TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.
This week’s topics include obesity management for primary treatment of type 2 diabetes, COVID containment in overnight camps for kids, medication mishaps and ED visits, and risk factors for cardiovascular disease over the last 20 years in the U.S.
0:40 Overnight camp strategies to reduce COVID infection
1:43 Cohort to keep together
2:43 Quite practical and doable
3:00 Trends in cardiovascular risk factors
4:00 Blacks and Hispanics at higher risk
5:00 Social issues under our control
6:02 Trends seem to be treading water
6:15 Medications and ED visits
7:19 Under 25 most are non-therapeutic
8:00 Obesity control as a primary treatment goal for T2D
9:00 Weight-centric approach
10:00 Increased inflammation, resistant to insulin
11:00 Requires huge change in practice management
Elizabeth Tracey: Should we shift the paradigm for the management of type 2 diabetes?
Rick Lange, MD: Can overnight youth camps teach us anything about dealing with COVID in schools?
Elizabeth: What are trends in cardiovascular risk factors for U.S. adults for the last 20 years?
Rick: And medication harms that result in an emergency room visit.
Elizabeth: That’s what we’re talking about this week on TT HealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Centre in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.
Rick: I’m Rick Lange, president of Texas Tech University Health Sciences Center in El Paso, where I’m also dean of the Paul L. Foster School of Medicine.
Elizabeth: Rick, since we clearly need some help regarding containment of COVID-19, why don’t we turn first to yours from MMWR — Morbidity and Mortality Weekly Report — can these overnight youth camps teach us anything about containing the infection?
Rick: Elizabeth, this was a fascinating report from my standpoint. It’s recent data. They looked at COVID transmission in close quarters in youths that were taking part in overnight camps that lasted from 2 to 8 weeks. This is from June to August of 2021. They looked at over 7,100 staff members and campers from 50 different states, 13 countries at 9 independently operated U.S. summer youth camps. Can this be done safely? Keep in mind that about 70% of these individuals were over the age of 12 and most of them were vaccinated. But there was a third of the population that was under the age of 12 and didn’t qualify for vaccination.
The camps implemented multiple prevention strategies, vaccination encouragement. They had testing before they arrived at camp, testing after they arrived at camp, podding or kind of cohorting to keep them together when they could, masking, physical distancing, and hand hygiene. One out of 1,000 developed an infection during this time. None of them were spread.
They were testing individuals when they arrived. Some of these were individuals that had arrived there, tested positive and they isolated them before they spread it. There were occasional times where the campers could go out into the community for a short period of time and they got it from the community. But the amazing thing is among these 7,000 campers and staff, there was no secondary transmission, so the infection rate was incredibly low, 0.1%. It shows that this multicomponent strategy can be very effective. All these measures can be applicable to schools.
Elizabeth: Exactly. Clearly, right now we’re seeing so much transmission in schools that have rather lax standards with regard to masking and distancing, and so forth. And a lot of parental concern about that. Tell me how practical you think this constellation of strategies is.
Rick: Well, Elizabeth I think it’s quite practical. All of these things are really doable. We just have to have the will to do it and more importantly use evidence-based medicine to drive these decisions. This isn’t a political decision. This is good evidence.
Elizabeth: Let’s see if anybody heeds this advice. Let’s turn to JAMA. This study is taking a look at trends in cardiovascular risk factors. I would note that these probably are substantially worse in the last almost 2 years that the pandemic has been going on, but this data is between 1998 and 2018.
It’s from NHANES. It’s a total of almost 51,000 participants 20 years or older. They took a look at, “Hey, what is going on with regard to all of these cardiovascular risk factors?”
The bad news is that quite a few of them worsened. Mean body mass index increased, mean hemoglobin A1c increased, serum total cholesterol actually decreased, smoking decreased, and mean systolic blood pressure decreased and then increased.
The upshot of it is that they also looked at ethnicity and sex-adjusted factors. Not surprisingly, the same groups that we find who are at higher risk for potentially deleterious health outcomes — Blacks and Hispanics — were at higher risk for all of these other negative outcomes. This difference was attenuated if they took into account education, income, homeownership, employment, health insurance, and access to healthcare. Attenuated, but not eliminated. The trend is going toward a more negative picture, and I suspect it has probably been significantly exacerbated in the last 18 months.
Rick: Some things got better and then worsened a little bit. It’s a combination of two things. The use of medications to decrease cholesterol, for example, to get blood pressure under control. The fact that smoking has decreased substantially, that’s great. Lifestyle interventions like hypertension, diabetes control, and weight management really haven’t improved significantly.
As you mentioned, there are still racial differences. A lot of those are driven by some of the social inequities and those things are correctable. You can’t say, “Well, it’s a genetic abnormality and we can’t do anything about it.” No, these are social issues that are under our control.
Elizabeth: The authors of the study do note that this is the first study to report that BMI, systolic blood pressure, and hemoglobin A1c were persistently higher in the Black population compared with the White population, even after they adjusted for these social determinants of health such as the ones you’ve cited: education, income, housing, employment, health insurance, and access to healthcare. So what does that suggest to you?
Rick: Other social determinants weren’t measured. Things like neighborhood and physical environment, do they have access to healthy food, and social integration. Those are additional things that weren’t measured and we know that they also affect health outcomes. We need to address those.
Elizabeth: What are you thinking? I would ask you to just comment on the notion that improvements in cardiovascular health outcomes have really plateaued for almost everybody recently. We saw this dramatic decline in deaths due to cardiovascular disease and now it just seems like it’s kind of treading water.
Rick: They looked at this over 20 years. In the first 10 years, there were significant improvements in a lot of things. Then we lost some of those improvements. We’ve not been as vigilant. It needs to be a continuous message, a continuous drumbeat.
Elizabeth: Let us remain in JAMA and turn to yours, which is how much medication error is sending people to the ED?
Rick: We’re not terribly surprised that some people will present to emergency department with harms from medications. This was fascinating because it actually took a look at not only what I’m going to call therapeutic medications — these are prescribed — but also non-therapeutic medications. It’s stratified by age groups, which medications are most likely to do it, and how many of those people got hospitalized.
Here is what they discovered. They looked at just under 100,000 cases and this is gathered from 60 different emergency departments that have participated in a national surveillance system.
For every 1,000 population, annually there is about six emergency room visits for medication harms. About 40% of those result in hospitalizations. The highest incidents of medication harms are in older individuals, those over the age of 65, due primarily to anticoagulants and also to diabetic medications, usually insulin. Contrast that with individuals under the age of 25, most of their medication harms are non-therapeutic. They weren’t prescribed for the individuals. The individuals either misused them, or abused them, or took them for self-harm purposes, or were sometimes over-the-counter medications.
Elizabeth: Hmm, increasing, decreasing, staying the same?
Rick: This didn’t look at trends, so I can’t tell that. Things you might be interested in: under the age of 5, the most common medication harms are due to antibiotics. In the older age groups from about 5 to 14 are medications to treat attention deficit hyperactivity disorder, 15 to 24 — psychiatric medications and over-the-counter medications, and from 25 to 44 for treating pain. This should give us information about how do we prevent in each of these specific age groups.
Elizabeth: Let’s turn to the Lancet. This is a review paper. It stems from the recently concluded European Diabetes Association meeting. They are suggesting here a paradigm shift, obesity management as a primary treatment goal for type 2 diabetes and saying it’s time to reframe this conversation.
Obesity, of course, we know increasing tremendously all over the world and associated with serious morbidity and mortality. Its metabolic complication — one of the main ones — is type 2 diabetes. That shifts it even at the beginning, right? What’s the cause of this? Ooh, it’s obesity. That’s the cause.
They say that weight loss, we know, is known to reverse those metabolic abnormalities for folks with type 2 diabetes. They are suggesting a loss of 15% more of body weight as a primary strategy for managing folks with type 2 diabetes.
They suggest that many patients with this particular condition would benefit from having a primarily weight-centric approach to their diabetes treatment. They basically do say that type 2 diabetes can have kind of two different phenotypes that are underneath it. Only some of them are going to respond to weight loss in this primary strategy. How do we recognize the people who might benefit most?
Key features that identify people that may benefit from this weight loss: the presence of central obesity, increased waist circumference, acanthosis nigricans (AN), multiple skin tags, hypertension, hypertriglyceridemia, nonalcoholic fatty liver disease, and/or laboratory evidence of hyperinsulinemia. What are your thoughts?
Rick: Let me try to condense all this information. They are calling this type of diabetes, adipose-centric. We know that the fat or adipose tissue increases inflammation. It makes it more likely that people are to be resistant to the insulin they make. You contrast that with those people that don’t make enough insulin. Probably the weight reduction is not going to be as helpful and they need to be treated primarily with medications.
Those in whom the diabetes is driven by the fat cells would benefit from the 15% weight reduction. You either test for insulin or just look at the patients. Their diabetes is most likely due to the accumulation of fat tissue.
The paradigm shift is, we’re focusing a lot on the glucose in the bloodstream. What they are saying is let’s focus on the weight loss and that can cause remission of type 2 diabetes or lack of progression. It doesn’t mean that it’s the only way. Sometimes people will need medications as well.
But I can tell you, as physicians, it’s easier just to give a medication. It’s easier to take the pill than it is to help somebody get through what’s necessary to decrease their weight. We have bariatric surgery as well. But since it’s easier to give them medication, we oftentimes avoid talking about weight reduction. This paper is trying to get us to re-center or refocus on the importance of that.
Elizabeth: They do admit that it’s going to require a huge change in practice management, both on the part of providers, but in everybody else who is involved with this. We know very well. We have talked about obesity so many times that reduction of 15% of body weight that’s sustained over time? That’s not an easy fix.
Rick: That’s why the authors say there is not just one way to do it. You may have to involve more than one thing: lifestyle interventions that we talked about, healthy nutrition, pharmacologic ways to do it, and then for those that have morbid obesity or don’t respond, bariatric surgery. One or more of these techniques.
Elizabeth: Well, I would be remiss in not pointing out that obesity is not an overnight problem and therefore something that we have advocated for in the past that’s mentioning it as that trends start to develop at every primary care interaction, and trying to prevent rather than deal with it once it’s florid, I think, is another part of this component strategy.
Rick: It’s going to take focus and a dedication to the resources to do it. Not only primary care physicians, but all physicians and support staff, dietitians, the whole armamentarium.
By the way, the insurance companies need to pick this up. I mean, they are willing to pay for medications, they’re willing to pay for treatment of the complications, but let’s pay for the prevention of diabetes by weight reduction.
Elizabeth: I love that point. On that note then, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey,
Rick: And I’m Rick Lange. Y’all listen up, and make healthy choices.