Clinician Reviews

This transcript has been edited for clarity.

There’s never been anything like the revolution in the treatment of obesity that we are now living through. Historically, there’s always been calorie counting and diets. Now, after a burst of interest in gastric bypass surgery, we have the amazing world of injectables. We all have heard about Ozempic, Mounjaro, and Wegovy.

These are being used by millions of Americans at this point, some on prescription for conditions like diabetes and some to bring about weight loss in prediabetes, or in some instances — as is often seen on American television — weight control or weight loss by people who just want to look better. Celebrities getting behind these injectables has really powered an explosion of use.

There still are ethical issues out there for practitioners. For one thing, there are some forms of semaglutide, a key ingredient in some of these injectables, that are made by compounding pharmacies. They’re not the name-brand prescription injectables made by large companies. They’re brewed up, if you will, by a specialty pharmacy trying to mimic the ingredient.

What we’ve seen in recent weeks is an explosion of overdoses. When a person uses one of these compounding pharmacies, usually in association with a spa or sometimes online sales of weight loss injectables, they’re not always certain about how to dose themselves, how much to give, and what to take. They could misread the instructions. The more that it’s up to them to determine the dose, the more there’s risk for error. Reports show as much as 1500% increases in poisoning of people who took, instead of a 10th of a milliliter, 10 mL of these compounded versions of the injectable drugs.

Everybody needs to be alert, and not only for adverse events from the prescription injectables. It is important to track that, make sure that people aren’t getting into trouble, and have contact with the FDA if you have a patient who reports some kind of adverse event they attribute to injectables.

It’s important to realize that there’s this generic, cheaper path, but it’s a more dangerous path. People need to know this if they’re going to try that route. Doctors should be aware of it. People should be ready to call the poison control center number in their area to make sure that they know what to do if they overdose on this stuff.

My own inclination is to try to discourage its use. I think it’s still too dangerous to have people self-dosing with ingredients that really are not yet FDA approved in terms of knowing that they’ve been tested in clinical trials.

The other big issue, aside from this Wild West world outside of prescribed injectables, is what to say to people who are obese or trying to manage their weight. I think people need to know all their options. It’s pretty easy to just say, “Let’s put you on one of these injectables” and prescribe it. For one thing, they may not be able to get it; there’s such huge demand that there are some shortages out there.

People may be better off trying to manage weight with diet, calorie counting, or lifestyle changes. After all, you could stay on these drugs forever to maintain your weight, but it’s not cheap. We don’t really know the long-term consequences of decades-long use of these drugs.

I think people should hear their options and maybe try something less invasive to begin with. If that doesn’t work, then move on to the injectables. It isn’t so clear to me — given the cost, some of the unknowns of long-term use, and some of the dangers of people sneaking around and trying to get things cheaper on the side — that going straight to injectables is our best answer.

I do think doctors should talk about weight with their patients, carefully, with the patient’s consent. Make sure there’s no stigma. Make sure we’re not doing anything to raise anxiety as we talk about this condition. After all, it is seen as a disease.

Then, maybe enter your way gradually into interventions, seeing if lifestyle change is possible. It’s cheap and easier to implement: better diet, better exercise, or calorie counting. Some people succeed. When they don’t, we should move on, but realize that we’ve got the equivalent of a black market. We need to encourage patients, if they use injectable weight loss drugs, to tell doctors so that they can be on alert about the dangers and risks of overdose.

Dr. Caplan is Director, Division of Medical Ethics, New York University Langone Medical Center, New York City. He disclosed an unpaid position with Johnson & Johnson’s Panel for Compassionate Drug Use, and serves as a contributing author and advisor for Medscape.

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity.

There’s never been anything like the revolution in the treatment of obesity that we are now living through. Historically, there’s always been calorie counting and diets. Now, after a burst of interest in gastric bypass surgery, we have the amazing world of injectables. We all have heard about Ozempic, Mounjaro, and Wegovy.

These are being used by millions of Americans at this point, some on prescription for conditions like diabetes and some to bring about weight loss in prediabetes, or in some instances — as is often seen on American television — weight control or weight loss by people who just want to look better. Celebrities getting behind these injectables has really powered an explosion of use.

There still are ethical issues out there for practitioners. For one thing, there are some forms of semaglutide, a key ingredient in some of these injectables, that are made by compounding pharmacies. They’re not the name-brand prescription injectables made by large companies. They’re brewed up, if you will, by a specialty pharmacy trying to mimic the ingredient.

What we’ve seen in recent weeks is an explosion of overdoses. When a person uses one of these compounding pharmacies, usually in association with a spa or sometimes online sales of weight loss injectables, they’re not always certain about how to dose themselves, how much to give, and what to take. They could misread the instructions. The more that it’s up to them to determine the dose, the more there’s risk for error. Reports show as much as 1500% increases in poisoning of people who took, instead of a 10th of a milliliter, 10 mL of these compounded versions of the injectable drugs.

Everybody needs to be alert, and not only for adverse events from the prescription injectables. It is important to track that, make sure that people aren’t getting into trouble, and have contact with the FDA if you have a patient who reports some kind of adverse event they attribute to injectables.

It’s important to realize that there’s this generic, cheaper path, but it’s a more dangerous path. People need to know this if they’re going to try that route. Doctors should be aware of it. People should be ready to call the poison control center number in their area to make sure that they know what to do if they overdose on this stuff.

My own inclination is to try to discourage its use. I think it’s still too dangerous to have people self-dosing with ingredients that really are not yet FDA approved in terms of knowing that they’ve been tested in clinical trials.

The other big issue, aside from this Wild West world outside of prescribed injectables, is what to say to people who are obese or trying to manage their weight. I think people need to know all their options. It’s pretty easy to just say, “Let’s put you on one of these injectables” and prescribe it. For one thing, they may not be able to get it; there’s such huge demand that there are some shortages out there.

People may be better off trying to manage weight with diet, calorie counting, or lifestyle changes. After all, you could stay on these drugs forever to maintain your weight, but it’s not cheap. We don’t really know the long-term consequences of decades-long use of these drugs.

I think people should hear their options and maybe try something less invasive to begin with. If that doesn’t work, then move on to the injectables. It isn’t so clear to me — given the cost, some of the unknowns of long-term use, and some of the dangers of people sneaking around and trying to get things cheaper on the side — that going straight to injectables is our best answer.

I do think doctors should talk about weight with their patients, carefully, with the patient’s consent. Make sure there’s no stigma. Make sure we’re not doing anything to raise anxiety as we talk about this condition. After all, it is seen as a disease.

Then, maybe enter your way gradually into interventions, seeing if lifestyle change is possible. It’s cheap and easier to implement: better diet, better exercise, or calorie counting. Some people succeed. When they don’t, we should move on, but realize that we’ve got the equivalent of a black market. We need to encourage patients, if they use injectable weight loss drugs, to tell doctors so that they can be on alert about the dangers and risks of overdose.

Dr. Caplan is Director, Division of Medical Ethics, New York University Langone Medical Center, New York City. He disclosed an unpaid position with Johnson & Johnson’s Panel for Compassionate Drug Use, and serves as a contributing author and advisor for Medscape.

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity.

There’s never been anything like the revolution in the treatment of obesity that we are now living through. Historically, there’s always been calorie counting and diets. Now, after a burst of interest in gastric bypass surgery, we have the amazing world of injectables. We all have heard about Ozempic, Mounjaro, and Wegovy.

These are being used by millions of Americans at this point, some on prescription for conditions like diabetes and some to bring about weight loss in prediabetes, or in some instances — as is often seen on American television — weight control or weight loss by people who just want to look better. Celebrities getting behind these injectables has really powered an explosion of use.

There still are ethical issues out there for practitioners. For one thing, there are some forms of semaglutide, a key ingredient in some of these injectables, that are made by compounding pharmacies. They’re not the name-brand prescription injectables made by large companies. They’re brewed up, if you will, by a specialty pharmacy trying to mimic the ingredient.

What we’ve seen in recent weeks is an explosion of overdoses. When a person uses one of these compounding pharmacies, usually in association with a spa or sometimes online sales of weight loss injectables, they’re not always certain about how to dose themselves, how much to give, and what to take. They could misread the instructions. The more that it’s up to them to determine the dose, the more there’s risk for error. Reports show as much as 1500% increases in poisoning of people who took, instead of a 10th of a milliliter, 10 mL of these compounded versions of the injectable drugs.

Everybody needs to be alert, and not only for adverse events from the prescription injectables. It is important to track that, make sure that people aren’t getting into trouble, and have contact with the FDA if you have a patient who reports some kind of adverse event they attribute to injectables.

It’s important to realize that there’s this generic, cheaper path, but it’s a more dangerous path. People need to know this if they’re going to try that route. Doctors should be aware of it. People should be ready to call the poison control center number in their area to make sure that they know what to do if they overdose on this stuff.

My own inclination is to try to discourage its use. I think it’s still too dangerous to have people self-dosing with ingredients that really are not yet FDA approved in terms of knowing that they’ve been tested in clinical trials.

The other big issue, aside from this Wild West world outside of prescribed injectables, is what to say to people who are obese or trying to manage their weight. I think people need to know all their options. It’s pretty easy to just say, “Let’s put you on one of these injectables” and prescribe it. For one thing, they may not be able to get it; there’s such huge demand that there are some shortages out there.

People may be better off trying to manage weight with diet, calorie counting, or lifestyle changes. After all, you could stay on these drugs forever to maintain your weight, but it’s not cheap. We don’t really know the long-term consequences of decades-long use of these drugs.

I think people should hear their options and maybe try something less invasive to begin with. If that doesn’t work, then move on to the injectables. It isn’t so clear to me — given the cost, some of the unknowns of long-term use, and some of the dangers of people sneaking around and trying to get things cheaper on the side — that going straight to injectables is our best answer.

I do think doctors should talk about weight with their patients, carefully, with the patient’s consent. Make sure there’s no stigma. Make sure we’re not doing anything to raise anxiety as we talk about this condition. After all, it is seen as a disease.

Then, maybe enter your way gradually into interventions, seeing if lifestyle change is possible. It’s cheap and easier to implement: better diet, better exercise, or calorie counting. Some people succeed. When they don’t, we should move on, but realize that we’ve got the equivalent of a black market. We need to encourage patients, if they use injectable weight loss drugs, to tell doctors so that they can be on alert about the dangers and risks of overdose.

Dr. Caplan is Director, Division of Medical Ethics, New York University Langone Medical Center, New York City. He disclosed an unpaid position with Johnson & Johnson’s Panel for Compassionate Drug Use, and serves as a contributing author and advisor for Medscape.

A version of this article appeared on Medscape.com.

It’s 2 a.m. and my phone wakes me up with a start. My patient, Christine Z*, is vomiting uncontrollably, and Dr Google has diagnosed her with acute pancreatitis from semaglutide (Wegovy). Ten hours, several imaging studies, one blood draw, and many bags of fluids later, the verdict is in: Christine is alarmingly constipated. In fact, her entire large intestine is packed to the brim with stool. In residency, we called this diagnosis FOS, and I’ll leave it to your imagination to figure out what it stands for.

In retrospect, Christine mentions that upon raising her Wegovy dose, her bowel movements had become increasingly smaller and infrequent. This begs the question: How can practitioners help offset side effects through dietary changes, and while we are at it, what other dietary advice is prudent at treatment onset?

Proper nutrition always starts with drinking copious amounts of water. In general, I recommend a minimum of 64 ounces of water daily in patients taking incretins such as semaglutide (Wegovy for weight loss, Ozempic and Rybelsus for type 2 diabetes) or tirzepatide (Zepbound for weight loss, Mounjaro for type 2 diabetes). While these medications don’t directly dehydrate patients, they can increase the risk for dehydration due to severe nausea. Drinking copious amounts of water can prevent dehydration, preserve kidney function, and minimize fatigue and dizziness. In addition, fluids help soften bowel movements, making them easier to pass.

Occasionally incretins make it so easy for patients to drop pounds that their eating patterns become sloppier — more sweets and simple carbohydrates. I recommend a realistic and low glycemic index meal plan. While no foods are strictly contraindicated, processed, high-sugar, and fatty foods are likely to worsen side effects like nausea and gastrointestinal distress. Similarly, alcohol not only worsens nausea, but it’s also likely to exacerbate reflux by relaxing the sphincter that separates the stomach from the esophagus.

The next most important dietary advice is consuming sufficient fiber. In the majority of patients, increasing fiber intake relieves constipation. There are two types of fiber: soluble and insoluble. In practical terms, most fiber-rich foods contain a mixture of these two types. The general recommendation is 38 g/d for men and 25 g/d for women. The caveat to this advice is that a minority of patients, such as those with irritable bowel syndrome, may develop worsening constipation with increasing fiber.

To minimize side effects, some patients find it useful to eat five small meals throughout the day rather than three larger meals. In addition, I recommend eating slowly and stopping before the point of satiety. Finally, because weight loss of any kind is inevitably associated with muscle loss, I stress the importance of adequate protein. In general, I advise 25-30 g of protein per meal.

Christine eventually restarted her Wegovy after recovering from her grueling night in the emergency room. As this was her second go-around on Wegovy, she dug out my “guide to preventing side effects of incretins” and followed it to a T. So far, she’s feeling great.

*The patient’s name has been changed.
 

A version of this article appeared on Medscape.com.

It’s 2 a.m. and my phone wakes me up with a start. My patient, Christine Z*, is vomiting uncontrollably, and Dr Google has diagnosed her with acute pancreatitis from semaglutide (Wegovy). Ten hours, several imaging studies, one blood draw, and many bags of fluids later, the verdict is in: Christine is alarmingly constipated. In fact, her entire large intestine is packed to the brim with stool. In residency, we called this diagnosis FOS, and I’ll leave it to your imagination to figure out what it stands for.

In retrospect, Christine mentions that upon raising her Wegovy dose, her bowel movements had become increasingly smaller and infrequent. This begs the question: How can practitioners help offset side effects through dietary changes, and while we are at it, what other dietary advice is prudent at treatment onset?

Proper nutrition always starts with drinking copious amounts of water. In general, I recommend a minimum of 64 ounces of water daily in patients taking incretins such as semaglutide (Wegovy for weight loss, Ozempic and Rybelsus for type 2 diabetes) or tirzepatide (Zepbound for weight loss, Mounjaro for type 2 diabetes). While these medications don’t directly dehydrate patients, they can increase the risk for dehydration due to severe nausea. Drinking copious amounts of water can prevent dehydration, preserve kidney function, and minimize fatigue and dizziness. In addition, fluids help soften bowel movements, making them easier to pass.

Occasionally incretins make it so easy for patients to drop pounds that their eating patterns become sloppier — more sweets and simple carbohydrates. I recommend a realistic and low glycemic index meal plan. While no foods are strictly contraindicated, processed, high-sugar, and fatty foods are likely to worsen side effects like nausea and gastrointestinal distress. Similarly, alcohol not only worsens nausea, but it’s also likely to exacerbate reflux by relaxing the sphincter that separates the stomach from the esophagus.

The next most important dietary advice is consuming sufficient fiber. In the majority of patients, increasing fiber intake relieves constipation. There are two types of fiber: soluble and insoluble. In practical terms, most fiber-rich foods contain a mixture of these two types. The general recommendation is 38 g/d for men and 25 g/d for women. The caveat to this advice is that a minority of patients, such as those with irritable bowel syndrome, may develop worsening constipation with increasing fiber.

To minimize side effects, some patients find it useful to eat five small meals throughout the day rather than three larger meals. In addition, I recommend eating slowly and stopping before the point of satiety. Finally, because weight loss of any kind is inevitably associated with muscle loss, I stress the importance of adequate protein. In general, I advise 25-30 g of protein per meal.

Christine eventually restarted her Wegovy after recovering from her grueling night in the emergency room. As this was her second go-around on Wegovy, she dug out my “guide to preventing side effects of incretins” and followed it to a T. So far, she’s feeling great.

*The patient’s name has been changed.
 

A version of this article appeared on Medscape.com.

It’s 2 a.m. and my phone wakes me up with a start. My patient, Christine Z*, is vomiting uncontrollably, and Dr Google has diagnosed her with acute pancreatitis from semaglutide (Wegovy). Ten hours, several imaging studies, one blood draw, and many bags of fluids later, the verdict is in: Christine is alarmingly constipated. In fact, her entire large intestine is packed to the brim with stool. In residency, we called this diagnosis FOS, and I’ll leave it to your imagination to figure out what it stands for.

In retrospect, Christine mentions that upon raising her Wegovy dose, her bowel movements had become increasingly smaller and infrequent. This begs the question: How can practitioners help offset side effects through dietary changes, and while we are at it, what other dietary advice is prudent at treatment onset?

Proper nutrition always starts with drinking copious amounts of water. In general, I recommend a minimum of 64 ounces of water daily in patients taking incretins such as semaglutide (Wegovy for weight loss, Ozempic and Rybelsus for type 2 diabetes) or tirzepatide (Zepbound for weight loss, Mounjaro for type 2 diabetes). While these medications don’t directly dehydrate patients, they can increase the risk for dehydration due to severe nausea. Drinking copious amounts of water can prevent dehydration, preserve kidney function, and minimize fatigue and dizziness. In addition, fluids help soften bowel movements, making them easier to pass.

Occasionally incretins make it so easy for patients to drop pounds that their eating patterns become sloppier — more sweets and simple carbohydrates. I recommend a realistic and low glycemic index meal plan. While no foods are strictly contraindicated, processed, high-sugar, and fatty foods are likely to worsen side effects like nausea and gastrointestinal distress. Similarly, alcohol not only worsens nausea, but it’s also likely to exacerbate reflux by relaxing the sphincter that separates the stomach from the esophagus.

The next most important dietary advice is consuming sufficient fiber. In the majority of patients, increasing fiber intake relieves constipation. There are two types of fiber: soluble and insoluble. In practical terms, most fiber-rich foods contain a mixture of these two types. The general recommendation is 38 g/d for men and 25 g/d for women. The caveat to this advice is that a minority of patients, such as those with irritable bowel syndrome, may develop worsening constipation with increasing fiber.

To minimize side effects, some patients find it useful to eat five small meals throughout the day rather than three larger meals. In addition, I recommend eating slowly and stopping before the point of satiety. Finally, because weight loss of any kind is inevitably associated with muscle loss, I stress the importance of adequate protein. In general, I advise 25-30 g of protein per meal.

Christine eventually restarted her Wegovy after recovering from her grueling night in the emergency room. As this was her second go-around on Wegovy, she dug out my “guide to preventing side effects of incretins” and followed it to a T. So far, she’s feeling great.

*The patient’s name has been changed.
 

A version of this article appeared on Medscape.com.

Men with cardiorespiratory fitness (CRF) who increased their CRF by more than 3% had a significantly lower risk of prostate cancer incidence, a large Swedish study found.

The prospective analysis, published in the British Journal of Sports Medicine, done in a cohort of nearly 58,000, was conducted by Kate A. Bolam, PhD, a clinical exercise physiologist at the Swedish School of Sport and Health Sciences in Stockholm.

“The findings suggest that physicians could work toward supporting patients to understand what types of activities could improve their fitness and ways they can incorporate these activities into their lives in an enjoyable way, or at the very least refer patients on to an exercise specialist,” Dr. Bolam said in an interview.

Grouped by baseline CRF, the association between change in absolute CRF and prostate cancer incidence was significant only for participants with a moderate baseline CRF. Moreover, changes in both absolute and relative CRF were not associated with prostate cancer mortality.

The lack of mortality significance may be due to the relatively few deaths from prostate cancer in the cohort, Dr. Bolam said. “It may be we weren’t powered to detect anything with such low numbers. And it’s not likely men will die from prostate cancer but more likely from more common chronic diseases such as heart disease.” The authors noted that unlike the case with other common cancers, there are relatively few preventable risk factors with strong evidence for reducing overall prostate cancer risk. “Aside from developmental factors, being diagnosed with overweight or obesity are the main risk factors for developing advanced prostate cancer, but insufficient evidence exists to extend this conclusion to non-advanced prostate cancer,” they wrote.

There is evidence, however, that exercise reduces all-cause mortality risk across many cancer types, including prostate.
 

Study details

The cohort was drawn from Swedish national health-profile database figures from 1982 to 2019. Participants completed an occupational health profile assessment including at least two valid CRF tests on a cycle ergometer. During a mean follow-up of 6.7 years, 592 (1%) of 57,652 men (mean age 41.3 years, standard deviation 10.55) were diagnosed with prostate cancer, and in 46 (.08%) prostate cancer was the primary cause of death.

An increase in absolute CRF (as a percentage of liters per minute of cardiac output) was associated with a reduced incidence risk, with a hazard ratio of 0.98 (95% CI, 0.96-0.99). Grouping participants as having increased (+3%), stable (±3%), or decreased (−3%) CRF, the investigators found increased fitness was associated with an HR for prostate cancer incidence of 0.65 (95% CI, 0.49-0.86), vs decreased fitness.

According to the authors, this and similar investigations of mechanisms behind physical activity benefits will lead to more targeted prevention recommendations. The results highlight the importance of encouraging the general public to increase CRF or reach moderate fitness levels, Dr. Bolam’s group wrote. The group is planning a similar study in breast cancer.

This study was funded by the Swedish Cancer Society. The authors declared no competing interests.

Men with cardiorespiratory fitness (CRF) who increased their CRF by more than 3% had a significantly lower risk of prostate cancer incidence, a large Swedish study found.

The prospective analysis, published in the British Journal of Sports Medicine, done in a cohort of nearly 58,000, was conducted by Kate A. Bolam, PhD, a clinical exercise physiologist at the Swedish School of Sport and Health Sciences in Stockholm.

“The findings suggest that physicians could work toward supporting patients to understand what types of activities could improve their fitness and ways they can incorporate these activities into their lives in an enjoyable way, or at the very least refer patients on to an exercise specialist,” Dr. Bolam said in an interview.

Grouped by baseline CRF, the association between change in absolute CRF and prostate cancer incidence was significant only for participants with a moderate baseline CRF. Moreover, changes in both absolute and relative CRF were not associated with prostate cancer mortality.

The lack of mortality significance may be due to the relatively few deaths from prostate cancer in the cohort, Dr. Bolam said. “It may be we weren’t powered to detect anything with such low numbers. And it’s not likely men will die from prostate cancer but more likely from more common chronic diseases such as heart disease.” The authors noted that unlike the case with other common cancers, there are relatively few preventable risk factors with strong evidence for reducing overall prostate cancer risk. “Aside from developmental factors, being diagnosed with overweight or obesity are the main risk factors for developing advanced prostate cancer, but insufficient evidence exists to extend this conclusion to non-advanced prostate cancer,” they wrote.

There is evidence, however, that exercise reduces all-cause mortality risk across many cancer types, including prostate.
 

Study details

The cohort was drawn from Swedish national health-profile database figures from 1982 to 2019. Participants completed an occupational health profile assessment including at least two valid CRF tests on a cycle ergometer. During a mean follow-up of 6.7 years, 592 (1%) of 57,652 men (mean age 41.3 years, standard deviation 10.55) were diagnosed with prostate cancer, and in 46 (.08%) prostate cancer was the primary cause of death.

An increase in absolute CRF (as a percentage of liters per minute of cardiac output) was associated with a reduced incidence risk, with a hazard ratio of 0.98 (95% CI, 0.96-0.99). Grouping participants as having increased (+3%), stable (±3%), or decreased (−3%) CRF, the investigators found increased fitness was associated with an HR for prostate cancer incidence of 0.65 (95% CI, 0.49-0.86), vs decreased fitness.

According to the authors, this and similar investigations of mechanisms behind physical activity benefits will lead to more targeted prevention recommendations. The results highlight the importance of encouraging the general public to increase CRF or reach moderate fitness levels, Dr. Bolam’s group wrote. The group is planning a similar study in breast cancer.

This study was funded by the Swedish Cancer Society. The authors declared no competing interests.

Men with cardiorespiratory fitness (CRF) who increased their CRF by more than 3% had a significantly lower risk of prostate cancer incidence, a large Swedish study found.

The prospective analysis, published in the British Journal of Sports Medicine, done in a cohort of nearly 58,000, was conducted by Kate A. Bolam, PhD, a clinical exercise physiologist at the Swedish School of Sport and Health Sciences in Stockholm.

“The findings suggest that physicians could work toward supporting patients to understand what types of activities could improve their fitness and ways they can incorporate these activities into their lives in an enjoyable way, or at the very least refer patients on to an exercise specialist,” Dr. Bolam said in an interview.

Grouped by baseline CRF, the association between change in absolute CRF and prostate cancer incidence was significant only for participants with a moderate baseline CRF. Moreover, changes in both absolute and relative CRF were not associated with prostate cancer mortality.

The lack of mortality significance may be due to the relatively few deaths from prostate cancer in the cohort, Dr. Bolam said. “It may be we weren’t powered to detect anything with such low numbers. And it’s not likely men will die from prostate cancer but more likely from more common chronic diseases such as heart disease.” The authors noted that unlike the case with other common cancers, there are relatively few preventable risk factors with strong evidence for reducing overall prostate cancer risk. “Aside from developmental factors, being diagnosed with overweight or obesity are the main risk factors for developing advanced prostate cancer, but insufficient evidence exists to extend this conclusion to non-advanced prostate cancer,” they wrote.

There is evidence, however, that exercise reduces all-cause mortality risk across many cancer types, including prostate.
 

Study details

The cohort was drawn from Swedish national health-profile database figures from 1982 to 2019. Participants completed an occupational health profile assessment including at least two valid CRF tests on a cycle ergometer. During a mean follow-up of 6.7 years, 592 (1%) of 57,652 men (mean age 41.3 years, standard deviation 10.55) were diagnosed with prostate cancer, and in 46 (.08%) prostate cancer was the primary cause of death.

An increase in absolute CRF (as a percentage of liters per minute of cardiac output) was associated with a reduced incidence risk, with a hazard ratio of 0.98 (95% CI, 0.96-0.99). Grouping participants as having increased (+3%), stable (±3%), or decreased (−3%) CRF, the investigators found increased fitness was associated with an HR for prostate cancer incidence of 0.65 (95% CI, 0.49-0.86), vs decreased fitness.

According to the authors, this and similar investigations of mechanisms behind physical activity benefits will lead to more targeted prevention recommendations. The results highlight the importance of encouraging the general public to increase CRF or reach moderate fitness levels, Dr. Bolam’s group wrote. The group is planning a similar study in breast cancer.

This study was funded by the Swedish Cancer Society. The authors declared no competing interests.

TOPLINE:

Women with menstrual or perimenopausal symptoms can relieve common physical and psychological issues through cold water swimming, a new study finds.

METHODOLOGY:

• Symptoms of menstrual cycles and perimenopause vary widely but frequently include mood swings, anxiety, depression, fatigue, hot flashes, and sleep disturbances.
• This is the first investigation of whether cold water swimming has an impact on these symptoms.
• Researchers conducted a 42-question online survey of 1114 women who were regularly swam in cold water. More than two-thirds of respondents (68.1%) were between 45 and 59 years of age.
• Some of the data included responses by women who were perimenopausal but still had menstrual symptoms.

TAKEAWAY:

• Researchers found that cold water swimming had multiple beneficial effects on both menstrual and perimenopausal symptoms.
• Women who swam more frequently and for longer reported more beneficial effects than women who swam less often or for less time per swim.
• Reduction of psychological and vasomotor symptoms were most often cited by cold-water swimmers.
• Perimenopausal women who swam regularly in winter and summer saw greater reduction in anxiety and hot flashes than did those who swam in the other seasons.

IN PRACTICE:

“Teaching women to swim safely and encouraging them to swim regularly may have a benefit on the debilitating symptoms associated with the perimenopause,” the authors wrote.

SOURCE:

The study was conducted by researchers from University College, London, and published online in Post Reproductive Health. The corresponding author is Joyce Harper, PhD, professor of reproductive science at EGA Institute for Women’s Health, University College London, England.

LIMITATIONS:

This was an observational study, with no control group. The underlying cause of improved psychological symptoms of perimenopause were not fully evaluated owing to unaccounted multiple variables. Use of an online survey may introduce sampling bias and not align with the population of all menstruating or perimenopausal women. Participants were primarily White and highly educated.

DISCLOSURES:

Dr. Harper disclosed giving paid talks on menopause to businesses and at conferences.

A version of this article appeared on Medscape.com.

TOPLINE:

Women with menstrual or perimenopausal symptoms can relieve common physical and psychological issues through cold water swimming, a new study finds.

METHODOLOGY:

• Symptoms of menstrual cycles and perimenopause vary widely but frequently include mood swings, anxiety, depression, fatigue, hot flashes, and sleep disturbances.
• This is the first investigation of whether cold water swimming has an impact on these symptoms.
• Researchers conducted a 42-question online survey of 1114 women who were regularly swam in cold water. More than two-thirds of respondents (68.1%) were between 45 and 59 years of age.
• Some of the data included responses by women who were perimenopausal but still had menstrual symptoms.

TAKEAWAY:

• Researchers found that cold water swimming had multiple beneficial effects on both menstrual and perimenopausal symptoms.
• Women who swam more frequently and for longer reported more beneficial effects than women who swam less often or for less time per swim.
• Reduction of psychological and vasomotor symptoms were most often cited by cold-water swimmers.
• Perimenopausal women who swam regularly in winter and summer saw greater reduction in anxiety and hot flashes than did those who swam in the other seasons.

IN PRACTICE:

“Teaching women to swim safely and encouraging them to swim regularly may have a benefit on the debilitating symptoms associated with the perimenopause,” the authors wrote.

SOURCE:

The study was conducted by researchers from University College, London, and published online in Post Reproductive Health. The corresponding author is Joyce Harper, PhD, professor of reproductive science at EGA Institute for Women’s Health, University College London, England.

LIMITATIONS:

This was an observational study, with no control group. The underlying cause of improved psychological symptoms of perimenopause were not fully evaluated owing to unaccounted multiple variables. Use of an online survey may introduce sampling bias and not align with the population of all menstruating or perimenopausal women. Participants were primarily White and highly educated.

DISCLOSURES:

Dr. Harper disclosed giving paid talks on menopause to businesses and at conferences.

A version of this article appeared on Medscape.com.

TOPLINE:

Women with menstrual or perimenopausal symptoms can relieve common physical and psychological issues through cold water swimming, a new study finds.

METHODOLOGY:

• Symptoms of menstrual cycles and perimenopause vary widely but frequently include mood swings, anxiety, depression, fatigue, hot flashes, and sleep disturbances.
• This is the first investigation of whether cold water swimming has an impact on these symptoms.
• Researchers conducted a 42-question online survey of 1114 women who were regularly swam in cold water. More than two-thirds of respondents (68.1%) were between 45 and 59 years of age.
• Some of the data included responses by women who were perimenopausal but still had menstrual symptoms.

TAKEAWAY:

• Researchers found that cold water swimming had multiple beneficial effects on both menstrual and perimenopausal symptoms.
• Women who swam more frequently and for longer reported more beneficial effects than women who swam less often or for less time per swim.
• Reduction of psychological and vasomotor symptoms were most often cited by cold-water swimmers.
• Perimenopausal women who swam regularly in winter and summer saw greater reduction in anxiety and hot flashes than did those who swam in the other seasons.

IN PRACTICE:

“Teaching women to swim safely and encouraging them to swim regularly may have a benefit on the debilitating symptoms associated with the perimenopause,” the authors wrote.

SOURCE:

The study was conducted by researchers from University College, London, and published online in Post Reproductive Health. The corresponding author is Joyce Harper, PhD, professor of reproductive science at EGA Institute for Women’s Health, University College London, England.

LIMITATIONS:

This was an observational study, with no control group. The underlying cause of improved psychological symptoms of perimenopause were not fully evaluated owing to unaccounted multiple variables. Use of an online survey may introduce sampling bias and not align with the population of all menstruating or perimenopausal women. Participants were primarily White and highly educated.

DISCLOSURES:

Dr. Harper disclosed giving paid talks on menopause to businesses and at conferences.

A version of this article appeared on Medscape.com.

ORLANDO, FLORIDA — For some people, acne carries a one-two punch. First, they experience acne that is significant enough to decrease their quality of life, followed by scarring that can last a lifetime. For those patients, dermatologists have several options: Subcision to lift the depression of the scar, laser treatment to lower the height of scar tissue, and injections to fill scars.

“In my practice, I find that these [acne scars] are probably the hardest things to treat. But along the way, I created a protocol that I would love to share with you today,” Robyn Siperstein, MD, said at the annual ODAC Dermatology, Aesthetic & Surgical Conference.

Dr. Siperstein starts by identifying the type of acne scar — rolling scars, boxcar scars, or ice pick scars. Rolling scars tend to be shallower with no sharp edges; boxcar scars are deeper, more defined round or oval depressions; and ice pick scars, as the name suggests, look like someone stuck tiny ice picks into the skin, leaving a sunken or pitted appearance.

“It’s really important to categorize so that we know which ones are going to be effectively treated with different modalities and which ones aren’t, so that we can give our patients realistic expectations,” said Dr. Siperstein, a cosmetic dermatologist in private practice in Boca Raton, Florida, and a clinical affiliate associate professor of dermatology at Florida Atlantic University, Boca Raton.

“There’s not going to be one treatment that’s right for everything,” she said. Different approaches may be required even for the same patient because some people present with all three types of acne scars, she added.

Combining Treatments

When it comes to injecting dermal fillers into acne scars to lift the depressed areas, the US Food and Drug Administration approved a filler with polymethyl methacrylate filler and bovine collagen (Bellafill) for this indication (moderate to severe, atrophic, distensible facial acne scars on the cheek in patients over age 21) in 2015. “And off-label, I use hyaluronic acid in my practice,” Dr. Siperstein said. Each filler “probably works a little bit better or differently on different types of scars.”

For rolling scars, she recommends hyaluronic acid (HA) dermal filler for everyone. “Of course, this is my opinion.” She was also a lead investigator in a randomized, placebo-controlled split-face study comparing HA filler with saline for correcting atrophic facial scars in 15 patients. The HA filler emerged superior, although there were some improvements with saline.

In her clinical experience, patients are happy with the results and ask, “Why didn’t the last four doctors do this?”

Boxcar scars are more challenging to fill with HA. In some cases, Dr. Siperstein is able to raise the depressed portion of the scar, but some of the vertical edges remain. In this scenario, she might combine treatments. Laser resurfacing, for example, might help convert boxcar scars into rolling scars, which then can be filled more successfully.

“Ice pick scars are tough,” Dr. Siperstein said. A punch removal technique can work in some cases, or she might try the “cross technique.” This involves placing acetic acid inside the scar using a Q-tip. “You have to be really careful,” she added, “because if you get it around the edges, it’s actually going to make the scar bigger.”
 

Choosing the Right Candidates

Selecting the right candidate for HA treatment of acne scars is essential. Dr. Siperstein shared the example of a lifeguard who had prominent acne scarring down the center of his chest. “He was embarrassed to go to the beach and take off his shirt. He said he felt like he had bullet holes in his chest.”

One month following treatment, “he had a really nice improvement, and now he feels really comfortable,” she said.

Some dermatologists might be reluctant to consider HA fillers for acne scarring because there is a misconception that HA is short-acting, lasting 6 months to 1 year before the effect wears off. That impression can persist from company-sponsored studies that limit follow-up to 6 months or 1 year “to get their drug to market,” she noted.

Also adding to this impression is that HA fillers in wrinkles may not last as long. Dr. Siperstein explained that wrinkles on the face are dynamic and constantly moving. In contrast, acne scars experience less movement, which helps the HA last longer. There is MRI evidence that shows HA fillers last over 2 years in the face, she added.

One tip to predict how well an acne scar might respond to filler injections is to squeeze it and look for the “dimple sign.” If the floor of the scar lifts up when squeezed, “we know that they’ll be a good candidate for hyaluronic acid filler.” Another tip is to inject HA in a retrograde technique high up in the skin. Inject tiny amounts — microdroplets — of the HA filler high on the dermis, she advised.

Deeper injections run the risk of raising the entire scar instead of filling it, she added.

Like many dermatologic procedures, before and after photos are essential to demonstrate improvements, Dr. Siperstein pointed out. Patients are often skeptical. “This happens a lot with acne scar patients. They’ve been to a million places that have promised results, they have not gotten them, and they are frustrated.”

Acne scars can result from picking, inflammation, or treatment. “This is what we see all day in clinic,” Dr. Siperstein said. “Somebody who had to undergo Accutane treatment but unfortunately is left with holes. This is a huge psychological burden on our patients,” she said, describing a younger patient who had scarring, which “led to depression — it was ruining his life.”

“His mom was willing to do whatever it took. And I said, You know what, I think filler will be enough,” Dr. Siperstein said. She counseled them that treatment would not make the scars disappear completely. But patients used to 10% improvements are very happy when their acne scars look 80% or 90% better, she added.

Dr. Siperstein received grant or research support and is a member of the speakers bureau for Allergan and Galderma. She is also a consultant/advisory board member for Allergan.
 

A version of this article appeared on Medscape.com.

ORLANDO, FLORIDA — For some people, acne carries a one-two punch. First, they experience acne that is significant enough to decrease their quality of life, followed by scarring that can last a lifetime. For those patients, dermatologists have several options: Subcision to lift the depression of the scar, laser treatment to lower the height of scar tissue, and injections to fill scars.

“In my practice, I find that these [acne scars] are probably the hardest things to treat. But along the way, I created a protocol that I would love to share with you today,” Robyn Siperstein, MD, said at the annual ODAC Dermatology, Aesthetic & Surgical Conference.

Dr. Siperstein starts by identifying the type of acne scar — rolling scars, boxcar scars, or ice pick scars. Rolling scars tend to be shallower with no sharp edges; boxcar scars are deeper, more defined round or oval depressions; and ice pick scars, as the name suggests, look like someone stuck tiny ice picks into the skin, leaving a sunken or pitted appearance.

“It’s really important to categorize so that we know which ones are going to be effectively treated with different modalities and which ones aren’t, so that we can give our patients realistic expectations,” said Dr. Siperstein, a cosmetic dermatologist in private practice in Boca Raton, Florida, and a clinical affiliate associate professor of dermatology at Florida Atlantic University, Boca Raton.

“There’s not going to be one treatment that’s right for everything,” she said. Different approaches may be required even for the same patient because some people present with all three types of acne scars, she added.

Combining Treatments

When it comes to injecting dermal fillers into acne scars to lift the depressed areas, the US Food and Drug Administration approved a filler with polymethyl methacrylate filler and bovine collagen (Bellafill) for this indication (moderate to severe, atrophic, distensible facial acne scars on the cheek in patients over age 21) in 2015. “And off-label, I use hyaluronic acid in my practice,” Dr. Siperstein said. Each filler “probably works a little bit better or differently on different types of scars.”

For rolling scars, she recommends hyaluronic acid (HA) dermal filler for everyone. “Of course, this is my opinion.” She was also a lead investigator in a randomized, placebo-controlled split-face study comparing HA filler with saline for correcting atrophic facial scars in 15 patients. The HA filler emerged superior, although there were some improvements with saline.

In her clinical experience, patients are happy with the results and ask, “Why didn’t the last four doctors do this?”

Boxcar scars are more challenging to fill with HA. In some cases, Dr. Siperstein is able to raise the depressed portion of the scar, but some of the vertical edges remain. In this scenario, she might combine treatments. Laser resurfacing, for example, might help convert boxcar scars into rolling scars, which then can be filled more successfully.

“Ice pick scars are tough,” Dr. Siperstein said. A punch removal technique can work in some cases, or she might try the “cross technique.” This involves placing acetic acid inside the scar using a Q-tip. “You have to be really careful,” she added, “because if you get it around the edges, it’s actually going to make the scar bigger.”
 

Choosing the Right Candidates

Selecting the right candidate for HA treatment of acne scars is essential. Dr. Siperstein shared the example of a lifeguard who had prominent acne scarring down the center of his chest. “He was embarrassed to go to the beach and take off his shirt. He said he felt like he had bullet holes in his chest.”

One month following treatment, “he had a really nice improvement, and now he feels really comfortable,” she said.

Some dermatologists might be reluctant to consider HA fillers for acne scarring because there is a misconception that HA is short-acting, lasting 6 months to 1 year before the effect wears off. That impression can persist from company-sponsored studies that limit follow-up to 6 months or 1 year “to get their drug to market,” she noted.

Also adding to this impression is that HA fillers in wrinkles may not last as long. Dr. Siperstein explained that wrinkles on the face are dynamic and constantly moving. In contrast, acne scars experience less movement, which helps the HA last longer. There is MRI evidence that shows HA fillers last over 2 years in the face, she added.

One tip to predict how well an acne scar might respond to filler injections is to squeeze it and look for the “dimple sign.” If the floor of the scar lifts up when squeezed, “we know that they’ll be a good candidate for hyaluronic acid filler.” Another tip is to inject HA in a retrograde technique high up in the skin. Inject tiny amounts — microdroplets — of the HA filler high on the dermis, she advised.

Deeper injections run the risk of raising the entire scar instead of filling it, she added.

Like many dermatologic procedures, before and after photos are essential to demonstrate improvements, Dr. Siperstein pointed out. Patients are often skeptical. “This happens a lot with acne scar patients. They’ve been to a million places that have promised results, they have not gotten them, and they are frustrated.”

Acne scars can result from picking, inflammation, or treatment. “This is what we see all day in clinic,” Dr. Siperstein said. “Somebody who had to undergo Accutane treatment but unfortunately is left with holes. This is a huge psychological burden on our patients,” she said, describing a younger patient who had scarring, which “led to depression — it was ruining his life.”

“His mom was willing to do whatever it took. And I said, You know what, I think filler will be enough,” Dr. Siperstein said. She counseled them that treatment would not make the scars disappear completely. But patients used to 10% improvements are very happy when their acne scars look 80% or 90% better, she added.

Dr. Siperstein received grant or research support and is a member of the speakers bureau for Allergan and Galderma. She is also a consultant/advisory board member for Allergan.
 

A version of this article appeared on Medscape.com.

ORLANDO, FLORIDA — For some people, acne carries a one-two punch. First, they experience acne that is significant enough to decrease their quality of life, followed by scarring that can last a lifetime. For those patients, dermatologists have several options: Subcision to lift the depression of the scar, laser treatment to lower the height of scar tissue, and injections to fill scars.

“In my practice, I find that these [acne scars] are probably the hardest things to treat. But along the way, I created a protocol that I would love to share with you today,” Robyn Siperstein, MD, said at the annual ODAC Dermatology, Aesthetic & Surgical Conference.

Dr. Siperstein starts by identifying the type of acne scar — rolling scars, boxcar scars, or ice pick scars. Rolling scars tend to be shallower with no sharp edges; boxcar scars are deeper, more defined round or oval depressions; and ice pick scars, as the name suggests, look like someone stuck tiny ice picks into the skin, leaving a sunken or pitted appearance.

“It’s really important to categorize so that we know which ones are going to be effectively treated with different modalities and which ones aren’t, so that we can give our patients realistic expectations,” said Dr. Siperstein, a cosmetic dermatologist in private practice in Boca Raton, Florida, and a clinical affiliate associate professor of dermatology at Florida Atlantic University, Boca Raton.

“There’s not going to be one treatment that’s right for everything,” she said. Different approaches may be required even for the same patient because some people present with all three types of acne scars, she added.

Combining Treatments

When it comes to injecting dermal fillers into acne scars to lift the depressed areas, the US Food and Drug Administration approved a filler with polymethyl methacrylate filler and bovine collagen (Bellafill) for this indication (moderate to severe, atrophic, distensible facial acne scars on the cheek in patients over age 21) in 2015. “And off-label, I use hyaluronic acid in my practice,” Dr. Siperstein said. Each filler “probably works a little bit better or differently on different types of scars.”

For rolling scars, she recommends hyaluronic acid (HA) dermal filler for everyone. “Of course, this is my opinion.” She was also a lead investigator in a randomized, placebo-controlled split-face study comparing HA filler with saline for correcting atrophic facial scars in 15 patients. The HA filler emerged superior, although there were some improvements with saline.

In her clinical experience, patients are happy with the results and ask, “Why didn’t the last four doctors do this?”

Boxcar scars are more challenging to fill with HA. In some cases, Dr. Siperstein is able to raise the depressed portion of the scar, but some of the vertical edges remain. In this scenario, she might combine treatments. Laser resurfacing, for example, might help convert boxcar scars into rolling scars, which then can be filled more successfully.

“Ice pick scars are tough,” Dr. Siperstein said. A punch removal technique can work in some cases, or she might try the “cross technique.” This involves placing acetic acid inside the scar using a Q-tip. “You have to be really careful,” she added, “because if you get it around the edges, it’s actually going to make the scar bigger.”
 

Choosing the Right Candidates

Selecting the right candidate for HA treatment of acne scars is essential. Dr. Siperstein shared the example of a lifeguard who had prominent acne scarring down the center of his chest. “He was embarrassed to go to the beach and take off his shirt. He said he felt like he had bullet holes in his chest.”

One month following treatment, “he had a really nice improvement, and now he feels really comfortable,” she said.

Some dermatologists might be reluctant to consider HA fillers for acne scarring because there is a misconception that HA is short-acting, lasting 6 months to 1 year before the effect wears off. That impression can persist from company-sponsored studies that limit follow-up to 6 months or 1 year “to get their drug to market,” she noted.

Also adding to this impression is that HA fillers in wrinkles may not last as long. Dr. Siperstein explained that wrinkles on the face are dynamic and constantly moving. In contrast, acne scars experience less movement, which helps the HA last longer. There is MRI evidence that shows HA fillers last over 2 years in the face, she added.

One tip to predict how well an acne scar might respond to filler injections is to squeeze it and look for the “dimple sign.” If the floor of the scar lifts up when squeezed, “we know that they’ll be a good candidate for hyaluronic acid filler.” Another tip is to inject HA in a retrograde technique high up in the skin. Inject tiny amounts — microdroplets — of the HA filler high on the dermis, she advised.

Deeper injections run the risk of raising the entire scar instead of filling it, she added.

Like many dermatologic procedures, before and after photos are essential to demonstrate improvements, Dr. Siperstein pointed out. Patients are often skeptical. “This happens a lot with acne scar patients. They’ve been to a million places that have promised results, they have not gotten them, and they are frustrated.”

Acne scars can result from picking, inflammation, or treatment. “This is what we see all day in clinic,” Dr. Siperstein said. “Somebody who had to undergo Accutane treatment but unfortunately is left with holes. This is a huge psychological burden on our patients,” she said, describing a younger patient who had scarring, which “led to depression — it was ruining his life.”

“His mom was willing to do whatever it took. And I said, You know what, I think filler will be enough,” Dr. Siperstein said. She counseled them that treatment would not make the scars disappear completely. But patients used to 10% improvements are very happy when their acne scars look 80% or 90% better, she added.

Dr. Siperstein received grant or research support and is a member of the speakers bureau for Allergan and Galderma. She is also a consultant/advisory board member for Allergan.
 

A version of this article appeared on Medscape.com.

Most Americans’ views about obesity and bariatric surgery are colored by stigmas, according to a new survey from the healthcare system at Orlando Health.

For example, most Americans believe that weight loss surgery should be pursued only as a last resort and that bariatric surgery is a shortcut to shedding pounds, the survey found.

Common stigmas could be deterring people who qualify for bariatric surgery from pursuing it, according to Orlando Health, located in Florida.

“Bariatric surgery is by no means an easy way out. If you have the courage to ask for help and commit to doing the hard work of changing your diet and improving your life, you’re a champion in my book,” said Andre Teixeira, MD, medical director and bariatric surgeon at Orlando Health Weight Loss and Bariatric Surgery Institute, Orlando, Florida.

“Surgery is simply a tool to jumpstart that change,” he said. “After surgery, it is up to the patient to learn how to eat well, implement exercise into their routine, and shift their mindset to maintain their health for the rest of their lives.”

The survey results were published in January by Orlando Health.
 

Surveying Americans

The national survey, conducted for Orlando Health by the market research firm Ipsos in early November 2023, asked 1017 US adults whether they agreed or disagreed with several statements about weight loss and bariatric surgery. The statements and responses are as follows:

• “Weight loss surgery is a shortcut to shedding pounds” — 60% strongly or somewhat agreed, 38% strongly or somewhat disagreed, and the remainder declined to answer.
• “Weight loss surgery is cosmetic and mainly impacts appearance” — 37% strongly or somewhat agreed, 61% strongly or somewhat disagreed, and the remainder declined to respond.
• “Exercise and diet should be enough for weight loss” — 61% strongly or somewhat agreed, 37% strongly or somewhat disagreed, and the remainder declined to respond.
• “Weight loss surgery should only be pursued as a last resort” — 79% strongly or somewhat agreed, 19% strongly or somewhat disagreed, and the remainder declined to answer.
• “Surgery should be more socially accepted as a way to lose weight” — 46% strongly or somewhat agreed, 52% strongly or somewhat disagreed, and the remainder declined to respond.

Men’s responses indicated that they are more likely to have negative views toward weight loss surgery than women. For example, 66% of men vs 54% of women respondents see weight loss surgery as a shortcut to losing weight. Conversely, 42% of men vs 50% of women said that surgery should be a more socially accepted weight loss method.

Opinions that might interfere with the willingness to have weight loss surgery were apparent among people with obesity. The survey found that 65% of respondents with obesity and 59% with extreme obesity view surgery as a shortcut. Eighty-two percent of respondents with obesity and 68% with extreme obesity see surgery as a last resort.

At the end of 2022, the American Society of Metabolic and Bariatric Surgery and the International Federation for the Surgery of Obesity and Metabolic Disorders updated their guidelines for metabolic and bariatric surgery for the first time since 1991, with the aim of expanding access to surgery, Orlando Health noted. However, only 1% of those who are clinically eligible end up undergoing weight loss surgery, even with advancements in laparoscopic and robotic techniques that have made it safer and less invasive, the health system added.

“Because of the stigma around obesity and bariatric surgery, so many of my patients feel defeated if they can’t lose weight on their own,” said Muhammad Ghanem, MD, a bariatric surgeon at Orlando Health.

“But when I tell them obesity is a disease and that many of its causes are outside of their control, you can see their relief,” he said. “They often even shed a tear because they’ve struggled with their weight all their lives and finally have some validation.”
 

Individualizing Treatment

Obesity treatment plans should be tailored to patients on the basis of individual factors such as body mass index, existing medical conditions, and family history, Dr. Teixeira said.

Besides bariatric surgery, patients also may consider options such as counseling, lifestyle changes, and medications including the latest weight loss drugs, he added.

The clinical approach to obesity treatment has evolved, said Miguel Burch, MD, director of general surgery and chief of minimally invasive and gastrointestinal surgery at Cedars-Sinai, Los Angeles, California, who was not involved in the survey.

“At one point in my career, I could say the only proven durable treatment for obesity is weight loss surgery. This was in the context of patients who were morbidly obese requiring risk reduction, not for a year or two but for decades, and not for 10-20 pounds but for 40-60 pounds of weight loss,” said Dr. Burch, who also directs the bariatric surgery program at Torrance Memorial Medical Center, Torrance, California.

“That was a previous era. We are now in a new one with the weight loss drugs,” Dr. Burch said. “In fact, it’s wonderful to have the opportunity to serve so many patients with an option other than just surgery.”

Still, Dr. Burch added, “we have to change the way we look at obesity management as being either surgery or medicine and start thinking about it more as a multidisciplinary approach to a chronic and potentially relapsing disease.”

A version of this article appeared on Medscape.com.

Most Americans’ views about obesity and bariatric surgery are colored by stigmas, according to a new survey from the healthcare system at Orlando Health.

For example, most Americans believe that weight loss surgery should be pursued only as a last resort and that bariatric surgery is a shortcut to shedding pounds, the survey found.

Common stigmas could be deterring people who qualify for bariatric surgery from pursuing it, according to Orlando Health, located in Florida.

“Bariatric surgery is by no means an easy way out. If you have the courage to ask for help and commit to doing the hard work of changing your diet and improving your life, you’re a champion in my book,” said Andre Teixeira, MD, medical director and bariatric surgeon at Orlando Health Weight Loss and Bariatric Surgery Institute, Orlando, Florida.

“Surgery is simply a tool to jumpstart that change,” he said. “After surgery, it is up to the patient to learn how to eat well, implement exercise into their routine, and shift their mindset to maintain their health for the rest of their lives.”

The survey results were published in January by Orlando Health.
 

Surveying Americans

The national survey, conducted for Orlando Health by the market research firm Ipsos in early November 2023, asked 1017 US adults whether they agreed or disagreed with several statements about weight loss and bariatric surgery. The statements and responses are as follows:

• “Weight loss surgery is a shortcut to shedding pounds” — 60% strongly or somewhat agreed, 38% strongly or somewhat disagreed, and the remainder declined to answer.
• “Weight loss surgery is cosmetic and mainly impacts appearance” — 37% strongly or somewhat agreed, 61% strongly or somewhat disagreed, and the remainder declined to respond.
• “Exercise and diet should be enough for weight loss” — 61% strongly or somewhat agreed, 37% strongly or somewhat disagreed, and the remainder declined to respond.
• “Weight loss surgery should only be pursued as a last resort” — 79% strongly or somewhat agreed, 19% strongly or somewhat disagreed, and the remainder declined to answer.
• “Surgery should be more socially accepted as a way to lose weight” — 46% strongly or somewhat agreed, 52% strongly or somewhat disagreed, and the remainder declined to respond.

Men’s responses indicated that they are more likely to have negative views toward weight loss surgery than women. For example, 66% of men vs 54% of women respondents see weight loss surgery as a shortcut to losing weight. Conversely, 42% of men vs 50% of women said that surgery should be a more socially accepted weight loss method.

Opinions that might interfere with the willingness to have weight loss surgery were apparent among people with obesity. The survey found that 65% of respondents with obesity and 59% with extreme obesity view surgery as a shortcut. Eighty-two percent of respondents with obesity and 68% with extreme obesity see surgery as a last resort.

At the end of 2022, the American Society of Metabolic and Bariatric Surgery and the International Federation for the Surgery of Obesity and Metabolic Disorders updated their guidelines for metabolic and bariatric surgery for the first time since 1991, with the aim of expanding access to surgery, Orlando Health noted. However, only 1% of those who are clinically eligible end up undergoing weight loss surgery, even with advancements in laparoscopic and robotic techniques that have made it safer and less invasive, the health system added.

“Because of the stigma around obesity and bariatric surgery, so many of my patients feel defeated if they can’t lose weight on their own,” said Muhammad Ghanem, MD, a bariatric surgeon at Orlando Health.

“But when I tell them obesity is a disease and that many of its causes are outside of their control, you can see their relief,” he said. “They often even shed a tear because they’ve struggled with their weight all their lives and finally have some validation.”
 

Individualizing Treatment

Obesity treatment plans should be tailored to patients on the basis of individual factors such as body mass index, existing medical conditions, and family history, Dr. Teixeira said.

Besides bariatric surgery, patients also may consider options such as counseling, lifestyle changes, and medications including the latest weight loss drugs, he added.

The clinical approach to obesity treatment has evolved, said Miguel Burch, MD, director of general surgery and chief of minimally invasive and gastrointestinal surgery at Cedars-Sinai, Los Angeles, California, who was not involved in the survey.

“At one point in my career, I could say the only proven durable treatment for obesity is weight loss surgery. This was in the context of patients who were morbidly obese requiring risk reduction, not for a year or two but for decades, and not for 10-20 pounds but for 40-60 pounds of weight loss,” said Dr. Burch, who also directs the bariatric surgery program at Torrance Memorial Medical Center, Torrance, California.

“That was a previous era. We are now in a new one with the weight loss drugs,” Dr. Burch said. “In fact, it’s wonderful to have the opportunity to serve so many patients with an option other than just surgery.”

Still, Dr. Burch added, “we have to change the way we look at obesity management as being either surgery or medicine and start thinking about it more as a multidisciplinary approach to a chronic and potentially relapsing disease.”

A version of this article appeared on Medscape.com.

Most Americans’ views about obesity and bariatric surgery are colored by stigmas, according to a new survey from the healthcare system at Orlando Health.

For example, most Americans believe that weight loss surgery should be pursued only as a last resort and that bariatric surgery is a shortcut to shedding pounds, the survey found.

Common stigmas could be deterring people who qualify for bariatric surgery from pursuing it, according to Orlando Health, located in Florida.

“Bariatric surgery is by no means an easy way out. If you have the courage to ask for help and commit to doing the hard work of changing your diet and improving your life, you’re a champion in my book,” said Andre Teixeira, MD, medical director and bariatric surgeon at Orlando Health Weight Loss and Bariatric Surgery Institute, Orlando, Florida.

“Surgery is simply a tool to jumpstart that change,” he said. “After surgery, it is up to the patient to learn how to eat well, implement exercise into their routine, and shift their mindset to maintain their health for the rest of their lives.”

The survey results were published in January by Orlando Health.
 

Surveying Americans

The national survey, conducted for Orlando Health by the market research firm Ipsos in early November 2023, asked 1017 US adults whether they agreed or disagreed with several statements about weight loss and bariatric surgery. The statements and responses are as follows:

• “Weight loss surgery is a shortcut to shedding pounds” — 60% strongly or somewhat agreed, 38% strongly or somewhat disagreed, and the remainder declined to answer.
• “Weight loss surgery is cosmetic and mainly impacts appearance” — 37% strongly or somewhat agreed, 61% strongly or somewhat disagreed, and the remainder declined to respond.
• “Exercise and diet should be enough for weight loss” — 61% strongly or somewhat agreed, 37% strongly or somewhat disagreed, and the remainder declined to respond.
• “Weight loss surgery should only be pursued as a last resort” — 79% strongly or somewhat agreed, 19% strongly or somewhat disagreed, and the remainder declined to answer.
• “Surgery should be more socially accepted as a way to lose weight” — 46% strongly or somewhat agreed, 52% strongly or somewhat disagreed, and the remainder declined to respond.

Men’s responses indicated that they are more likely to have negative views toward weight loss surgery than women. For example, 66% of men vs 54% of women respondents see weight loss surgery as a shortcut to losing weight. Conversely, 42% of men vs 50% of women said that surgery should be a more socially accepted weight loss method.

Opinions that might interfere with the willingness to have weight loss surgery were apparent among people with obesity. The survey found that 65% of respondents with obesity and 59% with extreme obesity view surgery as a shortcut. Eighty-two percent of respondents with obesity and 68% with extreme obesity see surgery as a last resort.

At the end of 2022, the American Society of Metabolic and Bariatric Surgery and the International Federation for the Surgery of Obesity and Metabolic Disorders updated their guidelines for metabolic and bariatric surgery for the first time since 1991, with the aim of expanding access to surgery, Orlando Health noted. However, only 1% of those who are clinically eligible end up undergoing weight loss surgery, even with advancements in laparoscopic and robotic techniques that have made it safer and less invasive, the health system added.

“Because of the stigma around obesity and bariatric surgery, so many of my patients feel defeated if they can’t lose weight on their own,” said Muhammad Ghanem, MD, a bariatric surgeon at Orlando Health.

“But when I tell them obesity is a disease and that many of its causes are outside of their control, you can see their relief,” he said. “They often even shed a tear because they’ve struggled with their weight all their lives and finally have some validation.”
 

Individualizing Treatment

Obesity treatment plans should be tailored to patients on the basis of individual factors such as body mass index, existing medical conditions, and family history, Dr. Teixeira said.

Besides bariatric surgery, patients also may consider options such as counseling, lifestyle changes, and medications including the latest weight loss drugs, he added.

The clinical approach to obesity treatment has evolved, said Miguel Burch, MD, director of general surgery and chief of minimally invasive and gastrointestinal surgery at Cedars-Sinai, Los Angeles, California, who was not involved in the survey.

“At one point in my career, I could say the only proven durable treatment for obesity is weight loss surgery. This was in the context of patients who were morbidly obese requiring risk reduction, not for a year or two but for decades, and not for 10-20 pounds but for 40-60 pounds of weight loss,” said Dr. Burch, who also directs the bariatric surgery program at Torrance Memorial Medical Center, Torrance, California.

“That was a previous era. We are now in a new one with the weight loss drugs,” Dr. Burch said. “In fact, it’s wonderful to have the opportunity to serve so many patients with an option other than just surgery.”

Still, Dr. Burch added, “we have to change the way we look at obesity management as being either surgery or medicine and start thinking about it more as a multidisciplinary approach to a chronic and potentially relapsing disease.”

A version of this article appeared on Medscape.com.

To curb alcohol-associated liver disease (ALD), alcohol consumption should be avoided among those with underlying obesity, chronic hepatitis C infection, hepatitis B virus infection, or a history of gastric bypass, according to a new clinical guideline from the American College of Gastroenterology.

In addition, health systems need to overcome barriers to treating alcohol use disorder (AUD) and commit to creating a multidisciplinary care model with behavioral interventions and pharmacotherapy for patients.

Experts were convened to develop these guidelines because it was “imperative to provide an up-to-date, evidence-based blueprint for how to care for patients, as well as guide prevention and research efforts in the field of ALD for the coming years,” said the first author, Loretta Jophlin, MD, PhD, assistant professor of medicine in gastroenterology, hepatology, and nutrition and medical director of liver transplantation at the University of Louisville in Kentucky.

“In recent years, perhaps fueled by the COVID-19 pandemic, alcohol use has been normalized in an increasing number of situations,” she said. “Drinking was normalized as a coping mechanism to deal with many of the sorrows we experienced during the pandemic, including loss of purposeful work and social isolation, and many more people are struggling with AUD. So many aspects of our culture have been inundated by the presence of alcohol use, and we need to work hard to denormalize this, first focusing on at-risk populations.”

The guideline was published in the January issue of the American Journal of Gastroenterology.
 

Updating ALD Recommendations

With ALD as the most common cause of advanced hepatic disease and a frequent indicator of eventual liver transplantation, the rising incidence of alcohol use during the past decade has led to rapid growth in ALD-related healthcare burdens, the guideline authors wrote.

In particular, those with ALD tend to present at an advanced stage and progress faster, which can lead to progressive fibrosis, cirrhosis, and hepatocellular carcinoma. This can include alcohol-associated hepatitis (AH), which often presents with a rapid onset or worsening of jaundice and can lead to acute or chronic liver failure.

To update the guideline, Dr. Jophlin and colleagues analyzed data based on a patient-intervention-comparison-outcome format, resulting in 34 key concepts or statements and 21 recommendations.

Among them, the authors recommended screening and treating AUD with the goal of helping patients who have not yet developed significant liver injury and preventing progression to advanced stages of ALD, particularly among at-risk groups who have had an increasing prevalence of severe AUD, including women, younger people, and Hispanic and American Indian patients.

“So many patients are still told to ‘stop drinking’ or ‘cut back’ but are provided no additional resources. Without offering referrals to treatment programs or pharmacologic therapies to assist in abstinence, many patients are not successful,” Dr. Jophlin said. “We hope these guidelines empower providers to consider selected [Food and Drug Administration]-approved medications, well-studied off-label therapies, and nonpharmacologic interventions to aid their patients’ journeys to abstinence and hopefully avert the progression of ALD.”

In addition, the guidelines provide recommendations for AH treatment. In patients with severe AH, the authors offered strong recommendations against the use of pentoxifylline and prophylactic antibiotics, and in support of corticosteroid therapy and intravenous N-acetyl cysteine as an adjuvant to corticosteroids.

Liver transplantation, which may be recommended for carefully selected patients, is being performed at many centers but remains relatively controversial, Dr. Jophlin said.

“Questions remain about ideal patient selection as center practices vary considerably, yet we have started to realize the impacts of relapse after transplantation,” she said. “The guidelines highlight the knowns and unknowns in this area and will hopefully serve as a catalyst for the dissemination of centers’ experiences and the development of a universal set of ethically sound, evidence-based guidelines to be used by all transplant centers.”
 

Policy Implications

Dr. Jophlin and colleagues noted the importance of policy aimed at alcohol use reduction, multidisciplinary care for AUD and ALD, and additional research around severe AH.

“As a practicing transplant hepatologist and medical director of a liver transplant program in the heart of Bourbon country, I am a part of just one healthcare team experiencing ALD, particularly AH, as a mass casualty event. Healthcare teams are fighting an unrelenting fire that the alcohol industry is pouring gasoline on,” Dr. Jophlin said. “It is imperative that healthcare providers have a voice in the policies that shape this preventable disease. We hope these guidelines inspire practitioners to explore our influence on how alcohol is regulated, marketed, and distributed.”

Additional interventions and public policy considerations could help reduce alcohol-related morbidity and mortality at a moment when the characteristics of those who present with AUD appear to be evolving.

“The typical person I’m seeing now is not someone who has been drinking heavily for decades. Rather, it’s a young person who has been drinking heavily for many months or a couple of years,” said James Burton, MD, a professor of medicine at the University of Colorado School of Medicine and medical director of liver transplantation at the University of Colorado Hospital’s Anschutz Medical Campus in Aurora.

Dr. Burton, who wasn’t involved with the guideline, noted it’s become more common for people to drink multiple alcoholic drinks per day for multiple times per week. Patients often don’t think it’s a problem, even as he discusses their liver-related issues.

“We can’t just keep living and working the way we were 10 years ago,” he said. “We’ve got to change how we approach treatment. We have to treat liver disease and AUD.”

The guideline was supported by several National Institutes of Health grants and an American College of Gastroenterology faculty development grant. The authors declared potential competing interests with various pharmaceutical companies. Dr. Burton reported no financial disclosures.

A version of this article appeared on Medscape.com.

To curb alcohol-associated liver disease (ALD), alcohol consumption should be avoided among those with underlying obesity, chronic hepatitis C infection, hepatitis B virus infection, or a history of gastric bypass, according to a new clinical guideline from the American College of Gastroenterology.

In addition, health systems need to overcome barriers to treating alcohol use disorder (AUD) and commit to creating a multidisciplinary care model with behavioral interventions and pharmacotherapy for patients.

Experts were convened to develop these guidelines because it was “imperative to provide an up-to-date, evidence-based blueprint for how to care for patients, as well as guide prevention and research efforts in the field of ALD for the coming years,” said the first author, Loretta Jophlin, MD, PhD, assistant professor of medicine in gastroenterology, hepatology, and nutrition and medical director of liver transplantation at the University of Louisville in Kentucky.

“In recent years, perhaps fueled by the COVID-19 pandemic, alcohol use has been normalized in an increasing number of situations,” she said. “Drinking was normalized as a coping mechanism to deal with many of the sorrows we experienced during the pandemic, including loss of purposeful work and social isolation, and many more people are struggling with AUD. So many aspects of our culture have been inundated by the presence of alcohol use, and we need to work hard to denormalize this, first focusing on at-risk populations.”

The guideline was published in the January issue of the American Journal of Gastroenterology.
 

Updating ALD Recommendations

With ALD as the most common cause of advanced hepatic disease and a frequent indicator of eventual liver transplantation, the rising incidence of alcohol use during the past decade has led to rapid growth in ALD-related healthcare burdens, the guideline authors wrote.

In particular, those with ALD tend to present at an advanced stage and progress faster, which can lead to progressive fibrosis, cirrhosis, and hepatocellular carcinoma. This can include alcohol-associated hepatitis (AH), which often presents with a rapid onset or worsening of jaundice and can lead to acute or chronic liver failure.

To update the guideline, Dr. Jophlin and colleagues analyzed data based on a patient-intervention-comparison-outcome format, resulting in 34 key concepts or statements and 21 recommendations.

Among them, the authors recommended screening and treating AUD with the goal of helping patients who have not yet developed significant liver injury and preventing progression to advanced stages of ALD, particularly among at-risk groups who have had an increasing prevalence of severe AUD, including women, younger people, and Hispanic and American Indian patients.

“So many patients are still told to ‘stop drinking’ or ‘cut back’ but are provided no additional resources. Without offering referrals to treatment programs or pharmacologic therapies to assist in abstinence, many patients are not successful,” Dr. Jophlin said. “We hope these guidelines empower providers to consider selected [Food and Drug Administration]-approved medications, well-studied off-label therapies, and nonpharmacologic interventions to aid their patients’ journeys to abstinence and hopefully avert the progression of ALD.”

In addition, the guidelines provide recommendations for AH treatment. In patients with severe AH, the authors offered strong recommendations against the use of pentoxifylline and prophylactic antibiotics, and in support of corticosteroid therapy and intravenous N-acetyl cysteine as an adjuvant to corticosteroids.

Liver transplantation, which may be recommended for carefully selected patients, is being performed at many centers but remains relatively controversial, Dr. Jophlin said.

“Questions remain about ideal patient selection as center practices vary considerably, yet we have started to realize the impacts of relapse after transplantation,” she said. “The guidelines highlight the knowns and unknowns in this area and will hopefully serve as a catalyst for the dissemination of centers’ experiences and the development of a universal set of ethically sound, evidence-based guidelines to be used by all transplant centers.”
 

Policy Implications

Dr. Jophlin and colleagues noted the importance of policy aimed at alcohol use reduction, multidisciplinary care for AUD and ALD, and additional research around severe AH.

“As a practicing transplant hepatologist and medical director of a liver transplant program in the heart of Bourbon country, I am a part of just one healthcare team experiencing ALD, particularly AH, as a mass casualty event. Healthcare teams are fighting an unrelenting fire that the alcohol industry is pouring gasoline on,” Dr. Jophlin said. “It is imperative that healthcare providers have a voice in the policies that shape this preventable disease. We hope these guidelines inspire practitioners to explore our influence on how alcohol is regulated, marketed, and distributed.”

Additional interventions and public policy considerations could help reduce alcohol-related morbidity and mortality at a moment when the characteristics of those who present with AUD appear to be evolving.

“The typical person I’m seeing now is not someone who has been drinking heavily for decades. Rather, it’s a young person who has been drinking heavily for many months or a couple of years,” said James Burton, MD, a professor of medicine at the University of Colorado School of Medicine and medical director of liver transplantation at the University of Colorado Hospital’s Anschutz Medical Campus in Aurora.

Dr. Burton, who wasn’t involved with the guideline, noted it’s become more common for people to drink multiple alcoholic drinks per day for multiple times per week. Patients often don’t think it’s a problem, even as he discusses their liver-related issues.

“We can’t just keep living and working the way we were 10 years ago,” he said. “We’ve got to change how we approach treatment. We have to treat liver disease and AUD.”

The guideline was supported by several National Institutes of Health grants and an American College of Gastroenterology faculty development grant. The authors declared potential competing interests with various pharmaceutical companies. Dr. Burton reported no financial disclosures.

A version of this article appeared on Medscape.com.

To curb alcohol-associated liver disease (ALD), alcohol consumption should be avoided among those with underlying obesity, chronic hepatitis C infection, hepatitis B virus infection, or a history of gastric bypass, according to a new clinical guideline from the American College of Gastroenterology.

In addition, health systems need to overcome barriers to treating alcohol use disorder (AUD) and commit to creating a multidisciplinary care model with behavioral interventions and pharmacotherapy for patients.

Experts were convened to develop these guidelines because it was “imperative to provide an up-to-date, evidence-based blueprint for how to care for patients, as well as guide prevention and research efforts in the field of ALD for the coming years,” said the first author, Loretta Jophlin, MD, PhD, assistant professor of medicine in gastroenterology, hepatology, and nutrition and medical director of liver transplantation at the University of Louisville in Kentucky.

“In recent years, perhaps fueled by the COVID-19 pandemic, alcohol use has been normalized in an increasing number of situations,” she said. “Drinking was normalized as a coping mechanism to deal with many of the sorrows we experienced during the pandemic, including loss of purposeful work and social isolation, and many more people are struggling with AUD. So many aspects of our culture have been inundated by the presence of alcohol use, and we need to work hard to denormalize this, first focusing on at-risk populations.”

The guideline was published in the January issue of the American Journal of Gastroenterology.
 

Updating ALD Recommendations

With ALD as the most common cause of advanced hepatic disease and a frequent indicator of eventual liver transplantation, the rising incidence of alcohol use during the past decade has led to rapid growth in ALD-related healthcare burdens, the guideline authors wrote.

In particular, those with ALD tend to present at an advanced stage and progress faster, which can lead to progressive fibrosis, cirrhosis, and hepatocellular carcinoma. This can include alcohol-associated hepatitis (AH), which often presents with a rapid onset or worsening of jaundice and can lead to acute or chronic liver failure.

To update the guideline, Dr. Jophlin and colleagues analyzed data based on a patient-intervention-comparison-outcome format, resulting in 34 key concepts or statements and 21 recommendations.

Among them, the authors recommended screening and treating AUD with the goal of helping patients who have not yet developed significant liver injury and preventing progression to advanced stages of ALD, particularly among at-risk groups who have had an increasing prevalence of severe AUD, including women, younger people, and Hispanic and American Indian patients.

“So many patients are still told to ‘stop drinking’ or ‘cut back’ but are provided no additional resources. Without offering referrals to treatment programs or pharmacologic therapies to assist in abstinence, many patients are not successful,” Dr. Jophlin said. “We hope these guidelines empower providers to consider selected [Food and Drug Administration]-approved medications, well-studied off-label therapies, and nonpharmacologic interventions to aid their patients’ journeys to abstinence and hopefully avert the progression of ALD.”

In addition, the guidelines provide recommendations for AH treatment. In patients with severe AH, the authors offered strong recommendations against the use of pentoxifylline and prophylactic antibiotics, and in support of corticosteroid therapy and intravenous N-acetyl cysteine as an adjuvant to corticosteroids.

Liver transplantation, which may be recommended for carefully selected patients, is being performed at many centers but remains relatively controversial, Dr. Jophlin said.

“Questions remain about ideal patient selection as center practices vary considerably, yet we have started to realize the impacts of relapse after transplantation,” she said. “The guidelines highlight the knowns and unknowns in this area and will hopefully serve as a catalyst for the dissemination of centers’ experiences and the development of a universal set of ethically sound, evidence-based guidelines to be used by all transplant centers.”
 

Policy Implications

Dr. Jophlin and colleagues noted the importance of policy aimed at alcohol use reduction, multidisciplinary care for AUD and ALD, and additional research around severe AH.

“As a practicing transplant hepatologist and medical director of a liver transplant program in the heart of Bourbon country, I am a part of just one healthcare team experiencing ALD, particularly AH, as a mass casualty event. Healthcare teams are fighting an unrelenting fire that the alcohol industry is pouring gasoline on,” Dr. Jophlin said. “It is imperative that healthcare providers have a voice in the policies that shape this preventable disease. We hope these guidelines inspire practitioners to explore our influence on how alcohol is regulated, marketed, and distributed.”

Additional interventions and public policy considerations could help reduce alcohol-related morbidity and mortality at a moment when the characteristics of those who present with AUD appear to be evolving.

“The typical person I’m seeing now is not someone who has been drinking heavily for decades. Rather, it’s a young person who has been drinking heavily for many months or a couple of years,” said James Burton, MD, a professor of medicine at the University of Colorado School of Medicine and medical director of liver transplantation at the University of Colorado Hospital’s Anschutz Medical Campus in Aurora.

Dr. Burton, who wasn’t involved with the guideline, noted it’s become more common for people to drink multiple alcoholic drinks per day for multiple times per week. Patients often don’t think it’s a problem, even as he discusses their liver-related issues.

“We can’t just keep living and working the way we were 10 years ago,” he said. “We’ve got to change how we approach treatment. We have to treat liver disease and AUD.”

The guideline was supported by several National Institutes of Health grants and an American College of Gastroenterology faculty development grant. The authors declared potential competing interests with various pharmaceutical companies. Dr. Burton reported no financial disclosures.

A version of this article appeared on Medscape.com.

Santé Publique France (SPF), the French national public health agency, has released the findings of the PEPS’PE study, which was launched in 2021. The study aims to prioritize, following extensive consultation, the health effects to be monitored for their potential link to endocrine disruptors (EDs). Out of 59 health effects suspected to be associated with exposure to EDs, 21 have been considered a priority for surveillance. Based on these results and others, SPF will expand the scope of the Agency’s surveillance by incorporating new pathologies.

As part of its environmental health program and the National Strategy on EDs, SPF has been conducting surveillance related to EDs targeting reproductive health since 2015. To incorporate new scientific knowledge, the PEPS’PE project aims to prioritize health effects related to EDs and identify health events to integrate into the agency’s current surveillance. The 59 health effects suspected to be associated with exposure to EDs were to be evaluated based on two criteria: The weight of evidence and the epidemiological and societal impact of the health effect. A diverse panel of international experts and French stakeholders in the field of EDs classified 21 health effects as a priority for surveillance.

Among these effects, six reproductive health effects are already monitored in the surveillance program: Cryptorchidism, hypospadias, early puberty, testicular cancer, alteration of sperm quality, and endometriosis. In addition, infertility and decreased fertility (which are not currently monitored for their link to EDs) have been included.

Metabolic effects (including overweight and obesity, cardiovascular diseases, type 2 diabetes, and metabolic syndrome), child neurodevelopmental disorders (including behavioral disorders, intellectual deficits, and attention-deficit disorders), cancers (including breast cancer, prostate cancer, lymphomas, and leukemias in children), and asthma have also been highlighted.

Furthermore, 22 effects were considered low priorities or deemed nonpriorities when, for example, they presented weak or moderate evidence with varying levels of interest in implementing surveillance. Finally, 16 health effects could not be prioritized because of a lack of scientific experts on these topics and a failure to achieve consensus (eg, bone disorders, adrenal disorders, and skin and eye disorders). Consensus was sought during this consultation using a Delphi method.

“These results indicate the need to expand the scope of the Agency’s surveillance beyond reproductive health, incorporating new pathologies when surveillance data are available,” SPF declared in a press release.

“With the initial decision elements obtained through this study, Santé Publique France will analyze the feasibility of implementing surveillance for effects classified as priorities.”
 

This article was translated from the Medscape French edition. A version of this article appeared on Medscape.com.

Santé Publique France (SPF), the French national public health agency, has released the findings of the PEPS’PE study, which was launched in 2021. The study aims to prioritize, following extensive consultation, the health effects to be monitored for their potential link to endocrine disruptors (EDs). Out of 59 health effects suspected to be associated with exposure to EDs, 21 have been considered a priority for surveillance. Based on these results and others, SPF will expand the scope of the Agency’s surveillance by incorporating new pathologies.

As part of its environmental health program and the National Strategy on EDs, SPF has been conducting surveillance related to EDs targeting reproductive health since 2015. To incorporate new scientific knowledge, the PEPS’PE project aims to prioritize health effects related to EDs and identify health events to integrate into the agency’s current surveillance. The 59 health effects suspected to be associated with exposure to EDs were to be evaluated based on two criteria: The weight of evidence and the epidemiological and societal impact of the health effect. A diverse panel of international experts and French stakeholders in the field of EDs classified 21 health effects as a priority for surveillance.

Among these effects, six reproductive health effects are already monitored in the surveillance program: Cryptorchidism, hypospadias, early puberty, testicular cancer, alteration of sperm quality, and endometriosis. In addition, infertility and decreased fertility (which are not currently monitored for their link to EDs) have been included.

Metabolic effects (including overweight and obesity, cardiovascular diseases, type 2 diabetes, and metabolic syndrome), child neurodevelopmental disorders (including behavioral disorders, intellectual deficits, and attention-deficit disorders), cancers (including breast cancer, prostate cancer, lymphomas, and leukemias in children), and asthma have also been highlighted.

Furthermore, 22 effects were considered low priorities or deemed nonpriorities when, for example, they presented weak or moderate evidence with varying levels of interest in implementing surveillance. Finally, 16 health effects could not be prioritized because of a lack of scientific experts on these topics and a failure to achieve consensus (eg, bone disorders, adrenal disorders, and skin and eye disorders). Consensus was sought during this consultation using a Delphi method.

“These results indicate the need to expand the scope of the Agency’s surveillance beyond reproductive health, incorporating new pathologies when surveillance data are available,” SPF declared in a press release.

“With the initial decision elements obtained through this study, Santé Publique France will analyze the feasibility of implementing surveillance for effects classified as priorities.”
 

This article was translated from the Medscape French edition. A version of this article appeared on Medscape.com.

Santé Publique France (SPF), the French national public health agency, has released the findings of the PEPS’PE study, which was launched in 2021. The study aims to prioritize, following extensive consultation, the health effects to be monitored for their potential link to endocrine disruptors (EDs). Out of 59 health effects suspected to be associated with exposure to EDs, 21 have been considered a priority for surveillance. Based on these results and others, SPF will expand the scope of the Agency’s surveillance by incorporating new pathologies.

As part of its environmental health program and the National Strategy on EDs, SPF has been conducting surveillance related to EDs targeting reproductive health since 2015. To incorporate new scientific knowledge, the PEPS’PE project aims to prioritize health effects related to EDs and identify health events to integrate into the agency’s current surveillance. The 59 health effects suspected to be associated with exposure to EDs were to be evaluated based on two criteria: The weight of evidence and the epidemiological and societal impact of the health effect. A diverse panel of international experts and French stakeholders in the field of EDs classified 21 health effects as a priority for surveillance.

Among these effects, six reproductive health effects are already monitored in the surveillance program: Cryptorchidism, hypospadias, early puberty, testicular cancer, alteration of sperm quality, and endometriosis. In addition, infertility and decreased fertility (which are not currently monitored for their link to EDs) have been included.

Metabolic effects (including overweight and obesity, cardiovascular diseases, type 2 diabetes, and metabolic syndrome), child neurodevelopmental disorders (including behavioral disorders, intellectual deficits, and attention-deficit disorders), cancers (including breast cancer, prostate cancer, lymphomas, and leukemias in children), and asthma have also been highlighted.

Furthermore, 22 effects were considered low priorities or deemed nonpriorities when, for example, they presented weak or moderate evidence with varying levels of interest in implementing surveillance. Finally, 16 health effects could not be prioritized because of a lack of scientific experts on these topics and a failure to achieve consensus (eg, bone disorders, adrenal disorders, and skin and eye disorders). Consensus was sought during this consultation using a Delphi method.

“These results indicate the need to expand the scope of the Agency’s surveillance beyond reproductive health, incorporating new pathologies when surveillance data are available,” SPF declared in a press release.

“With the initial decision elements obtained through this study, Santé Publique France will analyze the feasibility of implementing surveillance for effects classified as priorities.”
 

This article was translated from the Medscape French edition. A version of this article appeared on Medscape.com.

It’s that time of the year, when social media is rife with many top 5 and top 10 lists. Perhaps the beginning of a new year is a good time to review how different medications can have side effects beyond the disease state they’re used to address. Among the most common complications of many medications is the potential to disrupt glycemic control. Let’s revisit some of the most commonly used medications known to increase glucose levels and look at some practical tips on overcoming these.

1. Glucocorticoids

Without a doubt, corticosteroids are at the top of the list when it comes to the potential for increasing blood glucose levels. High-dose glucocorticoid therapy is known to lead to new-onset diabetes (steroid-induced diabetes). Similarly, people with preexisting diabetes may notice significant worsening of glycemic control when they start on glucocorticoid therapy. The extent of glucose elevation depends on their glycemic status prior to initiation on steroids, the dose and duration of glucocorticoid therapy, and comorbid conditions, among other factors.

Management tip: For those with previously well-controlled diabetes or borderline diabetes, glucocorticoid-induced hyperglycemia may be managed by metformin with or without sulfonylurea therapy, especially if corticosteroid treatment is low-dose and for a shorter duration. However, for many individuals with preexisting poorly controlled diabetes or those initiated on high-dose corticosteroids, insulin therapy would perhaps be the treatment of choice. Glucocorticoid therapy generally leads to more pronounced postprandial hyperglycemia compared with fasting hyperglycemia; hence, the use of short-acting insulin therapy or perhaps NPH insulin in the morning might be a better option for many individuals. Dietary modification plays an important role in limiting the extent of postprandial hyperglycemia. Use of continuous glucose monitoring (CGM) devices may also be very helpful for understanding glycemic excursions and how to adjust insulin. In individuals for whom glucocorticoid therapy is tapered down, it is important to adjust the dose of medications with potential to cause hypoglycemia, such as insulin/sulfonylurea therapy, as the degree of hyperglycemia may decrease with decreased dose of the glucocorticoid therapy.

2. Antipsychotic Therapy

Antipsychotic medications can be obesogenic; between 15% and 72% of people who take second-generation antipsychotics experience weight gain of 7% or more. Increases in weight are not the only factor contributing to an elevated risk of developing type 2 diabetes. Antipsychotics are thought to cause downregulation of intracellular insulin signaling, leading to insulin resistance. At the same time, there seems to be a direct effect on the pancreatic beta cells. Antagonism of the dopamine D2, serotonin 5-HT2C, and muscarinic M3 receptors impairs beta-cell response to changes in blood glucose. In addition to the pharmacologic effects, cell culture experiments have shown that antipsychotics increase apoptosis of beta cells. Increased weight and concomitant development of type 2 diabetes is seen particularly in agents that exhibit high muscarinic M3 and histamine H1 receptor blockade. The effect on glucose metabolism is seen the most with agents such as clozapine, olanzapine, and haloperidol and the least with agents such as ziprasidone.

Management tip: Given the ongoing change in the understanding of increases in weight and their association with the risk of developing type 2 diabetes, a metabolically safer approach involves starting with medications that have a lower propensity for weight gain, and the partial agonists/third-generation antipsychotics as a family presently have the best overall data.

3. Thiazide Diuretics

Thiazide diuretics are commonly used for the management of hypertension and are associated with metabolic complications including hypokalemia; higher cholesterol, triglycerides, and other circulating lipids; and elevated glucose. It’s thought that the reduced potassium level occurring as a result of these medications might contribute to new-onset diabetes. The hypokalemia occurring from these medications is thought to lead to a decrease in insulin secretion and sensitivity, which is dose dependent. Studies show that the number needed to harm for chlorthalidone-induced diabetes is 29 over 1 year. There is believed to be no additional risk beyond 1 year.

Management tip: It’s important to monitor potassium levels for those initiated on thiazide diuretics. If hypokalemia occurs, it would be pertinent to correct the hypokalemia with potassium supplements to mitigate the risk for new-onset diabetes.

4. Statin Therapy

Statin therapy is thought to be associated with decreased insulin sensitivity and impairment in insulin secretion. The overall incidence of diabetes is pegged to be between 9% and 12% on statin therapy on the basis of meta-analysis studies, and higher on the basis of population-based studies. Overall, the estimated number needed to harm is: 1 out of every 255 patients on statin therapy for 4 years may develop new-onset diabetes. Compare this with the extremely strong evidence for number needed to treat being 39 for 5 years with statin therapy in patients with preexisting heart disease to prevent one occurrence of a nonfatal myocardial infarction.

Management tip: Although statins are associated with a small incident increase in the risk of developing diabetes, the potential benefits of using statin therapy for both primary and secondary prevention of cardiovascular disease significantly outweigh any of the potential risks associated with hyperglycemia. This is an important discussion to have with patients who are reluctant to use statin therapy because of the potential risk for new-onset diabetes as a side effect.

5. Beta-Blockers

Beta-blockers are another commonly used group of medications for managing hypertension, heart failure, coronary artery disease, and arrhythmia. Nonvasodilating beta-blockers such as metoprolol and atenolol are more likely to be associated with increases in A1c, mean plasma glucose, body weight, and triglycerides compared with vasodilating beta-blockers such as carvedilol, nebivolol, and labetalol (Bakris GL et al; Giugliano D et al). Similarly, studies have also shown that atenolol and metoprolol are associated with increased odds of hypoglycemia compared with carvedilol. People on beta-blockers may have masking of some of the symptoms of hypoglycemia, such as tremor, irritability, and palpitations, while other symptoms such as diaphoresis may remain unaffected on beta-blockers.

Management tip: Education on recognizing and managing hypoglycemia would be important when starting patients on beta-blockers if they are on preexisting insulin/sulfonylurea therapy. Use of CGM devices may be helpful if there is a high risk for hypoglycemia, especially as symptoms of hypoglycemia are often masked.

Honorable Mention

Several other medications — including antiretroviral therapy, tyrosine kinase inhibitors, mechanistic target of rapamycin (mTOR) inhibitors, immunosuppressants, and interferon alpha — are associated with worsening glycemic control and new-onset diabetes. Consider these agents’ effects on blood glucose, especially in people with an elevated risk of developing diabetes or those with preexisting diabetes, when prescribing.

A special mention should also be made of androgen deprivation therapy. These include treatment options like goserelin and leuprolide, which are gonadotropin-releasing hormone (GnRH) agonist therapies and are commonly used for prostate cancer management. Depending on the patient, these agents may be used for prolonged duration. Androgen deprivation therapy, by definition, decreases testosterone levels in men, thereby leading to worsening insulin resistance. Increase in fat mass and concomitant muscle wasting have been associated with the use of these medications; these, in turn, lead to peripheral insulin resistance. Nearly 1 out of every 5 men treated with long-term androgen deprivation therapy may be prone to developing worsening of A1c by 1% or more.

Management tip: Men on androgen deprivation therapy should be encouraged to participate in regular physical activity to reduce the burden of insulin resistance and to promote cardiovascular health.

Drug-induced diabetes is potentially reversible in many cases. Similarly, worsening of glycemic control due to medications in people with preexisting diabetes may also attenuate once the effect of the drug wears off. Blood glucose should be monitored on an ongoing basis so that diabetes medications can be adjusted. For some individuals, however, the worsening of glycemic status may be more chronic and may require long-term use of antihyperglycemic agents, especially if the benefits of continuation of the medication leading to hyperglycemia far exceed any potential risks.
 

Dr. Jain is Clinical Instructor, Department of Endocrinology, University of British Columbia; Endocrinologist, Fraser River Endocrinology, Vancouver, British Columbia, Canada. He disclosed ties with Abbott, Amgen, Boehringer Ingelheim, Dexcom, Eli Lilly, Janssen, Medtronic, Merck, and Novo Nordisk.

A version of this article appeared on Medscape.com.

It’s that time of the year, when social media is rife with many top 5 and top 10 lists. Perhaps the beginning of a new year is a good time to review how different medications can have side effects beyond the disease state they’re used to address. Among the most common complications of many medications is the potential to disrupt glycemic control. Let’s revisit some of the most commonly used medications known to increase glucose levels and look at some practical tips on overcoming these.

1. Glucocorticoids

Without a doubt, corticosteroids are at the top of the list when it comes to the potential for increasing blood glucose levels. High-dose glucocorticoid therapy is known to lead to new-onset diabetes (steroid-induced diabetes). Similarly, people with preexisting diabetes may notice significant worsening of glycemic control when they start on glucocorticoid therapy. The extent of glucose elevation depends on their glycemic status prior to initiation on steroids, the dose and duration of glucocorticoid therapy, and comorbid conditions, among other factors.

Management tip: For those with previously well-controlled diabetes or borderline diabetes, glucocorticoid-induced hyperglycemia may be managed by metformin with or without sulfonylurea therapy, especially if corticosteroid treatment is low-dose and for a shorter duration. However, for many individuals with preexisting poorly controlled diabetes or those initiated on high-dose corticosteroids, insulin therapy would perhaps be the treatment of choice. Glucocorticoid therapy generally leads to more pronounced postprandial hyperglycemia compared with fasting hyperglycemia; hence, the use of short-acting insulin therapy or perhaps NPH insulin in the morning might be a better option for many individuals. Dietary modification plays an important role in limiting the extent of postprandial hyperglycemia. Use of continuous glucose monitoring (CGM) devices may also be very helpful for understanding glycemic excursions and how to adjust insulin. In individuals for whom glucocorticoid therapy is tapered down, it is important to adjust the dose of medications with potential to cause hypoglycemia, such as insulin/sulfonylurea therapy, as the degree of hyperglycemia may decrease with decreased dose of the glucocorticoid therapy.

2. Antipsychotic Therapy

Antipsychotic medications can be obesogenic; between 15% and 72% of people who take second-generation antipsychotics experience weight gain of 7% or more. Increases in weight are not the only factor contributing to an elevated risk of developing type 2 diabetes. Antipsychotics are thought to cause downregulation of intracellular insulin signaling, leading to insulin resistance. At the same time, there seems to be a direct effect on the pancreatic beta cells. Antagonism of the dopamine D2, serotonin 5-HT2C, and muscarinic M3 receptors impairs beta-cell response to changes in blood glucose. In addition to the pharmacologic effects, cell culture experiments have shown that antipsychotics increase apoptosis of beta cells. Increased weight and concomitant development of type 2 diabetes is seen particularly in agents that exhibit high muscarinic M3 and histamine H1 receptor blockade. The effect on glucose metabolism is seen the most with agents such as clozapine, olanzapine, and haloperidol and the least with agents such as ziprasidone.

Management tip: Given the ongoing change in the understanding of increases in weight and their association with the risk of developing type 2 diabetes, a metabolically safer approach involves starting with medications that have a lower propensity for weight gain, and the partial agonists/third-generation antipsychotics as a family presently have the best overall data.

3. Thiazide Diuretics

Thiazide diuretics are commonly used for the management of hypertension and are associated with metabolic complications including hypokalemia; higher cholesterol, triglycerides, and other circulating lipids; and elevated glucose. It’s thought that the reduced potassium level occurring as a result of these medications might contribute to new-onset diabetes. The hypokalemia occurring from these medications is thought to lead to a decrease in insulin secretion and sensitivity, which is dose dependent. Studies show that the number needed to harm for chlorthalidone-induced diabetes is 29 over 1 year. There is believed to be no additional risk beyond 1 year.

Management tip: It’s important to monitor potassium levels for those initiated on thiazide diuretics. If hypokalemia occurs, it would be pertinent to correct the hypokalemia with potassium supplements to mitigate the risk for new-onset diabetes.

4. Statin Therapy

Statin therapy is thought to be associated with decreased insulin sensitivity and impairment in insulin secretion. The overall incidence of diabetes is pegged to be between 9% and 12% on statin therapy on the basis of meta-analysis studies, and higher on the basis of population-based studies. Overall, the estimated number needed to harm is: 1 out of every 255 patients on statin therapy for 4 years may develop new-onset diabetes. Compare this with the extremely strong evidence for number needed to treat being 39 for 5 years with statin therapy in patients with preexisting heart disease to prevent one occurrence of a nonfatal myocardial infarction.

Management tip: Although statins are associated with a small incident increase in the risk of developing diabetes, the potential benefits of using statin therapy for both primary and secondary prevention of cardiovascular disease significantly outweigh any of the potential risks associated with hyperglycemia. This is an important discussion to have with patients who are reluctant to use statin therapy because of the potential risk for new-onset diabetes as a side effect.

5. Beta-Blockers

Beta-blockers are another commonly used group of medications for managing hypertension, heart failure, coronary artery disease, and arrhythmia. Nonvasodilating beta-blockers such as metoprolol and atenolol are more likely to be associated with increases in A1c, mean plasma glucose, body weight, and triglycerides compared with vasodilating beta-blockers such as carvedilol, nebivolol, and labetalol (Bakris GL et al; Giugliano D et al). Similarly, studies have also shown that atenolol and metoprolol are associated with increased odds of hypoglycemia compared with carvedilol. People on beta-blockers may have masking of some of the symptoms of hypoglycemia, such as tremor, irritability, and palpitations, while other symptoms such as diaphoresis may remain unaffected on beta-blockers.

Management tip: Education on recognizing and managing hypoglycemia would be important when starting patients on beta-blockers if they are on preexisting insulin/sulfonylurea therapy. Use of CGM devices may be helpful if there is a high risk for hypoglycemia, especially as symptoms of hypoglycemia are often masked.

Honorable Mention

Several other medications — including antiretroviral therapy, tyrosine kinase inhibitors, mechanistic target of rapamycin (mTOR) inhibitors, immunosuppressants, and interferon alpha — are associated with worsening glycemic control and new-onset diabetes. Consider these agents’ effects on blood glucose, especially in people with an elevated risk of developing diabetes or those with preexisting diabetes, when prescribing.

A special mention should also be made of androgen deprivation therapy. These include treatment options like goserelin and leuprolide, which are gonadotropin-releasing hormone (GnRH) agonist therapies and are commonly used for prostate cancer management. Depending on the patient, these agents may be used for prolonged duration. Androgen deprivation therapy, by definition, decreases testosterone levels in men, thereby leading to worsening insulin resistance. Increase in fat mass and concomitant muscle wasting have been associated with the use of these medications; these, in turn, lead to peripheral insulin resistance. Nearly 1 out of every 5 men treated with long-term androgen deprivation therapy may be prone to developing worsening of A1c by 1% or more.

Management tip: Men on androgen deprivation therapy should be encouraged to participate in regular physical activity to reduce the burden of insulin resistance and to promote cardiovascular health.

Drug-induced diabetes is potentially reversible in many cases. Similarly, worsening of glycemic control due to medications in people with preexisting diabetes may also attenuate once the effect of the drug wears off. Blood glucose should be monitored on an ongoing basis so that diabetes medications can be adjusted. For some individuals, however, the worsening of glycemic status may be more chronic and may require long-term use of antihyperglycemic agents, especially if the benefits of continuation of the medication leading to hyperglycemia far exceed any potential risks.
 

Dr. Jain is Clinical Instructor, Department of Endocrinology, University of British Columbia; Endocrinologist, Fraser River Endocrinology, Vancouver, British Columbia, Canada. He disclosed ties with Abbott, Amgen, Boehringer Ingelheim, Dexcom, Eli Lilly, Janssen, Medtronic, Merck, and Novo Nordisk.

A version of this article appeared on Medscape.com.

It’s that time of the year, when social media is rife with many top 5 and top 10 lists. Perhaps the beginning of a new year is a good time to review how different medications can have side effects beyond the disease state they’re used to address. Among the most common complications of many medications is the potential to disrupt glycemic control. Let’s revisit some of the most commonly used medications known to increase glucose levels and look at some practical tips on overcoming these.

1. Glucocorticoids

Without a doubt, corticosteroids are at the top of the list when it comes to the potential for increasing blood glucose levels. High-dose glucocorticoid therapy is known to lead to new-onset diabetes (steroid-induced diabetes). Similarly, people with preexisting diabetes may notice significant worsening of glycemic control when they start on glucocorticoid therapy. The extent of glucose elevation depends on their glycemic status prior to initiation on steroids, the dose and duration of glucocorticoid therapy, and comorbid conditions, among other factors.

Management tip: For those with previously well-controlled diabetes or borderline diabetes, glucocorticoid-induced hyperglycemia may be managed by metformin with or without sulfonylurea therapy, especially if corticosteroid treatment is low-dose and for a shorter duration. However, for many individuals with preexisting poorly controlled diabetes or those initiated on high-dose corticosteroids, insulin therapy would perhaps be the treatment of choice. Glucocorticoid therapy generally leads to more pronounced postprandial hyperglycemia compared with fasting hyperglycemia; hence, the use of short-acting insulin therapy or perhaps NPH insulin in the morning might be a better option for many individuals. Dietary modification plays an important role in limiting the extent of postprandial hyperglycemia. Use of continuous glucose monitoring (CGM) devices may also be very helpful for understanding glycemic excursions and how to adjust insulin. In individuals for whom glucocorticoid therapy is tapered down, it is important to adjust the dose of medications with potential to cause hypoglycemia, such as insulin/sulfonylurea therapy, as the degree of hyperglycemia may decrease with decreased dose of the glucocorticoid therapy.

2. Antipsychotic Therapy

Antipsychotic medications can be obesogenic; between 15% and 72% of people who take second-generation antipsychotics experience weight gain of 7% or more. Increases in weight are not the only factor contributing to an elevated risk of developing type 2 diabetes. Antipsychotics are thought to cause downregulation of intracellular insulin signaling, leading to insulin resistance. At the same time, there seems to be a direct effect on the pancreatic beta cells. Antagonism of the dopamine D2, serotonin 5-HT2C, and muscarinic M3 receptors impairs beta-cell response to changes in blood glucose. In addition to the pharmacologic effects, cell culture experiments have shown that antipsychotics increase apoptosis of beta cells. Increased weight and concomitant development of type 2 diabetes is seen particularly in agents that exhibit high muscarinic M3 and histamine H1 receptor blockade. The effect on glucose metabolism is seen the most with agents such as clozapine, olanzapine, and haloperidol and the least with agents such as ziprasidone.

Management tip: Given the ongoing change in the understanding of increases in weight and their association with the risk of developing type 2 diabetes, a metabolically safer approach involves starting with medications that have a lower propensity for weight gain, and the partial agonists/third-generation antipsychotics as a family presently have the best overall data.

3. Thiazide Diuretics

Thiazide diuretics are commonly used for the management of hypertension and are associated with metabolic complications including hypokalemia; higher cholesterol, triglycerides, and other circulating lipids; and elevated glucose. It’s thought that the reduced potassium level occurring as a result of these medications might contribute to new-onset diabetes. The hypokalemia occurring from these medications is thought to lead to a decrease in insulin secretion and sensitivity, which is dose dependent. Studies show that the number needed to harm for chlorthalidone-induced diabetes is 29 over 1 year. There is believed to be no additional risk beyond 1 year.

Management tip: It’s important to monitor potassium levels for those initiated on thiazide diuretics. If hypokalemia occurs, it would be pertinent to correct the hypokalemia with potassium supplements to mitigate the risk for new-onset diabetes.

4. Statin Therapy

Statin therapy is thought to be associated with decreased insulin sensitivity and impairment in insulin secretion. The overall incidence of diabetes is pegged to be between 9% and 12% on statin therapy on the basis of meta-analysis studies, and higher on the basis of population-based studies. Overall, the estimated number needed to harm is: 1 out of every 255 patients on statin therapy for 4 years may develop new-onset diabetes. Compare this with the extremely strong evidence for number needed to treat being 39 for 5 years with statin therapy in patients with preexisting heart disease to prevent one occurrence of a nonfatal myocardial infarction.

Management tip: Although statins are associated with a small incident increase in the risk of developing diabetes, the potential benefits of using statin therapy for both primary and secondary prevention of cardiovascular disease significantly outweigh any of the potential risks associated with hyperglycemia. This is an important discussion to have with patients who are reluctant to use statin therapy because of the potential risk for new-onset diabetes as a side effect.

5. Beta-Blockers

Beta-blockers are another commonly used group of medications for managing hypertension, heart failure, coronary artery disease, and arrhythmia. Nonvasodilating beta-blockers such as metoprolol and atenolol are more likely to be associated with increases in A1c, mean plasma glucose, body weight, and triglycerides compared with vasodilating beta-blockers such as carvedilol, nebivolol, and labetalol (Bakris GL et al; Giugliano D et al). Similarly, studies have also shown that atenolol and metoprolol are associated with increased odds of hypoglycemia compared with carvedilol. People on beta-blockers may have masking of some of the symptoms of hypoglycemia, such as tremor, irritability, and palpitations, while other symptoms such as diaphoresis may remain unaffected on beta-blockers.

Management tip: Education on recognizing and managing hypoglycemia would be important when starting patients on beta-blockers if they are on preexisting insulin/sulfonylurea therapy. Use of CGM devices may be helpful if there is a high risk for hypoglycemia, especially as symptoms of hypoglycemia are often masked.

Honorable Mention

Several other medications — including antiretroviral therapy, tyrosine kinase inhibitors, mechanistic target of rapamycin (mTOR) inhibitors, immunosuppressants, and interferon alpha — are associated with worsening glycemic control and new-onset diabetes. Consider these agents’ effects on blood glucose, especially in people with an elevated risk of developing diabetes or those with preexisting diabetes, when prescribing.

A special mention should also be made of androgen deprivation therapy. These include treatment options like goserelin and leuprolide, which are gonadotropin-releasing hormone (GnRH) agonist therapies and are commonly used for prostate cancer management. Depending on the patient, these agents may be used for prolonged duration. Androgen deprivation therapy, by definition, decreases testosterone levels in men, thereby leading to worsening insulin resistance. Increase in fat mass and concomitant muscle wasting have been associated with the use of these medications; these, in turn, lead to peripheral insulin resistance. Nearly 1 out of every 5 men treated with long-term androgen deprivation therapy may be prone to developing worsening of A1c by 1% or more.

Management tip: Men on androgen deprivation therapy should be encouraged to participate in regular physical activity to reduce the burden of insulin resistance and to promote cardiovascular health.

Drug-induced diabetes is potentially reversible in many cases. Similarly, worsening of glycemic control due to medications in people with preexisting diabetes may also attenuate once the effect of the drug wears off. Blood glucose should be monitored on an ongoing basis so that diabetes medications can be adjusted. For some individuals, however, the worsening of glycemic status may be more chronic and may require long-term use of antihyperglycemic agents, especially if the benefits of continuation of the medication leading to hyperglycemia far exceed any potential risks.
 

Dr. Jain is Clinical Instructor, Department of Endocrinology, University of British Columbia; Endocrinologist, Fraser River Endocrinology, Vancouver, British Columbia, Canada. He disclosed ties with Abbott, Amgen, Boehringer Ingelheim, Dexcom, Eli Lilly, Janssen, Medtronic, Merck, and Novo Nordisk.

A version of this article appeared on Medscape.com.

TOPLINE:

Migraine is associated with a significantly increased risk of developing inflammatory bowel disease (IBD), including both Crohn’s disease (CD) and ulcerative colitis (UC), a new nationwide, population-based cohort study showed.

METHODOLOGY:

• Investigators analyzed data from South Korea’s National Health Insurance Service (NHIS) database, which houses data for the nationwide obligatory health system for South Korean citizens.
• Individuals aged ≥ 20 years who had at least one national health screening in 2009 were enrolled in the study and followed until December 2019.
• Investigators searched the data for International Classification of Diseases (10th Revision) codes corresponding to migraine and IBD. IBD diagnoses were also based on clinical manifestation, endoscopic findings, and pathologic findings.

TAKEAWAY:

• More than 10 million people were enrolled in the study (55% male; mean age, 47 years), and of these, 2.8% were diagnosed with migraine during the study period.
• During a median follow-up of 10 years, the incidence of IBD was significantly higher in patients with migraine (adjusted hazard ratio [aHR], 1.31; P < .001), CD (aHR, 1.58; P < .001) and UC (aHR, 1.26; P < .001) than in those without migraine.
• in men vs women (aHR, 1.43 vs 1.12; P = .042).
• Investigators could only speculate about the mechanisms underlying the association between migraine and IBD but suggest pathological processes underlying both migraine and IBD, including proinflammatory cytokines and tumor necrosis factor alpha, may be involved.

IN PRACTICE:

“Clinicians should be aware of the potential risk of IBD in patients diagnosed with migraine especially in men for the development of UC and in migraineurs with a long disease duration for a further risk of CD,” the authors wrote.

SOURCE:

Hyunjung Lee, MD, of Seoul National University College of Medicine, Seoul, South Korea, led the study, which was published online on January 12, 2024, in Scientific Reports.

LIMITATIONS:

Disease severity of migraine and IBD was not available. In addition, certain medications taken to relieve migraine, such as nonsteroidal anti-inflammatory drugs like ibuprofen, could cause intestinal inflammation, but there was no medication information available.

DISCLOSURES:

There was no information about study funding nor disclosures from study authors.
 

A version of this article appeared on Medscape.com.

TOPLINE:

Migraine is associated with a significantly increased risk of developing inflammatory bowel disease (IBD), including both Crohn’s disease (CD) and ulcerative colitis (UC), a new nationwide, population-based cohort study showed.

METHODOLOGY:

• Investigators analyzed data from South Korea’s National Health Insurance Service (NHIS) database, which houses data for the nationwide obligatory health system for South Korean citizens.
• Individuals aged ≥ 20 years who had at least one national health screening in 2009 were enrolled in the study and followed until December 2019.
• Investigators searched the data for International Classification of Diseases (10th Revision) codes corresponding to migraine and IBD. IBD diagnoses were also based on clinical manifestation, endoscopic findings, and pathologic findings.

TAKEAWAY:

• More than 10 million people were enrolled in the study (55% male; mean age, 47 years), and of these, 2.8% were diagnosed with migraine during the study period.
• During a median follow-up of 10 years, the incidence of IBD was significantly higher in patients with migraine (adjusted hazard ratio [aHR], 1.31; P < .001), CD (aHR, 1.58; P < .001) and UC (aHR, 1.26; P < .001) than in those without migraine.
• in men vs women (aHR, 1.43 vs 1.12; P = .042).
• Investigators could only speculate about the mechanisms underlying the association between migraine and IBD but suggest pathological processes underlying both migraine and IBD, including proinflammatory cytokines and tumor necrosis factor alpha, may be involved.

IN PRACTICE:

“Clinicians should be aware of the potential risk of IBD in patients diagnosed with migraine especially in men for the development of UC and in migraineurs with a long disease duration for a further risk of CD,” the authors wrote.

SOURCE:

Hyunjung Lee, MD, of Seoul National University College of Medicine, Seoul, South Korea, led the study, which was published online on January 12, 2024, in Scientific Reports.

LIMITATIONS:

Disease severity of migraine and IBD was not available. In addition, certain medications taken to relieve migraine, such as nonsteroidal anti-inflammatory drugs like ibuprofen, could cause intestinal inflammation, but there was no medication information available.

DISCLOSURES:

There was no information about study funding nor disclosures from study authors.
 

A version of this article appeared on Medscape.com.

TOPLINE:

Migraine is associated with a significantly increased risk of developing inflammatory bowel disease (IBD), including both Crohn’s disease (CD) and ulcerative colitis (UC), a new nationwide, population-based cohort study showed.

METHODOLOGY:

• Investigators analyzed data from South Korea’s National Health Insurance Service (NHIS) database, which houses data for the nationwide obligatory health system for South Korean citizens.
• Individuals aged ≥ 20 years who had at least one national health screening in 2009 were enrolled in the study and followed until December 2019.
• Investigators searched the data for International Classification of Diseases (10th Revision) codes corresponding to migraine and IBD. IBD diagnoses were also based on clinical manifestation, endoscopic findings, and pathologic findings.

TAKEAWAY:

• More than 10 million people were enrolled in the study (55% male; mean age, 47 years), and of these, 2.8% were diagnosed with migraine during the study period.
• During a median follow-up of 10 years, the incidence of IBD was significantly higher in patients with migraine (adjusted hazard ratio [aHR], 1.31; P < .001), CD (aHR, 1.58; P < .001) and UC (aHR, 1.26; P < .001) than in those without migraine.
• in men vs women (aHR, 1.43 vs 1.12; P = .042).
• Investigators could only speculate about the mechanisms underlying the association between migraine and IBD but suggest pathological processes underlying both migraine and IBD, including proinflammatory cytokines and tumor necrosis factor alpha, may be involved.

IN PRACTICE:

“Clinicians should be aware of the potential risk of IBD in patients diagnosed with migraine especially in men for the development of UC and in migraineurs with a long disease duration for a further risk of CD,” the authors wrote.

SOURCE:

Hyunjung Lee, MD, of Seoul National University College of Medicine, Seoul, South Korea, led the study, which was published online on January 12, 2024, in Scientific Reports.

LIMITATIONS:

Disease severity of migraine and IBD was not available. In addition, certain medications taken to relieve migraine, such as nonsteroidal anti-inflammatory drugs like ibuprofen, could cause intestinal inflammation, but there was no medication information available.

DISCLOSURES:

There was no information about study funding nor disclosures from study authors.
 

A version of this article appeared on Medscape.com.