilkins, 2009. p. 283-96.
2. Boscarino JA*, Adams RE. Peritraumatic panic attacks and health outcomes two years after psychological trauma: Im¬plications for intervention and research. Psychiatry Res. 2009 May 15;167(12):139-50.
3. Boscarino JA, Erlich PM, Hoffman SN. Low serum cholesterol and external-cause mortality: Potential implications for research and surveillance. J Psychiatr Res. 2009 Jun;43(9):848-54.
4. Bourbeau PP, Swartz BL. First evalu¬ation of the WASP, a new automated microbiology plating instrument. J Clin Microbiol. 2009 Apr;47(4):1101-6.
5. Cai Q, Skelding K, Armstrong A,Jr, Desai D, Wood GC, Blankenship J. Predictors of long-term major adverse cardiac events and clinical restenosis following elective percutaneous coronary stenting. Angiology. 2009 Apr 1;60(2):141-7.
6. Clark MJ, Pellitteri PK. Assessing the impact of low baseline parathyroid hormone levels on surgical treatment of primary hyperparathyroidism. Laryngoscope. 2009 Jun;119(6):1100-5.
Crespo EM, Oliveira GBF, Honeycutt EF, Becker RC, Berger PB*, Moliterno DJ, Anstrom KJ, Abrams CS, Kleiman NS, Moll S, Rice L, Rodgers JE, Steinhubl SR*, Tapson VF, Granger CB, Ohman M, CATCH Registry Investigators. Evaluation and management of thrombocytopenia and suspected heparin-induced thrombocytopenia in hospitalized patients: the complications after thrombocytopenia caused by heparin (CATCH) registry. Am Heart J 2009 Apr;157(4):651-7.
7. Cronin H, Mowad C. Anaphylactic reaction to bacitracin ointment. Cutis. 2009 Mar;83(3):127-9.
8. Dalal R, Shah NR*. Comparative effectiveness of beta blockers in heart failure. [review]. Journal of Clinical Outcomes Management 2009 May;16(5):212-4.
Dasgupta A, Steinhubl SR*, Bhatt DL, Berger PB*, Shao M, Mak K-H, Fox KAA, Montalescot G, Weber MA, Haffner SM, Dimas AP, Steg G, Topol EJ, CHARISMA Investigators. Clinical outcomes of patients with diabetic nephropathy randomized to clopidogrel plus aspirin versus aspirin alone (a post hoc analysis of the clopidogrel for high atherothrombotic risk and ischemic stabilization, management, and avoidance [CHARISMA] trial). Am J Cardiol 2009 May 15;103(10):1359-63.
9. Dohse L, Elston DM. Botanical briefs: Trumpet vine (campsis radicans). Cutis. 2009 Apr;83(4):177-8.
10. Good CW, Blankenship JC, Scott TD, Skelding KA, Berger PB, Wood GC. Feasibility and safety of ad hoc percutaneous coronary intervention in the modern era. J Invasive Cardiol. 2009 May;21(5):194-200.
11. Hamou C, Shah NR*, Diponio L, Curtin CM. Pinch and elbow extension restoration in people with tetraplegia: a systematic review of the literature. J Hand Surg [Am]. 2009 Apr;34(4):692-9.
12. Huey NL, Clark AD*, Kluhsman BC, Lengerich EJ, ACTION Health Cancer Task Force. HPV vaccine attitudes and practices among primary care providers in Appalachian Pennsylvania. Prev Chronic Dis. 2009 Apr;6(2):A49.
13. Laraque D, Adams D, Steinbaum D, Zuckerbrot R, Schonfeld D, Jensen PS, Demaria T, Barrett M, Dela-Cruz M, Boscarino JA*. Reported physician skills in the management of children’s mental health problems following an educational intervention. Academic Pediatrics 2009 May;9(3):164-71. Larson S. Rural substance abuse policy report: substance abuse among rural residents. Rural Health Policy Institute: The Policy Report (Geisinger Center for Health Research). 2009 Apr:1-4.
14. Mascarenhas V, Kalyanasundaram A, Nassef LA, Lico S, Qureshi A. Simul¬taneous massive pulmonary embolism and impending paradoxical embolism through a patent foramen ovale. J Am Coll Cardiol. 2009 Apr 14;53(15):1338.
15. McKenna M, Widmaier JC. Plating of a periarticular medial clavicle fracture. Orthopedics. 2009 May;32(5):366.
16. Minnich ME. Childbirth preparation and nonpharmacologic analgesia. In: Chestnut DH, [et al.], editors. Chestnut’s obstetric anesthesia : principles and practice. 4th ed. Philadelphia, Mosby Elsevier, 2009. p. 405-14.
17. Nichols JL, Bieber EJ, Gell JS. Case of sisters with complete androgen insensitivity syndrome and discordant Mullerian remnants. Fertil Steril. 2009 Mar;91(3):932.e15-932.e18.
18. Nichols JL, Gordon TO, Bieber EJ. Postablation tubal sterilization syndrome with hematometra after thermal balloon ablation. J Gynecol Surg. 2009 Mar;25(1):17-21.
19. Oka T, Sudol M. Nuclear localization and pro-apoptotic signaling of YAP2 require intact PDZ-binding motif. Genes to Cells. 2009 May;14(5):607-15
20. Pellitteri PK. Surgical management of hyperthyroidism. In: Terris DJ, Gourin CG, editors. Thyroid and parathyroid diseases : medical and surgical management. New York, Thieme, 2009. p. 197-225.
21. Price MJ, Berger PB*, Angiolillo DJ, Teirstein PS, Tanguay J-F, Kandzari DE, Cannon CP, Topol EJ. Evaluation of individualized clopidogrel therapy after drug-eluting stent implantation in patients with high residual platelet reactivity: design and rationale of the GRAVITAS trial. Am Heart J 2009 May;157(5):818-824.e1.
22. uon J, Shah NR*. Comparative ef¬fectiveness in hypertension: what can we accomplish? [review]. Journal of Clinical Outcomes Management 2009 Feb; 16(2):59-61.
23. Shah NR*, Aragones A, Gany F. Missed opportunities for colorectal cancer screening. Journal of Immigrant & Refugee Studies. 2009;7(2):201-10.
24. Shah NR*, Hirsch AG*, Zacker C, Wood GC*, Schoenthaler A, Ogedegbe G, Stewart WF*. Predictors of ﬁrst-ﬁll adherence for patients with hypertension. Am J Hypertens. 2009 Apr;22(4):392-6.
25. Skelding KA, Berger P, Mascarenas V, Good C, Scott T, Buckley J, Sartorius J, Wood C, Blankenship J. Gender is an independent risk factor for mortality when a non-invasive strategy is employed in the setting of acute myocardial infarction. J Am Coll Cardiol. 2009 Mar;53(10 suppl A):A55.
26. Steinhubl SR, Bhatt DL, Brennan DM, Montalescot G, Hankey GJ, Eikelboom JW, Berger PB*, Topol EJ, CHARISMA Investigators. Aspirin to prevent cardiovascular disease: the association of aspirin dose and clopidogrel with thrombosis and bleeding. Ann Intern Med. 2009 Mar 17;150(6):379-86.
27. Ulrich JN*, Poudyal G, Marks SJ*, Vrabec TR*, Marks B*, Thapa AB, Shresta MK, Ruit S, Federman JL. Ocular telemedicine between Nepal and the USA: prevalence of vitreoretinal disease in rural Nepal. Br J Ophthalmol. 2009 May;93(5):698-9.
28. alker BB, Collins CA*. Developing an integrated primary care practice: strategies, techniques, and a case illustration. J Clin Psychol. 2009 Mar;65(3):268-80.
29. Walker JM, Carayon P. From tasks to processes: the case for changing health information technology to improve health care. Health Aff. 2009 Mar-Apr;28(2):467-77.
30. Weber V. A call for meta-leadership. Leadership Forum - Society of General Internal Medicine. 2009 Mar;1(3):4.
Weber VD, Buckley SD, Fitzgerald AS, Arborbesong PE. Leadership Forum -Society of General Internal Medicine. 2009 Mar;1(3).