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Water birth may have benefits for healthy women: Meta-analysis suggests
Water immersion during labor and birth significantly reduced use of medications, maternal pain, and postpartum hemorrhage, compared with standard care with no water immersion, based on data from 36 studies including more than 150,000 women.
“Resting and laboring in water can reduce fear, anxiety, and pain perception; it helps optimize the physiology of childbirth through the release of endogenous endorphins and oxytocin,” and data from randomized, controlled trials have shown a reduced need for epidural analgesia with water immersion, Ethel Burns, PhD, of Oxford (England) Brookes University Faculty of Health and Life Sciences, and colleagues wrote.
Although previous studies have not shown an increased risk for adverse events for newborns following water birth, “There is a need to understand which clinical practices, when performed as part of water immersion care, result in the optimum outcomes for mother and newborn,” the researchers said.
In a systematic review and meta-analysis published in BMJ Open, the researchers identified studies published since 2000 that examined maternal or neonatal interventions and/or outcomes when birthing pools were used for labor and/or birth.
The primary objective was to compare intrapartum interventions and outcomes for water immersion during labor with standard care with no water immersion.
Water immersion generally involves the use of a birth pool for relaxation and pain relief in early labor, and some women proceed with immersion through the second stage of labor and delivery. Of the 36 included studies, 31 took place in a hospital setting, 4 in a midwife-led setting, and 1 in a mixed setting. Most of the studies (25) involved women who planned to have/had a water birth, and these studies included 151,742 women. Another seven studies including 1,901 women involved in water immersion for labor only, three studies including 3,688 women involved in water immersion during labor and water birth; the timing of water immersion was unclear in the remaining study of 215 women.
Overall, water immersion significantly reduced the use of epidurals (odds ratio, 0.17), injected opioids (OR, 0.22), and episiotomy (OR, 0.16). Maternal pain and postpartum hemorrhage also were significantly reduced with water immersion (OR, 0.24 and OR, 0.69, respectively).
Maternal satisfaction was significantly increased with water immersion, and the odds of an intact perineum increased as well (OR, 1.95 and OR, 1.48).
The overall odds of cord avulsion increased with water immersion (OR, 1.94), but the absolute risk was low, compared with births without water immersion (4.3 vs. 1.3 per 1,000). No significant differences in other identified neonatal outcomes were observed across the studies.
The study findings were limited by several factors including the inconsistency of reporting on birth setting, care practices, interventions, and outcomes, and the inclusion of only three outcomes for meta-regression analysis, the researchers noted. In addition, only four studies were conducted in midwifery-led settings.
“This is important because birth pool use is most prevalent in midwifery-led settings,” the researchers wrote.” Evidence-based practice of water immersion requires research that reflects the context of care provision.
“We suggest that studies incorporate the following fundamentals to advance the evidence: birth pool description, clearly described maternal and obstetric characteristics, the birth setting, the care model and use of standardized definitions.”
Despite the limitations and need for additional research, the data overall support the potential benefits from water immersion births for healthy women and newborns, the researchers concluded.
A Clinical Report issued by the American Academy of Pediatrics in January 2022 advised against water immersion during the second stage of labor and delivery. According to the report, the potential for neonatal infections from organisms such as Legionella and Pseudomonas species, is low, but does exist, and could result in serious complications.
Education is essential
Increasing numbers of women are seeking home births and water births, Marissa Platner, MD, a maternal-fetal medicine specialist at Emory University, Atlanta, said in an interview.
“Given the conflicting data and lack of data, it is important to be able to educate birthing mothers based on best available evidence,” said Dr. Platner, who was not involved in the study.
“I was not surprised by the findings, because the adverse outcomes that are of concern, such as neonatal sepsis, were not clearly addressed,” Dr. Platner said. Given that sepsis “is a rare outcome in the population of low-risk individuals, the study may not have been powered to assess for this. The findings of maternal pain and satisfaction being improved with water immersion are well known. ACOG [American College of Obstetricians and Gynecologists] has also stated that water immersion during the first stage of labor is safe and can help with pain control.”
On a practical level, “I think clinicians can use this guidance to discuss the potential benefits of water immersion in the first stages of labor, but would caution women regarding the unknown but possible risks of the water birth, given these findings are less clear,” Dr. Platner said.
“I think the findings regarding maternal outcomes are valid and consistent with the AAP/ACOG recommendations in terms of improving maternal pain control; however, more research is needed to determine the safety of the second stage of labor occurring in the water, given the potential for neonatal infection and respiratory distress, which could not be adequately addressed in this study,” Dr. Platner emphasized.
The study was supported by Oxford Brookes University. The researchers had no financial conflicts to disclose. Dr. Platner had no financial conflicts to disclose.
Water immersion during labor and birth significantly reduced use of medications, maternal pain, and postpartum hemorrhage, compared with standard care with no water immersion, based on data from 36 studies including more than 150,000 women.
“Resting and laboring in water can reduce fear, anxiety, and pain perception; it helps optimize the physiology of childbirth through the release of endogenous endorphins and oxytocin,” and data from randomized, controlled trials have shown a reduced need for epidural analgesia with water immersion, Ethel Burns, PhD, of Oxford (England) Brookes University Faculty of Health and Life Sciences, and colleagues wrote.
Although previous studies have not shown an increased risk for adverse events for newborns following water birth, “There is a need to understand which clinical practices, when performed as part of water immersion care, result in the optimum outcomes for mother and newborn,” the researchers said.
In a systematic review and meta-analysis published in BMJ Open, the researchers identified studies published since 2000 that examined maternal or neonatal interventions and/or outcomes when birthing pools were used for labor and/or birth.
The primary objective was to compare intrapartum interventions and outcomes for water immersion during labor with standard care with no water immersion.
Water immersion generally involves the use of a birth pool for relaxation and pain relief in early labor, and some women proceed with immersion through the second stage of labor and delivery. Of the 36 included studies, 31 took place in a hospital setting, 4 in a midwife-led setting, and 1 in a mixed setting. Most of the studies (25) involved women who planned to have/had a water birth, and these studies included 151,742 women. Another seven studies including 1,901 women involved in water immersion for labor only, three studies including 3,688 women involved in water immersion during labor and water birth; the timing of water immersion was unclear in the remaining study of 215 women.
Overall, water immersion significantly reduced the use of epidurals (odds ratio, 0.17), injected opioids (OR, 0.22), and episiotomy (OR, 0.16). Maternal pain and postpartum hemorrhage also were significantly reduced with water immersion (OR, 0.24 and OR, 0.69, respectively).
Maternal satisfaction was significantly increased with water immersion, and the odds of an intact perineum increased as well (OR, 1.95 and OR, 1.48).
The overall odds of cord avulsion increased with water immersion (OR, 1.94), but the absolute risk was low, compared with births without water immersion (4.3 vs. 1.3 per 1,000). No significant differences in other identified neonatal outcomes were observed across the studies.
The study findings were limited by several factors including the inconsistency of reporting on birth setting, care practices, interventions, and outcomes, and the inclusion of only three outcomes for meta-regression analysis, the researchers noted. In addition, only four studies were conducted in midwifery-led settings.
“This is important because birth pool use is most prevalent in midwifery-led settings,” the researchers wrote.” Evidence-based practice of water immersion requires research that reflects the context of care provision.
“We suggest that studies incorporate the following fundamentals to advance the evidence: birth pool description, clearly described maternal and obstetric characteristics, the birth setting, the care model and use of standardized definitions.”
Despite the limitations and need for additional research, the data overall support the potential benefits from water immersion births for healthy women and newborns, the researchers concluded.
A Clinical Report issued by the American Academy of Pediatrics in January 2022 advised against water immersion during the second stage of labor and delivery. According to the report, the potential for neonatal infections from organisms such as Legionella and Pseudomonas species, is low, but does exist, and could result in serious complications.
Education is essential
Increasing numbers of women are seeking home births and water births, Marissa Platner, MD, a maternal-fetal medicine specialist at Emory University, Atlanta, said in an interview.
“Given the conflicting data and lack of data, it is important to be able to educate birthing mothers based on best available evidence,” said Dr. Platner, who was not involved in the study.
“I was not surprised by the findings, because the adverse outcomes that are of concern, such as neonatal sepsis, were not clearly addressed,” Dr. Platner said. Given that sepsis “is a rare outcome in the population of low-risk individuals, the study may not have been powered to assess for this. The findings of maternal pain and satisfaction being improved with water immersion are well known. ACOG [American College of Obstetricians and Gynecologists] has also stated that water immersion during the first stage of labor is safe and can help with pain control.”
On a practical level, “I think clinicians can use this guidance to discuss the potential benefits of water immersion in the first stages of labor, but would caution women regarding the unknown but possible risks of the water birth, given these findings are less clear,” Dr. Platner said.
“I think the findings regarding maternal outcomes are valid and consistent with the AAP/ACOG recommendations in terms of improving maternal pain control; however, more research is needed to determine the safety of the second stage of labor occurring in the water, given the potential for neonatal infection and respiratory distress, which could not be adequately addressed in this study,” Dr. Platner emphasized.
The study was supported by Oxford Brookes University. The researchers had no financial conflicts to disclose. Dr. Platner had no financial conflicts to disclose.
Water immersion during labor and birth significantly reduced use of medications, maternal pain, and postpartum hemorrhage, compared with standard care with no water immersion, based on data from 36 studies including more than 150,000 women.
“Resting and laboring in water can reduce fear, anxiety, and pain perception; it helps optimize the physiology of childbirth through the release of endogenous endorphins and oxytocin,” and data from randomized, controlled trials have shown a reduced need for epidural analgesia with water immersion, Ethel Burns, PhD, of Oxford (England) Brookes University Faculty of Health and Life Sciences, and colleagues wrote.
Although previous studies have not shown an increased risk for adverse events for newborns following water birth, “There is a need to understand which clinical practices, when performed as part of water immersion care, result in the optimum outcomes for mother and newborn,” the researchers said.
In a systematic review and meta-analysis published in BMJ Open, the researchers identified studies published since 2000 that examined maternal or neonatal interventions and/or outcomes when birthing pools were used for labor and/or birth.
The primary objective was to compare intrapartum interventions and outcomes for water immersion during labor with standard care with no water immersion.
Water immersion generally involves the use of a birth pool for relaxation and pain relief in early labor, and some women proceed with immersion through the second stage of labor and delivery. Of the 36 included studies, 31 took place in a hospital setting, 4 in a midwife-led setting, and 1 in a mixed setting. Most of the studies (25) involved women who planned to have/had a water birth, and these studies included 151,742 women. Another seven studies including 1,901 women involved in water immersion for labor only, three studies including 3,688 women involved in water immersion during labor and water birth; the timing of water immersion was unclear in the remaining study of 215 women.
Overall, water immersion significantly reduced the use of epidurals (odds ratio, 0.17), injected opioids (OR, 0.22), and episiotomy (OR, 0.16). Maternal pain and postpartum hemorrhage also were significantly reduced with water immersion (OR, 0.24 and OR, 0.69, respectively).
Maternal satisfaction was significantly increased with water immersion, and the odds of an intact perineum increased as well (OR, 1.95 and OR, 1.48).
The overall odds of cord avulsion increased with water immersion (OR, 1.94), but the absolute risk was low, compared with births without water immersion (4.3 vs. 1.3 per 1,000). No significant differences in other identified neonatal outcomes were observed across the studies.
The study findings were limited by several factors including the inconsistency of reporting on birth setting, care practices, interventions, and outcomes, and the inclusion of only three outcomes for meta-regression analysis, the researchers noted. In addition, only four studies were conducted in midwifery-led settings.
“This is important because birth pool use is most prevalent in midwifery-led settings,” the researchers wrote.” Evidence-based practice of water immersion requires research that reflects the context of care provision.
“We suggest that studies incorporate the following fundamentals to advance the evidence: birth pool description, clearly described maternal and obstetric characteristics, the birth setting, the care model and use of standardized definitions.”
Despite the limitations and need for additional research, the data overall support the potential benefits from water immersion births for healthy women and newborns, the researchers concluded.
A Clinical Report issued by the American Academy of Pediatrics in January 2022 advised against water immersion during the second stage of labor and delivery. According to the report, the potential for neonatal infections from organisms such as Legionella and Pseudomonas species, is low, but does exist, and could result in serious complications.
Education is essential
Increasing numbers of women are seeking home births and water births, Marissa Platner, MD, a maternal-fetal medicine specialist at Emory University, Atlanta, said in an interview.
“Given the conflicting data and lack of data, it is important to be able to educate birthing mothers based on best available evidence,” said Dr. Platner, who was not involved in the study.
“I was not surprised by the findings, because the adverse outcomes that are of concern, such as neonatal sepsis, were not clearly addressed,” Dr. Platner said. Given that sepsis “is a rare outcome in the population of low-risk individuals, the study may not have been powered to assess for this. The findings of maternal pain and satisfaction being improved with water immersion are well known. ACOG [American College of Obstetricians and Gynecologists] has also stated that water immersion during the first stage of labor is safe and can help with pain control.”
On a practical level, “I think clinicians can use this guidance to discuss the potential benefits of water immersion in the first stages of labor, but would caution women regarding the unknown but possible risks of the water birth, given these findings are less clear,” Dr. Platner said.
“I think the findings regarding maternal outcomes are valid and consistent with the AAP/ACOG recommendations in terms of improving maternal pain control; however, more research is needed to determine the safety of the second stage of labor occurring in the water, given the potential for neonatal infection and respiratory distress, which could not be adequately addressed in this study,” Dr. Platner emphasized.
The study was supported by Oxford Brookes University. The researchers had no financial conflicts to disclose. Dr. Platner had no financial conflicts to disclose.
FROM BMJ OPEN
Compulsivity contributes to poor outcomes in body-focused repetitive behaviors
Although body-focused repetitive behaviors (BFRBs), specifically trichotillomania and skin-picking disorder, are similar in clinical presentation to aspects of obsessive-compulsive disorder (OCD), the role of compulsivity in TTM and SPD has not been well studied, wrote Jon E. Grant, MD, of the University of Chicago and colleagues.
In a study published in the Journal of Psychiatric Research, the authors recruited 69 women and 22 men who met DSM-5 criteria for TTM and SPD. Participants completed diagnostic interviews, symptom inventories, and measures of disability/functioning. Compulsivity was measured using the 15-item Cambridge-Chicago Compulsivity Trait Scale (CHI-T). The average age of the participants was 30.9 years; 48 had TTM, 37 had SPD, and 2 had both conditions.
Overall, total CHI-T scores were significantly correlated with worse disability and quality of life, based on the Quality of Life Inventory (P = .0278) and the Sheehan Disability Scale (P = .0085) but not with severity of TTM or SPD symptoms. TTM and SPD symptoms were assessed using the Massachusetts General Hospital Hair Pulling Scale and the Skin Picking Symptom Symptom Assessment Scale.
“In the current study, we did not find a link between conventional symptom severity measures for BFRBs and disability or quality of life, whereas trans-diagnostic compulsivity did correlate with these clinically important parameters,” the researchers wrote in their discussion. “These findings might suggest the current symptom measures for BFRBs are not including an important aspect of the disease and that a fuller understanding of these symptoms requires measurement of compulsivity. Including validated measures of compulsivity in clinical trials of therapy or medication would also seem to be important for future work,” they said.
The study findings were limited by several factors including the use of a community sample that may not generalize to a clinical setting, the researchers noted. Other limitations include the cross-sectional design, which prevents conclusions about causality, the lack of a control group, and the relatively small sample size, they said.
However, the study is the first known to use a validated compulsivity measure to assess BFRBs, and the results suggest a clinically relevant impact of compulsivity on both psychosocial dysfunction and poor quality of life in this patient population, with possible implications for treatment, the researchers wrote.
The study received no outside funding. Lead author Dr. Grant disclosed research grants from Otsuka and Biohaven Pharmaceuticals, yearly compensation from Springer Publishing for acting as editor in chief of the Journal of Gambling Studies, and royalties from Oxford University Press, American Psychiatric Publishing, Norton Press, and McGraw Hill.
Although body-focused repetitive behaviors (BFRBs), specifically trichotillomania and skin-picking disorder, are similar in clinical presentation to aspects of obsessive-compulsive disorder (OCD), the role of compulsivity in TTM and SPD has not been well studied, wrote Jon E. Grant, MD, of the University of Chicago and colleagues.
In a study published in the Journal of Psychiatric Research, the authors recruited 69 women and 22 men who met DSM-5 criteria for TTM and SPD. Participants completed diagnostic interviews, symptom inventories, and measures of disability/functioning. Compulsivity was measured using the 15-item Cambridge-Chicago Compulsivity Trait Scale (CHI-T). The average age of the participants was 30.9 years; 48 had TTM, 37 had SPD, and 2 had both conditions.
Overall, total CHI-T scores were significantly correlated with worse disability and quality of life, based on the Quality of Life Inventory (P = .0278) and the Sheehan Disability Scale (P = .0085) but not with severity of TTM or SPD symptoms. TTM and SPD symptoms were assessed using the Massachusetts General Hospital Hair Pulling Scale and the Skin Picking Symptom Symptom Assessment Scale.
“In the current study, we did not find a link between conventional symptom severity measures for BFRBs and disability or quality of life, whereas trans-diagnostic compulsivity did correlate with these clinically important parameters,” the researchers wrote in their discussion. “These findings might suggest the current symptom measures for BFRBs are not including an important aspect of the disease and that a fuller understanding of these symptoms requires measurement of compulsivity. Including validated measures of compulsivity in clinical trials of therapy or medication would also seem to be important for future work,” they said.
The study findings were limited by several factors including the use of a community sample that may not generalize to a clinical setting, the researchers noted. Other limitations include the cross-sectional design, which prevents conclusions about causality, the lack of a control group, and the relatively small sample size, they said.
However, the study is the first known to use a validated compulsivity measure to assess BFRBs, and the results suggest a clinically relevant impact of compulsivity on both psychosocial dysfunction and poor quality of life in this patient population, with possible implications for treatment, the researchers wrote.
The study received no outside funding. Lead author Dr. Grant disclosed research grants from Otsuka and Biohaven Pharmaceuticals, yearly compensation from Springer Publishing for acting as editor in chief of the Journal of Gambling Studies, and royalties from Oxford University Press, American Psychiatric Publishing, Norton Press, and McGraw Hill.
Although body-focused repetitive behaviors (BFRBs), specifically trichotillomania and skin-picking disorder, are similar in clinical presentation to aspects of obsessive-compulsive disorder (OCD), the role of compulsivity in TTM and SPD has not been well studied, wrote Jon E. Grant, MD, of the University of Chicago and colleagues.
In a study published in the Journal of Psychiatric Research, the authors recruited 69 women and 22 men who met DSM-5 criteria for TTM and SPD. Participants completed diagnostic interviews, symptom inventories, and measures of disability/functioning. Compulsivity was measured using the 15-item Cambridge-Chicago Compulsivity Trait Scale (CHI-T). The average age of the participants was 30.9 years; 48 had TTM, 37 had SPD, and 2 had both conditions.
Overall, total CHI-T scores were significantly correlated with worse disability and quality of life, based on the Quality of Life Inventory (P = .0278) and the Sheehan Disability Scale (P = .0085) but not with severity of TTM or SPD symptoms. TTM and SPD symptoms were assessed using the Massachusetts General Hospital Hair Pulling Scale and the Skin Picking Symptom Symptom Assessment Scale.
“In the current study, we did not find a link between conventional symptom severity measures for BFRBs and disability or quality of life, whereas trans-diagnostic compulsivity did correlate with these clinically important parameters,” the researchers wrote in their discussion. “These findings might suggest the current symptom measures for BFRBs are not including an important aspect of the disease and that a fuller understanding of these symptoms requires measurement of compulsivity. Including validated measures of compulsivity in clinical trials of therapy or medication would also seem to be important for future work,” they said.
The study findings were limited by several factors including the use of a community sample that may not generalize to a clinical setting, the researchers noted. Other limitations include the cross-sectional design, which prevents conclusions about causality, the lack of a control group, and the relatively small sample size, they said.
However, the study is the first known to use a validated compulsivity measure to assess BFRBs, and the results suggest a clinically relevant impact of compulsivity on both psychosocial dysfunction and poor quality of life in this patient population, with possible implications for treatment, the researchers wrote.
The study received no outside funding. Lead author Dr. Grant disclosed research grants from Otsuka and Biohaven Pharmaceuticals, yearly compensation from Springer Publishing for acting as editor in chief of the Journal of Gambling Studies, and royalties from Oxford University Press, American Psychiatric Publishing, Norton Press, and McGraw Hill.
FROM THE JOURNAL OF PSYCHIATRIC RESEARCH
Mepolizumab curbed corticosteroid use for severe asthma
Use of mepolizumab significantly reduced the need for maintenance oral corticosteroids in adults with severe asthma, based on data from more than 800 individuals.
Many patients with severe asthma require bursts of systemic corticosteroids (SCS) or maintenance oral corticosteroids (mOCS) for disease control, but these strategies are associated with side effects that can increase the disease burden, wrote Charles Pilette, MD, of Cliniques Universitaires Saint-Luc, Brussels, and colleagues.
Previous studies have shown that the humanized, monoclonal anti-interleukin (IL)–5 antibody mepolizumab, which is approved for the treatment of severe asthma, reduced use of SCS and has shown effectiveness in less homogeneous populations, but robust, real-world data on the occurrence and magnitude of these effects are lacking, the researchers said.
In a study known as REALITI-A, the researchers enrolled 822 adults with asthma diagnoses from 82 centers in Europe, Canada, and the United States who initiated mepolizumab at a subcutaneous dose of 100 mg. The study endpoints included daily use of oral corticosteroids at baseline and 1 year, percentage reduction in oral corticosteroid use from baseline, patients discontinuing oral corticosteroids; the primary outcome was the rate of clinically significant exacerbations (CSEs). CSEs were defined as the need for OCS for at least 3 days/parenteral administration, and/or an emergency department or hospital admission before and after treatment. The mean age of the participants was 54 years, 63% were women, and 60% were never-smokers. The mean asthma duration was 19.7 years.
A total of 319 patients (39%), used mOCS at baseline, and dose information was available for 298.
Real-world outcomes
At 1 year, the median mOCS dose in the study population was reduced by 75%, and 64% reduced their mOCS dose by at least 50% from baseline.
In addition, the proportion of patients who discontinued daily mOCS increased from 29% during week 25-28 to 43% during week 53-56.
Overall, 80% of patients remained on mepolizumab at 1 year. Lack of efficacy and patient decision were the top two reasons for discontinuation (6% and 4%, respectively).
The primary outcome of rate of CSE decreased by a clinically significant rate ratio of 0.29 (P < .001).
“The requirement for SCS bursts was also reduced, as observed by a decreased rate of CSEs,” the researchers wrote in their discussion. The results were consistent for patients receiving lower (less than 10 mg/day) or higher (10 mg/day or more) mOCS doses at baseline, they said. No unexpected safety signals were noted during the study period.
“Furthermore, , or those requiring hospitalization or an ER visit, improved symptom control, and lower work productivity and activity impairment,” they added.
The study findings were limited by several factors including the observational design, lack of mepolizumab comparator, and open-label data capture, the researchers noted. However, the results were consistent with similar studies, and support the use of mepolizumab as part of the standard of care for clinically effective disease control in severe asthma patients, they concluded.
The study was funded by GlaxoSmithKline. Lead author Dr. Pilette disclosed fees for advisory boards, speaker meetings, and 42 research grants from GSK, AstraZeneca, Chiesi, Novartis, Teva, and ALK-Abello.
Use of mepolizumab significantly reduced the need for maintenance oral corticosteroids in adults with severe asthma, based on data from more than 800 individuals.
Many patients with severe asthma require bursts of systemic corticosteroids (SCS) or maintenance oral corticosteroids (mOCS) for disease control, but these strategies are associated with side effects that can increase the disease burden, wrote Charles Pilette, MD, of Cliniques Universitaires Saint-Luc, Brussels, and colleagues.
Previous studies have shown that the humanized, monoclonal anti-interleukin (IL)–5 antibody mepolizumab, which is approved for the treatment of severe asthma, reduced use of SCS and has shown effectiveness in less homogeneous populations, but robust, real-world data on the occurrence and magnitude of these effects are lacking, the researchers said.
In a study known as REALITI-A, the researchers enrolled 822 adults with asthma diagnoses from 82 centers in Europe, Canada, and the United States who initiated mepolizumab at a subcutaneous dose of 100 mg. The study endpoints included daily use of oral corticosteroids at baseline and 1 year, percentage reduction in oral corticosteroid use from baseline, patients discontinuing oral corticosteroids; the primary outcome was the rate of clinically significant exacerbations (CSEs). CSEs were defined as the need for OCS for at least 3 days/parenteral administration, and/or an emergency department or hospital admission before and after treatment. The mean age of the participants was 54 years, 63% were women, and 60% were never-smokers. The mean asthma duration was 19.7 years.
A total of 319 patients (39%), used mOCS at baseline, and dose information was available for 298.
Real-world outcomes
At 1 year, the median mOCS dose in the study population was reduced by 75%, and 64% reduced their mOCS dose by at least 50% from baseline.
In addition, the proportion of patients who discontinued daily mOCS increased from 29% during week 25-28 to 43% during week 53-56.
Overall, 80% of patients remained on mepolizumab at 1 year. Lack of efficacy and patient decision were the top two reasons for discontinuation (6% and 4%, respectively).
The primary outcome of rate of CSE decreased by a clinically significant rate ratio of 0.29 (P < .001).
“The requirement for SCS bursts was also reduced, as observed by a decreased rate of CSEs,” the researchers wrote in their discussion. The results were consistent for patients receiving lower (less than 10 mg/day) or higher (10 mg/day or more) mOCS doses at baseline, they said. No unexpected safety signals were noted during the study period.
“Furthermore, , or those requiring hospitalization or an ER visit, improved symptom control, and lower work productivity and activity impairment,” they added.
The study findings were limited by several factors including the observational design, lack of mepolizumab comparator, and open-label data capture, the researchers noted. However, the results were consistent with similar studies, and support the use of mepolizumab as part of the standard of care for clinically effective disease control in severe asthma patients, they concluded.
The study was funded by GlaxoSmithKline. Lead author Dr. Pilette disclosed fees for advisory boards, speaker meetings, and 42 research grants from GSK, AstraZeneca, Chiesi, Novartis, Teva, and ALK-Abello.
Use of mepolizumab significantly reduced the need for maintenance oral corticosteroids in adults with severe asthma, based on data from more than 800 individuals.
Many patients with severe asthma require bursts of systemic corticosteroids (SCS) or maintenance oral corticosteroids (mOCS) for disease control, but these strategies are associated with side effects that can increase the disease burden, wrote Charles Pilette, MD, of Cliniques Universitaires Saint-Luc, Brussels, and colleagues.
Previous studies have shown that the humanized, monoclonal anti-interleukin (IL)–5 antibody mepolizumab, which is approved for the treatment of severe asthma, reduced use of SCS and has shown effectiveness in less homogeneous populations, but robust, real-world data on the occurrence and magnitude of these effects are lacking, the researchers said.
In a study known as REALITI-A, the researchers enrolled 822 adults with asthma diagnoses from 82 centers in Europe, Canada, and the United States who initiated mepolizumab at a subcutaneous dose of 100 mg. The study endpoints included daily use of oral corticosteroids at baseline and 1 year, percentage reduction in oral corticosteroid use from baseline, patients discontinuing oral corticosteroids; the primary outcome was the rate of clinically significant exacerbations (CSEs). CSEs were defined as the need for OCS for at least 3 days/parenteral administration, and/or an emergency department or hospital admission before and after treatment. The mean age of the participants was 54 years, 63% were women, and 60% were never-smokers. The mean asthma duration was 19.7 years.
A total of 319 patients (39%), used mOCS at baseline, and dose information was available for 298.
Real-world outcomes
At 1 year, the median mOCS dose in the study population was reduced by 75%, and 64% reduced their mOCS dose by at least 50% from baseline.
In addition, the proportion of patients who discontinued daily mOCS increased from 29% during week 25-28 to 43% during week 53-56.
Overall, 80% of patients remained on mepolizumab at 1 year. Lack of efficacy and patient decision were the top two reasons for discontinuation (6% and 4%, respectively).
The primary outcome of rate of CSE decreased by a clinically significant rate ratio of 0.29 (P < .001).
“The requirement for SCS bursts was also reduced, as observed by a decreased rate of CSEs,” the researchers wrote in their discussion. The results were consistent for patients receiving lower (less than 10 mg/day) or higher (10 mg/day or more) mOCS doses at baseline, they said. No unexpected safety signals were noted during the study period.
“Furthermore, , or those requiring hospitalization or an ER visit, improved symptom control, and lower work productivity and activity impairment,” they added.
The study findings were limited by several factors including the observational design, lack of mepolizumab comparator, and open-label data capture, the researchers noted. However, the results were consistent with similar studies, and support the use of mepolizumab as part of the standard of care for clinically effective disease control in severe asthma patients, they concluded.
The study was funded by GlaxoSmithKline. Lead author Dr. Pilette disclosed fees for advisory boards, speaker meetings, and 42 research grants from GSK, AstraZeneca, Chiesi, Novartis, Teva, and ALK-Abello.
FROM JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY: IN PRACTICE
Air pollution mediates temperature’s impact on COPD
in adults with chronic obstructive pulmonary disease (COPD) based on data from 117 individuals.
COPD is attributed to environmental factors including air pollution, and air pollution has been linked to increased risk of hospitalization and mortality because of acute COPD exacerbation, wrote Huan Minh Tran, PhD, of Taipei (Taiwan) Medical University and colleagues. However, the effects of air pollution on climate-associated health outcomes in COPD have not been explored, they said.
In a study published in Science of The Total Environment the researchers identified 117 adult COPD patients at a single center in Taiwan. They measured lung function, 6-minute walking distance, oxygen desaturation, white blood cell count, and percent emphysema (defined as low attenuation area [LAA]) and linked them to 0- to 1-year, 0- to 3-year, and 0- to 5-year lags in exposures to relative humidity (RH), temperature, and air pollution. The mean age of the participants was 72.9 years; 93% were men.
Pollution was defined in terms of fine particulate matter (PM2.5).
Overall, an increase in RH by 1% was associated with increases in forced expiratory volume in 1 second (FEV1), eosinophils, and lymphocytes.
A 1% increase in RH also was associated with a decrease in the total-lobe LAA.
As for temperature, an increase of 1° C was associated with decreased oxygen desaturation and with decreases in right-, left-, and upper-lobe LAA values.
When the researchers examined the impact of pollution, they found that a 1 mcg/m3 increase in PM2.5 was associated with a decrease in the FEV1 as well as with an increase in oxygen desaturation. A 1 mcg/m3 increase in PM10 and PM2.5 was associated with increases in the total-, right-, left, and upper-lobe LAA; increases in lower-lobe LAA were associated with an increase in PM2.5 only.
“This is reasonable because PM2.5 can travel and deposit in distal parts of the lung, while PM10 is preferably deposited in the larger airways of the upper lung regions,” the researchers wrote in their discussion.
A one part per billion increase in nitrogen dioxide (NO2) was associated with decreased FEV1 and increased upper-lobe LAA.
“We observed that NO2 fully mediated the association between RH and FEV1, while PM2.5 fully mediated associations of temperature with oxygen saturation and emphysema severity in COPD patients,” the researchers added.
The study findings were limited by several factors including the relatively small and homogeneous male, Taiwanese population, which may limit generalizability, the researchers noted. Other limitations included the lack of control for factors such as body mass index, occupational exposure, comorbidities, medication use, and indoor air pollution, they said.
However, the results suggest that air pollution could have an effect on the established associations between climate and adverse health outcomes in COPD, and more research is needed. Climate change–related air pollution is an important public health issue, especially with regards to respiratory disease,” they concluded.
The study was supported by the Ministry of Science and Technology of Taiwan. The researchers had no financial conflicts to disclose.
in adults with chronic obstructive pulmonary disease (COPD) based on data from 117 individuals.
COPD is attributed to environmental factors including air pollution, and air pollution has been linked to increased risk of hospitalization and mortality because of acute COPD exacerbation, wrote Huan Minh Tran, PhD, of Taipei (Taiwan) Medical University and colleagues. However, the effects of air pollution on climate-associated health outcomes in COPD have not been explored, they said.
In a study published in Science of The Total Environment the researchers identified 117 adult COPD patients at a single center in Taiwan. They measured lung function, 6-minute walking distance, oxygen desaturation, white blood cell count, and percent emphysema (defined as low attenuation area [LAA]) and linked them to 0- to 1-year, 0- to 3-year, and 0- to 5-year lags in exposures to relative humidity (RH), temperature, and air pollution. The mean age of the participants was 72.9 years; 93% were men.
Pollution was defined in terms of fine particulate matter (PM2.5).
Overall, an increase in RH by 1% was associated with increases in forced expiratory volume in 1 second (FEV1), eosinophils, and lymphocytes.
A 1% increase in RH also was associated with a decrease in the total-lobe LAA.
As for temperature, an increase of 1° C was associated with decreased oxygen desaturation and with decreases in right-, left-, and upper-lobe LAA values.
When the researchers examined the impact of pollution, they found that a 1 mcg/m3 increase in PM2.5 was associated with a decrease in the FEV1 as well as with an increase in oxygen desaturation. A 1 mcg/m3 increase in PM10 and PM2.5 was associated with increases in the total-, right-, left, and upper-lobe LAA; increases in lower-lobe LAA were associated with an increase in PM2.5 only.
“This is reasonable because PM2.5 can travel and deposit in distal parts of the lung, while PM10 is preferably deposited in the larger airways of the upper lung regions,” the researchers wrote in their discussion.
A one part per billion increase in nitrogen dioxide (NO2) was associated with decreased FEV1 and increased upper-lobe LAA.
“We observed that NO2 fully mediated the association between RH and FEV1, while PM2.5 fully mediated associations of temperature with oxygen saturation and emphysema severity in COPD patients,” the researchers added.
The study findings were limited by several factors including the relatively small and homogeneous male, Taiwanese population, which may limit generalizability, the researchers noted. Other limitations included the lack of control for factors such as body mass index, occupational exposure, comorbidities, medication use, and indoor air pollution, they said.
However, the results suggest that air pollution could have an effect on the established associations between climate and adverse health outcomes in COPD, and more research is needed. Climate change–related air pollution is an important public health issue, especially with regards to respiratory disease,” they concluded.
The study was supported by the Ministry of Science and Technology of Taiwan. The researchers had no financial conflicts to disclose.
in adults with chronic obstructive pulmonary disease (COPD) based on data from 117 individuals.
COPD is attributed to environmental factors including air pollution, and air pollution has been linked to increased risk of hospitalization and mortality because of acute COPD exacerbation, wrote Huan Minh Tran, PhD, of Taipei (Taiwan) Medical University and colleagues. However, the effects of air pollution on climate-associated health outcomes in COPD have not been explored, they said.
In a study published in Science of The Total Environment the researchers identified 117 adult COPD patients at a single center in Taiwan. They measured lung function, 6-minute walking distance, oxygen desaturation, white blood cell count, and percent emphysema (defined as low attenuation area [LAA]) and linked them to 0- to 1-year, 0- to 3-year, and 0- to 5-year lags in exposures to relative humidity (RH), temperature, and air pollution. The mean age of the participants was 72.9 years; 93% were men.
Pollution was defined in terms of fine particulate matter (PM2.5).
Overall, an increase in RH by 1% was associated with increases in forced expiratory volume in 1 second (FEV1), eosinophils, and lymphocytes.
A 1% increase in RH also was associated with a decrease in the total-lobe LAA.
As for temperature, an increase of 1° C was associated with decreased oxygen desaturation and with decreases in right-, left-, and upper-lobe LAA values.
When the researchers examined the impact of pollution, they found that a 1 mcg/m3 increase in PM2.5 was associated with a decrease in the FEV1 as well as with an increase in oxygen desaturation. A 1 mcg/m3 increase in PM10 and PM2.5 was associated with increases in the total-, right-, left, and upper-lobe LAA; increases in lower-lobe LAA were associated with an increase in PM2.5 only.
“This is reasonable because PM2.5 can travel and deposit in distal parts of the lung, while PM10 is preferably deposited in the larger airways of the upper lung regions,” the researchers wrote in their discussion.
A one part per billion increase in nitrogen dioxide (NO2) was associated with decreased FEV1 and increased upper-lobe LAA.
“We observed that NO2 fully mediated the association between RH and FEV1, while PM2.5 fully mediated associations of temperature with oxygen saturation and emphysema severity in COPD patients,” the researchers added.
The study findings were limited by several factors including the relatively small and homogeneous male, Taiwanese population, which may limit generalizability, the researchers noted. Other limitations included the lack of control for factors such as body mass index, occupational exposure, comorbidities, medication use, and indoor air pollution, they said.
However, the results suggest that air pollution could have an effect on the established associations between climate and adverse health outcomes in COPD, and more research is needed. Climate change–related air pollution is an important public health issue, especially with regards to respiratory disease,” they concluded.
The study was supported by the Ministry of Science and Technology of Taiwan. The researchers had no financial conflicts to disclose.
FROM SCIENCE OF THE TOTAL ENVIRONMENT
Menstrual phase impacts exercise effects in type 1 diabetes
Women with type 1 diabetes may need additional glucose after exercise during the luteal phase of the menstrual cycle, compared with other times, according to a study in nine women.
“We know that exercise is very beneficial for people with type 1 diabetes; we also know that fear of hypoglycemia is a major barrier to exercise in this population,” said Jane E. Yardley, PhD, in a presentation at the annual scientific sessions of the American Diabetes Association, New Orleans. Women with type 1 diabetes (T1D) perceive more barriers, compared with men, she added.
The menstrual cycle could be an additional barrier to exercise for women with T1D because it increases glucose fluctuations that have not been well documented in the literature to date, said Dr. Yardley, of the University of Alberta, Augustana.
The follicular phase of the menstrual cycle lasts from menses to the midcycle, about 14 days later. This is followed by the luteal phase, which lasts until approximately day 28, Dr. Yardley explained. Data on insulin sensitivity have shown that the late luteal phase is associated with “a little less insulin sensitivity” in women with T1D, she noted.
To assess the relationship between menstrual cycle, glucose control, and exercise, Dr. Yardley and colleagues compared the effects of a moderate aerobic exercise on glycemic responses between the early follicular and late luteal phases of the menstrual cycle in nine female participants with T1D.
The exercise involved 45 minutes of aerobic cycling at 50% of predetermined peak oxygen uptake (VO2peak) for 45 min. The mean age of the participants was 30.2 years, the mean hemoglobin A1C was 7.4%, and the mean VO2peak was 32.5 mL/kg per min. The women reported regular menstrual cycles, and none were using oral contraceptives.
Blood samples were collected before and immediately after exercise and after an hour of recovery. Participants wore continuous glucose monitors for at least 1 hour before and after exercise.
Menstrual cycle was confirmed via estrogen, estradiol, and progesterone.
Insulin levels varied greatly among the study participants, but the differences were not significant, Dr. Yardley said. Glucose levels consistently decreased during exercise and increased after exercise, she noted.
No significant difference in glucose was observed between the follicular and luteal phases.
However, “this needs to be interpreted in the context of the safety profiles that are in place in our lab,” which include carbohydrate supplements for individuals whose blood glucose levels drop below 4.5 mmol/L, she said.
In the current study, 6 of 9 participants required additional carbohydrates during the luteal phase, but only 1 participant needed additional carbohydrates during the follicular phase, she noted. For this reason, no differences were noted. “We actually prevented changes,” she said.
No significant differences were noted in mean glucose levels or number of hypoglycemic episodes at any of the time points between the two phases.
“One place where we did see a difference was in hyperglycemia 24 hours after exercise,” Dr. Yardley said. Level 1 hyperglycemia 24 hours after exercise was significantly more frequent in the follicular phase, compared with the luteal phase (P = .028).
The study findings were limited by the small sample size and homogenous population, and more research is needed to interpret the data, said Dr. Yardley.
However, the need for more glucose supplementation to prevent hypoglycemia during the luteal phase suggests a higher hypoglycemic risk associated with aerobic exercise during this time, she said.
In addition, the results suggest that the menstrual cycle should be taken into consideration when female participants are involved in exercise studies, she noted.
Study supports personalized exercise plans
“It is important to evaluate effects of exercise in people with type 1 diabetes and evaluate whether there is a difference those effects in men and women,” said Helena W. Rodbard, MD, an endocrinologist in private practice in Rockville, Md., in an interview. “There is also a need to evaluate to what extent the changes in blood glucose patterns in women in response to exercise differ depending on the phase of the ovarian cycle,” said Dr. Rodbard, who was not involved in the study.
In the current study, “the researchers observed a decline in glucose during a 45-minute period of moderate aerobic exercise, cycling at 50% VO2peak followed by an increase during a 60-minute recovery period. There was a suggestive finding, in the nine subjects, that more carbohydrate supplementation was needed during the late luteal phase of the menstrual cycle than during the follicular phase,” Dr. Rodbard noted. “In contrast, the authors reported a significantly increased degree of hyperglycemia during the recovery phase for subjects during the follicular phase. These findings are consistent with and extend several recent studies from Dr. Yardley and coworkers, who have been focused on this area of research,” she said.
“This study provides provocative evidence that glucose responses to aerobic exercise in women may depend on the timing in relationship to their ovarian cycle,” said Dr. Rodbard. “These findings are based on a small group of subjects and were present in some but not all subjects. Clinicians should encourage women to evaluate and record their experiences during and after exercise in terms of need for carbohydrate supplementation for documented or symptomatic hypoglycemia and in terms of glucose changes as recorded using continuous glucose monitoring (CGM), both in relation to type of exercise and in relation to time in the menstrual cycle,” she said.
The findings also highlight the importance of individualized therapy that is “based on subjective inputs combined with analysis of CGM data during and following exercise,” said Dr. Rodbard. “It is likely that use of Automated Insulin Delivery (AID) will be helpful in achieving this level of individualization in view of the wide range of types, intensity, and duration of physical activity and exercise in which people with T1D engage and the myriad factors that can influence the glycemic response,” she said.
Looking ahead, “the authors and others should expand the present series of subjects using aerobic exercise and examine other types of exercise as well,” Dr. Rodbard noted. “It will be important to evaluate the consistency of these changes in glucose patterns within individuals on multiple occasions, and it would be helpful to repeat the studies in women using oral contraceptives.”
Dr. Yardley disclosed research support from Abbott, Dexcom, and LifeScan and disclosed serving on the speaker’s bureau for Abbott Diabetes. Dr. Rodbard had no financial conflicts to disclose. She serves on the Editorial Advisory Board of Clinical Endocrinology News.
Women with type 1 diabetes may need additional glucose after exercise during the luteal phase of the menstrual cycle, compared with other times, according to a study in nine women.
“We know that exercise is very beneficial for people with type 1 diabetes; we also know that fear of hypoglycemia is a major barrier to exercise in this population,” said Jane E. Yardley, PhD, in a presentation at the annual scientific sessions of the American Diabetes Association, New Orleans. Women with type 1 diabetes (T1D) perceive more barriers, compared with men, she added.
The menstrual cycle could be an additional barrier to exercise for women with T1D because it increases glucose fluctuations that have not been well documented in the literature to date, said Dr. Yardley, of the University of Alberta, Augustana.
The follicular phase of the menstrual cycle lasts from menses to the midcycle, about 14 days later. This is followed by the luteal phase, which lasts until approximately day 28, Dr. Yardley explained. Data on insulin sensitivity have shown that the late luteal phase is associated with “a little less insulin sensitivity” in women with T1D, she noted.
To assess the relationship between menstrual cycle, glucose control, and exercise, Dr. Yardley and colleagues compared the effects of a moderate aerobic exercise on glycemic responses between the early follicular and late luteal phases of the menstrual cycle in nine female participants with T1D.
The exercise involved 45 minutes of aerobic cycling at 50% of predetermined peak oxygen uptake (VO2peak) for 45 min. The mean age of the participants was 30.2 years, the mean hemoglobin A1C was 7.4%, and the mean VO2peak was 32.5 mL/kg per min. The women reported regular menstrual cycles, and none were using oral contraceptives.
Blood samples were collected before and immediately after exercise and after an hour of recovery. Participants wore continuous glucose monitors for at least 1 hour before and after exercise.
Menstrual cycle was confirmed via estrogen, estradiol, and progesterone.
Insulin levels varied greatly among the study participants, but the differences were not significant, Dr. Yardley said. Glucose levels consistently decreased during exercise and increased after exercise, she noted.
No significant difference in glucose was observed between the follicular and luteal phases.
However, “this needs to be interpreted in the context of the safety profiles that are in place in our lab,” which include carbohydrate supplements for individuals whose blood glucose levels drop below 4.5 mmol/L, she said.
In the current study, 6 of 9 participants required additional carbohydrates during the luteal phase, but only 1 participant needed additional carbohydrates during the follicular phase, she noted. For this reason, no differences were noted. “We actually prevented changes,” she said.
No significant differences were noted in mean glucose levels or number of hypoglycemic episodes at any of the time points between the two phases.
“One place where we did see a difference was in hyperglycemia 24 hours after exercise,” Dr. Yardley said. Level 1 hyperglycemia 24 hours after exercise was significantly more frequent in the follicular phase, compared with the luteal phase (P = .028).
The study findings were limited by the small sample size and homogenous population, and more research is needed to interpret the data, said Dr. Yardley.
However, the need for more glucose supplementation to prevent hypoglycemia during the luteal phase suggests a higher hypoglycemic risk associated with aerobic exercise during this time, she said.
In addition, the results suggest that the menstrual cycle should be taken into consideration when female participants are involved in exercise studies, she noted.
Study supports personalized exercise plans
“It is important to evaluate effects of exercise in people with type 1 diabetes and evaluate whether there is a difference those effects in men and women,” said Helena W. Rodbard, MD, an endocrinologist in private practice in Rockville, Md., in an interview. “There is also a need to evaluate to what extent the changes in blood glucose patterns in women in response to exercise differ depending on the phase of the ovarian cycle,” said Dr. Rodbard, who was not involved in the study.
In the current study, “the researchers observed a decline in glucose during a 45-minute period of moderate aerobic exercise, cycling at 50% VO2peak followed by an increase during a 60-minute recovery period. There was a suggestive finding, in the nine subjects, that more carbohydrate supplementation was needed during the late luteal phase of the menstrual cycle than during the follicular phase,” Dr. Rodbard noted. “In contrast, the authors reported a significantly increased degree of hyperglycemia during the recovery phase for subjects during the follicular phase. These findings are consistent with and extend several recent studies from Dr. Yardley and coworkers, who have been focused on this area of research,” she said.
“This study provides provocative evidence that glucose responses to aerobic exercise in women may depend on the timing in relationship to their ovarian cycle,” said Dr. Rodbard. “These findings are based on a small group of subjects and were present in some but not all subjects. Clinicians should encourage women to evaluate and record their experiences during and after exercise in terms of need for carbohydrate supplementation for documented or symptomatic hypoglycemia and in terms of glucose changes as recorded using continuous glucose monitoring (CGM), both in relation to type of exercise and in relation to time in the menstrual cycle,” she said.
The findings also highlight the importance of individualized therapy that is “based on subjective inputs combined with analysis of CGM data during and following exercise,” said Dr. Rodbard. “It is likely that use of Automated Insulin Delivery (AID) will be helpful in achieving this level of individualization in view of the wide range of types, intensity, and duration of physical activity and exercise in which people with T1D engage and the myriad factors that can influence the glycemic response,” she said.
Looking ahead, “the authors and others should expand the present series of subjects using aerobic exercise and examine other types of exercise as well,” Dr. Rodbard noted. “It will be important to evaluate the consistency of these changes in glucose patterns within individuals on multiple occasions, and it would be helpful to repeat the studies in women using oral contraceptives.”
Dr. Yardley disclosed research support from Abbott, Dexcom, and LifeScan and disclosed serving on the speaker’s bureau for Abbott Diabetes. Dr. Rodbard had no financial conflicts to disclose. She serves on the Editorial Advisory Board of Clinical Endocrinology News.
Women with type 1 diabetes may need additional glucose after exercise during the luteal phase of the menstrual cycle, compared with other times, according to a study in nine women.
“We know that exercise is very beneficial for people with type 1 diabetes; we also know that fear of hypoglycemia is a major barrier to exercise in this population,” said Jane E. Yardley, PhD, in a presentation at the annual scientific sessions of the American Diabetes Association, New Orleans. Women with type 1 diabetes (T1D) perceive more barriers, compared with men, she added.
The menstrual cycle could be an additional barrier to exercise for women with T1D because it increases glucose fluctuations that have not been well documented in the literature to date, said Dr. Yardley, of the University of Alberta, Augustana.
The follicular phase of the menstrual cycle lasts from menses to the midcycle, about 14 days later. This is followed by the luteal phase, which lasts until approximately day 28, Dr. Yardley explained. Data on insulin sensitivity have shown that the late luteal phase is associated with “a little less insulin sensitivity” in women with T1D, she noted.
To assess the relationship between menstrual cycle, glucose control, and exercise, Dr. Yardley and colleagues compared the effects of a moderate aerobic exercise on glycemic responses between the early follicular and late luteal phases of the menstrual cycle in nine female participants with T1D.
The exercise involved 45 minutes of aerobic cycling at 50% of predetermined peak oxygen uptake (VO2peak) for 45 min. The mean age of the participants was 30.2 years, the mean hemoglobin A1C was 7.4%, and the mean VO2peak was 32.5 mL/kg per min. The women reported regular menstrual cycles, and none were using oral contraceptives.
Blood samples were collected before and immediately after exercise and after an hour of recovery. Participants wore continuous glucose monitors for at least 1 hour before and after exercise.
Menstrual cycle was confirmed via estrogen, estradiol, and progesterone.
Insulin levels varied greatly among the study participants, but the differences were not significant, Dr. Yardley said. Glucose levels consistently decreased during exercise and increased after exercise, she noted.
No significant difference in glucose was observed between the follicular and luteal phases.
However, “this needs to be interpreted in the context of the safety profiles that are in place in our lab,” which include carbohydrate supplements for individuals whose blood glucose levels drop below 4.5 mmol/L, she said.
In the current study, 6 of 9 participants required additional carbohydrates during the luteal phase, but only 1 participant needed additional carbohydrates during the follicular phase, she noted. For this reason, no differences were noted. “We actually prevented changes,” she said.
No significant differences were noted in mean glucose levels or number of hypoglycemic episodes at any of the time points between the two phases.
“One place where we did see a difference was in hyperglycemia 24 hours after exercise,” Dr. Yardley said. Level 1 hyperglycemia 24 hours after exercise was significantly more frequent in the follicular phase, compared with the luteal phase (P = .028).
The study findings were limited by the small sample size and homogenous population, and more research is needed to interpret the data, said Dr. Yardley.
However, the need for more glucose supplementation to prevent hypoglycemia during the luteal phase suggests a higher hypoglycemic risk associated with aerobic exercise during this time, she said.
In addition, the results suggest that the menstrual cycle should be taken into consideration when female participants are involved in exercise studies, she noted.
Study supports personalized exercise plans
“It is important to evaluate effects of exercise in people with type 1 diabetes and evaluate whether there is a difference those effects in men and women,” said Helena W. Rodbard, MD, an endocrinologist in private practice in Rockville, Md., in an interview. “There is also a need to evaluate to what extent the changes in blood glucose patterns in women in response to exercise differ depending on the phase of the ovarian cycle,” said Dr. Rodbard, who was not involved in the study.
In the current study, “the researchers observed a decline in glucose during a 45-minute period of moderate aerobic exercise, cycling at 50% VO2peak followed by an increase during a 60-minute recovery period. There was a suggestive finding, in the nine subjects, that more carbohydrate supplementation was needed during the late luteal phase of the menstrual cycle than during the follicular phase,” Dr. Rodbard noted. “In contrast, the authors reported a significantly increased degree of hyperglycemia during the recovery phase for subjects during the follicular phase. These findings are consistent with and extend several recent studies from Dr. Yardley and coworkers, who have been focused on this area of research,” she said.
“This study provides provocative evidence that glucose responses to aerobic exercise in women may depend on the timing in relationship to their ovarian cycle,” said Dr. Rodbard. “These findings are based on a small group of subjects and were present in some but not all subjects. Clinicians should encourage women to evaluate and record their experiences during and after exercise in terms of need for carbohydrate supplementation for documented or symptomatic hypoglycemia and in terms of glucose changes as recorded using continuous glucose monitoring (CGM), both in relation to type of exercise and in relation to time in the menstrual cycle,” she said.
The findings also highlight the importance of individualized therapy that is “based on subjective inputs combined with analysis of CGM data during and following exercise,” said Dr. Rodbard. “It is likely that use of Automated Insulin Delivery (AID) will be helpful in achieving this level of individualization in view of the wide range of types, intensity, and duration of physical activity and exercise in which people with T1D engage and the myriad factors that can influence the glycemic response,” she said.
Looking ahead, “the authors and others should expand the present series of subjects using aerobic exercise and examine other types of exercise as well,” Dr. Rodbard noted. “It will be important to evaluate the consistency of these changes in glucose patterns within individuals on multiple occasions, and it would be helpful to repeat the studies in women using oral contraceptives.”
Dr. Yardley disclosed research support from Abbott, Dexcom, and LifeScan and disclosed serving on the speaker’s bureau for Abbott Diabetes. Dr. Rodbard had no financial conflicts to disclose. She serves on the Editorial Advisory Board of Clinical Endocrinology News.
FROM ADA 2022
Cannabis use causes spike in ED visits
Cannabis users had a 22% increased risk of an emergency department (ED) visit or hospitalization compared to nonusers, as determined from data from more than 30,000 individuals.
Although cannabis contains compounds similar to tobacco, “data published on the association between cannabis smoking and airways health have been contradictory,” and whether smoking cannabis increases a user’s risk of developing acute respiratory illness remains unclear, wrote Nicholas T. Vozoris, MD, of the University of Toronto, and colleagues.
In a study published in BMJ Open Respiratory Research, the investigators reviewed national health records data from 35,114 individuals aged 12-65 years for the period January 2009 to December 2015. Of these persons, 4,807 of the 6,425 who reported cannabis use in the past year were matched with 10,395 never-users who served as controls. The mean age of the study population at the index date was 35 years, and 42% were women; demographics were similar between users and control persons.
Overall, the odds of respiratory-related emergency department visits or hospitalizations were not significantly different between the cannabis users and the control persons (3.6% vs. 3.9%; odds ratio, 0.91). However, cannabis users had significantly greater odds of all-cause ED visits or hospitalizations (30.0% vs. 26.0%; OR, 1.22). All-cause mortality was 0.2% for both groups.
Respiratory problems were the second-highest reason for all-cause visits, the researchers noted. The lack of a difference in respiratory-related visits between cannabis users and nonusers conflicts somewhat with previous studies on this topic, which were limited, the researchers noted in their discussion.
The negative results also might stem from factors for which the researchers could not adjust, including insufficient cannabis smoke exposure among users in the study population, noninhalational cannabis use, which is less likely to have a respiratory effect, and possible secondhand exposure among control persons.
“It is also possible that our analysis might have been insufficiently powered to detect a significant signal with respect to the primary outcome,” they noted.
However, after the researchers controlled for multiple variables, the risk of an equally important morbidity outcome, all-cause ED visits or hospitalizations, was significantly greater among cannabis users than among control individuals, and respiratory reasons were the second most common cause for ED visits and hospitalizations in the all-cause outcome, they emphasized.
The study findings were limited by several factors, including the retrospective and observational design and the inability to control for all confounding variables, the researchers noted. Other limitations include the use of self-reports and potential for bias, the inability to perform dose-response analysis, and the high number of infrequent cannabis users in the study population.
However, the results suggest that cannabis use is associated with an increased risk of serious health events and should be discouraged, although more research is needed to confirm the current study findings, they concluded.
Consider range of causes for cannabis emergency visits
“With growing numbers of states legalizing recreational use of cannabis, it’s important to understand whether cannabis use is associated with increased emergency department visits,” Robert D. Glatter, MD, an emergency medicine physician at Lenox Hill Hospital, New York, told this news organization.
Previous studies have shown an association between increased ED visits and cannabis use in states, especially with edibles, where cannabis is legal, and “the current study reinforces the elevated risk of ED visits along with hospitalizations,” he said.
“While the researchers found no increased risk of respiratory-related complaints among users compared to the general population, there was an associated increase in ED visits and hospitalizations, which is important to understand,” said Dr. Glatter, who was not involved in the study.
“While this observational study found that the incidence of respiratory complaints was not significantly different among frequent users of cannabis, the increased odds that cannabis users would require evaluation in the emergency room or even hospitalization was still apparent even after the investigators controlled for such factors as use of alcohol, tobacco, illicit drug use, or other mental health–related disorders,” Dr. Glatter noted.
“That said, it’s a bit surprising that with the continued popularity of vaping, especially among teens, there was still not any appreciable or significant increase in respiratory complaints observed. Beyond this finding, I was not surprised by the overall conclusions of the current study, as we continue to see an elevated number of patients presenting to the ED with adverse events related to cannabis use.”
Dr. Glatter noted that “the majority of patients we see in the ED are associated with use of edibles, since it takes longer for the person to feel the effects, leading the user to consume more of the product up front, with delayed effects lasting up to 12 hours. This is what gets people into trouble and leads to toxicity of cannabis, or ‘overdoses,’ “ he explained.
When consuming edible cannabis products, “[p]eople need to begin at low dosages and not take additional gummies up front, since it can take up to 2 or even 3 hours in some cases to feel the initial effects. With the drug’s effects lasting up to 12 hours, it’s especially important to avoid operating any motor vehicles, bicycles, or scooters, since reaction time is impaired, as well as overall judgment, balance, and fine motor skills,” Dr. Glatter said.
Cannabis can land users in the ED for a range of reasons, said Dr. Glatter. “According to the study, 15% of the emergency room visits and hospitalizations were due to acute trauma, 14% due to respiratory issues, and 13% to gastrointestinal illnesses. These effects were seen in first-time users but not those with chronic use, according to the study inclusion criteria.”
Cannabis use could result in physical injuries through “impaired judgment, coordination, combined with an altered state of consciousness or generalized drowsiness, that could contribute to an increase in motor vehicle collisions, along with an increased risk for falls leading to lacerations, fractures, contusions, or bruising,” said Dr. Glatter. “Cannabis may also lead to an altered sense of perception related to interactions with others, resulting in feelings of anxiety or restlessness culminating in physical altercations and other injuries.”
The current study indicates the need for understanding the potential physical and psychological effects of cannabis use, he said.
“Additional research is needed to better understand the relative percentage cases related to edibles vs. inhalation presenting to the ED,” he noted. “There is no question that edibles continue to present significant dangers for those who don’t read labels or remain poorly informed regarding their dosing as a result of delayed onset and longer duration,” he said. To help reduce risk of toxicity, the concept of a “high lasting 12-15 hours, as with edibles, as opposed to 3-4 hours from inhalation must be clearly stated on packaging and better communicated with users, as the toxicity with edibles is more often from lack of prior knowledge about onset of effects related to dosing.”
In addition, the “potential for psychosis to develop with more chronic cannabis use, along with cannabinoid hyperemesis syndrome should be on every clinician’s radar,” Dr. Glatter emphasized.
“The bottom line is that as more states legalize the use of cannabis, it’s vital to also implement comprehensive public education efforts to provide users with the reported risks associated with not only inhalation (vaping or flower) but also edibles, which account for an increasingly greater percentage of ED visits and associated adverse effects,” he said.
The study was supported by the Lung Association–Ontario, as well as by grants from the Ontario Ministry of Health and the Ministry of Long-Term Care. The researchers and Dr. Glatter have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Cannabis users had a 22% increased risk of an emergency department (ED) visit or hospitalization compared to nonusers, as determined from data from more than 30,000 individuals.
Although cannabis contains compounds similar to tobacco, “data published on the association between cannabis smoking and airways health have been contradictory,” and whether smoking cannabis increases a user’s risk of developing acute respiratory illness remains unclear, wrote Nicholas T. Vozoris, MD, of the University of Toronto, and colleagues.
In a study published in BMJ Open Respiratory Research, the investigators reviewed national health records data from 35,114 individuals aged 12-65 years for the period January 2009 to December 2015. Of these persons, 4,807 of the 6,425 who reported cannabis use in the past year were matched with 10,395 never-users who served as controls. The mean age of the study population at the index date was 35 years, and 42% were women; demographics were similar between users and control persons.
Overall, the odds of respiratory-related emergency department visits or hospitalizations were not significantly different between the cannabis users and the control persons (3.6% vs. 3.9%; odds ratio, 0.91). However, cannabis users had significantly greater odds of all-cause ED visits or hospitalizations (30.0% vs. 26.0%; OR, 1.22). All-cause mortality was 0.2% for both groups.
Respiratory problems were the second-highest reason for all-cause visits, the researchers noted. The lack of a difference in respiratory-related visits between cannabis users and nonusers conflicts somewhat with previous studies on this topic, which were limited, the researchers noted in their discussion.
The negative results also might stem from factors for which the researchers could not adjust, including insufficient cannabis smoke exposure among users in the study population, noninhalational cannabis use, which is less likely to have a respiratory effect, and possible secondhand exposure among control persons.
“It is also possible that our analysis might have been insufficiently powered to detect a significant signal with respect to the primary outcome,” they noted.
However, after the researchers controlled for multiple variables, the risk of an equally important morbidity outcome, all-cause ED visits or hospitalizations, was significantly greater among cannabis users than among control individuals, and respiratory reasons were the second most common cause for ED visits and hospitalizations in the all-cause outcome, they emphasized.
The study findings were limited by several factors, including the retrospective and observational design and the inability to control for all confounding variables, the researchers noted. Other limitations include the use of self-reports and potential for bias, the inability to perform dose-response analysis, and the high number of infrequent cannabis users in the study population.
However, the results suggest that cannabis use is associated with an increased risk of serious health events and should be discouraged, although more research is needed to confirm the current study findings, they concluded.
Consider range of causes for cannabis emergency visits
“With growing numbers of states legalizing recreational use of cannabis, it’s important to understand whether cannabis use is associated with increased emergency department visits,” Robert D. Glatter, MD, an emergency medicine physician at Lenox Hill Hospital, New York, told this news organization.
Previous studies have shown an association between increased ED visits and cannabis use in states, especially with edibles, where cannabis is legal, and “the current study reinforces the elevated risk of ED visits along with hospitalizations,” he said.
“While the researchers found no increased risk of respiratory-related complaints among users compared to the general population, there was an associated increase in ED visits and hospitalizations, which is important to understand,” said Dr. Glatter, who was not involved in the study.
“While this observational study found that the incidence of respiratory complaints was not significantly different among frequent users of cannabis, the increased odds that cannabis users would require evaluation in the emergency room or even hospitalization was still apparent even after the investigators controlled for such factors as use of alcohol, tobacco, illicit drug use, or other mental health–related disorders,” Dr. Glatter noted.
“That said, it’s a bit surprising that with the continued popularity of vaping, especially among teens, there was still not any appreciable or significant increase in respiratory complaints observed. Beyond this finding, I was not surprised by the overall conclusions of the current study, as we continue to see an elevated number of patients presenting to the ED with adverse events related to cannabis use.”
Dr. Glatter noted that “the majority of patients we see in the ED are associated with use of edibles, since it takes longer for the person to feel the effects, leading the user to consume more of the product up front, with delayed effects lasting up to 12 hours. This is what gets people into trouble and leads to toxicity of cannabis, or ‘overdoses,’ “ he explained.
When consuming edible cannabis products, “[p]eople need to begin at low dosages and not take additional gummies up front, since it can take up to 2 or even 3 hours in some cases to feel the initial effects. With the drug’s effects lasting up to 12 hours, it’s especially important to avoid operating any motor vehicles, bicycles, or scooters, since reaction time is impaired, as well as overall judgment, balance, and fine motor skills,” Dr. Glatter said.
Cannabis can land users in the ED for a range of reasons, said Dr. Glatter. “According to the study, 15% of the emergency room visits and hospitalizations were due to acute trauma, 14% due to respiratory issues, and 13% to gastrointestinal illnesses. These effects were seen in first-time users but not those with chronic use, according to the study inclusion criteria.”
Cannabis use could result in physical injuries through “impaired judgment, coordination, combined with an altered state of consciousness or generalized drowsiness, that could contribute to an increase in motor vehicle collisions, along with an increased risk for falls leading to lacerations, fractures, contusions, or bruising,” said Dr. Glatter. “Cannabis may also lead to an altered sense of perception related to interactions with others, resulting in feelings of anxiety or restlessness culminating in physical altercations and other injuries.”
The current study indicates the need for understanding the potential physical and psychological effects of cannabis use, he said.
“Additional research is needed to better understand the relative percentage cases related to edibles vs. inhalation presenting to the ED,” he noted. “There is no question that edibles continue to present significant dangers for those who don’t read labels or remain poorly informed regarding their dosing as a result of delayed onset and longer duration,” he said. To help reduce risk of toxicity, the concept of a “high lasting 12-15 hours, as with edibles, as opposed to 3-4 hours from inhalation must be clearly stated on packaging and better communicated with users, as the toxicity with edibles is more often from lack of prior knowledge about onset of effects related to dosing.”
In addition, the “potential for psychosis to develop with more chronic cannabis use, along with cannabinoid hyperemesis syndrome should be on every clinician’s radar,” Dr. Glatter emphasized.
“The bottom line is that as more states legalize the use of cannabis, it’s vital to also implement comprehensive public education efforts to provide users with the reported risks associated with not only inhalation (vaping or flower) but also edibles, which account for an increasingly greater percentage of ED visits and associated adverse effects,” he said.
The study was supported by the Lung Association–Ontario, as well as by grants from the Ontario Ministry of Health and the Ministry of Long-Term Care. The researchers and Dr. Glatter have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Cannabis users had a 22% increased risk of an emergency department (ED) visit or hospitalization compared to nonusers, as determined from data from more than 30,000 individuals.
Although cannabis contains compounds similar to tobacco, “data published on the association between cannabis smoking and airways health have been contradictory,” and whether smoking cannabis increases a user’s risk of developing acute respiratory illness remains unclear, wrote Nicholas T. Vozoris, MD, of the University of Toronto, and colleagues.
In a study published in BMJ Open Respiratory Research, the investigators reviewed national health records data from 35,114 individuals aged 12-65 years for the period January 2009 to December 2015. Of these persons, 4,807 of the 6,425 who reported cannabis use in the past year were matched with 10,395 never-users who served as controls. The mean age of the study population at the index date was 35 years, and 42% were women; demographics were similar between users and control persons.
Overall, the odds of respiratory-related emergency department visits or hospitalizations were not significantly different between the cannabis users and the control persons (3.6% vs. 3.9%; odds ratio, 0.91). However, cannabis users had significantly greater odds of all-cause ED visits or hospitalizations (30.0% vs. 26.0%; OR, 1.22). All-cause mortality was 0.2% for both groups.
Respiratory problems were the second-highest reason for all-cause visits, the researchers noted. The lack of a difference in respiratory-related visits between cannabis users and nonusers conflicts somewhat with previous studies on this topic, which were limited, the researchers noted in their discussion.
The negative results also might stem from factors for which the researchers could not adjust, including insufficient cannabis smoke exposure among users in the study population, noninhalational cannabis use, which is less likely to have a respiratory effect, and possible secondhand exposure among control persons.
“It is also possible that our analysis might have been insufficiently powered to detect a significant signal with respect to the primary outcome,” they noted.
However, after the researchers controlled for multiple variables, the risk of an equally important morbidity outcome, all-cause ED visits or hospitalizations, was significantly greater among cannabis users than among control individuals, and respiratory reasons were the second most common cause for ED visits and hospitalizations in the all-cause outcome, they emphasized.
The study findings were limited by several factors, including the retrospective and observational design and the inability to control for all confounding variables, the researchers noted. Other limitations include the use of self-reports and potential for bias, the inability to perform dose-response analysis, and the high number of infrequent cannabis users in the study population.
However, the results suggest that cannabis use is associated with an increased risk of serious health events and should be discouraged, although more research is needed to confirm the current study findings, they concluded.
Consider range of causes for cannabis emergency visits
“With growing numbers of states legalizing recreational use of cannabis, it’s important to understand whether cannabis use is associated with increased emergency department visits,” Robert D. Glatter, MD, an emergency medicine physician at Lenox Hill Hospital, New York, told this news organization.
Previous studies have shown an association between increased ED visits and cannabis use in states, especially with edibles, where cannabis is legal, and “the current study reinforces the elevated risk of ED visits along with hospitalizations,” he said.
“While the researchers found no increased risk of respiratory-related complaints among users compared to the general population, there was an associated increase in ED visits and hospitalizations, which is important to understand,” said Dr. Glatter, who was not involved in the study.
“While this observational study found that the incidence of respiratory complaints was not significantly different among frequent users of cannabis, the increased odds that cannabis users would require evaluation in the emergency room or even hospitalization was still apparent even after the investigators controlled for such factors as use of alcohol, tobacco, illicit drug use, or other mental health–related disorders,” Dr. Glatter noted.
“That said, it’s a bit surprising that with the continued popularity of vaping, especially among teens, there was still not any appreciable or significant increase in respiratory complaints observed. Beyond this finding, I was not surprised by the overall conclusions of the current study, as we continue to see an elevated number of patients presenting to the ED with adverse events related to cannabis use.”
Dr. Glatter noted that “the majority of patients we see in the ED are associated with use of edibles, since it takes longer for the person to feel the effects, leading the user to consume more of the product up front, with delayed effects lasting up to 12 hours. This is what gets people into trouble and leads to toxicity of cannabis, or ‘overdoses,’ “ he explained.
When consuming edible cannabis products, “[p]eople need to begin at low dosages and not take additional gummies up front, since it can take up to 2 or even 3 hours in some cases to feel the initial effects. With the drug’s effects lasting up to 12 hours, it’s especially important to avoid operating any motor vehicles, bicycles, or scooters, since reaction time is impaired, as well as overall judgment, balance, and fine motor skills,” Dr. Glatter said.
Cannabis can land users in the ED for a range of reasons, said Dr. Glatter. “According to the study, 15% of the emergency room visits and hospitalizations were due to acute trauma, 14% due to respiratory issues, and 13% to gastrointestinal illnesses. These effects were seen in first-time users but not those with chronic use, according to the study inclusion criteria.”
Cannabis use could result in physical injuries through “impaired judgment, coordination, combined with an altered state of consciousness or generalized drowsiness, that could contribute to an increase in motor vehicle collisions, along with an increased risk for falls leading to lacerations, fractures, contusions, or bruising,” said Dr. Glatter. “Cannabis may also lead to an altered sense of perception related to interactions with others, resulting in feelings of anxiety or restlessness culminating in physical altercations and other injuries.”
The current study indicates the need for understanding the potential physical and psychological effects of cannabis use, he said.
“Additional research is needed to better understand the relative percentage cases related to edibles vs. inhalation presenting to the ED,” he noted. “There is no question that edibles continue to present significant dangers for those who don’t read labels or remain poorly informed regarding their dosing as a result of delayed onset and longer duration,” he said. To help reduce risk of toxicity, the concept of a “high lasting 12-15 hours, as with edibles, as opposed to 3-4 hours from inhalation must be clearly stated on packaging and better communicated with users, as the toxicity with edibles is more often from lack of prior knowledge about onset of effects related to dosing.”
In addition, the “potential for psychosis to develop with more chronic cannabis use, along with cannabinoid hyperemesis syndrome should be on every clinician’s radar,” Dr. Glatter emphasized.
“The bottom line is that as more states legalize the use of cannabis, it’s vital to also implement comprehensive public education efforts to provide users with the reported risks associated with not only inhalation (vaping or flower) but also edibles, which account for an increasingly greater percentage of ED visits and associated adverse effects,” he said.
The study was supported by the Lung Association–Ontario, as well as by grants from the Ontario Ministry of Health and the Ministry of Long-Term Care. The researchers and Dr. Glatter have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Primary care providers miss out on payments for prevention, coordination
According to the new research, primary care physicians used these codes for a median of only 2.3% of services provided to eligible patients.
“Investing in primary care is good for the health of patients, for achieving health equity, and for improving the value of health care spending, and yet the U.S. underinvests in primary care,” lead author Sumit D. Agarwal, MD, of Brigham and Women’s Hospital, Boston, said in an interview.
“One strategy to rectify this has been to add billing codes to the physician fee schedule for PCPs to use and thus raise primary care spending; Medicare has been activating new codes for the better part of 2 decades, and we wanted to investigate how successful this strategy of adding codes to the Medicare Physician Fee Schedule (MPFS) schedule has been to inform discussions on how best to finance primary care in the United States,” he said.
In a study published in Annals of Internal Medicine, Dr. Agarwal and colleagues reviewed nationally representative claims and survey data from 2019 and 2020. They analyzed 34 distinct prevention and coordination codes in 13 categories that have been added the MPFS since 2005. Of these, four involved coordination of care (cognitive impairment, behavioral health integration, chronic care management, and transitional care management). The other nine categories in prevention were wellness visits, advance care planning, shared decision making for lung cancer screening, obesity counseling, behavioral counseling for CVD, depression screening, alcohol misuse counseling, alcohol misuse screening, and smoking cessation counseling.
Overall, 8.8%-100% of older adult patients were eligible for preventive services. A range of patients (5.0%-60.6%) had codes for receiving services in their patient information.
“However, a much smaller fraction of eligible patients was billed for having received the service, ranging from less than 1% for alcohol misuse counseling or obesity counseling to 35.8% for wellness visits, with most below 10%,” the researchers wrote.
The median use of billing codes was 2.3% for eligible patients.
A PCP who provided and billed preventive services to half of all eligible patients could potentially increase revenues of $1,269 to $45,406 per code, with an annual revenue increase of $124,435 (interquartile range $30,654 to $226,813) for prevention services. Similarly, providing and billing coordination of care service to half of all eligible patients could increase revenue by $86,082 (IQR, $18,011 to $154,152).
“Importantly, all of these prevention and coordination codes involve decomposing the comprehensive care of a patient into component parts, each with multiple steps and checklists, which may be inconsistent with how PCPs practice and document care,” the researchers wrote in their discussion. “Unlike hospitals, primary care practices are typically unable to use departments of trained coders to maximize billing and ensure that documentation matches the requirements specified in billing rules,” they added.
The study findings were limited by several factors including the focus only on the Medicare segment of PCPs’ panels, which suggests conservative estimates of reimbursement, the researchers noted. Other limitations include response bias to the use of surveys, lack of survey data on specific billing requirements, and the potential underestimation of services by PCPs who delivered some, but not all, components of a service code.
However, the results reflect previous research to show the underutilization of prevention and coordination codes in primary care, and the need for ways to increase their use, the researchers said. “The discrepancies between service eligibility, provision of services regardless of billing, and actual billing suggest that attempting to codify each distinct activity done by a PCP in the MPFS may not be an effective strategy for supporting primary care,” they concluded.
Barriers to code use persist for PCPs
“What surprised us was that there were many codes; we analyzed 34 in the paper in 13 distinct categories of services, and Medicare continues to add new primary care codes to the fee schedule,” Dr. Agarwal said in an interview. Also surprising, “take-up is low virtually across the board, and this isn’t for lack of eligibility,” he said. The low use of the codes “is not for lack of counseling patients on diet, drinking, exercise, smoking, or anything else for which these codes are meant to pay PCPs ... The potential revenue from these codes in aggregate is huge,” Dr. Agarwal emphasized.
“My hope is not necessarily that physicians read this study and start using some or all of these codes more frequently,” said Dr. Agarwal. “It can be tempting to think of this as money left on the table, but it’s not; there are compliance, billing, and opportunity costs from using these codes,” he said. “For individual PCPs seeing individual patients for the breadth that is primary care, I’m not sure the juice is worth the squeeze,” he added. “My coauthors and I are all primary care physicians. We know from our research and first-hand that these codes can be cumbersome to use.” These codes also don’t reflect how PCPs practice, he said. “PCPs are not in the business of slicing and dicing a visit or patient to extract as much revenue as possible. The physician-patient interaction is more complex, and richer, than these codes imply. Instead, I hope our paper encourages Medicare and policymakers to take a harder look at other strategies for investing in primary care,” Dr. Agarwal added.
As for additional research, “Primary care spending is going in the wrong direction,” said Dr. Agarwal. “We need to figure out how best to finance primary care in the United States.”
Recent studies have examined the successes and limitations of the primary care medical home model, Medicare’s Comprehensive Primary Care Initiative, and primary care spending legislation, he said. “Our study is another piece of the puzzle: at least in its current form,” and the results suggest “that one-off codes were nice in theory but not in practice,” he noted.
New codes are cumbersome
“It’s tempting to interpret underuse of new billing codes as a simple change management problem,” Davoren Chick, MD, chief learning officer of the American College of Physicians, wrote in an accompanying editorial. However, the underuse of codes for preventive service and coordination of care likely stems from the details of the codes, he said.
The new codes require the documentation of specific components and a minimum duration of services, he explained. “Codes that reward discrete service episodes disadvantage physicians who appropriately integrate preventive services within a continuous patient care relationship,” he added.
Dr. Chick presented an example of a primary care physician who would have to deliver intensive behavioral therapy for obesity in 15-minute episodes outside of a routine office visit to meet the billing criteria for current Medicare codes.
Dr. Chick called on clinicians to educate themselves on the coding rules for the services they provide “not only to optimize current payment but also to advocate for change.”
He concluded: “Widespread underuse of new preventive service and coordination of care codes reflects system failure, not physician failure. We must stand firm with this knowledge to demand increased payment for feasible, patient-centered primary care commensurate with its value in achieving better outcomes and lower costs.”
The study was supported by the National Institute on Aging of the National Institutes of Health. Dr. Agarwal and Dr. Chick had no financial conflicts to disclose.
According to the new research, primary care physicians used these codes for a median of only 2.3% of services provided to eligible patients.
“Investing in primary care is good for the health of patients, for achieving health equity, and for improving the value of health care spending, and yet the U.S. underinvests in primary care,” lead author Sumit D. Agarwal, MD, of Brigham and Women’s Hospital, Boston, said in an interview.
“One strategy to rectify this has been to add billing codes to the physician fee schedule for PCPs to use and thus raise primary care spending; Medicare has been activating new codes for the better part of 2 decades, and we wanted to investigate how successful this strategy of adding codes to the Medicare Physician Fee Schedule (MPFS) schedule has been to inform discussions on how best to finance primary care in the United States,” he said.
In a study published in Annals of Internal Medicine, Dr. Agarwal and colleagues reviewed nationally representative claims and survey data from 2019 and 2020. They analyzed 34 distinct prevention and coordination codes in 13 categories that have been added the MPFS since 2005. Of these, four involved coordination of care (cognitive impairment, behavioral health integration, chronic care management, and transitional care management). The other nine categories in prevention were wellness visits, advance care planning, shared decision making for lung cancer screening, obesity counseling, behavioral counseling for CVD, depression screening, alcohol misuse counseling, alcohol misuse screening, and smoking cessation counseling.
Overall, 8.8%-100% of older adult patients were eligible for preventive services. A range of patients (5.0%-60.6%) had codes for receiving services in their patient information.
“However, a much smaller fraction of eligible patients was billed for having received the service, ranging from less than 1% for alcohol misuse counseling or obesity counseling to 35.8% for wellness visits, with most below 10%,” the researchers wrote.
The median use of billing codes was 2.3% for eligible patients.
A PCP who provided and billed preventive services to half of all eligible patients could potentially increase revenues of $1,269 to $45,406 per code, with an annual revenue increase of $124,435 (interquartile range $30,654 to $226,813) for prevention services. Similarly, providing and billing coordination of care service to half of all eligible patients could increase revenue by $86,082 (IQR, $18,011 to $154,152).
“Importantly, all of these prevention and coordination codes involve decomposing the comprehensive care of a patient into component parts, each with multiple steps and checklists, which may be inconsistent with how PCPs practice and document care,” the researchers wrote in their discussion. “Unlike hospitals, primary care practices are typically unable to use departments of trained coders to maximize billing and ensure that documentation matches the requirements specified in billing rules,” they added.
The study findings were limited by several factors including the focus only on the Medicare segment of PCPs’ panels, which suggests conservative estimates of reimbursement, the researchers noted. Other limitations include response bias to the use of surveys, lack of survey data on specific billing requirements, and the potential underestimation of services by PCPs who delivered some, but not all, components of a service code.
However, the results reflect previous research to show the underutilization of prevention and coordination codes in primary care, and the need for ways to increase their use, the researchers said. “The discrepancies between service eligibility, provision of services regardless of billing, and actual billing suggest that attempting to codify each distinct activity done by a PCP in the MPFS may not be an effective strategy for supporting primary care,” they concluded.
Barriers to code use persist for PCPs
“What surprised us was that there were many codes; we analyzed 34 in the paper in 13 distinct categories of services, and Medicare continues to add new primary care codes to the fee schedule,” Dr. Agarwal said in an interview. Also surprising, “take-up is low virtually across the board, and this isn’t for lack of eligibility,” he said. The low use of the codes “is not for lack of counseling patients on diet, drinking, exercise, smoking, or anything else for which these codes are meant to pay PCPs ... The potential revenue from these codes in aggregate is huge,” Dr. Agarwal emphasized.
“My hope is not necessarily that physicians read this study and start using some or all of these codes more frequently,” said Dr. Agarwal. “It can be tempting to think of this as money left on the table, but it’s not; there are compliance, billing, and opportunity costs from using these codes,” he said. “For individual PCPs seeing individual patients for the breadth that is primary care, I’m not sure the juice is worth the squeeze,” he added. “My coauthors and I are all primary care physicians. We know from our research and first-hand that these codes can be cumbersome to use.” These codes also don’t reflect how PCPs practice, he said. “PCPs are not in the business of slicing and dicing a visit or patient to extract as much revenue as possible. The physician-patient interaction is more complex, and richer, than these codes imply. Instead, I hope our paper encourages Medicare and policymakers to take a harder look at other strategies for investing in primary care,” Dr. Agarwal added.
As for additional research, “Primary care spending is going in the wrong direction,” said Dr. Agarwal. “We need to figure out how best to finance primary care in the United States.”
Recent studies have examined the successes and limitations of the primary care medical home model, Medicare’s Comprehensive Primary Care Initiative, and primary care spending legislation, he said. “Our study is another piece of the puzzle: at least in its current form,” and the results suggest “that one-off codes were nice in theory but not in practice,” he noted.
New codes are cumbersome
“It’s tempting to interpret underuse of new billing codes as a simple change management problem,” Davoren Chick, MD, chief learning officer of the American College of Physicians, wrote in an accompanying editorial. However, the underuse of codes for preventive service and coordination of care likely stems from the details of the codes, he said.
The new codes require the documentation of specific components and a minimum duration of services, he explained. “Codes that reward discrete service episodes disadvantage physicians who appropriately integrate preventive services within a continuous patient care relationship,” he added.
Dr. Chick presented an example of a primary care physician who would have to deliver intensive behavioral therapy for obesity in 15-minute episodes outside of a routine office visit to meet the billing criteria for current Medicare codes.
Dr. Chick called on clinicians to educate themselves on the coding rules for the services they provide “not only to optimize current payment but also to advocate for change.”
He concluded: “Widespread underuse of new preventive service and coordination of care codes reflects system failure, not physician failure. We must stand firm with this knowledge to demand increased payment for feasible, patient-centered primary care commensurate with its value in achieving better outcomes and lower costs.”
The study was supported by the National Institute on Aging of the National Institutes of Health. Dr. Agarwal and Dr. Chick had no financial conflicts to disclose.
According to the new research, primary care physicians used these codes for a median of only 2.3% of services provided to eligible patients.
“Investing in primary care is good for the health of patients, for achieving health equity, and for improving the value of health care spending, and yet the U.S. underinvests in primary care,” lead author Sumit D. Agarwal, MD, of Brigham and Women’s Hospital, Boston, said in an interview.
“One strategy to rectify this has been to add billing codes to the physician fee schedule for PCPs to use and thus raise primary care spending; Medicare has been activating new codes for the better part of 2 decades, and we wanted to investigate how successful this strategy of adding codes to the Medicare Physician Fee Schedule (MPFS) schedule has been to inform discussions on how best to finance primary care in the United States,” he said.
In a study published in Annals of Internal Medicine, Dr. Agarwal and colleagues reviewed nationally representative claims and survey data from 2019 and 2020. They analyzed 34 distinct prevention and coordination codes in 13 categories that have been added the MPFS since 2005. Of these, four involved coordination of care (cognitive impairment, behavioral health integration, chronic care management, and transitional care management). The other nine categories in prevention were wellness visits, advance care planning, shared decision making for lung cancer screening, obesity counseling, behavioral counseling for CVD, depression screening, alcohol misuse counseling, alcohol misuse screening, and smoking cessation counseling.
Overall, 8.8%-100% of older adult patients were eligible for preventive services. A range of patients (5.0%-60.6%) had codes for receiving services in their patient information.
“However, a much smaller fraction of eligible patients was billed for having received the service, ranging from less than 1% for alcohol misuse counseling or obesity counseling to 35.8% for wellness visits, with most below 10%,” the researchers wrote.
The median use of billing codes was 2.3% for eligible patients.
A PCP who provided and billed preventive services to half of all eligible patients could potentially increase revenues of $1,269 to $45,406 per code, with an annual revenue increase of $124,435 (interquartile range $30,654 to $226,813) for prevention services. Similarly, providing and billing coordination of care service to half of all eligible patients could increase revenue by $86,082 (IQR, $18,011 to $154,152).
“Importantly, all of these prevention and coordination codes involve decomposing the comprehensive care of a patient into component parts, each with multiple steps and checklists, which may be inconsistent with how PCPs practice and document care,” the researchers wrote in their discussion. “Unlike hospitals, primary care practices are typically unable to use departments of trained coders to maximize billing and ensure that documentation matches the requirements specified in billing rules,” they added.
The study findings were limited by several factors including the focus only on the Medicare segment of PCPs’ panels, which suggests conservative estimates of reimbursement, the researchers noted. Other limitations include response bias to the use of surveys, lack of survey data on specific billing requirements, and the potential underestimation of services by PCPs who delivered some, but not all, components of a service code.
However, the results reflect previous research to show the underutilization of prevention and coordination codes in primary care, and the need for ways to increase their use, the researchers said. “The discrepancies between service eligibility, provision of services regardless of billing, and actual billing suggest that attempting to codify each distinct activity done by a PCP in the MPFS may not be an effective strategy for supporting primary care,” they concluded.
Barriers to code use persist for PCPs
“What surprised us was that there were many codes; we analyzed 34 in the paper in 13 distinct categories of services, and Medicare continues to add new primary care codes to the fee schedule,” Dr. Agarwal said in an interview. Also surprising, “take-up is low virtually across the board, and this isn’t for lack of eligibility,” he said. The low use of the codes “is not for lack of counseling patients on diet, drinking, exercise, smoking, or anything else for which these codes are meant to pay PCPs ... The potential revenue from these codes in aggregate is huge,” Dr. Agarwal emphasized.
“My hope is not necessarily that physicians read this study and start using some or all of these codes more frequently,” said Dr. Agarwal. “It can be tempting to think of this as money left on the table, but it’s not; there are compliance, billing, and opportunity costs from using these codes,” he said. “For individual PCPs seeing individual patients for the breadth that is primary care, I’m not sure the juice is worth the squeeze,” he added. “My coauthors and I are all primary care physicians. We know from our research and first-hand that these codes can be cumbersome to use.” These codes also don’t reflect how PCPs practice, he said. “PCPs are not in the business of slicing and dicing a visit or patient to extract as much revenue as possible. The physician-patient interaction is more complex, and richer, than these codes imply. Instead, I hope our paper encourages Medicare and policymakers to take a harder look at other strategies for investing in primary care,” Dr. Agarwal added.
As for additional research, “Primary care spending is going in the wrong direction,” said Dr. Agarwal. “We need to figure out how best to finance primary care in the United States.”
Recent studies have examined the successes and limitations of the primary care medical home model, Medicare’s Comprehensive Primary Care Initiative, and primary care spending legislation, he said. “Our study is another piece of the puzzle: at least in its current form,” and the results suggest “that one-off codes were nice in theory but not in practice,” he noted.
New codes are cumbersome
“It’s tempting to interpret underuse of new billing codes as a simple change management problem,” Davoren Chick, MD, chief learning officer of the American College of Physicians, wrote in an accompanying editorial. However, the underuse of codes for preventive service and coordination of care likely stems from the details of the codes, he said.
The new codes require the documentation of specific components and a minimum duration of services, he explained. “Codes that reward discrete service episodes disadvantage physicians who appropriately integrate preventive services within a continuous patient care relationship,” he added.
Dr. Chick presented an example of a primary care physician who would have to deliver intensive behavioral therapy for obesity in 15-minute episodes outside of a routine office visit to meet the billing criteria for current Medicare codes.
Dr. Chick called on clinicians to educate themselves on the coding rules for the services they provide “not only to optimize current payment but also to advocate for change.”
He concluded: “Widespread underuse of new preventive service and coordination of care codes reflects system failure, not physician failure. We must stand firm with this knowledge to demand increased payment for feasible, patient-centered primary care commensurate with its value in achieving better outcomes and lower costs.”
The study was supported by the National Institute on Aging of the National Institutes of Health. Dr. Agarwal and Dr. Chick had no financial conflicts to disclose.
FROM ANNALS OF INTERNAL MEDICINE
Lifestyle medicine eases anxiety symptoms
Despite the availability of effective treatment strategies, including pharmacotherapy, psychotherapy, and combination therapy, the prevalence of anxiety continues to increase, especially in low-income and conflict-ridden countries, Vincent Wing-Hei Wong, a PhD student at The Chinese University of Hong Kong, and colleagues wrote.
Previous studies have shown that lifestyle factors including diet, sleep, and sedentary behavior are involved in the development of anxiety symptoms, but the impact of lifestyle medicine (LM) as a treatment for anxiety has not been well studied, they wrote.
In a meta-analysis published in the Journal of Affective Disorders, the researchers identified 53 randomized, controlled trials with a total of 18,894 participants. Anxiety symptoms were measured using self-report questionnaires including the Hospital Anxiety and Depression Scale, the Depression Anxiety and Stress Scale, and the General Anxiety Disorder–7. Random-effects models were used to assess the effect of the intervention at immediate post treatment, short-term follow-up (1-3 months post treatment), medium follow-up (4-6 months), and long-term follow-up (7 months or more).
The studies included various combinations of LM intervention involving exercise, stress management, and sleep management. The interventions ranged from 1 month to 4 years, with an average duration of 6.3 months.
Overall, patients randomized to multicomponent LM interventions showed significantly improved symptoms compared to controls immediately after treatment and at short-term follow-up (P < .001 for both).
However, no significant differences were noted between the multicomponent LM intervention and control groups at medium-term follow-up, the researchers said. Only one study included data on long-term effects, so these effects were not evaluated in a meta-analysis, and more research is needed.
In a subgroup analysis, the effect was greatest for individuals with moderate anxiety symptoms at baseline (P < .05). “Our results could perhaps be explained by the occurrence of floor effect; those with higher baseline anxiety symptoms have greater room for improvement relative to those with fewer symptoms,” the researchers wrote.
The study findings were limited by several factors including the risk of overall bias and publication bias for the selected studies, as well as the limited degree of improvement because most patients had minimal anxiety symptoms at baseline, the researchers noted. Other limitations included the small number of studies for subgroup comparisons and the use of self-reports.
However, the results were strengthened by the use of broad search terms to capture multiple lifestyle determinants, and the diverse study populations and backgrounds from individuals in 19 countries.
The results support findings from previous studies, and support the value of multicomponent LM interventions for patients with anxiety in the short-term and immediately after treatment, the researchers emphasized.
“The LM approach, which leverages a range of universal lifestyle measures to manage anxiety and other common mental disorders such as depression, may be a viable solution to address the huge mental health burden through empowering individuals to practice self-management,” they concluded.
However, the researchers acknowledged the need for more randomized, controlled trials targeting patients with higher baseline anxiety levels or anxiety disorders, and using technology to improve treatment adherence.
The study received no outside funding. The researchers had no financial conflicts to disclose.
Despite the availability of effective treatment strategies, including pharmacotherapy, psychotherapy, and combination therapy, the prevalence of anxiety continues to increase, especially in low-income and conflict-ridden countries, Vincent Wing-Hei Wong, a PhD student at The Chinese University of Hong Kong, and colleagues wrote.
Previous studies have shown that lifestyle factors including diet, sleep, and sedentary behavior are involved in the development of anxiety symptoms, but the impact of lifestyle medicine (LM) as a treatment for anxiety has not been well studied, they wrote.
In a meta-analysis published in the Journal of Affective Disorders, the researchers identified 53 randomized, controlled trials with a total of 18,894 participants. Anxiety symptoms were measured using self-report questionnaires including the Hospital Anxiety and Depression Scale, the Depression Anxiety and Stress Scale, and the General Anxiety Disorder–7. Random-effects models were used to assess the effect of the intervention at immediate post treatment, short-term follow-up (1-3 months post treatment), medium follow-up (4-6 months), and long-term follow-up (7 months or more).
The studies included various combinations of LM intervention involving exercise, stress management, and sleep management. The interventions ranged from 1 month to 4 years, with an average duration of 6.3 months.
Overall, patients randomized to multicomponent LM interventions showed significantly improved symptoms compared to controls immediately after treatment and at short-term follow-up (P < .001 for both).
However, no significant differences were noted between the multicomponent LM intervention and control groups at medium-term follow-up, the researchers said. Only one study included data on long-term effects, so these effects were not evaluated in a meta-analysis, and more research is needed.
In a subgroup analysis, the effect was greatest for individuals with moderate anxiety symptoms at baseline (P < .05). “Our results could perhaps be explained by the occurrence of floor effect; those with higher baseline anxiety symptoms have greater room for improvement relative to those with fewer symptoms,” the researchers wrote.
The study findings were limited by several factors including the risk of overall bias and publication bias for the selected studies, as well as the limited degree of improvement because most patients had minimal anxiety symptoms at baseline, the researchers noted. Other limitations included the small number of studies for subgroup comparisons and the use of self-reports.
However, the results were strengthened by the use of broad search terms to capture multiple lifestyle determinants, and the diverse study populations and backgrounds from individuals in 19 countries.
The results support findings from previous studies, and support the value of multicomponent LM interventions for patients with anxiety in the short-term and immediately after treatment, the researchers emphasized.
“The LM approach, which leverages a range of universal lifestyle measures to manage anxiety and other common mental disorders such as depression, may be a viable solution to address the huge mental health burden through empowering individuals to practice self-management,” they concluded.
However, the researchers acknowledged the need for more randomized, controlled trials targeting patients with higher baseline anxiety levels or anxiety disorders, and using technology to improve treatment adherence.
The study received no outside funding. The researchers had no financial conflicts to disclose.
Despite the availability of effective treatment strategies, including pharmacotherapy, psychotherapy, and combination therapy, the prevalence of anxiety continues to increase, especially in low-income and conflict-ridden countries, Vincent Wing-Hei Wong, a PhD student at The Chinese University of Hong Kong, and colleagues wrote.
Previous studies have shown that lifestyle factors including diet, sleep, and sedentary behavior are involved in the development of anxiety symptoms, but the impact of lifestyle medicine (LM) as a treatment for anxiety has not been well studied, they wrote.
In a meta-analysis published in the Journal of Affective Disorders, the researchers identified 53 randomized, controlled trials with a total of 18,894 participants. Anxiety symptoms were measured using self-report questionnaires including the Hospital Anxiety and Depression Scale, the Depression Anxiety and Stress Scale, and the General Anxiety Disorder–7. Random-effects models were used to assess the effect of the intervention at immediate post treatment, short-term follow-up (1-3 months post treatment), medium follow-up (4-6 months), and long-term follow-up (7 months or more).
The studies included various combinations of LM intervention involving exercise, stress management, and sleep management. The interventions ranged from 1 month to 4 years, with an average duration of 6.3 months.
Overall, patients randomized to multicomponent LM interventions showed significantly improved symptoms compared to controls immediately after treatment and at short-term follow-up (P < .001 for both).
However, no significant differences were noted between the multicomponent LM intervention and control groups at medium-term follow-up, the researchers said. Only one study included data on long-term effects, so these effects were not evaluated in a meta-analysis, and more research is needed.
In a subgroup analysis, the effect was greatest for individuals with moderate anxiety symptoms at baseline (P < .05). “Our results could perhaps be explained by the occurrence of floor effect; those with higher baseline anxiety symptoms have greater room for improvement relative to those with fewer symptoms,” the researchers wrote.
The study findings were limited by several factors including the risk of overall bias and publication bias for the selected studies, as well as the limited degree of improvement because most patients had minimal anxiety symptoms at baseline, the researchers noted. Other limitations included the small number of studies for subgroup comparisons and the use of self-reports.
However, the results were strengthened by the use of broad search terms to capture multiple lifestyle determinants, and the diverse study populations and backgrounds from individuals in 19 countries.
The results support findings from previous studies, and support the value of multicomponent LM interventions for patients with anxiety in the short-term and immediately after treatment, the researchers emphasized.
“The LM approach, which leverages a range of universal lifestyle measures to manage anxiety and other common mental disorders such as depression, may be a viable solution to address the huge mental health burden through empowering individuals to practice self-management,” they concluded.
However, the researchers acknowledged the need for more randomized, controlled trials targeting patients with higher baseline anxiety levels or anxiety disorders, and using technology to improve treatment adherence.
The study received no outside funding. The researchers had no financial conflicts to disclose.
FROM THE JOURNAL OF AFFECTIVE DISORDERS
Food insecurity drives poor glycemic control
People with diabetes who had a poor-quality diet and food insecurity were significantly more likely to have poor glycemic and cholesterol control than were those with a healthier diet and food security, based on data from a national study of more than 2,000 individuals.
The American Diabetes Association recommends a high-quality diet for people with diabetes (PWD) to achieve treatment goals; however, roughly 18% of PWD in the United States are food insecure and/or have a poor-quality diet, Sarah S. Casagrande, PhD, of DLH Corporation, Silver Spring, Md., and colleagues wrote in a poster presented at the annual scientific sessions of the ADA in New Orleans.
To examine the impact of food insecurity and diet quality on diabetes and lipid management, the researchers reviewed data from 2,075 adults with self-reported diabetes who completed the National Health and Nutrition Examination Surveys between 2013 and 2018.
Diet quality was divided into quartiles based on the 2015 Healthy Eating Index. Food insecurity was assessed using a standard 10-item questionnaire including questions about running out of food and not being able to afford more, reducing meal sizes, eating less or not at all, and going hungry because of lack of money for food.
The logistic regression analysis controlled for factors including sociodemographics, health care use, smoking, diabetes medications, blood pressure medication use, cholesterol medication use, and body mass index.
Overall, 17.6% of the participants were food insecure and had a low-quality diet, 14.2% were food insecure with a high-quality diet, 33.1% were food secure with a low-quality diet, and 35.2% were food secure with a high-quality diet.
PWD in the food insecure/low-quality diet group were significantly more likely to be younger, non-Hispanic black or Hispanic, and uninsured compared to those in the food secure/high-quality diet group (P < .001 for all).
When the researchers examined glycemic control, they found that PWD in the food insecurity/low-quality diet groups were significantly more likely than were those with food security/high-quality diets to have hemoglobin A1c of at least 7.0% (adjusted odds ratio, 1.85), A1c of at least 8.0% (aOR, 1.79), low HDL cholesterol (aOR, 1.69), and high triglycerides (aOR, 3.26).
PWD with food insecurity but a high-quality diet also were significantly more likely than were those with food security and a high quality diet to have A1c of at least 7.0% (aOR, 1.69), A1c of at least 8.0% (aOR, 1.83), and high triglycerides (aOR, 2.44). PWD with food security but a low-quality diet were significantly more likely than was the food security/high-quality diet group to have A1c of at least 7% (aOR, 1.55).
The study findings were limited by several factors including the cross-sectional design, reliance on self-reports, and inability to distinguish between type 1 and type 2 diabetes, the researchers wrote.
However, the results were strengthened by the large, nationally representative sample and the inclusion of multiple clinical outcomes in the patient assessment, they said.
The results suggest that food insecurity had a significant impact on both glycemic control and cholesterol management independent of diet quality, the researchers noted. Based on these findings, health care providers treating PWD may wish to assess their patients’ food security status, and “interventions could address disparities in food security,” they concluded.
Food insecurity a growing problem
“With more communities being pushed into state of war, drought, and famine globally, it is important to track impact of food insecurity and low quality food on common medical conditions like diabetes in our vulnerable communities,” Romesh K. Khardori, MD, professor of medicine: endocrinology, and metabolism at Eastern Virginia Medical School, Norfolk, said in an interview.
Dr. Khardori, who was not involved in the study, said he was not surprised by the current study findings.
“Type of food, amount of food, and quality of food have been stressed in diabetes management for more than 100 years,” he said. “Organizations charged with recommendations, such as the ADA and American Dietetic Association, have regularly updated their recommendations,” he noted. “It was not surprising, therefore, to find food insecurity and low quality tied to poor glycemic control.”
The take-home message for clinicians is to consider the availability and quality of food that their patients are exposed to when evaluating barriers to proper glycemic control, Dr. Khardori emphasized.
However, additional research is needed to explore whether the prescription of a sufficient amount of good quality food would alleviate the adverse impact seen in the current study, he said.
The study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases. The researchers and Dr. Khardori had no financial conflicts to disclose.
People with diabetes who had a poor-quality diet and food insecurity were significantly more likely to have poor glycemic and cholesterol control than were those with a healthier diet and food security, based on data from a national study of more than 2,000 individuals.
The American Diabetes Association recommends a high-quality diet for people with diabetes (PWD) to achieve treatment goals; however, roughly 18% of PWD in the United States are food insecure and/or have a poor-quality diet, Sarah S. Casagrande, PhD, of DLH Corporation, Silver Spring, Md., and colleagues wrote in a poster presented at the annual scientific sessions of the ADA in New Orleans.
To examine the impact of food insecurity and diet quality on diabetes and lipid management, the researchers reviewed data from 2,075 adults with self-reported diabetes who completed the National Health and Nutrition Examination Surveys between 2013 and 2018.
Diet quality was divided into quartiles based on the 2015 Healthy Eating Index. Food insecurity was assessed using a standard 10-item questionnaire including questions about running out of food and not being able to afford more, reducing meal sizes, eating less or not at all, and going hungry because of lack of money for food.
The logistic regression analysis controlled for factors including sociodemographics, health care use, smoking, diabetes medications, blood pressure medication use, cholesterol medication use, and body mass index.
Overall, 17.6% of the participants were food insecure and had a low-quality diet, 14.2% were food insecure with a high-quality diet, 33.1% were food secure with a low-quality diet, and 35.2% were food secure with a high-quality diet.
PWD in the food insecure/low-quality diet group were significantly more likely to be younger, non-Hispanic black or Hispanic, and uninsured compared to those in the food secure/high-quality diet group (P < .001 for all).
When the researchers examined glycemic control, they found that PWD in the food insecurity/low-quality diet groups were significantly more likely than were those with food security/high-quality diets to have hemoglobin A1c of at least 7.0% (adjusted odds ratio, 1.85), A1c of at least 8.0% (aOR, 1.79), low HDL cholesterol (aOR, 1.69), and high triglycerides (aOR, 3.26).
PWD with food insecurity but a high-quality diet also were significantly more likely than were those with food security and a high quality diet to have A1c of at least 7.0% (aOR, 1.69), A1c of at least 8.0% (aOR, 1.83), and high triglycerides (aOR, 2.44). PWD with food security but a low-quality diet were significantly more likely than was the food security/high-quality diet group to have A1c of at least 7% (aOR, 1.55).
The study findings were limited by several factors including the cross-sectional design, reliance on self-reports, and inability to distinguish between type 1 and type 2 diabetes, the researchers wrote.
However, the results were strengthened by the large, nationally representative sample and the inclusion of multiple clinical outcomes in the patient assessment, they said.
The results suggest that food insecurity had a significant impact on both glycemic control and cholesterol management independent of diet quality, the researchers noted. Based on these findings, health care providers treating PWD may wish to assess their patients’ food security status, and “interventions could address disparities in food security,” they concluded.
Food insecurity a growing problem
“With more communities being pushed into state of war, drought, and famine globally, it is important to track impact of food insecurity and low quality food on common medical conditions like diabetes in our vulnerable communities,” Romesh K. Khardori, MD, professor of medicine: endocrinology, and metabolism at Eastern Virginia Medical School, Norfolk, said in an interview.
Dr. Khardori, who was not involved in the study, said he was not surprised by the current study findings.
“Type of food, amount of food, and quality of food have been stressed in diabetes management for more than 100 years,” he said. “Organizations charged with recommendations, such as the ADA and American Dietetic Association, have regularly updated their recommendations,” he noted. “It was not surprising, therefore, to find food insecurity and low quality tied to poor glycemic control.”
The take-home message for clinicians is to consider the availability and quality of food that their patients are exposed to when evaluating barriers to proper glycemic control, Dr. Khardori emphasized.
However, additional research is needed to explore whether the prescription of a sufficient amount of good quality food would alleviate the adverse impact seen in the current study, he said.
The study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases. The researchers and Dr. Khardori had no financial conflicts to disclose.
People with diabetes who had a poor-quality diet and food insecurity were significantly more likely to have poor glycemic and cholesterol control than were those with a healthier diet and food security, based on data from a national study of more than 2,000 individuals.
The American Diabetes Association recommends a high-quality diet for people with diabetes (PWD) to achieve treatment goals; however, roughly 18% of PWD in the United States are food insecure and/or have a poor-quality diet, Sarah S. Casagrande, PhD, of DLH Corporation, Silver Spring, Md., and colleagues wrote in a poster presented at the annual scientific sessions of the ADA in New Orleans.
To examine the impact of food insecurity and diet quality on diabetes and lipid management, the researchers reviewed data from 2,075 adults with self-reported diabetes who completed the National Health and Nutrition Examination Surveys between 2013 and 2018.
Diet quality was divided into quartiles based on the 2015 Healthy Eating Index. Food insecurity was assessed using a standard 10-item questionnaire including questions about running out of food and not being able to afford more, reducing meal sizes, eating less or not at all, and going hungry because of lack of money for food.
The logistic regression analysis controlled for factors including sociodemographics, health care use, smoking, diabetes medications, blood pressure medication use, cholesterol medication use, and body mass index.
Overall, 17.6% of the participants were food insecure and had a low-quality diet, 14.2% were food insecure with a high-quality diet, 33.1% were food secure with a low-quality diet, and 35.2% were food secure with a high-quality diet.
PWD in the food insecure/low-quality diet group were significantly more likely to be younger, non-Hispanic black or Hispanic, and uninsured compared to those in the food secure/high-quality diet group (P < .001 for all).
When the researchers examined glycemic control, they found that PWD in the food insecurity/low-quality diet groups were significantly more likely than were those with food security/high-quality diets to have hemoglobin A1c of at least 7.0% (adjusted odds ratio, 1.85), A1c of at least 8.0% (aOR, 1.79), low HDL cholesterol (aOR, 1.69), and high triglycerides (aOR, 3.26).
PWD with food insecurity but a high-quality diet also were significantly more likely than were those with food security and a high quality diet to have A1c of at least 7.0% (aOR, 1.69), A1c of at least 8.0% (aOR, 1.83), and high triglycerides (aOR, 2.44). PWD with food security but a low-quality diet were significantly more likely than was the food security/high-quality diet group to have A1c of at least 7% (aOR, 1.55).
The study findings were limited by several factors including the cross-sectional design, reliance on self-reports, and inability to distinguish between type 1 and type 2 diabetes, the researchers wrote.
However, the results were strengthened by the large, nationally representative sample and the inclusion of multiple clinical outcomes in the patient assessment, they said.
The results suggest that food insecurity had a significant impact on both glycemic control and cholesterol management independent of diet quality, the researchers noted. Based on these findings, health care providers treating PWD may wish to assess their patients’ food security status, and “interventions could address disparities in food security,” they concluded.
Food insecurity a growing problem
“With more communities being pushed into state of war, drought, and famine globally, it is important to track impact of food insecurity and low quality food on common medical conditions like diabetes in our vulnerable communities,” Romesh K. Khardori, MD, professor of medicine: endocrinology, and metabolism at Eastern Virginia Medical School, Norfolk, said in an interview.
Dr. Khardori, who was not involved in the study, said he was not surprised by the current study findings.
“Type of food, amount of food, and quality of food have been stressed in diabetes management for more than 100 years,” he said. “Organizations charged with recommendations, such as the ADA and American Dietetic Association, have regularly updated their recommendations,” he noted. “It was not surprising, therefore, to find food insecurity and low quality tied to poor glycemic control.”
The take-home message for clinicians is to consider the availability and quality of food that their patients are exposed to when evaluating barriers to proper glycemic control, Dr. Khardori emphasized.
However, additional research is needed to explore whether the prescription of a sufficient amount of good quality food would alleviate the adverse impact seen in the current study, he said.
The study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases. The researchers and Dr. Khardori had no financial conflicts to disclose.
FROM ADA 2022
Race drives disparities in life expectancy across states
“Life expectancy is an important measure of the health of the entire population,” corresponding author Gregory Roth, MD, a cardiologist at the University of Washington, Seattle, said in an interview. “We know race, ethnicity and where you live all affect health, but we wanted to look at the long arc over many decades to understand where subpopulations have been, and where they are headed. Also, it is important to understand how race and place interact, so we looked at race/ethnicity groups within each state to see where disparities exist that need to be addressed.”
In the study, published in Annals of Internal Medicine, researchers led by Catherine O. Johnson, PhD, of the University of Washington, Seattle, reviewed data from 23 states, using regression models based on Census data and deidentified death records. They examined life expectancy for subgroups of individuals reporting Hispanic, non-Hispanic Black, or non-Hispanic White race or ethnicity.
Overall, most states showed an improvement in life expectancy between 1990 and 2019. For women, the mean life expectancy across states increased from 79.3 years in 1990 to 81.3 years in 2019. For men, the mean life expectancy across states increased from 72.6 years in 1990 to 76.3 years in 2019.
However, the researchers found significant disparities across the three racial subgroups between and within states when life expectancy was examined by race/ethnicity, independent of the average life expectancy for an entire state overall. They defined disparity as the difference in life expectancy between states for those in different racial/ethnic groups.
Without considering race/ethnicity, disparities in life expectancy across states decreased from 8.0 years and 12.2 years in 1990 to 7.9 and 7.8 years in 2019, for females and males, respectively.
When race/ethnicity was taken into account, disparities in life expectancy decreased, but the differences across states were greater than when race was not considered; 20.7 years for females and 24.5 years for males in 1990, decreasing to 18.5 years for females and 23.7 years for males in 2019.
Despite the overall improvements, disparities in life expectancy persisted across all states within each race/ethnicity group.
Among females, for example, non-Hispanic Black females had the lowest mean life expectancy across states in 1990 (74.2 years) but had the greatest improvement on average (6.9% increase) by 2019. However, the mean LE for non-Hispanic Black females remained lower than it did for non-Hispanic White and Hispanic females.
Among males, the researchers found differences in life expectancies across states between the people of the three different ethnicities they studied. The greatest difference in life expectancies in 1990 was 24.5 years. This occurred between non-Hispanic Black males in the District of Columbia and Hispanic males in Georgia. The life expectancy for these non-Hispanic Black males was 59.4 years, versus 83.8 years for these Hispanic males that year.
This reduced life expectancy for non-Hispanic Black males persisted, although it improved slightly by 2019. That year, the largest race-based disparity – which was approximately 24 years – occurred between non-Hispanic Black males in the District of Columbia and Hispanic males in Virginia. For the Hispanic males in Virgina, the LE was 90.7 years versus 66.9 years for non-Hispanic Black males in the District of Columbia.
The findings were limited by several factors including the review of data from only 23 states, the focus on life expectancy from birth versus other ages, and the challenges of defining Hispanic ethnicity, the researchers noted. However, the results support that the potential use of state-level analysis that includes race/ethnicity could be a valuable tool for measuring health inequity as part of national average trends, they said.
Health has truly stagnated for some in certain states
“Subpopulations in some states have much longer life expectancy now than 30 years ago. But in some states, we were struck by how health has truly stagnated for some,” Dr. Roth said in an interview. “We were surprised by the scale of the overall gap; a difference of about 8 years between states is more than twice that if you drill down to race/ethnicity groups in each state.”
A key message from the study is the need for all clinicians to advocate for improved access to primary care, “which is increasingly hard to obtain for many people,” said Dr. Roth. “So much of health is determined by key risk factors such as high blood pressure, high cholesterol, obesity, diabetes, alcohol use, tobacco use. But many of the determinants of health are not in the healthcare system, and include efforts to improve education, interrupt cycles of poverty, and teach healthy behaviors at a very young age. “Racism remains a underdiscussed part of these disparities, and we need better ways to measure the impact of social policies that end up impacting health down the road,” he said.
Looking ahead: “There is a lot to be learned from the states that have improved life expectancy the most. We need researchers to work together to identify and communicate what are those best practices, and what state governments can do to play their part.”
State-level differences reveal variations in health care
“The findings add to our growing knowledge of large and persistent racial/ethnic health disparities and changes in disparities during recent stagnation in U.S. life expectancy,” wrote Hedwig Lee, PhD, of Washington University in St. Louis, and Kathleen M. Harris, PhD, of the University of North Carolina at Chapel Hill, in an accompanying editorial.
The focus on state-level differences provides a unique window into the huge variation in life expectancy by race/ethnicity across the United States. The data suggest that “a person’s life expectancy in the United States may depend more on where you live than it has in the past,” they noted. For example, the editorialists highlighted that life expectancy for non-Hispanic Black men in 2019 averaged 81.1 years in Rhode Island, but 66.9 years in the District of Columbia.
They also noted the study’s lack of data for many states with high mortality rates and high proportions of non-Hispanic Black persons, Hispanic persons, and those with low socioeconomic states. Including data from these areas may have yielded even greater disparities in life expectancy.
“Despite substantial declines in mortality among Black persons during the study period, a non-Hispanic Black person’s life expectancy remained persistently lower than that of non-Hispanic White and Hispanic persons, both within and across states,” the editorialists wrote. “Future research needs to unpack the complex web of factors driving health and well-being by enabling better understanding of the places where we see persistent health disadvantage and advantage and the state-based explanations for these increasingly important differences determining population risk and resilience. We should be outraged by disparities in longevity and called to act to eliminate them.”
Identifying the problem is the first step
“In order to address or fix a problem we should first identify and quantify the problem,” Noel Deep, MD, an internal medicine physician in private practice in Antigo, Wisc., said in an interview.
“This study provides us with the information regarding the trends in life expectancy within states and the disparities in life expectancy when race/ ethnicity and gender are factored into the equation,” said Dr. Deep, who was not involved in the study. “Based on previously available data, we are aware of the increase in life expectancy in the United States over the last few decades, as well as differences in life expectancy for the different ethnicities/races and genders, but these data provide averages, not state or geographical differences. By having this knowledge at a state level, we can use that data to make health policies that address those health inequities and allocate appropriate resources at a state or local level.”
Several studies have identified disparities in health care and life expectancy based on the zip codes, such as the U.S. Small-Area Life Expectancy Estimates Project in 2018. The current study “provides further information for health care professionals and policy makers about the disparities in health outcomes and life expectancy based on race as well as gender, and it is quite detailed,” he said.
“As clinicians, we should strive to ensure that we are addressing these health inequities through our provision of clinical care and through our advocacy on behalf of our patients so that our nation’s health will improve overall,” he said.
“I would like to see future studies look at the socioeconomic status (income), urban versus rural residence, and place of birth (especially for immigrants),” said Dr. Deep. He also emphasized a need for studies to include the demographics for Hispanic populations; given the possible selection error “because of only healthy individuals immigrating to the United States or the older sicker Hispanics who might be migrating back to their homelands and not being included in the data and falsely increasing the life expectancy for this race/ ethnic groups.
“I would also like to see some research into the cultural and social factors that might explain why Hispanic populations might have a higher life expectancy even if their socioeconomic status is poor,” he said.
The study was supported by the National Heart, Lung, and Blood Institute. The researchers had no financial conflicts to disclose. The editorialists had no financial conflicts to disclose. Dr. Deep had no financial conflicts to disclose, but serves on the editorial advisory board of Internal Medicine News and as chair of the AMA’s Council on Science and Public Health.
“Life expectancy is an important measure of the health of the entire population,” corresponding author Gregory Roth, MD, a cardiologist at the University of Washington, Seattle, said in an interview. “We know race, ethnicity and where you live all affect health, but we wanted to look at the long arc over many decades to understand where subpopulations have been, and where they are headed. Also, it is important to understand how race and place interact, so we looked at race/ethnicity groups within each state to see where disparities exist that need to be addressed.”
In the study, published in Annals of Internal Medicine, researchers led by Catherine O. Johnson, PhD, of the University of Washington, Seattle, reviewed data from 23 states, using regression models based on Census data and deidentified death records. They examined life expectancy for subgroups of individuals reporting Hispanic, non-Hispanic Black, or non-Hispanic White race or ethnicity.
Overall, most states showed an improvement in life expectancy between 1990 and 2019. For women, the mean life expectancy across states increased from 79.3 years in 1990 to 81.3 years in 2019. For men, the mean life expectancy across states increased from 72.6 years in 1990 to 76.3 years in 2019.
However, the researchers found significant disparities across the three racial subgroups between and within states when life expectancy was examined by race/ethnicity, independent of the average life expectancy for an entire state overall. They defined disparity as the difference in life expectancy between states for those in different racial/ethnic groups.
Without considering race/ethnicity, disparities in life expectancy across states decreased from 8.0 years and 12.2 years in 1990 to 7.9 and 7.8 years in 2019, for females and males, respectively.
When race/ethnicity was taken into account, disparities in life expectancy decreased, but the differences across states were greater than when race was not considered; 20.7 years for females and 24.5 years for males in 1990, decreasing to 18.5 years for females and 23.7 years for males in 2019.
Despite the overall improvements, disparities in life expectancy persisted across all states within each race/ethnicity group.
Among females, for example, non-Hispanic Black females had the lowest mean life expectancy across states in 1990 (74.2 years) but had the greatest improvement on average (6.9% increase) by 2019. However, the mean LE for non-Hispanic Black females remained lower than it did for non-Hispanic White and Hispanic females.
Among males, the researchers found differences in life expectancies across states between the people of the three different ethnicities they studied. The greatest difference in life expectancies in 1990 was 24.5 years. This occurred between non-Hispanic Black males in the District of Columbia and Hispanic males in Georgia. The life expectancy for these non-Hispanic Black males was 59.4 years, versus 83.8 years for these Hispanic males that year.
This reduced life expectancy for non-Hispanic Black males persisted, although it improved slightly by 2019. That year, the largest race-based disparity – which was approximately 24 years – occurred between non-Hispanic Black males in the District of Columbia and Hispanic males in Virginia. For the Hispanic males in Virgina, the LE was 90.7 years versus 66.9 years for non-Hispanic Black males in the District of Columbia.
The findings were limited by several factors including the review of data from only 23 states, the focus on life expectancy from birth versus other ages, and the challenges of defining Hispanic ethnicity, the researchers noted. However, the results support that the potential use of state-level analysis that includes race/ethnicity could be a valuable tool for measuring health inequity as part of national average trends, they said.
Health has truly stagnated for some in certain states
“Subpopulations in some states have much longer life expectancy now than 30 years ago. But in some states, we were struck by how health has truly stagnated for some,” Dr. Roth said in an interview. “We were surprised by the scale of the overall gap; a difference of about 8 years between states is more than twice that if you drill down to race/ethnicity groups in each state.”
A key message from the study is the need for all clinicians to advocate for improved access to primary care, “which is increasingly hard to obtain for many people,” said Dr. Roth. “So much of health is determined by key risk factors such as high blood pressure, high cholesterol, obesity, diabetes, alcohol use, tobacco use. But many of the determinants of health are not in the healthcare system, and include efforts to improve education, interrupt cycles of poverty, and teach healthy behaviors at a very young age. “Racism remains a underdiscussed part of these disparities, and we need better ways to measure the impact of social policies that end up impacting health down the road,” he said.
Looking ahead: “There is a lot to be learned from the states that have improved life expectancy the most. We need researchers to work together to identify and communicate what are those best practices, and what state governments can do to play their part.”
State-level differences reveal variations in health care
“The findings add to our growing knowledge of large and persistent racial/ethnic health disparities and changes in disparities during recent stagnation in U.S. life expectancy,” wrote Hedwig Lee, PhD, of Washington University in St. Louis, and Kathleen M. Harris, PhD, of the University of North Carolina at Chapel Hill, in an accompanying editorial.
The focus on state-level differences provides a unique window into the huge variation in life expectancy by race/ethnicity across the United States. The data suggest that “a person’s life expectancy in the United States may depend more on where you live than it has in the past,” they noted. For example, the editorialists highlighted that life expectancy for non-Hispanic Black men in 2019 averaged 81.1 years in Rhode Island, but 66.9 years in the District of Columbia.
They also noted the study’s lack of data for many states with high mortality rates and high proportions of non-Hispanic Black persons, Hispanic persons, and those with low socioeconomic states. Including data from these areas may have yielded even greater disparities in life expectancy.
“Despite substantial declines in mortality among Black persons during the study period, a non-Hispanic Black person’s life expectancy remained persistently lower than that of non-Hispanic White and Hispanic persons, both within and across states,” the editorialists wrote. “Future research needs to unpack the complex web of factors driving health and well-being by enabling better understanding of the places where we see persistent health disadvantage and advantage and the state-based explanations for these increasingly important differences determining population risk and resilience. We should be outraged by disparities in longevity and called to act to eliminate them.”
Identifying the problem is the first step
“In order to address or fix a problem we should first identify and quantify the problem,” Noel Deep, MD, an internal medicine physician in private practice in Antigo, Wisc., said in an interview.
“This study provides us with the information regarding the trends in life expectancy within states and the disparities in life expectancy when race/ ethnicity and gender are factored into the equation,” said Dr. Deep, who was not involved in the study. “Based on previously available data, we are aware of the increase in life expectancy in the United States over the last few decades, as well as differences in life expectancy for the different ethnicities/races and genders, but these data provide averages, not state or geographical differences. By having this knowledge at a state level, we can use that data to make health policies that address those health inequities and allocate appropriate resources at a state or local level.”
Several studies have identified disparities in health care and life expectancy based on the zip codes, such as the U.S. Small-Area Life Expectancy Estimates Project in 2018. The current study “provides further information for health care professionals and policy makers about the disparities in health outcomes and life expectancy based on race as well as gender, and it is quite detailed,” he said.
“As clinicians, we should strive to ensure that we are addressing these health inequities through our provision of clinical care and through our advocacy on behalf of our patients so that our nation’s health will improve overall,” he said.
“I would like to see future studies look at the socioeconomic status (income), urban versus rural residence, and place of birth (especially for immigrants),” said Dr. Deep. He also emphasized a need for studies to include the demographics for Hispanic populations; given the possible selection error “because of only healthy individuals immigrating to the United States or the older sicker Hispanics who might be migrating back to their homelands and not being included in the data and falsely increasing the life expectancy for this race/ ethnic groups.
“I would also like to see some research into the cultural and social factors that might explain why Hispanic populations might have a higher life expectancy even if their socioeconomic status is poor,” he said.
The study was supported by the National Heart, Lung, and Blood Institute. The researchers had no financial conflicts to disclose. The editorialists had no financial conflicts to disclose. Dr. Deep had no financial conflicts to disclose, but serves on the editorial advisory board of Internal Medicine News and as chair of the AMA’s Council on Science and Public Health.
“Life expectancy is an important measure of the health of the entire population,” corresponding author Gregory Roth, MD, a cardiologist at the University of Washington, Seattle, said in an interview. “We know race, ethnicity and where you live all affect health, but we wanted to look at the long arc over many decades to understand where subpopulations have been, and where they are headed. Also, it is important to understand how race and place interact, so we looked at race/ethnicity groups within each state to see where disparities exist that need to be addressed.”
In the study, published in Annals of Internal Medicine, researchers led by Catherine O. Johnson, PhD, of the University of Washington, Seattle, reviewed data from 23 states, using regression models based on Census data and deidentified death records. They examined life expectancy for subgroups of individuals reporting Hispanic, non-Hispanic Black, or non-Hispanic White race or ethnicity.
Overall, most states showed an improvement in life expectancy between 1990 and 2019. For women, the mean life expectancy across states increased from 79.3 years in 1990 to 81.3 years in 2019. For men, the mean life expectancy across states increased from 72.6 years in 1990 to 76.3 years in 2019.
However, the researchers found significant disparities across the three racial subgroups between and within states when life expectancy was examined by race/ethnicity, independent of the average life expectancy for an entire state overall. They defined disparity as the difference in life expectancy between states for those in different racial/ethnic groups.
Without considering race/ethnicity, disparities in life expectancy across states decreased from 8.0 years and 12.2 years in 1990 to 7.9 and 7.8 years in 2019, for females and males, respectively.
When race/ethnicity was taken into account, disparities in life expectancy decreased, but the differences across states were greater than when race was not considered; 20.7 years for females and 24.5 years for males in 1990, decreasing to 18.5 years for females and 23.7 years for males in 2019.
Despite the overall improvements, disparities in life expectancy persisted across all states within each race/ethnicity group.
Among females, for example, non-Hispanic Black females had the lowest mean life expectancy across states in 1990 (74.2 years) but had the greatest improvement on average (6.9% increase) by 2019. However, the mean LE for non-Hispanic Black females remained lower than it did for non-Hispanic White and Hispanic females.
Among males, the researchers found differences in life expectancies across states between the people of the three different ethnicities they studied. The greatest difference in life expectancies in 1990 was 24.5 years. This occurred between non-Hispanic Black males in the District of Columbia and Hispanic males in Georgia. The life expectancy for these non-Hispanic Black males was 59.4 years, versus 83.8 years for these Hispanic males that year.
This reduced life expectancy for non-Hispanic Black males persisted, although it improved slightly by 2019. That year, the largest race-based disparity – which was approximately 24 years – occurred between non-Hispanic Black males in the District of Columbia and Hispanic males in Virginia. For the Hispanic males in Virgina, the LE was 90.7 years versus 66.9 years for non-Hispanic Black males in the District of Columbia.
The findings were limited by several factors including the review of data from only 23 states, the focus on life expectancy from birth versus other ages, and the challenges of defining Hispanic ethnicity, the researchers noted. However, the results support that the potential use of state-level analysis that includes race/ethnicity could be a valuable tool for measuring health inequity as part of national average trends, they said.
Health has truly stagnated for some in certain states
“Subpopulations in some states have much longer life expectancy now than 30 years ago. But in some states, we were struck by how health has truly stagnated for some,” Dr. Roth said in an interview. “We were surprised by the scale of the overall gap; a difference of about 8 years between states is more than twice that if you drill down to race/ethnicity groups in each state.”
A key message from the study is the need for all clinicians to advocate for improved access to primary care, “which is increasingly hard to obtain for many people,” said Dr. Roth. “So much of health is determined by key risk factors such as high blood pressure, high cholesterol, obesity, diabetes, alcohol use, tobacco use. But many of the determinants of health are not in the healthcare system, and include efforts to improve education, interrupt cycles of poverty, and teach healthy behaviors at a very young age. “Racism remains a underdiscussed part of these disparities, and we need better ways to measure the impact of social policies that end up impacting health down the road,” he said.
Looking ahead: “There is a lot to be learned from the states that have improved life expectancy the most. We need researchers to work together to identify and communicate what are those best practices, and what state governments can do to play their part.”
State-level differences reveal variations in health care
“The findings add to our growing knowledge of large and persistent racial/ethnic health disparities and changes in disparities during recent stagnation in U.S. life expectancy,” wrote Hedwig Lee, PhD, of Washington University in St. Louis, and Kathleen M. Harris, PhD, of the University of North Carolina at Chapel Hill, in an accompanying editorial.
The focus on state-level differences provides a unique window into the huge variation in life expectancy by race/ethnicity across the United States. The data suggest that “a person’s life expectancy in the United States may depend more on where you live than it has in the past,” they noted. For example, the editorialists highlighted that life expectancy for non-Hispanic Black men in 2019 averaged 81.1 years in Rhode Island, but 66.9 years in the District of Columbia.
They also noted the study’s lack of data for many states with high mortality rates and high proportions of non-Hispanic Black persons, Hispanic persons, and those with low socioeconomic states. Including data from these areas may have yielded even greater disparities in life expectancy.
“Despite substantial declines in mortality among Black persons during the study period, a non-Hispanic Black person’s life expectancy remained persistently lower than that of non-Hispanic White and Hispanic persons, both within and across states,” the editorialists wrote. “Future research needs to unpack the complex web of factors driving health and well-being by enabling better understanding of the places where we see persistent health disadvantage and advantage and the state-based explanations for these increasingly important differences determining population risk and resilience. We should be outraged by disparities in longevity and called to act to eliminate them.”
Identifying the problem is the first step
“In order to address or fix a problem we should first identify and quantify the problem,” Noel Deep, MD, an internal medicine physician in private practice in Antigo, Wisc., said in an interview.
“This study provides us with the information regarding the trends in life expectancy within states and the disparities in life expectancy when race/ ethnicity and gender are factored into the equation,” said Dr. Deep, who was not involved in the study. “Based on previously available data, we are aware of the increase in life expectancy in the United States over the last few decades, as well as differences in life expectancy for the different ethnicities/races and genders, but these data provide averages, not state or geographical differences. By having this knowledge at a state level, we can use that data to make health policies that address those health inequities and allocate appropriate resources at a state or local level.”
Several studies have identified disparities in health care and life expectancy based on the zip codes, such as the U.S. Small-Area Life Expectancy Estimates Project in 2018. The current study “provides further information for health care professionals and policy makers about the disparities in health outcomes and life expectancy based on race as well as gender, and it is quite detailed,” he said.
“As clinicians, we should strive to ensure that we are addressing these health inequities through our provision of clinical care and through our advocacy on behalf of our patients so that our nation’s health will improve overall,” he said.
“I would like to see future studies look at the socioeconomic status (income), urban versus rural residence, and place of birth (especially for immigrants),” said Dr. Deep. He also emphasized a need for studies to include the demographics for Hispanic populations; given the possible selection error “because of only healthy individuals immigrating to the United States or the older sicker Hispanics who might be migrating back to their homelands and not being included in the data and falsely increasing the life expectancy for this race/ ethnic groups.
“I would also like to see some research into the cultural and social factors that might explain why Hispanic populations might have a higher life expectancy even if their socioeconomic status is poor,” he said.
The study was supported by the National Heart, Lung, and Blood Institute. The researchers had no financial conflicts to disclose. The editorialists had no financial conflicts to disclose. Dr. Deep had no financial conflicts to disclose, but serves on the editorial advisory board of Internal Medicine News and as chair of the AMA’s Council on Science and Public Health.
FROM ANNALS OF INTERNAL MEDICINE