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October 10 - 13, 2018
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Vol. 3 No. 35

Asthma patients said to ‘fare better’
when involved in treatment decisions

NAMPA, IDAHO – The importance of asthma-patient involvement in treatment decisions was underscored in a recent study that is anything but news to one long-time medical practitioner.

Research published in Annals of Allergy, Asthma & Immunology in July reflects data from 189 persistent-asthma patients aged 55-and-older. It indicates that older asthmatic adults with a greater desire to take part in decision-making have a higher asthma-related quality of life.

Brian K. Bizik, MS, PA-C, physician assistant, Terry Reilly Health Center, Nampa, Idaho, says these findings match up with his professional experience.

“With people over 55, there is a desire to become involved with decisions,” says Bizik, past president, Association of PAs in Allergy, Asthma and Immunology, and a faculty member of Cardiovascular, Allergy, & Respiratory Summit (CARPS). “With patient involvement, there is more compliance with medication use and prescription refills. Patients involved in decision-making fare better in dealing with their asthma, including in terms of self-recognition of symptoms.”

In terms of older adults, he adds, “some are accustomed to the patriarchal view of patients doing what their medical providers tell them; they were raised that way. It is a change for them to be involved in the decision-making process, as older patients are more rooted in a hierarchical system.”

Bizik concurs with the study’s findings that women show higher preferences for autonomy than men.

“Women,” he says, “are more likely than men to want autonomy for treatment of chronic conditions. Men may have false feelings of invincibility; women are more likely to have had the role of caregivers in their families, and to have been involved with medical care for their children.”

The research advocates the use of education and action plans in helping with patient treatment and improving asthma-related outcomes.
Bizik is a big supporter of action plans.

“When physician assistants (PAs) and nurse practitioners (NPs) become involved in goal-setting and action plans,” he says, “we see a significant increase in medication compliance, and prescription refills go up; outcomes are better, and there are fewer in-patient visits.”

“This is not a process where you talk to the patient and send them home,” Bizik adds. “We use a written action plan. We ask patients how they feel about things, and the patient’s perception of their medical provider goes up. When they return for a check-up, it’s time for goal-setting, and action plans.”

Bizik looks at patients’ symptoms as well as what they do during the day, including exercise and walking.

“I have one patient,” he explains, “who is 22, who tells me that when she walks seven blocks, she struggles for air.” Information like this, Bizik says, is helpful when it comes to compiling written, printed-out action plans, which he has utilized for the past 18 years, noting treatment levels, including medications.

His current action plans feature a “traffic-light” approach:

  • Green---asthma well-controlled, use daily or as-needed inhalers as prescribed
  • Yellow---symptoms like wheezing have increased, may be time to add an oral medication like prednisone, or use controller-inhaler more frequently
  • Red---symptoms have increased despite additional medications, and a visit with provider, or to emergency room, may be needed

The study concludes that appreciating patient-preferences can be a channel to improve patient care, better patient outcomes, and enhanced physician-patient relationships.

“It all comes down to preferences,” Bizik says. “We ask patients how they are doing, and discuss the type of inhalers they should use, the best time for them to take their medications, and how involved they want to be with their treatment and care. Some just want their treatments written out to follow, others want shared decision-making. We ask patients how involved they want to be.”

“Some patients,” he says, “don’t know why they are struggling to breathe, and then they learn they have asthma. We talk to patients about inhalers, and how to do breathing tests at home. If they are struggling, it comforts them to know they can use an inhaler. Just knowing they have an inhaler at home and that they can use it, helps. Knowing their choices is empowering and calming.”

CITATION: Keerthi R. Karamched, MD, Wei Hao, MA, et. al. The impact of patient autonomy on older adults with asthma. Annals of Allergy, Asthma & Immunology. July 2018 Volume 121, Issue 1, Pages 65-68. E1. https://www.annallergy.org/article/S1081-1206(18)30331-4/fulltext

 


Patient-led ideas, co-design supported
in study of mental-health service users

WELLINGTON, NEW ZEALAND – Patient-led ideas and co-design should be key principles in programs and environmental design for weight loss, according to a study involving long-term psychiatric patients published in September in BMC Psychiatry.

Its authors---including Susanna Every-Palmer and Mark A. Huthwaite, University of Otago, Wellington, Wellington, New Zealand---noted that obesity is a significant problem among people with serious mental illness, and aimed to consider body size from the perspective of long-stay psychiatric in-patients.

The researchers focused on:

  • weight gain and its causes and impacts
  • diet and physical activity
  • the perceived ability to make meaningful changes in these domains

The authors considered weight from the perspective of an in-patient group, while noting that many themes are more broadly applicable to mental-health service users. Participants were overweight, and cared about this, with 75% reporting attempts to lose weight.

Self-blame and disgust were evident in some, alongside a reduced sense of control and personal efficacy. Participants attributed weight gain to a combination of physical, psychological and social factors, with the prevailing theme that institutional constraints made it difficult to live a healthy life, and that changing this was beyond their control.

Overall, given the interest and range of imaginative ideas about strategies for weight loss, participants showed themselves worthy-and-engaged collaborators in the quest for better health outcomes.

The mixed-methods study involving 51 long-term psychiatric forensic-and-rehabilitation in-patients used semi-structured interviews, combined with biometric and demographic data; 94% of participants were overweight or obese.

Qualitative responses indicated low personal effectiveness and self-stigmatization. Participants viewed their weight gain as something “done to them” through medication, hospitalization and leave restrictions.

Many had an external locus of control, viewing weight loss as desirable but unachievable, inhibited by environmental factors and requiring a quantum of motivation they found hard to muster.

Despite this, participants were thoughtful and interested, had sound ideas for weight loss, and wished to be engaged in a shared endeavor to achieve better health outcomes.

CITATION: Susanna Every-Palmer, Mark A. Huthwaite, et. al. Long-term psychiatric inpatients’ perspectives on weight gain, body satisfaction, diet and physical activity: a mixed methods study. BMC Psychiatry. Received: 30 November 2017. Accepted: 5 September 2018. Published: 18 September 2018. https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-018-1878-5

 


Research indicates CV events likelier
for those with diabetes, high TG levels

PORTLAND, ORE. – A recent study indicates that despite statin‐controlled low-density lipoprotein cholesterol (LDL‐C) levels, cardiovascular (CV) events are greater among patients with diabetes and high triglyceride (TG) levels.

Authors of the study published in September in Cholesterol. Diabetes, Obesity and Metabolism indicate that, as they controlled for cardiometabolic risk factors, it is likely that the difference in TG levels contributed to the excess risk observed in patients with high TGs.

The researchers---including Gregory A. Nichols, who is affiliated with the Kaiser Permanente Center for Health Research, Portland, Ore., and Sephy Philip, Amarin Pharma Inc., Bedminster, N.J.---set out to determine whether high TGs in the presence of statin‐controlled LDL‐C influence cardiovascular disease (CVD) risk among patients with diabetes in real‐world clinical practice.

They identified adults with diabetes from the Southern California and Northwest regions of Kaiser Permanente, including patients on statin therapy with LDL‐C from 40-to-100 mg/dL who were not on other lipid‐lowering therapies and had prior diagnoses of atherosclerotic CVD or at least one other CVD risk factor.

The researchers grouped patients into high (200-to-499 mg/dL, 5,542 patients) or normal (less-than 150 mg/dL, 22,411 patients) TGs from 2010 through December, 2016, to compare incidence rates and rate ratios of first non‐fatal myocardial infarction (MI); non‐fatal stroke; unstable angina; and coronary revascularization.
They adjusted the multivariable analyses for:

  • age
  • sex
  • ace/ethnicity
  • smoking status
  • blood pressure
  • HbA1c
  • serum creatinine
  • presence of ischemic heart disease
  • study site

The adjusted-rate ratios for the four outcomes were all statistically-significantly different. The incidence rate for non‐fatal MI was 30% higher in the high TG group. The rate was 23% higher for non‐fatal stroke; 21% higher for coronary revascularization; and non-significantly 33% higher for unstable angina.

CITATION: Gregory A. Nichols Ph.D., Sephy Philip RPh, PharmD, et. al.  Increased Residual Cardiovascular Risk in Patients with Diabetes and High vs. Normal Triglycerides Despite Statin-Controlled LDL. Cholesterol. Diabetes, Obesity and Metabolism. First published: 17 September 2018. https://onlinelibrary.wiley.com/doi/abs/10.1111/dom.13537?af=R

 


Higher BMI called significantly associated
with CKD risk among hypertensive patients

GUANGZHOU, CHINA – Higher body mass index (BMI), but not waist circumference, is significantly associated with an increased risk of chronic kidney disease (CKD) development in hypertensive patients with normal kidney function, according to a study published in October in the Journal of Hypertension.

Its authors---including Liling Xie and Binyan Wang, Southern Medical University, Guangzhou, China.---investigated the relationship of BMI and waist circumference with the development of CKD by assessing 12, 672 hypertensive patients with estimated glomerular filtration rates (eGFRs) at least 60 ml/min per 1.73 m from the renal sub-study of the China Stroke Primary Prevention Trial (CSPPT).

The primary outcome was the development of CKD, defined as a decrease in eGFR of at least 30% and end-stage renal disease.
A secondary outcome was rapid renal-function decline.

Over a median follow-up of 4.4 years, the risk of the primary event or rapid-renal function decline increased with each increment of BMI.

Consistently, compared with those with normal weight, participants with obesity had an increased risk of the primary event and rapid-renal function decline.

However, waist circumference had no obvious effect on the risk of the primary event or rapid-renal function decline.

CITATION: Xie, Liling, Wang, Binyan, et. al. BMI is associated with the development of chronic kidney diseases in hypertensive patients with normal renal function. Journal of Hypertension. October 2018. Volume 36. Issue 10, pages 2085-2091. https://journals.lww.com/jhypertension/Abstract/2018/10000/BMI_is_associated_with_the_development_of_chronic.8.aspx

 

Assessment of osteoporosis and CD
argues against routine screenings

NEW YORK – About one-in-62 osteoporosis patients have biopsy‐verified celiac disease (CD), a prevalence comparable to that in the general population, according to a study indicating that these findings argue against routinely screening these patients for CD.

The study published in July in Alimentary Pharmacology and Therapeutics notes that this recommendation is contrary to current guideline recommendations and recommends further studies on such screening programs.

Its authors---including Monika Laszkowska and Srihari Mahadev, Celiac Disease Center at Columbia University, New York---conducted a systematic review of articles published in PubMed, Medline or EMBASE through May, 2017, to identify studies looking at prevalence of CD in patients with osteoporosis.

The researchers utilized fixed‐effects inverse variance‐weighted models and tested heterogeneity through sub-group analysis as well as through meta‐regression.

They identified eight relevant studies, comprising data from 3,188 people with osteoporosis. Of these, 59 had CD.

A weighted pooled analysis demonstrated biopsy‐confirmed CD in 1.6% of individuals with osteoporosis. The heterogeneity was moderate, and influenced by the underlying CD prevalence in the general population.

After adding four studies involving 814 people with CD defined as positive tissue transglutaminase or endomysial antibodies, the pooled prevalence was comparable.

CITATION: Monika Laszkowska, Srihari Mahadev, et. al. Systematic review with meta-analysis: the prevalence of coeliac disease in patients with osteoporosis. Alimentary Pharmacology and Therapeutics. First published 8 July 2018. https://onlinelibrary.wiley.com/doi/abs/10.1111/apt.14911?af=R&

 

Gestational diabetes-screening protocol
is questioned in Clinician Reviews article

An article in Clinician Reviews reports that a one-step protocol for gestational diabetes- screening increased diagnoses by 41%, with no evidence of improvement in maternal or neo-natal outcomes, according to a study published in Obstetrics and Gynecology. The article indicates that the oral glucose tolerance test (OGTT) recommended for all pregnant women in 2010, is still widely-used. The study involved data from more than 23,000 women receiving pre-natal care in Washington State between January, 2009, and December, 2014. The article can be accessed at https://www.mdedge.com/clinicianreviews/article/175076/obstetrics/one-step-gestational-diabetes-screening-doesnt-improve

 

 

Vol. 3 No. 34

Kidney expert: Connecting the dots
between medical conditions is vital

OCEANSIDE, CALIF. – High among the countless services nurse practitioners (NPs) and physician assistants (PAs) provide patients is the practice of helping connect the dots between various medical conditions.

“Patients aren’t always aware, for instance, of the link between chronic kidney disease (CKD) and blood pressure,” says Kim Zuber, PA-C, executive director of the American Academy of Nephrology PAs and past chair of the National Kidney Foundation/Council of Advanced Practitioners. “One patient who I have been seeing for seven years didn’t know she had CKD---I told her, and she was surprised. She thought I was just treating her for high blood pressure.”

“Patients don’t always see cause-and-effect,” says Zuber, of Oceanside, Calif., a faculty member of the Metabolic & Endocrine Disease Summit (MEDS). “They just think in terms of one box, for diabetes, another, for CKD, another, for blood pressure, and they don’t see the interactions between the boxes. NPs and PAs can explain and reiterate to them that these boxes interact and cause complications with other boxes. Patients see everything in separate boxes and don’t see the implications, the complications, involving other boxes.”

“Part of the cause,” Zuber says, “is that medicine is getting more-and-more specialized. Endocrinology, cardiology, they think these are separate boxes, different groups. One thing that NPs and PAs can do is educate and explain that these boxes are all interconnected. We need to explain the connections, between blood pressure and CKD, and ways to battle cardiovascular disease, and dementia. I don’t think patients know this.”

One study published in June, Zuber notes, ties higher-than-normal mid-life blood pressure to increased risk of developing dementia later in life. Another, published in May, indicates that modest population-wide reductions in systolic blood pressure have the potential for primary CKD prevention.

Two points from the latter research---the Atherosclerosis Risk in Communities (ARIC) study---are of particular interest to Zuber.

One is that “prevention-oriented lifestyle modifications” can help in disease incidence and progression. The kidney-disease expert reports especially good results in one aspect of this approach.

“Salt,” she says, “is a huge issue, one that we might be able to better impact than exercise and weight. I explain to patients that it takes salt as many days to clear their system as their kidney-disease stage: three for stage 3 CKD, four for stage 4 CKD.

“I encourage what I call ‘salt holidays’ and allow four per-year for any kind of pork: bacon, ham, spare ribs. For example: ham for Easter, July 4th for barbecue ribs. Maybe patients will take eight holidays instead of four, but this still will make them cut down significantly on salt. I worked in the South, where people love barbecue ribs; so even if they eat them monthly instead of weekly, that is a huge decrease.”

The study also indicates that blacks are twice as likely as whites to have above-goal blood pressure. Zuber’s experiences in the South alerted her to the fact that many Southerners attend church on Sundays, followed up with pot-lucks or family meals often including fried chicken and macaroni-and-cheese.

“My patients,” she recalls, “went out of their way to prepare low-salt foods to bring to church; I had a dietician teach cooking classes for this population.”

This pro-active approach, Zuber says, is one that NPs and PAs should wield, not only in battling CKD, but in decreasing the costs of the financially-troubled Medicare program: She notes that one Centers for Disease Control (CDC) study indicates that 20% of all Medicare dollars are spent on CKD patients, and that the CDC reports that CKD is four times higher among Medicare beneficiaries 65-and-older with high blood pressure than without.

“If we as NPs and PAs work to keep our patients from developing CKD, we can not only help our patients, we can save Medicare dollars in the long run,” Zuber says. “We can reach our patients with this information by making them more cognizant of blood-pressure issues, by finding out whether they are taking their medications, and, with high blood pressure, looking for secondary causes.”
“NPs and PAs,” she concludes, “are very good at patient education. We need to make the best use of the time we spend with patients.”

CITATION: Shakia T. Hardy, Ph.D., Donglin Zeng, Ph.D., et, al. Primary prevention of chronic kidney disease through population-based strategies for blood pressure control: The ARIC study. The Journal of Clinical Hypertension. First published: 23 May 2018. https://onlinelibrary.wiley.com/doi/abs/10.1111/jch.13311 Jessica G. Abell, Mika Kivimaki, et. al. Association between systolic blood pressure and dementia in the Whitehall II cohort study: role of age, duration, and threshold used to define hypertension. European Heart Journal. Received 21 July 2017. Revised 24 October 2017. Editorial decision 2 May 2018. Accepted 3 May 2018. Published 12 June 2018. https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehy288/5032485

 


ADA issues new position statement
on care for pediatric T1D patients

PALO ALTO, CALIF. – The American Diabetes Association (ADA) issued a new position statement recently regarding care for pediatric patients with type 1 diabetes (T1D), including recommendations concerning expeditious diagnosis and endocrinologist consultations.

Authors of the article published in August in Diabetes Care include Jane L. Chiang, who is affiliated with Diasome Pharmaceuticals, Palo Alto, Calif.

Diagnosis recommendations include:

  • diagnosis of T1D diabetes should be pursued expeditiously
  • a pediatric endocrinologist should be consulted before making a diagnosis of T1D when isolated glycosuria or hyperglycemia are discovered in the setting of acute illness and in the absence of classic symptoms
  • distinguishing between T1D, type 2 diabetes, monogenic diabetes, and other forms of diabetes is based on history, patient characteristics, and laboratory tests, including an islet auto-anti-body panel

A team of eight pediatric diabetes authorities worked on the position statement, which is comprised of recommendations and guidelines based on the body of evidence from more than 190 pieces of literature, including consensus reports and research studies.

The updated ADA pediatric T1D position statement is the first since 2005. The majority of recommendations for youth with T1D rely on supportive evidence from cohort/registry studies or expert consensus-and-clinical experience.

The authors note that there are improved outcomes for patients when there is adequate payor reimbursement for supplies and devices needed to optimize T1D management, especially in the pediatric population.

CITATION: Jane L. Chiang, David M. Maahs, et. al. Type 1 Diabetes in Children and Adolescents: A Position Statement by the American Diabetes Association. Diabetes Care. August 2018. Volume 41, Issue 8. http://care.diabetesjournals.org/content/early/2018/07/19/dci18-0023 American Diabetes Association Issues New Position Statement on Care for Pediatric Patients with Type 1 Diabetes. http://www.diabetes.org/newsroom/press-releases/2018/position-statement-care-pediatric-patients-type-1-diabetes.html

 


Inadequate availability of asthma meds
cited as barrier to low-income patients

BALTIMORE – Inadequate availability of asthma medications in the home is a barrier to adherence among low-income urban pre-schoolers, according to research indicating that assessment of medication readiness should be incorporated into clinical care.

Authors of the study published in August in Pediatrics---including Jennifer A. Callaghan-Koru, University of Maryland, Baltimore, and Kristin A. Riekert, Johns Hopkins University, Baltimore---call poor availability an under-recognized barrier to adherence and say interventions are needed to improve medication management and knowledge to increase adherence.

The researchers noted that having a medication available in the home is a pre-requisite to medication adherence, and set out to assess asthma-medication readiness among low-income urban-minority pre-school-aged children, as well as the association between beliefs about medications and medication readiness.

During a baseline assessment, a research assistant visited subjects’ homes to administer caregiver surveys and observe the following criteria in the medication-readiness index:

  • the physical presence and expiration status of medications
  • the counter status of metered-dose inhalers
  • caregiver knowledge of medication type and dosing instructions

Of 288 enrolled children (mean age 4.2 years, 92% African-American, 60% boys), 277 of their caregivers reported a rescue medication, but only 79% had it in the home. Also, only 60% met all medication-readiness criteria.

Among the 161 children prescribed controller medications, only 79% had it in the home, and only 49% met all readiness criteria.

Fewer worries and concerns about medications were associated with higher odds of meeting all readiness criteria for controller medications.

CITATION: Jennifer A. Callaghan-Koru, Kristin A. Riekert, et. al. Home Medication Readiness for Preschool Children With Asthma. Pediatrics. Published August 2018. Accepted June 13, 2018.http://pediatrics.aappublications.org/content/early/2018/08/03/peds.2018-0829?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token

 


Study: 24-month denosumab persistence
improves BMD for osteoporotic women

LOS ANGELES – Recent research indicates that persistence with denosumab for 24 months improves bone mineral density (BMD) among post-menopausal women with osteoporosis.

The study involving patients treated in routine clinical practice in the United States and Canada was first published in August in Archives of Osteoporosis.

Its authors---including Stuart L. Silverman, David Geffen School of Medicine at UCLA, Los Angeles, and Ethel S. Siris, Columbia University Medical Center, New York---conducted a prospective-cohort study indicating that 24-month persistence with denosumab was 58%.

Their single-arm study evaluated 24-month persistence with denosumab administered every six months in post-menopausal women receiving treatment for osteoporosis in real-world clinical practice in the United States and Canada.

Endpoints and analyses included:

  • the percentage of patients who persist with denosumab at 24 months
  • the total number of injections received by each patient
  • changes in BMD in persistent patients
  • the incidence of serious adverse events (SAEs) and fractures

Among 935 enrolled patients, 24-month persistence was 58% (50% in U.S. patients and 75% in Canadian patients).

A majority of patients received at least four injections over the observation period (62% of U.S. patients and 81% of Canadian patients).

Among patients who were persistent at 24 months and who had a baseline, 12-month, and 24-month dual-energy X-ray absorptiometry (DXA) scans, mean BMD increased from baseline to 24 months by 7.8% at the lumbar spine and 2.1% at the femoral neck.
SAEs and fractures were reported for 122 patients and 54 patients, respectively.

CITATION: Stuart L. Silverman, E. Siris, et. al. Persistence at 24 months with denosumab among postmenopausal women with osteoporosis: results of a prospective cohort study. Archives of Osteoporosis. December 2018, 13:85. First online: 07 August 2018. https://link.springer.com/article/10.1007%2Fs11657-018-0491-z

 

 

Long-sleep duration is associated
with risk of obesity among adults

WUHAN, CHINA – Long-sleep duration is associated with risk of obesity in adults, according to a study published in August in the Journal of Public Health.
Its authors, who recommend more cohort studies with objective measures to confirm this relationship, include Wenjia Liu, Wuhan University, Wuhan, China, and Rui Zhang, South-Central University for Nationalities, Wuhan, China.

Their meta-analysis assessed whether long-sleep duration is associated with the risk of obesity, weight gain, body mass index (BMI) change or weight change in adults.

PubMed, Embase, Cochrane Library, Elsevier Science Direct, Science Online, MEDLINE and CINAHL were searched for English articles published before May, 2017.

Sixteen cohort studies involving 329,888 participants from eight countries were included in the analysis. Pooled relative risks (RRs) or regression coefficients with 95% confidence intervals (CI) were estimated.

Heterogeneity and publication bias were tested; sensitivity analysis was also performed.

The authors found that long-sleep duration was associated with higher risk of obesity, but had no significant associations with weight gain, BMI change, or weight change.

Long-sleep duration increased the risk of weight gain in three situations: among men, in studies with less-than-five years’ follow-up, and when sleep duration was nine-hours-or-more.

CITATION: Wenjia Liu, Rui Zhang, et. al. Long sleep duration predicts a higher risk of obesity in adults: a meta-analysis of prospective cohort studies. Journal of Public Health. Published: 13 August 2018. Received: 17 November 2017. Revision Received: 04 July 2018. https://academic.oup.com/jpubhealth/advance-article-abstract/doi/10.1093/pubmed/fdy135/5071832?redirectedFrom=fulltext

 

Task-force statement backs screening

as fracture-prevention tool for women

An article in Clinician Reviews reports that the U.S. Preventive Services Task Force (USPSTF) commissioned a systematic-evidence review that indicates that bone-measurement tests and clinical-risk assessment tools are accurate for predicting osteoporotic fractures in women. Written by Aarisha Shrestha, DO, Family Medicine Residency Program at Abington (Pa)-Jefferson Health, and Neil Skolnik, MD, Jefferson Medical College, Philadelphia, the article states that for all women older than 65, as well as post-menopausal women younger than 65 who are at increased risk, there is evidence supporting screenings to prevent fractures. For men, there is insufficient evidence to screen. The article can be accessed at https://www.mdedge.com/clinicianreviews/article/171697/preventive-care/screening-osteoporosis-prevent-fractures-uspstf

 
 

Vol. 3 No. 33

Coaching stressed as key element
in battle to avoid bad eating habits

ONSET, WAREHAM, MASS. – A study noting the link between obesity among women in their 30s and subsequent development of breast cancer summons a strong, basic statement from one women’s-health expert.

“The pain of staying the same,” says R. Mimi Secor, senior faculty at Advanced Practice Education Associates (APEA), “has to be greater than the pain of change.”

The nurse practitioner (NP), national speaker, consultant, award-winning author and Metabolic & Endocrine Disease Summit (MEDS) faculty member points to the importance of coaching patients in order to sway them from bad eating habits, as well as unwise alcohol use.

The study published in April in BMC Public Health supports prevention efforts targeting weight in women below 40 and potentially lifelong alcohol consumption to reduce breast-cancer risk in middle-aged women. Its authors note correlations between stress and alcohol and between stress and obesity, with obesity occurring during the ages of 31-to-40 emerging as an independent breast-cancer predictor.

Dr. Secor---a resident of Onset, Wareham, Mass.---says NPs and physician assistants (PAs) should view this study as a reminder that “health, education, and coaching of patients is important for young women so they can control their weight, prepare and eat healthy foods, and not gain more than 30 pounds during pregnancy.”

“We need to take active roles,” she says, “in coaching, and look at patients’ mindsets, lifestyles, and challenges, and break down their goals into lifestyle changes. Clinicians need to get patients to record what foods they eat before making any adjustments, then look at the data and make precise, educated assessments. The best advice is driven by what patients tell us.”

People eat, Dr. Secor says, “for emotional reasons. There is addiction to food, caused by issues in their lives. Food is something we turn to, a security blanket. But patients can’t make changes without developing new habits. People eat junk food to help deal with stress; we try to get them to turn to exercise, meditation, or calling friends instead.”

Dr. Secor, who has been coached since 2000 to change eating habits, says clinicians “are short-circuited by time pressures. It is hit-and-run, with so many patients to deal with, leaving no time to be effective. We get them in, check the numbers, maybe do a quick exam. It is really important to be health-role models, to show we have made changes in our own lives.”

She adds that NPs and PAs “are all feeling the (time) crunch, and coaching is the first thing to go. Coaching holds them accountable, and it is driven by patients. We negotiate with them, have them take out their phones, set dates to check in with us, set timelines.”

Therapy, she stresses, “looks back---coaching looks forward.”

Dr. Secor offers these approaches to help women under 40 with weight issues:

  • State facts about links between obesity and breast cancer. “These studies illuminate the importance of controlling obesity at a young age, not just in their 30s, but teens, pre-teens.”
  • Urge lifetime health habits, with the assistance of family members, friends and co-workers. “People feel like alien life forms when they are trying to change eating habits and their friends are ordering burgers and fries.” She lives this reality at home: “I bought my husband a lemon cake yesterday; he keeps it in the garage.”
  • Work on patients’ mindsets. “Everybody brings their baggage.”
  • Note the ties, as noted in the study, between weight gain and alcohol use, to stress, which can spur over-eating and alcohol consumption. “Alcohol is empty calories and is a poison that shuts down metabolism. When you have an alcoholic drink with food, the food sits there, excessive calories. It is better to have a drink separately from food.”

Calling fear “a powerful agent of change,” Dr. Secor suggests that clinicians ask patients “on a scale of one-to-10, how committed they are. What is their self-esteem? Are they always trying to meet other’s needs instead of their own?”

Finally, Dr. Secor says women are generally unaware of the association between weight gain and breast cancer, which is something “we need to shout out from the mountain-tops.”

With technological help.

“We need more education for the masses,” she concludes. “We need to speak where people will listen. I communicate via podcasts, Facebook, as well as traditional media, though that is not where we reach younger people. We have a mandate to get our message out to the masses.”

CITATION: E.R. Miller, C. Wilson, et. al. Connecting the dots between breast cancer, obesity and alcohol consumption in middle-aged women: ecological and case control studies. BMC Public Health. Received: 1 September 2017. Accepted: 22 March 2018. Published: 6 April 2018. https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-5357-1

 


Diabetes-specific distress is detailed
in research on depression diagnosis

TRIPURA, INDIA – Recognizing depression with self-administered questionnaires may be influenced by concomitant presence of symptoms due to diabetes-specific distress, according to recently-published research.

The study published in July in Diabetes Research and Clinical Practice also indicates that proper diagnosis of depression may be established by structured clinical interviews and psycho-social management of type 2 diabetes (T2DM), and should possibly include assessment of depression and diabetes-specific distress.

Its authors include Mukut Roy, who is affiliated with Tripura Medical College, Tripura, India, and Nilanjan Sengupta, Nilratan Sircar Medical College, Kolkata, India.

The study included 250 adult patients with T2DM who were assessed for depression based on Beck Depression Inventory (BDI) and Diagnostic and Statistical Manual, Fourth edition (DSM IV) criteria.

Diabetes-specific distress was assessed as per Diabetes Distress Scale (DDS) scores.

Among the study population, based on BDI scores, 97 patients were found to suffer from depression; based on DSM IV criteria, prevalence of depression was 29.2%.

Sixty-two patients were found to suffer from diabetes-specific distress based on DDS scores.

Patients with severe diabetes-specific distress had associated matching of symptoms with mild depression based on BDI scores.

These same individuals were non-depressed as per DSM-IV criteria.

CITATION: Mukut Roy, Nilanjan Sengupta, et. al. Type 2 diabetes and influence of diabetes-specific distress on depression. Diabetes Research and Clinical Practice. Published online: July 15, 2018. Accepted: July 3, 2018. Received in revised form: February 15, 2018. Received: November 28, 2016. https://www.diabetesresearchclinicalpractice.com/article/S0168-8227(16)30734-3/fulltext?rss=yes

 

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Simple, inexpensive method cited
in kidney-organoid growth study

AUCKLAND, NEW ZEALAND – A study published in July in Stem Cell Reports indicates that researchers have established a simple-and-inexpensive method to grow kidney organoids in bulk from human-induced pluripotent stem cells.

Its authors---including Aneta Przepiorski and Veronika Sander, who are affiliated with the University of Auckland, Auckland, New Zealand---utilized a method involving the formation of embryoid bodies in the presence of a Wnt agonist followed by culture in medium supplemented with a substitute for fibroblast growth factor 9.

Highlights of the study include:
•    a technically-simple and cost-efficient protocol for kidney-organoid generation
•    tubular organoids are obtained rapidly, with high efficiency, yield, and robustness
•    organoids contain nephrons that correspond to human-fetal nephrons
•    the application to model congenital kidney defects is presented

The organoids showed optimal-tissue morphology at day 14; a comparison with fetal-human kidneys suggested that day-14 organoid tissue resembles late capillary loop-stage nephrons.

Deletion of HNF1B, a transcription factor linked to congenital kidney defects, interfered with tubulogenesis, validating the experimental system.

The researchers conclude that their approach for generating kidney organoids is simple, rapid, scalable, and works robustly for a range of different pluripotent stem-cell lines.

Their method, they report, overcomes many of the drawbacks hampering existing protocols, and provides the advance needed in order for kidney organoids to be effectively used for future applications, including drug testing and cell-replacement therapies where there is a requirement to generate large amounts of tissue.
 

CITATION: Aneta Przepiorski, Veronika Sander, et. al. A Simple Bioreactor-Based Method to Generate Kidney Organoids from Pluripotent Stem Cells. Stem Cell Reports. Published Online: July 19, 2018. Publication stage: In Press Corrected Proof. https://www.cell.com/stem-cell-reports/fulltext/S2213-6711(18)30281-9

 


Men with DS, high FRAX risk are said
at greater MOF, hip-fracture danger

MADISON, WIS. – Recent research indicates that men with both dysmobility syndrome (DS) and a Fracture Risk Assessment Tool (FRAX) risk above National Osteoporosis Foundation (NOF) treatment thresholds have higher major osteoporotic fracture (MOF) and hip-fracture risk than men with neither condition.

The study published in April in in the Journal of Bone and Mineral Research proposes the term DS to identify individuals with impaired musculoskeletal health, a risk factor for falls and fractures.

Its authors---including Bjoern Buehring and Karen E. Hansen, University of Wisconsin-Madison, Madison, Wis.---utilized their Osteoporotic Fractures in Men (MrOS) study, which enrolled 5,994 men aged 65-and-over between March, 2000, and April, 2002.

They used baseline data to determine whether DS increased fracture risk, independent of FRAX.

Men met DS criteria at baseline if they had three-or-more of the following: total body fat more-than-30%; spine or hip T‐score at least –2.5; grip strength less-than-30 kg; gait speed less-than-1.0 m/s; one-or-more falls within 12 months; and appendicular lean mass/height2 of less-than-7.26 kg/m2.

They examined whether baseline DS increased the risk of hip and MOFs over a median of 14 years.

Among 5,834 men, mean age 74 plus-or-minus six years, 471 had DS and 635 experienced an MOF, including 274 hip fractures.

Prediction of MOF using the FRAX score provided a concordance value of 0.67 plus-or-minus 0.012. Concordance increased to 0.69 plus-or-minus 0.012 by adding DS and to 0.70 plus-or-minus 0.012 by adding DS and age to the multivariate model.

Kaplan‐Meier curves indicated that men with both DS and a FRAX risk above the NOF treatment thresholds had higher MOF fracture risk than men with neither condition.

The researchers suggest further studies to determine the optimal criteria for DS, and to test DS as a predictor of falls and fractures, especially in women.
 

CITATION: Bjoern Buehring, Karen E. Hansen, et. al. Dysmobility Syndrome Independently Increases Fracture Risk in the Osteoporotic Fractures in Men (MrOS) Prospective Cohort Study. Journal of Bone and Mineral Research. First published: 27 April 2018. https://onlinelibrary.wiley.com/doi/abs/10.1002/jbmr.3455?af=R

 

Hypertensive disorders in pregnancy
linked to severe-maternal morbidity

SEATTLE – Hypertensive disorders in pregnancy are strongly associated with severe maternal morbidity in a dose-dependent relationship, according to a recent study suggesting that strategies to address rising maternal-morbidity rates should include early recognition and management of hypertension.

The study published in July in the American Journal of Obstetrics & Gynecology also indicates that prevention strategies focused on hypertension might also impact medically-indicated pre-term deliveries.

Its authors---including Jane Hitti and Laura Sienas, University of Washington Medical Center, Seattle---also found increased severe-maternal morbidity among American Indian/Alaskan Native women, a disadvantaged population in Washington State.

This, they indicate, underscores the role that socio-economic factors may play in adverse maternal-health outcomes. As 39% of severe-maternal morbidity diagnoses were present on admission, this measure, the researchers conclude, should be risk-adjusted if used as a quality metric for comparison between hospitals.

The researchers’ retrospective cross-sectional analysis assessed rates of severe-maternal morbidity diagnoses and procedures for all 7,025 women who delivered at the University of Washington Medical Center from Oct. 1, 2013, through May 31, 2017.

Severe-maternal morbidity was determined from pre-specified International Classification of Diseases diagnosis and procedure codes; all diagnoses were confirmed by chart review.
Of 7,025 deliveries, 284 had severe-maternal morbidity; 154 had transfusion only; 27 had other procedures; and 103 women had 149 severe-maternal morbidity diagnoses.

Severe preeclampsia occurred in 438 deliveries. Notably, hypertension was associated with severe-maternal morbidity in a dose-dependent fashion, with the strongest association observed for preeclampsia with severe features.

Severe-maternal morbidity was also significantly associated with preeclampsia without severe features, chronic hypertension, pre-term delivery, pre-gestational diabetes, and multiple gestation.

Among women with severe-maternal morbidity, over one third of pre-term births were associated with maternal hypertension. American Indian/Alaskan Native women had significantly higher severe-maternal morbidity rates compared to other racial/ethnic groups.

Overall, 39.6% of severe-maternal morbidity diagnoses were present on admission.
 

CITATION: Jane Hitti, MD, Laura Sienas, MD, et. al. Contribution of hypertension to severe maternal morbidity. American Journal of Obstetrics & Gynecology. Published online: July 15, 2018. Accepted: July 2, 2018. Received in revised form: June 29, 2018. Received: March 2, 2018. https://www.ajog.org/article/S0002-9378(18)30571-4/fulltext?rss=yes

 

Clinician Reviews article addresses
hypertension and diabetes issues

An article posted in August in Clinician Reviews addresses the issue of hypertension and diabetes. Written by Tracey T. Thurnes, MPAS, PA-C, who is affiliated with Elon University, Elon, N.C., the article notes that hypertension, a modifiable risk factor, is prevalent among diabetes patients. Thurnes reports that anti-hypertensive therapy in these patients reduces atherosclerotic cardiovascular disease (ASCVD), the leading cause of morbidity and mortality among those with diabetes, and that blood-pressure control---including lifestyle management---is recommended. The article can be accessed at https://www.mdedge.com/clinicianreviews/article/171416/endocrinology/hypertension-and-diabetes-addressing-common

 

 

Vol. 3 No. 32

Vitamin D deficiency study notes
importance of adiposity location

LAGUNA NIGUEL, CALIF. – Specific attention for vitamin D deficiency should be given to patients with a high amount of visceral adipose tissue (VAT), according to a recent study one medical expert says is notable in focusing on adiposity location in terms of vitamin D levels.

Research published in May in Endocrine Abstracts, based on a population-based cohort study of patients aged 45-to-65, notes that the relationship between different adiposity measures and 25(OH)D concentrations differed by gender. Among women, total body fat and VAT were inversely related to 25(OH)D concentrations; for men, VAT and hepatic fat were inversely related to 25(OH)D concentrations. In men and women, VAT was most strongly associated with 25(OH)D concentrations.

Ji Hyun Chun, PA-C, BC-ADM, OptumCare Medical Group, Laguna Niguel, Calif., and a faculty member of Metabolic & Disease Summit (MEDS), says that “what's new in this study is that it states that where the adiposity is matters in terms of vitamin D levels, subcutaneous versus visceral: There was higher correlation of visceral adiposity and chances of having low vitamin D.”

Chun, president of the American Society of Endocrine Physician Assistants (ASEPA), also stresses that this research supports the necessity of lifestyle changes to fight weight problems as well as the importance of vitamin D assessments and, when appropriate, supplementation.

He adds that “as vitamin D is a fat-soluble vitamin, patients with increased adiposity are at higher risk of lower circulating serum vitamin D levels. One has to have enough to saturate the adipose tissue before we have enough to circulate in the vascular system.”

Chun also says that visceral adiposity “is really the culprit of metabolic complications associated with obesity, rather than subcutaneous adiposity.”

He adds, though, that “it can work in both ways: We have to think, suspect, and screen for low vitamin D in patients with increased visceral adiposity, but also think, suspect, screen for visceral adiposity in obese patients with low vitamin D.”

The research, a cross-sectional analysis of baseline measurements of the Netherlands Epidemiology of Obesity study, is, says Chun, “an association study rather than causal-relation study, and is still ‘chicken-or-the-egg’ status.”

It is also one of countless indicators of the urgency of battling weight problems.

“No matter what,” Chun asserts, “lifestyle intervention to reduce fat burden is of utmost importance in any patients burdened by extra weight, not just to correct vitamin D problems, but for overall health status, obviously. We perhaps could use this study as another motivator, and reason, to encourage patients to improve their weight status.”

Chun also states that, “in the meantime, we could supplement them with vitamin D to keep their levels in adequate range. However, what is still to be answered is whether the detrimental effects on the bone metabolism from vitamin D deficiency is to the same degree in low vitamin D in obese individuals.”

Classic complications of vitamin D, he also notes, “would occur from severe vitamin D deficiencies. Those affected this way might actually have very low vitamin D status anywhere in the body.”

“Would having vitamin D stored in adipose tissue in obese individuals, and just not enough circulating in blood stream, have a protective role? I don't believe there is an answer to this, and it will be very hard to know. Obese individuals have slightly higher bone mineral density (higher bone mass) than those with normal body weight, yet they have higher risk of fracture, despite the higher BMD. Does this suggest defects in bone quality?”

He asks, too, whether health-care professionals should correlate the effects with parathyroid hormone (PTH).

“Does PTH” he asks, “start to rise at the same level of vitamin D in individuals with normal weight versus overweight, or start to rise at a different threshold? Is that threshold lower or higher?

CITATION: Rachida Rafiq, Floor Walschot, et. al. Associations of different body fat deposits with serum 25-hydroxyvitamin D concentrations. Endocrine Abstracts. (2018) 56 OC6. 5. May 2018. https://www.endocrine-abstracts.org/ea/0056/ea0056oc6.5

 


 

Level of urbanization is targeted
in research on obesity prevalence

HYATTSVILLE, MD. – A nationally-representative survey of adults in the United States indicates that the age-adjusted prevalence of obesity and severe obesity in 2013-to-2016 varied by level of urbanization.

The study published in June in the Journal of the American Medical Association  indicates a greater prevalence of obesity and severe obesity among adults living in non-metropolitan statistical areas compared with adults living in large metropolitan-statistical areas.

Its authors---including Craig M. Hales and Cheryl D. Fryar, National Center for Health Statistics, US Centers for Disease Control and Prevention, Hyattsville, MD.---utilized the 2001-to-2016 National Health and Nutrition Examination Survey.

That cross-sectional analysis involved 10,792 adults aged 20 or older and revealed differences in the prevalence of obesity and severe obesity by age group, race and Hispanic origin, and education level.

The prevalence of obesity was significantly greater among women living in non-metropolitan statistical areas (MSAs) compared with women living in large MSAs; the prevalence of severe obesity in non-MSAs was higher than in large MSAs among men and women.

Differences in age group, race and Hispanic origin, education level, or smoking status were not related to the differences in the prevalence of obesity and severe obesity by urbanization level.

During 2013-to-2016, 38.9% of U.S. adults had obesity, and 7.6% had severe obesity. Men living in medium or small MSAs had a higher age-adjusted prevalence of obesity compared with men living in large MSAs.

The age-adjusted prevalence among men living in non-MSAs was not significantly different compared with men living in large MSAs.

The age-adjusted prevalence of obesity was higher among women living in medium or small MSAs compared with women living in large MSAs, and among women living in non-MSAs compared with women living in large MSAs.

Similar patterns were seen for severe obesity, except that the difference between men living in large MSAs compared with non-MSAs was significant.

CITATION: Craig M. Hales, MD, Cheryl D. Fryar, MSPH, et. al. Differences in Obesity Prevalence by Demographic Characteristics and Urbanization Level Among Adults in the United States, 2013-2016. Journal of the American Medical Association  June 19, 2018. 2018;319(23):2419-2429. https://jamanetwork.com/journals/jama/article-abstract/2685156?utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jama&utm_content=etoc&utm_term=061918

 

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Sarcopenia, osteoporosis examined
in frailty-risk reduction assessment

TOKYO – Preventing osteoporosis and co-existence of osteoporosis and sarcopenia may help reduce frailty risk, according to a study published in June in Osteoporosis International.

Its authors---including Noriko Yoshimura and Shigeyuki Muraki, who are affiliated with The University of Tokyo---examined the contribution of sarcopenia and osteoporosis to the occurrence of frailty using four-year follow-up information of a population-based cohort study.

That four-year study involved 1,083 subjects aged 60-and-older; the prevalence of frailty was estimated to be 5.6%, and osteoporosis was found to be significantly associated with frailty.

The presence of both osteoporosis and sarcopenia increased the risk of frailty compared to the presence of osteoporosis or sarcopenia alone.

The second survey of the Research on Osteoarthritis/Osteoporosis Against Disability (ROAD) study was conducted between 2008-and-2010; the 1,083 subjects, including 372 men, completed all examinations on frailty, sarcopenia, and osteoporosis, defined using Fried’s definition, Asian Working Group for Sarcopenia criteria, and World Health Organization (WHO) criteria, respectively.

The third survey was conducted between 2012-and-2013; 749 of 1,083 participants enrolled from the second survey (248 men, 501 women) completed assessments identical to those in the second survey.

The prevalence of frailty in the second survey was 5.6% (men, 3.8%; women, 6.6%). The cumulative incidence of frailty was 1.2% per year (men, 0.8% per year; women, 1.3% per year).

After adjustment for confounding factors, logistic-regression analysis indicated that osteoporosis was significantly associated with the occurrence of frailty.
The occurrence of frailty significantly increased according to the presence of osteoporosis and sarcopenia.

CITATION: N. Yoshimura, S. Muraki, et. al. Do sarcopenia and/or osteoporosis increase the risk of frailty? A 4-year observation of the second and third ROAD study surveys. Osteoporosis International. First online: 21 June 2018. https://link.springer.com/article/10.1007%2Fs00198-018-4596-4

 


 

Chance of fracture is called elevated
for young, middle-aged adults with T1DM

CLAYTON, AUSTRALIA – A recent study indicates that in the absence of age‐related comorbidities, fracture risk remains significantly elevated in young- and middle‐aged adults with type 1 diabetes mellitus (T1DM).

The study published in June in Clinical Endocrinology also indicates that younger age does not mitigate against hip-fracture risk in T1DM and suggests that health professionals should be aware of this risk.

Its authors---including Eleanor P. Thong and Madhuni Herath, Monash Health, Clayton, Australia---urge further studies to evaluate the mechanisms of fracture in T1DM.

Their systematic review and meta‐analysis was designed to determine the fracture risk of T1DM patients aged 18 to 50, using Ovid MEDLINE, PubMed, EMBASE, EBM reviews, and relevant conference abstracts.

Six studies were included in the meta‐analysis; 1,724 fractures occurred in 35,925 patients with T1DM and 48,253 fractures occurred in 2,455,016 controls.

The risk ratio (RR) for all fractures was 1.88; 56 hip fractures occurred among 34,707 patients with T1DM and 594 hip fractures occurred in 2,295,177 controls.

The RR of hip fractures was 4.40; females and males with T1DM had RRs of 5.79 and 3.67, respectively.

CITATION: Eleanor P. Thong, Madhuni Herath, et. al. Fracture risk in young and middle-aged adults with Type 1 diabetes mellitus: a systematic review and meta-analysis. Clinical Endocrinology. First published: 7 June 2018. https://onlinelibrary.wiley.com/doi/abs/10.1111/cen.13761?af=R&

 

Smoking within 5 minutes of waking
tied to higher possibility of asthma

GRAND FORKS, N.D. – Research involving more than 4,000 subjects indicates that smoking within five minutes of waking---an indicator of nicotine dependence---is associated with a significantly-increased risk of lifetime asthma in smokers.

The study published in June in BMC Pulmonary Medicine indicates that more detailed risk assessment of smokers, closer monitoring, and increased support for smoking cessation for those at risk for asthma could ultimately reduce the disease burden associated with asthma.

Its authors, including Arielle S. Selya and Sunita Thapa, University of North Dakota, Grand Forks, N.D., drew their data from five pooled cross-sectional waves, from 2005-to-2014, of the National Health and Nutrition Examination Survey (NHANES), conducted by the Centers for Disease Control (CDC).

Their final sample consisted of 4,081 current adult smokers aged 20 or older.

Weighted logistic regressions were run, examining the relationship between smoking within five minutes of waking and outcomes of lifetime asthma, past-year asthma, and having had an asthma attack in the past year.
Control variables included:

  • demographics
  • smoking behavior
  • family history of asthma
  • depression
  • obesity
  • second-hand smoking exposure

After adjusting for smoking behavior, smoking within five minutes was associated with an approximately 50% increase in the odds of lifetime asthma and past-year asthma, respectively.
After additionally adjusting for demographics and other asthma-risk factors, smoking within five minutes of waking was associated with a four-fold increase in the odds of lifetime asthma.

CITATION: Arielle S. Selya, Sunita Thapa, et. al. Earlier smoking after waking and the risk of asthma: a cross-sectional study using NHANES data. BMC Pulmonary Medicine. Received: 2 April 2018. Accepted: 13 June 2018. Published: 18 June 2018. https://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-018-0672-y

 

Native Americans said to benefit
from IHS in kidney-disease fight

A Renal Consult article in Clinician Reviews in July reports on the successful efforts of  Indian Health Services (IHS) to reduce kidney disease among Native Americans. Written by Mandy E. Thompson, PA-C, who practices at the Kidney Center of Denver Health, and Robin Bassett, DNP, Nephrology and Hypertension Associates, Anchorage, the story details how IHS staffers integrated population- and team-based approaches to help cut the rate of diabetes-related kidney failure among Native Americans by 54% from 1996-to-2013. The article can be accessed at https://www.mdedge.com/clinicianreviews/article/169149/nephrology/how-ihs-reduced-kidney-disease-highest-risk-population

 

 

Vol. 3 No. 31

 

Vitamin D deficiency study notes
importance of adiposity location

LAGUNA NIGUEL, CALIF. – Specific attention for vitamin D deficiency should be given to patients with a high amount of visceral adipose tissue (VAT), according to a recent study one medical expert says is notable in focusing on adiposity location in terms of vitamin D levels.

Research published in May in Endocrine Abstracts, based on a population-based cohort study of patients aged 45-to-65, notes that the relationship between different adiposity measures and 25(OH)D concentrations differed by gender. Among women, total body fat and VAT were inversely related to 25(OH)D concentrations; for men, VAT and hepatic fat were inversely related to 25(OH)D concentrations. In men and women, VAT was most strongly associated with 25(OH)D concentrations.

Ji Hyun Chun, PA-C, BC-ADM, OptumCare Medical Group, Laguna Niguel, Calif., and a faculty member of Metabolic & Disease Summit (MEDS), says that “what's new in this study is that it states that where the adiposity is matters in terms of vitamin D levels, subcutaneous versus visceral: There was higher correlation of visceral adiposity and chances of having low vitamin D.”

Chun, president of the American Society of Endocrine Physician Assistants (ASEPA), also stresses that this research supports the necessity of lifestyle changes to fight weight problems as well as the importance of vitamin D assessments and, when appropriate, supplementation.

He adds that “as vitamin D is a fat-soluble vitamin, patients with increased adiposity are at higher risk of lower circulating serum vitamin D levels. One has to have enough to saturate the adipose tissue before we have enough to circulate in the vascular system.”

Chun also says that visceral adiposity “is really the culprit of metabolic complications associated with obesity, rather than subcutaneous adiposity.”

He adds, though, that “it can work in both ways: We have to think, suspect, and screen for low vitamin D in patients with increased visceral adiposity, but also think, suspect, screen for visceral adiposity in obese patients with low vitamin D.”

The research, a cross-sectional analysis of baseline measurements of the Netherlands Epidemiology of Obesity study, is, says Chun, “an association study rather than causal-relation study, and is still ‘chicken-or-the-egg’ status.”

It is also one of countless indicators of the urgency of battling weight problems.

“No matter what,” Chun asserts, “lifestyle intervention to reduce fat burden is of utmost importance in any patients burdened by extra weight, not just to correct vitamin D problems, but for overall health status, obviously. We perhaps could use this study as another motivator, and reason, to encourage patients to improve their weight status.”

Chun also states that, “in the meantime, we could supplement them with vitamin D to keep their levels in adequate range. However, what is still to be answered is whether the detrimental effects on the bone metabolism from vitamin D deficiency is to the same degree in low vitamin D in obese individuals.”

Classic complications of vitamin D, he also notes, “would occur from severe vitamin D deficiencies. Those affected this way might actually have very low vitamin D status anywhere in the body.”

“Would having vitamin D stored in adipose tissue in obese individuals, and just not enough circulating in blood stream, have a protective role? I don't believe there is an answer to this, and it will be very hard to know. Obese individuals have slightly higher bone mineral density (higher bone mass) than those with normal body weight, yet they have higher risk of fracture, despite the higher BMD. Does this suggest defects in bone quality?”

He asks, too, whether health-care professionals should correlate the effects with parathyroid hormone (PTH).

“Does PTH” he asks, “start to rise at the same level of vitamin D in individuals with normal weight versus overweight, or start to rise at a different threshold? Is that threshold lower or higher?

CITATION: Rachida Rafiq, Floor Walschot, et. al. Associations of different body fat deposits with serum 25-hydroxyvitamin D concentrations. Endocrine Abstracts. (2018) 56 OC6. 5. May 2018. https://www.endocrine-abstracts.org/ea/0056/ea0056oc6.5

 

 

ad

 

Level of urbanization is targeted
in research on obesity prevalence
 

HYATTSVILLE, MD. – A nationally-representative survey of adults in the United States indicates that the age-adjusted prevalence of obesity and severe obesity in 2013-to-2016 varied by level of urbanization.

The study published in June in the Journal of the American Medical Association indicates a greater prevalence of obesity and severe obesity among adults living in non-metropolitan statistical areas compared with adults living in large metropolitan-statistical areas.

Its authors---including Craig M. Hales and Cheryl D. Fryar, National Center for Health Statistics, US Centers for Disease Control and Prevention, Hyattsville, MD.---utilized the 2001-to-2016 National Health and Nutrition Examination Survey.
That cross-sectional analysis involved 10,792 adults aged 20 or older and revealed differences in the prevalence of obesity and severe obesity by age group, race and Hispanic origin, and education level.

The prevalence of obesity was significantly greater among women living in non-metropolitan statistical areas (MSAs) compared with women living in large MSAs; the prevalence of severe obesity in non-MSAs was higher than in large MSAs among men and women.

Differences in age group, race and Hispanic origin, education level, or smoking status were not related to the differences in the prevalence of obesity and severe obesity by urbanization level.

During 2013-to-2016, 38.9% of U.S. adults had obesity, and 7.6% had severe obesity. Men living in medium or small MSAs had a higher age-adjusted prevalence of obesity compared with men living in large MSAs.

The age-adjusted prevalence among men living in non-MSAs was not significantly different compared with men living in large MSAs.

The age-adjusted prevalence of obesity was higher among women living in medium or small MSAs compared with women living in large MSAs, and among women living in non-MSAs compared with women living in large MSAs.

Similar patterns were seen for severe obesity, except that the difference between men living in large MSAs compared with non-MSAs was significant.
 

CITATION: Craig M. Hales, MD, Cheryl D. Fryar, MSPH, et. al. Differences in Obesity Prevalence by Demographic Characteristics and Urbanization Level Among Adults in the United States, 2013-2016. Journal of the American Medical Association  June 19, 2018. 2018;319(23):2419-2429. https://jamanetwork.com/journals/jama/article-abstract/2685156?utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jama&utm_content=etoc&utm_term=061918

 

ad

 

Sarcopenia, osteoporosis examined
in frailty-risk reduction assessment
 

TOKYO – Preventing osteoporosis and co-existence of osteoporosis and sarcopenia may help reduce frailty risk, according to a study published in June in Osteoporosis International.

Its authors---including Noriko Yoshimura and Shigeyuki Muraki, who are affiliated with The University of Tokyo---examined the contribution of sarcopenia and osteoporosis to the occurrence of frailty using four-year follow-up information of a population-based cohort study.

That four-year study involved 1,083 subjects aged 60-and-older; the prevalence of frailty was estimated to be 5.6%, and osteoporosis was found to be significantly associated with frailty.

The presence of both osteoporosis and sarcopenia increased the risk of frailty compared to the presence of osteoporosis or sarcopenia alone.

The second survey of the Research on Osteoarthritis/Osteoporosis Against Disability (ROAD) study was conducted between 2008-and-2010; the 1,083 subjects, including 372 men, completed all examinations on frailty, sarcopenia, and osteoporosis, defined using Fried’s definition, Asian Working Group for Sarcopenia criteria, and World Health Organization (WHO) criteria, respectively.

The third survey was conducted between 2012-and-2013; 749 of 1,083 participants enrolled from the second survey (248 men, 501 women) completed assessments identical to those in the second survey.

The prevalence of frailty in the second survey was 5.6% (men, 3.8%; women, 6.6%). The cumulative incidence of frailty was 1.2% per year (men, 0.8% per year; women, 1.3% per year).

After adjustment for confounding factors, logistic-regression analysis indicated that osteoporosis was significantly associated with the occurrence of frailty.

The occurrence of frailty significantly increased according to the presence of osteoporosis and sarcopenia.
 

CITATION: N. Yoshimura, S. Muraki, et. al. Do sarcopenia and/or osteoporosis increase the risk of frailty? A 4-year observation of the second and third ROAD study surveys. Osteoporosis International. First online: 21 June 2018. https://link.springer.com/article/10.1007%2Fs00198-018-4596-4

 

 


 

Chance of fracture is called elevated
for young, middle-aged adults with T1DM
 

CLAYTON, AUSTRALIA – A recent study indicates that in the absence of age‐related comorbidities, fracture risk remains significantly elevated in young- and middle‐aged adults with type 1 diabetes mellitus (T1DM).

The study published in June in Clinical Endocrinology also indicates that younger age does not mitigate against hip-fracture risk in T1DM and suggests that health professionals should be aware of this risk.

Its authors---including Eleanor P. Thong and Madhuni Herath, Monash Health, Clayton, Australia---urge further studies to evaluate the mechanisms of fracture in T1DM.

Their systematic review and meta‐analysis was designed to determine the fracture risk of T1DM patients aged 18 to 50, using Ovid MEDLINE, PubMed, EMBASE, EBM reviews, and relevant conference abstracts.

Six studies were included in the meta‐analysis; 1,724 fractures occurred in 35,925 patients with T1DM and 48,253 fractures occurred in 2,455,016 controls.

The risk ratio (RR) for all fractures was 1.88; 56 hip fractures occurred among 34,707 patients with T1DM and 594 hip fractures occurred in 2,295,177 controls.

The RR of hip fractures was 4.40; females and males with T1DM had RRs of 5.79 and 3.67, respectively.
 

CITATION: Eleanor P. Thong, Madhuni Herath, et. al. Fracture risk in young and middle-aged adults with Type 1 diabetes mellitus: a systematic review and meta-analysis. Clinical Endocrinology. First published: 7 June 2018. https://onlinelibrary.wiley.com/doi/abs/10.1111/cen.13761?af=R&

 

 

Smoking within 5 minutes of waking
tied to higher possibility of asthma
 

GRAND FORKS, N.D. – Research involving more than 4,000 subjects indicates that smoking within five minutes of waking---an indicator of nicotine dependence---is associated with a significantly-increased risk of lifetime asthma in smokers.

The study published in June in BMC Pulmonary Medicine indicates that more detailed risk assessment of smokers, closer monitoring, and increased support for smoking cessation for those at risk for asthma could ultimately reduce the disease burden associated with asthma.

Its authors, including Arielle S. Selya and Sunita Thapa, University of North Dakota, Grand Forks, N.D., drew their data from five pooled cross-sectional waves, from 2005-to-2014, of the National Health and Nutrition Examination Survey (NHANES), conducted by the Centers for Disease Control (CDC).

Their final sample consisted of 4,081 current adult smokers aged 20 or older.

Weighted logistic regressions were run, examining the relationship between smoking within five minutes of waking and outcomes of lifetime asthma, past-year asthma, and having had an asthma attack in the past year.

Control variables included:

  • demographics
  • smoking behavior
  • family history of asthma
  • depression
  • obesity
  • second-hand smoking exposure

After adjusting for smoking behavior, smoking within five minutes was associated with an approximately 50% increase in the odds of lifetime asthma and past-year asthma, respectively.

After additionally adjusting for demographics and other asthma-risk factors, smoking within five minutes of waking was associated with a four-fold increase in the odds of lifetime asthma.
 

CITATION: Arielle S. Selya, Sunita Thapa, et. al. Earlier smoking after waking and the risk of asthma: a cross-sectional study using NHANES data. BMC Pulmonary Medicine. Received: 2 April 2018. Accepted: 13 June 2018. Published: 18 June 2018. https://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-018-0672-y

 

 

Native Americans said to benefit
from IHS in kidney-disease fight
 

A Renal Consult article in Clinician Reviews in July reports on the successful efforts of  Indian Health Services (IHS) to reduce kidney disease among Native Americans. Written by Mandy E. Thompson, PA-C, who practices at the Kidney Center of Denver Health, and Robin Bassett, DNP, Nephrology and Hypertension Associates, Anchorage, the story details how IHS staffers integrated population- and team-based approaches to help cut the rate of diabetes-related kidney failure among Native Americans by 54% from 1996-to-2013. The article can be accessed at https://www.mdedge.com/clinicianreviews/article/169149/nephrology/how-ihs-reduced-kidney-disease-highest-risk-population

 

 

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