MADRID – A late diagnosis of chronic kidney disease is cause for concern. Scientific societies are therefore advocating for screening at younger ages to reverse this trend and slow the progression of the disease. Nearly all patients seen in primary care are candidates for screening because of their risk factors for kidney disease.

During the 29th National Conference of General and Family Medicine of the Spanish Society for General and Family Physicians, Teresa Benedito, MD, family doctor and member of the society’s cardiovascular group, and Roberto Alcázar, MD, nephrologist at the Infanta Leonor University Hospital, Madrid, presented a clinical case encountered in primary care. They used this case to frame a strong argument for the importance of early screening for chronic kidney disease, and they discussed how to properly manage such screening.

The presentation followed the guidelines in the SEMG publication regarding the management and referral of patients with type 2 diabetes. Dr. Benedito explained that the first thing to ask oneself during a patient visit is “whether they present risk factors for kidney disease. If so, we can’t let them leave before we do a kidney screening.” She then listed the factors in question: age older than 60 years, African heritage, family history of chronic kidney disease, decreased kidney mass, weight loss at birth, hypertension, diabetes, smoking, obesity, and low socioeconomic status.

For his part, Dr. Alcázar mentioned how these factors are similar to cardiovascular risk factors, because “the kidneys are a ball of vessels with double capillarization for purifying blood. They’re the organs with the most arteries per unit of weight, so anything that can damage the arteries can damage the kidneys.”
 

Candidates for screening

“Chronic kidney disease develops in 15% of the adult population in Spain. So, it’s worth asking how many patients have been diagnosed and who should we should be screening.” To the factors listed above, Dr. Alcázar added treatment with nephrotoxic drugs (including nonsteroidal anti-inflammatory drugs) for patients with obstructive urinary tract disease, and a history of acute kidney injury for patients with chronic autoimmune disease or neoplasms. “Thus, nearly all patients seen in primary care would need to be screened.”

Another fundamental question raised was whether patients should be screened before age 60 years. “As a nephrologist, I feel that we have been diagnosing chronic kidney disease late, even though we’ve been doing everything by the book,” said Dr. Alcázar. In his opinion, “the answer to whether we should be screening earlier ... is yes, for two reasons: first, because it’s cost-effective, and second, because it’s very inexpensive.”

Dr. Benedito explained in detail the process for diagnosing this disease. She began by defining the disease as changes in kidney structure and function that last longer than 3 months. These changes are identified by use of two criteria: glomerular filtration rate less than 60 mL/min and kidney injury or lesions with or without reduced filtration rate (renal biopsy, albumin/creatinine ratio greater than 30 mg/g, proteinuria, alterations in urinary sediment or in imaging tests). Thus, “if one of these two criteria persists for more than 3 months, the diagnosis is chronic kidney disease. Also, high creatinine levels are not diagnostic for the disease,” she emphasized.
 

Two related parameters

Glomerular filtration and albuminuria “are highly relevant, because screening for chronic kidney disease is based on these two parameters,” said Dr. Benedito. Glomerular filtration rate varies with age, sex, ethnicity, and body mass. It is useful for identifying the stage of the disease and for monitoring disease progression. Albuminuria, on the other hand, is an indication of the severity of the disease. It’s an early marker for kidney injury and systemic disease and is more sensitive than proteinuria. Therefore, “this factor, together with glomerular filtration rate, allows us to detect, classify, and monitor the progression of chronic kidney disease.”

On this point, Dr. Alcázar emphasized the importance of trends, since variation in glomerular filtration depends on serum creatinine, which can vary by nearly 9%. He explained that glomerular filtration rate is related to the number of nephrons remaining. A glomerular filtration rate of less than 60 mL/min implies that more than half of the nephrons in each kidney have been lost. Albuminuria informs about structural damage (that is, the condition of the remaining nephrons). It’s therefore essential to test for both parameters. “We need to be actively monitoring and then making our decisions based on trends and not on isolated results. We need to be aware of albuminuria when we make our decisions,” said Dr. Alcázar. Some studies have shown the importance of testing for albuminuria whenever creatinine level is assessed. “We need to buy into this. If we don’t do this, we’ll only ever have half the information we need.”
 

Reducing late diagnosis

According to the IBERICAN study, 14% of patients seen in primary care in Spain have chronic kidney disease. “This statistic should make us stop and think, own our responsibility, and ask ourselves why this screening isn’t taking place [earlier],” said Dr. Benedito. She added, “We need to head off this trend toward late diagnosis. As the disease progresses, it significantly increases cardiovascular risk and leads to higher mortality, going on dialysis, transplants, et cetera.”

Dr. Alcázar noted that 80% of nephrology cases that are referred to him come from primary care. He explained the need to understand that “these patients have a sevenfold greater risk of suffering a serious cardiovascular event within the next year than people without kidney problems.” Most of these patients will experience an event, even if they don’t undergo dialysis (stage 3 and those near stage 4).
 

Correct staging

Also fundamental is having a detailed understanding of how staging is performed. Dr. Benedito explained that a chart that pairs glomerular filtration rate (six categories) with the level of albuminuria (three categories) should be used during the visit. For example, a case might be classified as G3a-A2. However, the simplified form of the chart may prove more practical. It classifies chronic kidney disease as being associated with mild, moderate, and severe risk, using different colors to aid comprehension.

Dr. Alcázar noted that the latest guidelines from the European Society of Hypertension for 2023 include albuminuria as an important parameter. The guidelines indicate that for a patient with moderate or severe risk, it is not necessary to calculate their score. “It’s considered high cardiovascular risk, and steps would need to be taken for intervention.”

He then listed the tools available for reversing albuminuria. The process begins by reducing salt consumption and involves the use of medications (angiotensin-converting enzyme inhibitors/angiotensin II receptor antagonists, aldosterone receptor antagonists, glucagon-like peptide-1 analogues, and sodium-glucose cotransporter-2 inhibitors, which slow kidney damage regardless of other measures) and strict management of cardiovascular risk factors (smoking, weight management, blood glucose, hypertension, and moderate physical activity).
 

Reducing cardiovascular risk

Dr. Alcázar highlighted important factors to keep in mind when managing each of the cardiovascular risk factors. For hypertension, the aim is to achieve levels less than 130/80 mm Hg, although recommendations vary, depending on the guidelines consulted. “KDIGO (Kidney Disease: Improving Global Outcomes) 2021 states that there is no evidence for monitoring diastolic blood pressure, only systolic blood pressure. If we measure it according to the standardized form, SBP should be less than 120 mm Hg, and if not, we would fall back on readings of 130/80 mm Hg.”

For lipid control (specifically, low-density lipoprotein cholesterol), the staging chart indicates that for patients at mild risk, levels should be less than 100 mg/dL; for those at moderate risk, less than 70 mg/dL; and for those at severe risk, less than 55 mg/dL. Hypertriglyceridemia “should only be treated with fibrates if it comes in over 1,000 mg/dL. Also, care must be taken, because these drugs interfere with creatinine excretion, increasing it,” said Dr. Alcázar.

Guidelines from the KDIGO and the American Diabetes Association state that anyone with diabetes and chronic kidney disease should receive a sodium-glucose cotransporter-2 inhibitor if their glomerular filtration rate exceeds 20 mL/min, “which may contradict slightly what it says on the label. Also, if they have hypertension, they should take an angiotensin-converting enzyme inhibitor,” said Dr. Alcázar. He added that “oral antidiabetics, including metformin, must be adjusted based on renal function if glomerular filtration rate is under 30 mL/min.”
 

Act immediately

When asked whether the course of chronic kidney disease can be changed, Dr. Alcázar responded with an emphatic yes and added that cardiovascular risk can also be substantially reduced. “As nephrologists, we don’t have access to patients in early stages. But family doctors do. Hence the importance of early screening, because going on dialysis at age 60 isn’t the same as at 80.” Currently, “scientific societies are encouraging authorities to screen for chronic kidney disease at earlier ages.”

Regarding drug-based therapy, Dr. Alcázar said that “empagliflozin is not currently indicated for chronic kidney disease in adults.” This sodium-glucose cotransporter-2 inhibitor delays kidney disease and reduces morbidity. Both benefits were highlighted in two recent studies (DAPA-CKD and CREDENCE). Published in January, EMPA-KIDNEY presents a new twist on nephroprotection for patients with chronic kidney disease (diabetic or not) whose glomerular filtration rates are between 20 and 40 mL/min without albuminuria or whose glomerular filtration rates are between 45 and 90 mL/min with albuminuria. For more than 6,000 patients, empagliflozin was observed “to clearly reduce kidney disease progression, cardiovascular mortality and all-cause mortality, and the need to go on dialysis,” stated Dr. Alcázar.
 

What professionals expect

Dr. Benedito also explained the criteria for referral to a specialist: glomerular filtration rate less than 30 mL/min (unless the patient is older than 80 years and does not have progressively worsening renal function), albumin/creatinine ratio greater than 300 mg/g, acute worsening of renal function, progressive worsening of renal function of greater than 5 mL/min/yr, chronic kidney disease, hypertension treated with triple therapy (including a diuretic) at maximum doses, anemia of less than 10 g/dL, and nonurologic hematuria, especially in combination with albuminuria.

Dr. Benedito explained what nephrologists expect from family doctors in the management of chronic kidney disease: “screening for early detection, identifying and treating risk factors for chronic kidney disease, detecting progression and complications, adjusting drugs based on glomerular filtration rate, and ensuring that our patients are benefiting from sodium-glucose cotransporter-2 inhibitors. These are among the most important steps to be taken.”

Dr. Alcázar mentioned what family doctors expect from nephrologists: “two-way communication, accessibility, coordination of actions to be taken, and using shared and mutually agreed-upon protocols.”

This article was translated from the Medscape Spanish Edition and a version appeared on Medscape.com.

MADRID – A late diagnosis of chronic kidney disease is cause for concern. Scientific societies are therefore advocating for screening at younger ages to reverse this trend and slow the progression of the disease. Nearly all patients seen in primary care are candidates for screening because of their risk factors for kidney disease.

During the 29th National Conference of General and Family Medicine of the Spanish Society for General and Family Physicians, Teresa Benedito, MD, family doctor and member of the society’s cardiovascular group, and Roberto Alcázar, MD, nephrologist at the Infanta Leonor University Hospital, Madrid, presented a clinical case encountered in primary care. They used this case to frame a strong argument for the importance of early screening for chronic kidney disease, and they discussed how to properly manage such screening.

The presentation followed the guidelines in the SEMG publication regarding the management and referral of patients with type 2 diabetes. Dr. Benedito explained that the first thing to ask oneself during a patient visit is “whether they present risk factors for kidney disease. If so, we can’t let them leave before we do a kidney screening.” She then listed the factors in question: age older than 60 years, African heritage, family history of chronic kidney disease, decreased kidney mass, weight loss at birth, hypertension, diabetes, smoking, obesity, and low socioeconomic status.

For his part, Dr. Alcázar mentioned how these factors are similar to cardiovascular risk factors, because “the kidneys are a ball of vessels with double capillarization for purifying blood. They’re the organs with the most arteries per unit of weight, so anything that can damage the arteries can damage the kidneys.”
 

Candidates for screening

“Chronic kidney disease develops in 15% of the adult population in Spain. So, it’s worth asking how many patients have been diagnosed and who should we should be screening.” To the factors listed above, Dr. Alcázar added treatment with nephrotoxic drugs (including nonsteroidal anti-inflammatory drugs) for patients with obstructive urinary tract disease, and a history of acute kidney injury for patients with chronic autoimmune disease or neoplasms. “Thus, nearly all patients seen in primary care would need to be screened.”

Another fundamental question raised was whether patients should be screened before age 60 years. “As a nephrologist, I feel that we have been diagnosing chronic kidney disease late, even though we’ve been doing everything by the book,” said Dr. Alcázar. In his opinion, “the answer to whether we should be screening earlier ... is yes, for two reasons: first, because it’s cost-effective, and second, because it’s very inexpensive.”

Dr. Benedito explained in detail the process for diagnosing this disease. She began by defining the disease as changes in kidney structure and function that last longer than 3 months. These changes are identified by use of two criteria: glomerular filtration rate less than 60 mL/min and kidney injury or lesions with or without reduced filtration rate (renal biopsy, albumin/creatinine ratio greater than 30 mg/g, proteinuria, alterations in urinary sediment or in imaging tests). Thus, “if one of these two criteria persists for more than 3 months, the diagnosis is chronic kidney disease. Also, high creatinine levels are not diagnostic for the disease,” she emphasized.
 

Two related parameters

Glomerular filtration and albuminuria “are highly relevant, because screening for chronic kidney disease is based on these two parameters,” said Dr. Benedito. Glomerular filtration rate varies with age, sex, ethnicity, and body mass. It is useful for identifying the stage of the disease and for monitoring disease progression. Albuminuria, on the other hand, is an indication of the severity of the disease. It’s an early marker for kidney injury and systemic disease and is more sensitive than proteinuria. Therefore, “this factor, together with glomerular filtration rate, allows us to detect, classify, and monitor the progression of chronic kidney disease.”

On this point, Dr. Alcázar emphasized the importance of trends, since variation in glomerular filtration depends on serum creatinine, which can vary by nearly 9%. He explained that glomerular filtration rate is related to the number of nephrons remaining. A glomerular filtration rate of less than 60 mL/min implies that more than half of the nephrons in each kidney have been lost. Albuminuria informs about structural damage (that is, the condition of the remaining nephrons). It’s therefore essential to test for both parameters. “We need to be actively monitoring and then making our decisions based on trends and not on isolated results. We need to be aware of albuminuria when we make our decisions,” said Dr. Alcázar. Some studies have shown the importance of testing for albuminuria whenever creatinine level is assessed. “We need to buy into this. If we don’t do this, we’ll only ever have half the information we need.”
 

Reducing late diagnosis

According to the IBERICAN study, 14% of patients seen in primary care in Spain have chronic kidney disease. “This statistic should make us stop and think, own our responsibility, and ask ourselves why this screening isn’t taking place [earlier],” said Dr. Benedito. She added, “We need to head off this trend toward late diagnosis. As the disease progresses, it significantly increases cardiovascular risk and leads to higher mortality, going on dialysis, transplants, et cetera.”

Dr. Alcázar noted that 80% of nephrology cases that are referred to him come from primary care. He explained the need to understand that “these patients have a sevenfold greater risk of suffering a serious cardiovascular event within the next year than people without kidney problems.” Most of these patients will experience an event, even if they don’t undergo dialysis (stage 3 and those near stage 4).
 

Correct staging

Also fundamental is having a detailed understanding of how staging is performed. Dr. Benedito explained that a chart that pairs glomerular filtration rate (six categories) with the level of albuminuria (three categories) should be used during the visit. For example, a case might be classified as G3a-A2. However, the simplified form of the chart may prove more practical. It classifies chronic kidney disease as being associated with mild, moderate, and severe risk, using different colors to aid comprehension.

Dr. Alcázar noted that the latest guidelines from the European Society of Hypertension for 2023 include albuminuria as an important parameter. The guidelines indicate that for a patient with moderate or severe risk, it is not necessary to calculate their score. “It’s considered high cardiovascular risk, and steps would need to be taken for intervention.”

He then listed the tools available for reversing albuminuria. The process begins by reducing salt consumption and involves the use of medications (angiotensin-converting enzyme inhibitors/angiotensin II receptor antagonists, aldosterone receptor antagonists, glucagon-like peptide-1 analogues, and sodium-glucose cotransporter-2 inhibitors, which slow kidney damage regardless of other measures) and strict management of cardiovascular risk factors (smoking, weight management, blood glucose, hypertension, and moderate physical activity).
 

Reducing cardiovascular risk

Dr. Alcázar highlighted important factors to keep in mind when managing each of the cardiovascular risk factors. For hypertension, the aim is to achieve levels less than 130/80 mm Hg, although recommendations vary, depending on the guidelines consulted. “KDIGO (Kidney Disease: Improving Global Outcomes) 2021 states that there is no evidence for monitoring diastolic blood pressure, only systolic blood pressure. If we measure it according to the standardized form, SBP should be less than 120 mm Hg, and if not, we would fall back on readings of 130/80 mm Hg.”

For lipid control (specifically, low-density lipoprotein cholesterol), the staging chart indicates that for patients at mild risk, levels should be less than 100 mg/dL; for those at moderate risk, less than 70 mg/dL; and for those at severe risk, less than 55 mg/dL. Hypertriglyceridemia “should only be treated with fibrates if it comes in over 1,000 mg/dL. Also, care must be taken, because these drugs interfere with creatinine excretion, increasing it,” said Dr. Alcázar.

Guidelines from the KDIGO and the American Diabetes Association state that anyone with diabetes and chronic kidney disease should receive a sodium-glucose cotransporter-2 inhibitor if their glomerular filtration rate exceeds 20 mL/min, “which may contradict slightly what it says on the label. Also, if they have hypertension, they should take an angiotensin-converting enzyme inhibitor,” said Dr. Alcázar. He added that “oral antidiabetics, including metformin, must be adjusted based on renal function if glomerular filtration rate is under 30 mL/min.”
 

Act immediately

When asked whether the course of chronic kidney disease can be changed, Dr. Alcázar responded with an emphatic yes and added that cardiovascular risk can also be substantially reduced. “As nephrologists, we don’t have access to patients in early stages. But family doctors do. Hence the importance of early screening, because going on dialysis at age 60 isn’t the same as at 80.” Currently, “scientific societies are encouraging authorities to screen for chronic kidney disease at earlier ages.”

Regarding drug-based therapy, Dr. Alcázar said that “empagliflozin is not currently indicated for chronic kidney disease in adults.” This sodium-glucose cotransporter-2 inhibitor delays kidney disease and reduces morbidity. Both benefits were highlighted in two recent studies (DAPA-CKD and CREDENCE). Published in January, EMPA-KIDNEY presents a new twist on nephroprotection for patients with chronic kidney disease (diabetic or not) whose glomerular filtration rates are between 20 and 40 mL/min without albuminuria or whose glomerular filtration rates are between 45 and 90 mL/min with albuminuria. For more than 6,000 patients, empagliflozin was observed “to clearly reduce kidney disease progression, cardiovascular mortality and all-cause mortality, and the need to go on dialysis,” stated Dr. Alcázar.
 

What professionals expect

Dr. Benedito also explained the criteria for referral to a specialist: glomerular filtration rate less than 30 mL/min (unless the patient is older than 80 years and does not have progressively worsening renal function), albumin/creatinine ratio greater than 300 mg/g, acute worsening of renal function, progressive worsening of renal function of greater than 5 mL/min/yr, chronic kidney disease, hypertension treated with triple therapy (including a diuretic) at maximum doses, anemia of less than 10 g/dL, and nonurologic hematuria, especially in combination with albuminuria.

Dr. Benedito explained what nephrologists expect from family doctors in the management of chronic kidney disease: “screening for early detection, identifying and treating risk factors for chronic kidney disease, detecting progression and complications, adjusting drugs based on glomerular filtration rate, and ensuring that our patients are benefiting from sodium-glucose cotransporter-2 inhibitors. These are among the most important steps to be taken.”

Dr. Alcázar mentioned what family doctors expect from nephrologists: “two-way communication, accessibility, coordination of actions to be taken, and using shared and mutually agreed-upon protocols.”

This article was translated from the Medscape Spanish Edition and a version appeared on Medscape.com.

MADRID – A late diagnosis of chronic kidney disease is cause for concern. Scientific societies are therefore advocating for screening at younger ages to reverse this trend and slow the progression of the disease. Nearly all patients seen in primary care are candidates for screening because of their risk factors for kidney disease.

During the 29th National Conference of General and Family Medicine of the Spanish Society for General and Family Physicians, Teresa Benedito, MD, family doctor and member of the society’s cardiovascular group, and Roberto Alcázar, MD, nephrologist at the Infanta Leonor University Hospital, Madrid, presented a clinical case encountered in primary care. They used this case to frame a strong argument for the importance of early screening for chronic kidney disease, and they discussed how to properly manage such screening.

The presentation followed the guidelines in the SEMG publication regarding the management and referral of patients with type 2 diabetes. Dr. Benedito explained that the first thing to ask oneself during a patient visit is “whether they present risk factors for kidney disease. If so, we can’t let them leave before we do a kidney screening.” She then listed the factors in question: age older than 60 years, African heritage, family history of chronic kidney disease, decreased kidney mass, weight loss at birth, hypertension, diabetes, smoking, obesity, and low socioeconomic status.

For his part, Dr. Alcázar mentioned how these factors are similar to cardiovascular risk factors, because “the kidneys are a ball of vessels with double capillarization for purifying blood. They’re the organs with the most arteries per unit of weight, so anything that can damage the arteries can damage the kidneys.”
 

Candidates for screening

“Chronic kidney disease develops in 15% of the adult population in Spain. So, it’s worth asking how many patients have been diagnosed and who should we should be screening.” To the factors listed above, Dr. Alcázar added treatment with nephrotoxic drugs (including nonsteroidal anti-inflammatory drugs) for patients with obstructive urinary tract disease, and a history of acute kidney injury for patients with chronic autoimmune disease or neoplasms. “Thus, nearly all patients seen in primary care would need to be screened.”

Another fundamental question raised was whether patients should be screened before age 60 years. “As a nephrologist, I feel that we have been diagnosing chronic kidney disease late, even though we’ve been doing everything by the book,” said Dr. Alcázar. In his opinion, “the answer to whether we should be screening earlier ... is yes, for two reasons: first, because it’s cost-effective, and second, because it’s very inexpensive.”

Dr. Benedito explained in detail the process for diagnosing this disease. She began by defining the disease as changes in kidney structure and function that last longer than 3 months. These changes are identified by use of two criteria: glomerular filtration rate less than 60 mL/min and kidney injury or lesions with or without reduced filtration rate (renal biopsy, albumin/creatinine ratio greater than 30 mg/g, proteinuria, alterations in urinary sediment or in imaging tests). Thus, “if one of these two criteria persists for more than 3 months, the diagnosis is chronic kidney disease. Also, high creatinine levels are not diagnostic for the disease,” she emphasized.
 

Two related parameters

Glomerular filtration and albuminuria “are highly relevant, because screening for chronic kidney disease is based on these two parameters,” said Dr. Benedito. Glomerular filtration rate varies with age, sex, ethnicity, and body mass. It is useful for identifying the stage of the disease and for monitoring disease progression. Albuminuria, on the other hand, is an indication of the severity of the disease. It’s an early marker for kidney injury and systemic disease and is more sensitive than proteinuria. Therefore, “this factor, together with glomerular filtration rate, allows us to detect, classify, and monitor the progression of chronic kidney disease.”

On this point, Dr. Alcázar emphasized the importance of trends, since variation in glomerular filtration depends on serum creatinine, which can vary by nearly 9%. He explained that glomerular filtration rate is related to the number of nephrons remaining. A glomerular filtration rate of less than 60 mL/min implies that more than half of the nephrons in each kidney have been lost. Albuminuria informs about structural damage (that is, the condition of the remaining nephrons). It’s therefore essential to test for both parameters. “We need to be actively monitoring and then making our decisions based on trends and not on isolated results. We need to be aware of albuminuria when we make our decisions,” said Dr. Alcázar. Some studies have shown the importance of testing for albuminuria whenever creatinine level is assessed. “We need to buy into this. If we don’t do this, we’ll only ever have half the information we need.”
 

Reducing late diagnosis

According to the IBERICAN study, 14% of patients seen in primary care in Spain have chronic kidney disease. “This statistic should make us stop and think, own our responsibility, and ask ourselves why this screening isn’t taking place [earlier],” said Dr. Benedito. She added, “We need to head off this trend toward late diagnosis. As the disease progresses, it significantly increases cardiovascular risk and leads to higher mortality, going on dialysis, transplants, et cetera.”

Dr. Alcázar noted that 80% of nephrology cases that are referred to him come from primary care. He explained the need to understand that “these patients have a sevenfold greater risk of suffering a serious cardiovascular event within the next year than people without kidney problems.” Most of these patients will experience an event, even if they don’t undergo dialysis (stage 3 and those near stage 4).
 

Correct staging

Also fundamental is having a detailed understanding of how staging is performed. Dr. Benedito explained that a chart that pairs glomerular filtration rate (six categories) with the level of albuminuria (three categories) should be used during the visit. For example, a case might be classified as G3a-A2. However, the simplified form of the chart may prove more practical. It classifies chronic kidney disease as being associated with mild, moderate, and severe risk, using different colors to aid comprehension.

Dr. Alcázar noted that the latest guidelines from the European Society of Hypertension for 2023 include albuminuria as an important parameter. The guidelines indicate that for a patient with moderate or severe risk, it is not necessary to calculate their score. “It’s considered high cardiovascular risk, and steps would need to be taken for intervention.”

He then listed the tools available for reversing albuminuria. The process begins by reducing salt consumption and involves the use of medications (angiotensin-converting enzyme inhibitors/angiotensin II receptor antagonists, aldosterone receptor antagonists, glucagon-like peptide-1 analogues, and sodium-glucose cotransporter-2 inhibitors, which slow kidney damage regardless of other measures) and strict management of cardiovascular risk factors (smoking, weight management, blood glucose, hypertension, and moderate physical activity).
 

Reducing cardiovascular risk

Dr. Alcázar highlighted important factors to keep in mind when managing each of the cardiovascular risk factors. For hypertension, the aim is to achieve levels less than 130/80 mm Hg, although recommendations vary, depending on the guidelines consulted. “KDIGO (Kidney Disease: Improving Global Outcomes) 2021 states that there is no evidence for monitoring diastolic blood pressure, only systolic blood pressure. If we measure it according to the standardized form, SBP should be less than 120 mm Hg, and if not, we would fall back on readings of 130/80 mm Hg.”

For lipid control (specifically, low-density lipoprotein cholesterol), the staging chart indicates that for patients at mild risk, levels should be less than 100 mg/dL; for those at moderate risk, less than 70 mg/dL; and for those at severe risk, less than 55 mg/dL. Hypertriglyceridemia “should only be treated with fibrates if it comes in over 1,000 mg/dL. Also, care must be taken, because these drugs interfere with creatinine excretion, increasing it,” said Dr. Alcázar.

Guidelines from the KDIGO and the American Diabetes Association state that anyone with diabetes and chronic kidney disease should receive a sodium-glucose cotransporter-2 inhibitor if their glomerular filtration rate exceeds 20 mL/min, “which may contradict slightly what it says on the label. Also, if they have hypertension, they should take an angiotensin-converting enzyme inhibitor,” said Dr. Alcázar. He added that “oral antidiabetics, including metformin, must be adjusted based on renal function if glomerular filtration rate is under 30 mL/min.”
 

Act immediately

When asked whether the course of chronic kidney disease can be changed, Dr. Alcázar responded with an emphatic yes and added that cardiovascular risk can also be substantially reduced. “As nephrologists, we don’t have access to patients in early stages. But family doctors do. Hence the importance of early screening, because going on dialysis at age 60 isn’t the same as at 80.” Currently, “scientific societies are encouraging authorities to screen for chronic kidney disease at earlier ages.”

Regarding drug-based therapy, Dr. Alcázar said that “empagliflozin is not currently indicated for chronic kidney disease in adults.” This sodium-glucose cotransporter-2 inhibitor delays kidney disease and reduces morbidity. Both benefits were highlighted in two recent studies (DAPA-CKD and CREDENCE). Published in January, EMPA-KIDNEY presents a new twist on nephroprotection for patients with chronic kidney disease (diabetic or not) whose glomerular filtration rates are between 20 and 40 mL/min without albuminuria or whose glomerular filtration rates are between 45 and 90 mL/min with albuminuria. For more than 6,000 patients, empagliflozin was observed “to clearly reduce kidney disease progression, cardiovascular mortality and all-cause mortality, and the need to go on dialysis,” stated Dr. Alcázar.
 

What professionals expect

Dr. Benedito also explained the criteria for referral to a specialist: glomerular filtration rate less than 30 mL/min (unless the patient is older than 80 years and does not have progressively worsening renal function), albumin/creatinine ratio greater than 300 mg/g, acute worsening of renal function, progressive worsening of renal function of greater than 5 mL/min/yr, chronic kidney disease, hypertension treated with triple therapy (including a diuretic) at maximum doses, anemia of less than 10 g/dL, and nonurologic hematuria, especially in combination with albuminuria.

Dr. Benedito explained what nephrologists expect from family doctors in the management of chronic kidney disease: “screening for early detection, identifying and treating risk factors for chronic kidney disease, detecting progression and complications, adjusting drugs based on glomerular filtration rate, and ensuring that our patients are benefiting from sodium-glucose cotransporter-2 inhibitors. These are among the most important steps to be taken.”

Dr. Alcázar mentioned what family doctors expect from nephrologists: “two-way communication, accessibility, coordination of actions to be taken, and using shared and mutually agreed-upon protocols.”

This article was translated from the Medscape Spanish Edition and a version appeared on Medscape.com.

Recent news highlights advancements in the understanding of Alzheimer’s disease: Increased information on biomarkers to be used for evaluation and diagnosis and recent studies on lifestyle factors or medications that do and do not correlate with Alzheimer’s disease.

It is helpful for family medicine physicians and other primary care physicians to be aware of this information to better help our patients and their families. When we have patients with strong family history of cognitive decline, they often will ask us for an early assessment or help with next steps and requests for treatment. Patients and their families want to understand what testing will be done by the neurologist they will likely be seeing.

An article published in Alzheimer’s and Dementia put forward a consensus statement by 11 European scientific societies on diagnosis and management of the disease. These societies defined work flows for processes to utilize biomarkers to diagnose Alzheimer’s disease. Although these work flows may help with diagnosis, they are not able to definitively rule out other causes of dementia. However, they may lead to consistency in how treatments are determined.¹ More consistency will be helpful in counseling patients and their families on the next steps in the treatment plan.

Another study evaluated the correlation between lean mass and dementia. This study demonstrated a decreased risk of dementia in patients with higher lean mass. It is unclear from this study whether the higher lean mass is protective or if decreased cognitive function decreases the amount of lean mass. However, this study does provide hope in two possible ways: it provides potentially predictive information on who may be more at risk of declining cognitive function as well as a modifiable risk factor to address.² Family physicians may use this as part of their counseling for patients who are concerned about their potential risk of dementia. It is yet another reason why we may counsel on healthy diet and weight-bearing exercise to help maintain lean mass.

Other associations related to dementia have been disproven. An article in Gastroenterology discussed the association between cognitive decline and use of proton pump inhibitors and H₂ blockers – indicating that there is no association.³ Although there are reasons why we want to limit the use of these medications – particularly when they are not needed, it is a relief that they are not causing cognitive decline in patients.

Most of these studies provide information that is helpful for both family medicine physicians and patients. We are learning more about cognitive decline and Alzheimer’s disease. This gives hope to patients with strong family history that we may be able to reduce their risks. These studies also give us possible risk factors on which we can counsel our patients.

Developments in Alzheimer’s disease research are speeding ahead and give family physicians a bit more information to discuss with patients and their families as they face the challenging symptoms of cognitive decline. Future research, it is hoped, will help with treatment plans and modifiable risk factors to improve the outcomes for patients at high risk of cognitive decline.

Dr. Wheat is associate professor of family and community medicine at Northwestern University in Chicago. She has no conflicts of interest.

References

1. Massa F et al. Alzheimer’s and Dementia. 2023;19(S2):e062216.

2. Daghlas I et al. BMJ Medicine. 2023;2(1):e000354.

3. Mehta R et al. Gastroenterology. 2023 Jun 12. doi: 10.1053/j.gastro.2023.05.052.

Recent news highlights advancements in the understanding of Alzheimer’s disease: Increased information on biomarkers to be used for evaluation and diagnosis and recent studies on lifestyle factors or medications that do and do not correlate with Alzheimer’s disease.

It is helpful for family medicine physicians and other primary care physicians to be aware of this information to better help our patients and their families. When we have patients with strong family history of cognitive decline, they often will ask us for an early assessment or help with next steps and requests for treatment. Patients and their families want to understand what testing will be done by the neurologist they will likely be seeing.

An article published in Alzheimer’s and Dementia put forward a consensus statement by 11 European scientific societies on diagnosis and management of the disease. These societies defined work flows for processes to utilize biomarkers to diagnose Alzheimer’s disease. Although these work flows may help with diagnosis, they are not able to definitively rule out other causes of dementia. However, they may lead to consistency in how treatments are determined.¹ More consistency will be helpful in counseling patients and their families on the next steps in the treatment plan.

Another study evaluated the correlation between lean mass and dementia. This study demonstrated a decreased risk of dementia in patients with higher lean mass. It is unclear from this study whether the higher lean mass is protective or if decreased cognitive function decreases the amount of lean mass. However, this study does provide hope in two possible ways: it provides potentially predictive information on who may be more at risk of declining cognitive function as well as a modifiable risk factor to address.² Family physicians may use this as part of their counseling for patients who are concerned about their potential risk of dementia. It is yet another reason why we may counsel on healthy diet and weight-bearing exercise to help maintain lean mass.

Other associations related to dementia have been disproven. An article in Gastroenterology discussed the association between cognitive decline and use of proton pump inhibitors and H₂ blockers – indicating that there is no association.³ Although there are reasons why we want to limit the use of these medications – particularly when they are not needed, it is a relief that they are not causing cognitive decline in patients.

Most of these studies provide information that is helpful for both family medicine physicians and patients. We are learning more about cognitive decline and Alzheimer’s disease. This gives hope to patients with strong family history that we may be able to reduce their risks. These studies also give us possible risk factors on which we can counsel our patients.

Developments in Alzheimer’s disease research are speeding ahead and give family physicians a bit more information to discuss with patients and their families as they face the challenging symptoms of cognitive decline. Future research, it is hoped, will help with treatment plans and modifiable risk factors to improve the outcomes for patients at high risk of cognitive decline.

Dr. Wheat is associate professor of family and community medicine at Northwestern University in Chicago. She has no conflicts of interest.

References

1. Massa F et al. Alzheimer’s and Dementia. 2023;19(S2):e062216.

2. Daghlas I et al. BMJ Medicine. 2023;2(1):e000354.

3. Mehta R et al. Gastroenterology. 2023 Jun 12. doi: 10.1053/j.gastro.2023.05.052.

Recent news highlights advancements in the understanding of Alzheimer’s disease: Increased information on biomarkers to be used for evaluation and diagnosis and recent studies on lifestyle factors or medications that do and do not correlate with Alzheimer’s disease.

It is helpful for family medicine physicians and other primary care physicians to be aware of this information to better help our patients and their families. When we have patients with strong family history of cognitive decline, they often will ask us for an early assessment or help with next steps and requests for treatment. Patients and their families want to understand what testing will be done by the neurologist they will likely be seeing.

An article published in Alzheimer’s and Dementia put forward a consensus statement by 11 European scientific societies on diagnosis and management of the disease. These societies defined work flows for processes to utilize biomarkers to diagnose Alzheimer’s disease. Although these work flows may help with diagnosis, they are not able to definitively rule out other causes of dementia. However, they may lead to consistency in how treatments are determined.¹ More consistency will be helpful in counseling patients and their families on the next steps in the treatment plan.

Another study evaluated the correlation between lean mass and dementia. This study demonstrated a decreased risk of dementia in patients with higher lean mass. It is unclear from this study whether the higher lean mass is protective or if decreased cognitive function decreases the amount of lean mass. However, this study does provide hope in two possible ways: it provides potentially predictive information on who may be more at risk of declining cognitive function as well as a modifiable risk factor to address.² Family physicians may use this as part of their counseling for patients who are concerned about their potential risk of dementia. It is yet another reason why we may counsel on healthy diet and weight-bearing exercise to help maintain lean mass.

Other associations related to dementia have been disproven. An article in Gastroenterology discussed the association between cognitive decline and use of proton pump inhibitors and H₂ blockers – indicating that there is no association.³ Although there are reasons why we want to limit the use of these medications – particularly when they are not needed, it is a relief that they are not causing cognitive decline in patients.

Most of these studies provide information that is helpful for both family medicine physicians and patients. We are learning more about cognitive decline and Alzheimer’s disease. This gives hope to patients with strong family history that we may be able to reduce their risks. These studies also give us possible risk factors on which we can counsel our patients.

Developments in Alzheimer’s disease research are speeding ahead and give family physicians a bit more information to discuss with patients and their families as they face the challenging symptoms of cognitive decline. Future research, it is hoped, will help with treatment plans and modifiable risk factors to improve the outcomes for patients at high risk of cognitive decline.

Dr. Wheat is associate professor of family and community medicine at Northwestern University in Chicago. She has no conflicts of interest.

References

1. Massa F et al. Alzheimer’s and Dementia. 2023;19(S2):e062216.

2. Daghlas I et al. BMJ Medicine. 2023;2(1):e000354.

3. Mehta R et al. Gastroenterology. 2023 Jun 12. doi: 10.1053/j.gastro.2023.05.052.

According to the World Health Organization (WHO), approximately 5% of adults (or 280 million people) suffer from depression globally. Although depression is more common in women, it can affect anyone. It is seen in all socioeconomic classes, ages, and races. In response, the WHO developed the Mental Health Gap Action Programme to bring mental health care services to those in need.

Depression can lead to severe consequences, such as loss of employment, relationships difficulties, and suicide. In fact, suicide is the 10th leading cause of death in the United States.

The U.S. Preventive Services Task Force (USPSTF), in past years, concluded that there was insufficient evidence to screen adolescents and adults for depression, However, new guidelines were issued this year in which the task force concluded there was a moderate benefit to screening adults for depression but insufficient evidence to screen for suicide risk. The agency now recommends screening for depression in all adults, even in the absence of risk factors, by using brief screening instruments such as the PHQ (Patient Health Questionnaire).

As family doctors, we have witnessed the burden of depression in our practices. The previous recommendations neglected the fact that mental health disorders were often purposely hidden because of stigma. Many patients do not readily come for treatment for mental illness and sometimes do not even accept these diagnoses. It is good that screening is now recommended, but we need to do more to tear down the stigma attached to mental illness.

These new guidelines do not address the effect that the lack of available mental health services has on treatment. It can take months to get an appointment for a patient with a mental health disorder, even if that person is potentially suicidal. Primary care physicians are often left treating these disorders; sometimes we are treating mental illness whether we feel comfortable doing so or not. Patients may not receive the best care but it is better than no care at all.

Although treating anxiety and depression is common for primary care doctors, specialists should be contacted when cases get more complicated. Even a call to crisis intervention can lead to an emergency department visit with discharge back to the family doctor because there is nowhere else to send the patient. The burden falls on us when we are already burdened by many other things, such as the rising rates of obesity with the resultant consequences of diabetes and heart disease. We simply do not have the time or expertise to treat complicated mental illness.

Creating guidelines to diagnose more undetected cases of depression without increasing the infrastructure to handle it is only going to lead to more pressure on family doctors. Many of us are already burnt out and at our limits. Yes, we want to diagnose every case of depression we can and to treat these patients for these disorders, but we need help.

Another problem with the guidelines is the recommendation to screen for depression and not suicide risk. As family doctors, we ask all patients who are depressed if they have thoughts of hurting themselves or others. Also, some people who commit suicide are not clinically depressed. These questions are simple to ask on an intake form.

Screening for depression is a pretty simple process. A patient can complete a screening tool or the clinician can directly ask the questions. It is a quick, noninvasive process. The Diagnostic and Statistical Manual of Mental Disorders criteria for diagnosing depression are pretty rigid and straightforward so misdiagnoses are not likely to be common.

The new guidelines do not make recommendations for treatment. In the real world, we often see patients unable to get the medications we prescribe because their insurance won’t cover it. Having guidelines supporting medication use would be very helpful.

In the area where I practice, it is difficult to refer a patient for counseling despite there being a plethora of counselors, therapists, and psychologists. These mental health providers often take only cash-paying patients, which eliminates access for many patients.

If we truly want to address the ever-increasing rates of depression in our country, we need to do much more than create new screening guidelines (screening that many family doctors were already doing). We must remove stigma, especially in the health care setting, fund mental health services, make them more readily available, and provide care that is affordable and covered by insurance. Until then, we are just going to add to the load of family doctors until we either break or leave our profession. Patients deserve better.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. She was paid by Pfizer as a consultant on Paxlovid and is the editor in chief of Physician’s Weekly.

According to the World Health Organization (WHO), approximately 5% of adults (or 280 million people) suffer from depression globally. Although depression is more common in women, it can affect anyone. It is seen in all socioeconomic classes, ages, and races. In response, the WHO developed the Mental Health Gap Action Programme to bring mental health care services to those in need.

Depression can lead to severe consequences, such as loss of employment, relationships difficulties, and suicide. In fact, suicide is the 10th leading cause of death in the United States.

The U.S. Preventive Services Task Force (USPSTF), in past years, concluded that there was insufficient evidence to screen adolescents and adults for depression, However, new guidelines were issued this year in which the task force concluded there was a moderate benefit to screening adults for depression but insufficient evidence to screen for suicide risk. The agency now recommends screening for depression in all adults, even in the absence of risk factors, by using brief screening instruments such as the PHQ (Patient Health Questionnaire).

As family doctors, we have witnessed the burden of depression in our practices. The previous recommendations neglected the fact that mental health disorders were often purposely hidden because of stigma. Many patients do not readily come for treatment for mental illness and sometimes do not even accept these diagnoses. It is good that screening is now recommended, but we need to do more to tear down the stigma attached to mental illness.

These new guidelines do not address the effect that the lack of available mental health services has on treatment. It can take months to get an appointment for a patient with a mental health disorder, even if that person is potentially suicidal. Primary care physicians are often left treating these disorders; sometimes we are treating mental illness whether we feel comfortable doing so or not. Patients may not receive the best care but it is better than no care at all.

Although treating anxiety and depression is common for primary care doctors, specialists should be contacted when cases get more complicated. Even a call to crisis intervention can lead to an emergency department visit with discharge back to the family doctor because there is nowhere else to send the patient. The burden falls on us when we are already burdened by many other things, such as the rising rates of obesity with the resultant consequences of diabetes and heart disease. We simply do not have the time or expertise to treat complicated mental illness.

Creating guidelines to diagnose more undetected cases of depression without increasing the infrastructure to handle it is only going to lead to more pressure on family doctors. Many of us are already burnt out and at our limits. Yes, we want to diagnose every case of depression we can and to treat these patients for these disorders, but we need help.

Another problem with the guidelines is the recommendation to screen for depression and not suicide risk. As family doctors, we ask all patients who are depressed if they have thoughts of hurting themselves or others. Also, some people who commit suicide are not clinically depressed. These questions are simple to ask on an intake form.

Screening for depression is a pretty simple process. A patient can complete a screening tool or the clinician can directly ask the questions. It is a quick, noninvasive process. The Diagnostic and Statistical Manual of Mental Disorders criteria for diagnosing depression are pretty rigid and straightforward so misdiagnoses are not likely to be common.

The new guidelines do not make recommendations for treatment. In the real world, we often see patients unable to get the medications we prescribe because their insurance won’t cover it. Having guidelines supporting medication use would be very helpful.

In the area where I practice, it is difficult to refer a patient for counseling despite there being a plethora of counselors, therapists, and psychologists. These mental health providers often take only cash-paying patients, which eliminates access for many patients.

If we truly want to address the ever-increasing rates of depression in our country, we need to do much more than create new screening guidelines (screening that many family doctors were already doing). We must remove stigma, especially in the health care setting, fund mental health services, make them more readily available, and provide care that is affordable and covered by insurance. Until then, we are just going to add to the load of family doctors until we either break or leave our profession. Patients deserve better.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. She was paid by Pfizer as a consultant on Paxlovid and is the editor in chief of Physician’s Weekly.

According to the World Health Organization (WHO), approximately 5% of adults (or 280 million people) suffer from depression globally. Although depression is more common in women, it can affect anyone. It is seen in all socioeconomic classes, ages, and races. In response, the WHO developed the Mental Health Gap Action Programme to bring mental health care services to those in need.

Depression can lead to severe consequences, such as loss of employment, relationships difficulties, and suicide. In fact, suicide is the 10th leading cause of death in the United States.

The U.S. Preventive Services Task Force (USPSTF), in past years, concluded that there was insufficient evidence to screen adolescents and adults for depression, However, new guidelines were issued this year in which the task force concluded there was a moderate benefit to screening adults for depression but insufficient evidence to screen for suicide risk. The agency now recommends screening for depression in all adults, even in the absence of risk factors, by using brief screening instruments such as the PHQ (Patient Health Questionnaire).

As family doctors, we have witnessed the burden of depression in our practices. The previous recommendations neglected the fact that mental health disorders were often purposely hidden because of stigma. Many patients do not readily come for treatment for mental illness and sometimes do not even accept these diagnoses. It is good that screening is now recommended, but we need to do more to tear down the stigma attached to mental illness.

These new guidelines do not address the effect that the lack of available mental health services has on treatment. It can take months to get an appointment for a patient with a mental health disorder, even if that person is potentially suicidal. Primary care physicians are often left treating these disorders; sometimes we are treating mental illness whether we feel comfortable doing so or not. Patients may not receive the best care but it is better than no care at all.

Although treating anxiety and depression is common for primary care doctors, specialists should be contacted when cases get more complicated. Even a call to crisis intervention can lead to an emergency department visit with discharge back to the family doctor because there is nowhere else to send the patient. The burden falls on us when we are already burdened by many other things, such as the rising rates of obesity with the resultant consequences of diabetes and heart disease. We simply do not have the time or expertise to treat complicated mental illness.

Creating guidelines to diagnose more undetected cases of depression without increasing the infrastructure to handle it is only going to lead to more pressure on family doctors. Many of us are already burnt out and at our limits. Yes, we want to diagnose every case of depression we can and to treat these patients for these disorders, but we need help.

Another problem with the guidelines is the recommendation to screen for depression and not suicide risk. As family doctors, we ask all patients who are depressed if they have thoughts of hurting themselves or others. Also, some people who commit suicide are not clinically depressed. These questions are simple to ask on an intake form.

Screening for depression is a pretty simple process. A patient can complete a screening tool or the clinician can directly ask the questions. It is a quick, noninvasive process. The Diagnostic and Statistical Manual of Mental Disorders criteria for diagnosing depression are pretty rigid and straightforward so misdiagnoses are not likely to be common.

The new guidelines do not make recommendations for treatment. In the real world, we often see patients unable to get the medications we prescribe because their insurance won’t cover it. Having guidelines supporting medication use would be very helpful.

In the area where I practice, it is difficult to refer a patient for counseling despite there being a plethora of counselors, therapists, and psychologists. These mental health providers often take only cash-paying patients, which eliminates access for many patients.

If we truly want to address the ever-increasing rates of depression in our country, we need to do much more than create new screening guidelines (screening that many family doctors were already doing). We must remove stigma, especially in the health care setting, fund mental health services, make them more readily available, and provide care that is affordable and covered by insurance. Until then, we are just going to add to the load of family doctors until we either break or leave our profession. Patients deserve better.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Robert Wood Johnson Medical School, New Brunswick, N.J. She was paid by Pfizer as a consultant on Paxlovid and is the editor in chief of Physician’s Weekly.

A new generation of medications designed to help individuals lose weight is in the news and stirring considerable debate within medical, insurer, and employer circles. Indeed, these drugs show striking results, compared with weight loss drugs of the past, with some research reporting a 15%-20% loss in body weight when used as an adjunct to intensive behavior therapy and intensive lifestyle intervention.
 

Obesity and associated chronic diseases are at an epidemic level in the United States and carry enormous personal, family, and societal burdens. As an exercise physiologist and a dual board-certified cardiologist and lifestyle medicine specialist, I am grateful for modern medicine and have leveraged the efficacy of many medications in patient care. I also recognize that it is in my patients’ and my own best interests to strive for health restoration rather than default to a lifetime of disease management. This is especially urgent when it comes to children.

That’s why as physicians we must not allow these new medications to overshadow an evidence-based comprehensive lifestyle approach – the first recommended treatment in most chronic disease care guidelines – as the optimal step toward achieving long-term health improvement.

As a matter of fact, too often lost in news stories about the success of obesity drugs like tirzepatide and semaglutide is that research study participants also received intensive lifestyle interventions. Regardless of whether clinicians ultimately prescribe weight loss medications, it is important that they first engage in patient-centered discussions that provide information about all the available treatment options and explore with patients an adequate dose of lifestyle intervention before pronouncing this approach a failure.

Merely advising a patient to eat better or exercise more is rarely sufficient information, much less sufficient dosing information, for significant weight loss. As a recent American College of Lifestyle Medicine position statement on the treatment of obesity put it: “While adequately dosed lifestyle interventions may unilaterally achieve success, obesity is a complex, multifactorial disease wherein patients may require approaches beyond lifestyle alone. However, lifestyle interventions are too often not adequately ‘dosed’ for success.”

Appetite suppression may reduce food intake, but optimal health requires eating nutrient-dense foods high in fiber and healthy fats, and preserving muscle mass through physical activity. Simply reducing the portion size of the same unhealthy, ultraprocessed foods that the patient ate before starting medication does not achieve optimal health, no matter what the scale says. ACLM’s position statement emphasizes that “a comprehensive lifestyle medicine approach prevents and treats many other comorbidities associated with overweight and obesity, including, but not limited to, hypertension, high cholesterol, heart disease, type 2 diabetes, and arthritis, and a lifestyle medicine approach can also reduce the risk of many types of cancer.”

This is even more critical in children, who may not fully understand how to eat healthfully. Furthermore, the long-term effects of weight loss medication on their still-developing bodies are unclear. Decades ago, we didn’t face an epidemic of childhood obesity; type 2 diabetes was called “adult-onset” because it was a lifestyle-related chronic disease that didn’t manifest until adulthood. We would never have considered weight-loss medications for children or gastric bypass for teens. Yet, this lifestyle-related chronic disease is now afflicting our youth.

We have allowed an abnormal food environment to fester, with nearly 60% of the American diet now consisting of ultraprocessed foods. Obesity within families may be related to shared genetics but may also be due to shared food, lifestyle, and environmental factors passed down through generations. A successful obesity treatment plan should address as many of those drivers of obesity as possible, as well as access to healthy food, transportation, and other social determinants of health.

Cost is a major consideration in clinical decision-making for weight loss treatment. The new obesity drugs are expensive, and patients probably must continue to take them throughout their lives to avoid regaining lost weight. With 70% of Americans and 90% of seniors already taking prescription drugs, the United States already spends more on pharmaceuticals than the rest of the world combined. Not all insurance plans cover these medications for the treatment of obesity, and as patients covered through one insurance plan may lose coverage on their next plan, they could be forced to stop the medications and pay out of pocket or experience fluctuations in their weight. Health care providers should consider the physical and emotional burden of weight cycling and strategically advance lifestyle measures to mitigate weight fluctuations in such patients.

Shared decisions between patients and their families and health care providers will become even more important in the rollout of new medications and obesity management guidelines. I’m hopeful that the elevated attention to obesity solutions will shepherd in thoughtful collaborations among board-certified obesity specialists, lifestyle medicine specialists, and primary care providers. ACLM, in support of the White House Conference on Hunger, Nutrition and Health, has offered 5.5 hours of complimentary CE/CME coursework in nutrition and food as medicine to 100,000 health professionals. This free opportunity (valued at $220) is an excellent step toward establishing a foundation of lifestyle medicine knowledge for health professionals treating patients for obesity. Clinicians can register here.

Let’s all get this right: Lifestyle behavior is the foundation of patients’ health and wellness at every stage of life, with or without adjunctive medication therapy. New tools like weight loss medications will arise but cannot truly achieve optimal health without lifestyle medicine as a continuum throughout a patient’s life.

A version of this article first appeared on Medscape.com.

A new generation of medications designed to help individuals lose weight is in the news and stirring considerable debate within medical, insurer, and employer circles. Indeed, these drugs show striking results, compared with weight loss drugs of the past, with some research reporting a 15%-20% loss in body weight when used as an adjunct to intensive behavior therapy and intensive lifestyle intervention.
 

Obesity and associated chronic diseases are at an epidemic level in the United States and carry enormous personal, family, and societal burdens. As an exercise physiologist and a dual board-certified cardiologist and lifestyle medicine specialist, I am grateful for modern medicine and have leveraged the efficacy of many medications in patient care. I also recognize that it is in my patients’ and my own best interests to strive for health restoration rather than default to a lifetime of disease management. This is especially urgent when it comes to children.

That’s why as physicians we must not allow these new medications to overshadow an evidence-based comprehensive lifestyle approach – the first recommended treatment in most chronic disease care guidelines – as the optimal step toward achieving long-term health improvement.

As a matter of fact, too often lost in news stories about the success of obesity drugs like tirzepatide and semaglutide is that research study participants also received intensive lifestyle interventions. Regardless of whether clinicians ultimately prescribe weight loss medications, it is important that they first engage in patient-centered discussions that provide information about all the available treatment options and explore with patients an adequate dose of lifestyle intervention before pronouncing this approach a failure.

Merely advising a patient to eat better or exercise more is rarely sufficient information, much less sufficient dosing information, for significant weight loss. As a recent American College of Lifestyle Medicine position statement on the treatment of obesity put it: “While adequately dosed lifestyle interventions may unilaterally achieve success, obesity is a complex, multifactorial disease wherein patients may require approaches beyond lifestyle alone. However, lifestyle interventions are too often not adequately ‘dosed’ for success.”

Appetite suppression may reduce food intake, but optimal health requires eating nutrient-dense foods high in fiber and healthy fats, and preserving muscle mass through physical activity. Simply reducing the portion size of the same unhealthy, ultraprocessed foods that the patient ate before starting medication does not achieve optimal health, no matter what the scale says. ACLM’s position statement emphasizes that “a comprehensive lifestyle medicine approach prevents and treats many other comorbidities associated with overweight and obesity, including, but not limited to, hypertension, high cholesterol, heart disease, type 2 diabetes, and arthritis, and a lifestyle medicine approach can also reduce the risk of many types of cancer.”

This is even more critical in children, who may not fully understand how to eat healthfully. Furthermore, the long-term effects of weight loss medication on their still-developing bodies are unclear. Decades ago, we didn’t face an epidemic of childhood obesity; type 2 diabetes was called “adult-onset” because it was a lifestyle-related chronic disease that didn’t manifest until adulthood. We would never have considered weight-loss medications for children or gastric bypass for teens. Yet, this lifestyle-related chronic disease is now afflicting our youth.

We have allowed an abnormal food environment to fester, with nearly 60% of the American diet now consisting of ultraprocessed foods. Obesity within families may be related to shared genetics but may also be due to shared food, lifestyle, and environmental factors passed down through generations. A successful obesity treatment plan should address as many of those drivers of obesity as possible, as well as access to healthy food, transportation, and other social determinants of health.

Cost is a major consideration in clinical decision-making for weight loss treatment. The new obesity drugs are expensive, and patients probably must continue to take them throughout their lives to avoid regaining lost weight. With 70% of Americans and 90% of seniors already taking prescription drugs, the United States already spends more on pharmaceuticals than the rest of the world combined. Not all insurance plans cover these medications for the treatment of obesity, and as patients covered through one insurance plan may lose coverage on their next plan, they could be forced to stop the medications and pay out of pocket or experience fluctuations in their weight. Health care providers should consider the physical and emotional burden of weight cycling and strategically advance lifestyle measures to mitigate weight fluctuations in such patients.

Shared decisions between patients and their families and health care providers will become even more important in the rollout of new medications and obesity management guidelines. I’m hopeful that the elevated attention to obesity solutions will shepherd in thoughtful collaborations among board-certified obesity specialists, lifestyle medicine specialists, and primary care providers. ACLM, in support of the White House Conference on Hunger, Nutrition and Health, has offered 5.5 hours of complimentary CE/CME coursework in nutrition and food as medicine to 100,000 health professionals. This free opportunity (valued at $220) is an excellent step toward establishing a foundation of lifestyle medicine knowledge for health professionals treating patients for obesity. Clinicians can register here.

Let’s all get this right: Lifestyle behavior is the foundation of patients’ health and wellness at every stage of life, with or without adjunctive medication therapy. New tools like weight loss medications will arise but cannot truly achieve optimal health without lifestyle medicine as a continuum throughout a patient’s life.

A version of this article first appeared on Medscape.com.

A new generation of medications designed to help individuals lose weight is in the news and stirring considerable debate within medical, insurer, and employer circles. Indeed, these drugs show striking results, compared with weight loss drugs of the past, with some research reporting a 15%-20% loss in body weight when used as an adjunct to intensive behavior therapy and intensive lifestyle intervention.
 

Obesity and associated chronic diseases are at an epidemic level in the United States and carry enormous personal, family, and societal burdens. As an exercise physiologist and a dual board-certified cardiologist and lifestyle medicine specialist, I am grateful for modern medicine and have leveraged the efficacy of many medications in patient care. I also recognize that it is in my patients’ and my own best interests to strive for health restoration rather than default to a lifetime of disease management. This is especially urgent when it comes to children.

That’s why as physicians we must not allow these new medications to overshadow an evidence-based comprehensive lifestyle approach – the first recommended treatment in most chronic disease care guidelines – as the optimal step toward achieving long-term health improvement.

As a matter of fact, too often lost in news stories about the success of obesity drugs like tirzepatide and semaglutide is that research study participants also received intensive lifestyle interventions. Regardless of whether clinicians ultimately prescribe weight loss medications, it is important that they first engage in patient-centered discussions that provide information about all the available treatment options and explore with patients an adequate dose of lifestyle intervention before pronouncing this approach a failure.

Merely advising a patient to eat better or exercise more is rarely sufficient information, much less sufficient dosing information, for significant weight loss. As a recent American College of Lifestyle Medicine position statement on the treatment of obesity put it: “While adequately dosed lifestyle interventions may unilaterally achieve success, obesity is a complex, multifactorial disease wherein patients may require approaches beyond lifestyle alone. However, lifestyle interventions are too often not adequately ‘dosed’ for success.”

Appetite suppression may reduce food intake, but optimal health requires eating nutrient-dense foods high in fiber and healthy fats, and preserving muscle mass through physical activity. Simply reducing the portion size of the same unhealthy, ultraprocessed foods that the patient ate before starting medication does not achieve optimal health, no matter what the scale says. ACLM’s position statement emphasizes that “a comprehensive lifestyle medicine approach prevents and treats many other comorbidities associated with overweight and obesity, including, but not limited to, hypertension, high cholesterol, heart disease, type 2 diabetes, and arthritis, and a lifestyle medicine approach can also reduce the risk of many types of cancer.”

This is even more critical in children, who may not fully understand how to eat healthfully. Furthermore, the long-term effects of weight loss medication on their still-developing bodies are unclear. Decades ago, we didn’t face an epidemic of childhood obesity; type 2 diabetes was called “adult-onset” because it was a lifestyle-related chronic disease that didn’t manifest until adulthood. We would never have considered weight-loss medications for children or gastric bypass for teens. Yet, this lifestyle-related chronic disease is now afflicting our youth.

We have allowed an abnormal food environment to fester, with nearly 60% of the American diet now consisting of ultraprocessed foods. Obesity within families may be related to shared genetics but may also be due to shared food, lifestyle, and environmental factors passed down through generations. A successful obesity treatment plan should address as many of those drivers of obesity as possible, as well as access to healthy food, transportation, and other social determinants of health.

Cost is a major consideration in clinical decision-making for weight loss treatment. The new obesity drugs are expensive, and patients probably must continue to take them throughout their lives to avoid regaining lost weight. With 70% of Americans and 90% of seniors already taking prescription drugs, the United States already spends more on pharmaceuticals than the rest of the world combined. Not all insurance plans cover these medications for the treatment of obesity, and as patients covered through one insurance plan may lose coverage on their next plan, they could be forced to stop the medications and pay out of pocket or experience fluctuations in their weight. Health care providers should consider the physical and emotional burden of weight cycling and strategically advance lifestyle measures to mitigate weight fluctuations in such patients.

Shared decisions between patients and their families and health care providers will become even more important in the rollout of new medications and obesity management guidelines. I’m hopeful that the elevated attention to obesity solutions will shepherd in thoughtful collaborations among board-certified obesity specialists, lifestyle medicine specialists, and primary care providers. ACLM, in support of the White House Conference on Hunger, Nutrition and Health, has offered 5.5 hours of complimentary CE/CME coursework in nutrition and food as medicine to 100,000 health professionals. This free opportunity (valued at $220) is an excellent step toward establishing a foundation of lifestyle medicine knowledge for health professionals treating patients for obesity. Clinicians can register here.

Let’s all get this right: Lifestyle behavior is the foundation of patients’ health and wellness at every stage of life, with or without adjunctive medication therapy. New tools like weight loss medications will arise but cannot truly achieve optimal health without lifestyle medicine as a continuum throughout a patient’s life.

A version of this article first appeared on Medscape.com.

Over the past few years, there has been rampant misinformation regarding gender-affirming care for transgender youth. In particular, there has been confusion regarding how care is administered, and what types of care are considered at various stages of development. This primer will help you understand the developmental approach to supporting transgender youth.

Gender-affirming care is a broad term that can encapsulate many different domains: social, legal, medical, and surgical affirmation. While people generally think of medical and surgical aspects of gender-affirming care, other domains can be just as important. For example, a 2020 publication in The Lancet Public Health found that access to gender-congruent government identification documents was associated with lower odds of severe psychological distress and suicidality.¹ 

Stanford Lucille Packard Children's Hospital.

Considerations for prepubertal children

The youngest developmental stage at which a young person may seek care regarding gender diversity is the prepubertal childhood stage. Guidelines set forth by The Endocrine Society and The World Professional Association for Transgender Health make it clear that no medical or surgical interventions are considered at this developmental stage.^2,3 However, some young people may choose to pursue a “social transition.” Though this may sound like one thing, social transition can mean very different things for different people. It may include any combination of adopting a new name, pronouns, hairstyle, clothing, etc. Young people may also choose to pursue these various aspects of social transition in all settings, or sometimes only in some settings (for example, only at home if they don’t yet feel comfortable doing so at school). Research so far shows that prepubertal children who are allowed to socially transition have levels of anxiety and depression nearly indistinguishable from their cisgender peers.⁴ While some in the past have raised the question of whether a social transition increases a child’s degree of gender incongruence and thus their likelihood to “persist” in a transgender identity, research has suggested this is not the case, and that gender identity does not meaningfully differ before and after a social transition.⁵ It’s worth noting, that “desistance” of a young person’s transgender identity is generally not considered an ethical goal and that gender identity conversion efforts (that is, attempts to force transgender people to be cisgender) have been labeled unethical by the American Academy of Child & Adolescent Psychiatry.

Sadly, transgender children are victims of bullying at high rates in their schools and communities. Creating safe and affirming school and community environments can be some of the highest yield ways in which providers can support the mental health of gender-diverse youth at this stage. Gender Spectrum is an excellent nonprofit that provides resources to help families and communities with some of these nonmedical supports.

 

Early adolescence and pubertal suppression

The earliest gender-affirming medical intervention that may be considered is pubertal suppression. Pubertal suppression is achieved with gonadotropin-releasing hormone agonists. This class of medications is Food and Drug Administration approved in pediatrics for precocious puberty – a condition in which young people enter puberty much earlier than expected (sometimes as early as age 3). For that condition, the rationale is to delay puberty until the patient reaches a more developmentally normative age for puberty to begin. The rationale for pubertal suppression for adolescent gender dysphoria is somewhat similar – these medications allow for the temporary pausing of puberty, which can be particularly helpful for adolescents who are having severe negative psychological reactions to the ways in which their bodies are developing. The major advantage here is that pubertal suppression can be reversed (if the medication is stopped, endogenous puberty will proceed), whereas puberty itself cannot be easily reversed (resulting in adult transgender people needing surgery and other interventions later in life, if these changes can be fully undone at all). As with all medications, puberty blockers do carry known side effects, including falling behind on bone density (sex hormones are needed to mineralize bones). Because of this, it is generally recommended that adolescents have their bone density monitored during treatment, pursue avenues to improve bone health (for example, exercise), and either stop the puberty blocker to undergo endogenous puberty or start gender-affirming hormones (estrogen or testosterone) by around age 16. 

It is also important to note that, under current guidelines, an adolescent must first undergo a comprehensive biopsychosocial mental health evaluation prior to starting pubertal suppression to ensure the clinical team has a comprehensive understanding of the adolescent’s mental health, that all potential gender supports that are needed are put into place, and that the adolescent and their guardians have a strong understanding of the medical intervention, its risks, side effects, and potential benefits. In addition, consent must be provided by parents or legal guardians, whereas adolescents themselves provide assent. Several studies have linked access to pubertal suppression, when indicated for gender dysphoria, to improved mental health outcomes (for example, van der Miesen and colleagues, Turban and colleagues, de Vries and colleagues, and Costa and colleagues).^6-9

 

Later adolescence and gender-affirming hormones

Later in adolescence, transgender youth may be candidates for gender-affirming hormone treatment (for example, estrogen or testosterone) to induce pubertal changes that align with their gender identities. Once again, under current guidelines, a comprehensive mental health biopsychosocial evaluation must be conducted prior to initiation of these treatments. Part of this evaluation includes fertility counseling and consideration of fertility preservation (for example, oocyte or semen cryopreservation), given the potential for these medications to impact fertility. It also involves discussion of several of the physiologic changes from these medications that can be irreversible (for example, voice changes from testosterone are particularly difficult to reverse in the future). Tables of the physical changes from these medications, when they begin after starting, and when they generally reach their maximum are available in the Endocrine Society guidelines.² The past endocrine society guidelines recommended not initiating gender-affirming hormones until age 16. The most recent guidelines note that there may be instances in which providers may consider starting them as early as age 13 (for example, to reduce risk of falling behind on bone density, or if a patient is having psychological distress related to their peers going through puberty while they are still in a prepubertal state). The latest World Professional Association for Transgender Health Standards of Care removed specific age cutoffs, highlighting the importance of a multidisciplinary team of mental health and hormone prescribing providers working together to understand the best course of action for a particular patient. As with pubertal suppression, several studies have linked access to gender-affirming hormones to improve mental health for adolescents with gender dysphoria (for example, Turban and colleagues, Chen and colleagues, de Vries and colleagues, Allen and colleagues, and Tordoff and colleagues).^10-14

Gender-affirming surgeries

The vast majority of gender-affirming surgeries are not considered until adulthood. The most notable exception to this is masculinizing top surgery for trans masculine and nonbinary adolescents. As with all surgeries, this is a major decision, and requires agreement from a mental health provider, a medical provider, and the surgeon. Early research suggests such surgeries result in improved chest dysphoria and that regret rates appear to be low.^15,16 While the latest World Professional Association for Transgender Health similarly removed strict age cutoffs for gender-affirming surgery, again noting the importance of individualized care, I suspect most will read this change in the context of the Endocrine Society guidelines and past WPATH guidelines that noted gender-affirming genital surgeries are not offered until adulthood (a rare exception perhaps being someone pursuing a gender-affirming vaginoplasty at say age 17 in the summer prior to college to avoid needing to take off from school for surgical recovery). Gender-affirming genital surgeries are generally much more involved surgeries with prolonged recovery times. 

Given the substantial proportion of young people who openly identify as transgender,¹⁷ and the proliferation of misinformation, political rhetoric, and legislation that can impact gender-affirming care for adolescents with gender dysphoria,¹⁸ it is essential that providers have accurate, up-to-date information on what this care entails and how it is provided.

Dr. Turban is director of the gender psychiatry program at the University of California, San Francisco, where he is an assistant professor of child & adolescent psychiatry and affiliate faculty at the Philip R. Lee Institute for Health Policy Studies. He is on Twitter @jack_turban.
 

References

1. Malta M et al. Lancet Public Health. 2020 Apr;5(4):e178-9.

2. Hembree WC et al. J Clin Endocrinol Metab. 2017 Nov 1;102(11):3869-903.

3. Coleman E et al. Int J Transgend Health. 2022 Sep 6;23(Suppl 1):S1-259.

4. Durwood L et al. J Am Acad Child Adolesc Psychiatry. 2017 Feb;56(2):116-23.e2.

5. Rae JR et al. Psychol Sci. 2019 May;30(5):669-81.

6. van der Miesen AIR et al. J Adolesc Health. 2020 Jun;66(6):699-704.

7. Turban JL et al. Pediatrics. 2020 Feb;145(2):e20191725.

8. de Vries ALC et al. J Sex Med. 2011 Aug;8(8):2276-83.

9. Costa R et al. J Sex Med. 2015 Nov;12(11):2206-14.

10. Turban JL et al. PLoS One. 2022 Jan 12;17(1):e0261039.

11. Chen D et al. N Engl J Med. 2023;388:240-50.

12. de Vries ALC et al. Pediatrics. 2014 Oct;134(4):696-70.

13. Allen LR et al. Clin Pract Pediatr Psychol. 2019. doi: 10.1037/cpp0000288.

14. Tordoff DM et al. JAMA Netw Open. 2022 Feb 1;5(2):e220978.

15. Olson-Kennedy J et al. JAMA Pediatr. 2018;172(5):431-6.

16. Tang A et al. Ann Plast Surg. 2022 May;88(4 Suppl):S325-31

17. Johns MM et al. Morb Mortal Wkly Rep. 2019 Jan 25;68(3):67-71.

18. Turban JL et al. JAMA. 2021;325(22):2251-2.

Over the past few years, there has been rampant misinformation regarding gender-affirming care for transgender youth. In particular, there has been confusion regarding how care is administered, and what types of care are considered at various stages of development. This primer will help you understand the developmental approach to supporting transgender youth.

Gender-affirming care is a broad term that can encapsulate many different domains: social, legal, medical, and surgical affirmation. While people generally think of medical and surgical aspects of gender-affirming care, other domains can be just as important. For example, a 2020 publication in The Lancet Public Health found that access to gender-congruent government identification documents was associated with lower odds of severe psychological distress and suicidality.¹ 

Stanford Lucille Packard Children's Hospital.

Considerations for prepubertal children

The youngest developmental stage at which a young person may seek care regarding gender diversity is the prepubertal childhood stage. Guidelines set forth by The Endocrine Society and The World Professional Association for Transgender Health make it clear that no medical or surgical interventions are considered at this developmental stage.^2,3 However, some young people may choose to pursue a “social transition.” Though this may sound like one thing, social transition can mean very different things for different people. It may include any combination of adopting a new name, pronouns, hairstyle, clothing, etc. Young people may also choose to pursue these various aspects of social transition in all settings, or sometimes only in some settings (for example, only at home if they don’t yet feel comfortable doing so at school). Research so far shows that prepubertal children who are allowed to socially transition have levels of anxiety and depression nearly indistinguishable from their cisgender peers.⁴ While some in the past have raised the question of whether a social transition increases a child’s degree of gender incongruence and thus their likelihood to “persist” in a transgender identity, research has suggested this is not the case, and that gender identity does not meaningfully differ before and after a social transition.⁵ It’s worth noting, that “desistance” of a young person’s transgender identity is generally not considered an ethical goal and that gender identity conversion efforts (that is, attempts to force transgender people to be cisgender) have been labeled unethical by the American Academy of Child & Adolescent Psychiatry.

Sadly, transgender children are victims of bullying at high rates in their schools and communities. Creating safe and affirming school and community environments can be some of the highest yield ways in which providers can support the mental health of gender-diverse youth at this stage. Gender Spectrum is an excellent nonprofit that provides resources to help families and communities with some of these nonmedical supports.

 

Early adolescence and pubertal suppression

The earliest gender-affirming medical intervention that may be considered is pubertal suppression. Pubertal suppression is achieved with gonadotropin-releasing hormone agonists. This class of medications is Food and Drug Administration approved in pediatrics for precocious puberty – a condition in which young people enter puberty much earlier than expected (sometimes as early as age 3). For that condition, the rationale is to delay puberty until the patient reaches a more developmentally normative age for puberty to begin. The rationale for pubertal suppression for adolescent gender dysphoria is somewhat similar – these medications allow for the temporary pausing of puberty, which can be particularly helpful for adolescents who are having severe negative psychological reactions to the ways in which their bodies are developing. The major advantage here is that pubertal suppression can be reversed (if the medication is stopped, endogenous puberty will proceed), whereas puberty itself cannot be easily reversed (resulting in adult transgender people needing surgery and other interventions later in life, if these changes can be fully undone at all). As with all medications, puberty blockers do carry known side effects, including falling behind on bone density (sex hormones are needed to mineralize bones). Because of this, it is generally recommended that adolescents have their bone density monitored during treatment, pursue avenues to improve bone health (for example, exercise), and either stop the puberty blocker to undergo endogenous puberty or start gender-affirming hormones (estrogen or testosterone) by around age 16. 

It is also important to note that, under current guidelines, an adolescent must first undergo a comprehensive biopsychosocial mental health evaluation prior to starting pubertal suppression to ensure the clinical team has a comprehensive understanding of the adolescent’s mental health, that all potential gender supports that are needed are put into place, and that the adolescent and their guardians have a strong understanding of the medical intervention, its risks, side effects, and potential benefits. In addition, consent must be provided by parents or legal guardians, whereas adolescents themselves provide assent. Several studies have linked access to pubertal suppression, when indicated for gender dysphoria, to improved mental health outcomes (for example, van der Miesen and colleagues, Turban and colleagues, de Vries and colleagues, and Costa and colleagues).^6-9

 

Later adolescence and gender-affirming hormones

Later in adolescence, transgender youth may be candidates for gender-affirming hormone treatment (for example, estrogen or testosterone) to induce pubertal changes that align with their gender identities. Once again, under current guidelines, a comprehensive mental health biopsychosocial evaluation must be conducted prior to initiation of these treatments. Part of this evaluation includes fertility counseling and consideration of fertility preservation (for example, oocyte or semen cryopreservation), given the potential for these medications to impact fertility. It also involves discussion of several of the physiologic changes from these medications that can be irreversible (for example, voice changes from testosterone are particularly difficult to reverse in the future). Tables of the physical changes from these medications, when they begin after starting, and when they generally reach their maximum are available in the Endocrine Society guidelines.² The past endocrine society guidelines recommended not initiating gender-affirming hormones until age 16. The most recent guidelines note that there may be instances in which providers may consider starting them as early as age 13 (for example, to reduce risk of falling behind on bone density, or if a patient is having psychological distress related to their peers going through puberty while they are still in a prepubertal state). The latest World Professional Association for Transgender Health Standards of Care removed specific age cutoffs, highlighting the importance of a multidisciplinary team of mental health and hormone prescribing providers working together to understand the best course of action for a particular patient. As with pubertal suppression, several studies have linked access to gender-affirming hormones to improve mental health for adolescents with gender dysphoria (for example, Turban and colleagues, Chen and colleagues, de Vries and colleagues, Allen and colleagues, and Tordoff and colleagues).^10-14

Gender-affirming surgeries

The vast majority of gender-affirming surgeries are not considered until adulthood. The most notable exception to this is masculinizing top surgery for trans masculine and nonbinary adolescents. As with all surgeries, this is a major decision, and requires agreement from a mental health provider, a medical provider, and the surgeon. Early research suggests such surgeries result in improved chest dysphoria and that regret rates appear to be low.^15,16 While the latest World Professional Association for Transgender Health similarly removed strict age cutoffs for gender-affirming surgery, again noting the importance of individualized care, I suspect most will read this change in the context of the Endocrine Society guidelines and past WPATH guidelines that noted gender-affirming genital surgeries are not offered until adulthood (a rare exception perhaps being someone pursuing a gender-affirming vaginoplasty at say age 17 in the summer prior to college to avoid needing to take off from school for surgical recovery). Gender-affirming genital surgeries are generally much more involved surgeries with prolonged recovery times. 

Given the substantial proportion of young people who openly identify as transgender,¹⁷ and the proliferation of misinformation, political rhetoric, and legislation that can impact gender-affirming care for adolescents with gender dysphoria,¹⁸ it is essential that providers have accurate, up-to-date information on what this care entails and how it is provided.

Dr. Turban is director of the gender psychiatry program at the University of California, San Francisco, where he is an assistant professor of child & adolescent psychiatry and affiliate faculty at the Philip R. Lee Institute for Health Policy Studies. He is on Twitter @jack_turban.
 

References

1. Malta M et al. Lancet Public Health. 2020 Apr;5(4):e178-9.

2. Hembree WC et al. J Clin Endocrinol Metab. 2017 Nov 1;102(11):3869-903.

3. Coleman E et al. Int J Transgend Health. 2022 Sep 6;23(Suppl 1):S1-259.

4. Durwood L et al. J Am Acad Child Adolesc Psychiatry. 2017 Feb;56(2):116-23.e2.

5. Rae JR et al. Psychol Sci. 2019 May;30(5):669-81.

6. van der Miesen AIR et al. J Adolesc Health. 2020 Jun;66(6):699-704.

7. Turban JL et al. Pediatrics. 2020 Feb;145(2):e20191725.

8. de Vries ALC et al. J Sex Med. 2011 Aug;8(8):2276-83.

9. Costa R et al. J Sex Med. 2015 Nov;12(11):2206-14.

10. Turban JL et al. PLoS One. 2022 Jan 12;17(1):e0261039.

11. Chen D et al. N Engl J Med. 2023;388:240-50.

12. de Vries ALC et al. Pediatrics. 2014 Oct;134(4):696-70.

13. Allen LR et al. Clin Pract Pediatr Psychol. 2019. doi: 10.1037/cpp0000288.

14. Tordoff DM et al. JAMA Netw Open. 2022 Feb 1;5(2):e220978.

15. Olson-Kennedy J et al. JAMA Pediatr. 2018;172(5):431-6.

16. Tang A et al. Ann Plast Surg. 2022 May;88(4 Suppl):S325-31

17. Johns MM et al. Morb Mortal Wkly Rep. 2019 Jan 25;68(3):67-71.

18. Turban JL et al. JAMA. 2021;325(22):2251-2.

Over the past few years, there has been rampant misinformation regarding gender-affirming care for transgender youth. In particular, there has been confusion regarding how care is administered, and what types of care are considered at various stages of development. This primer will help you understand the developmental approach to supporting transgender youth.

Gender-affirming care is a broad term that can encapsulate many different domains: social, legal, medical, and surgical affirmation. While people generally think of medical and surgical aspects of gender-affirming care, other domains can be just as important. For example, a 2020 publication in The Lancet Public Health found that access to gender-congruent government identification documents was associated with lower odds of severe psychological distress and suicidality.¹ 

Stanford Lucille Packard Children's Hospital.

Considerations for prepubertal children

The youngest developmental stage at which a young person may seek care regarding gender diversity is the prepubertal childhood stage. Guidelines set forth by The Endocrine Society and The World Professional Association for Transgender Health make it clear that no medical or surgical interventions are considered at this developmental stage.^2,3 However, some young people may choose to pursue a “social transition.” Though this may sound like one thing, social transition can mean very different things for different people. It may include any combination of adopting a new name, pronouns, hairstyle, clothing, etc. Young people may also choose to pursue these various aspects of social transition in all settings, or sometimes only in some settings (for example, only at home if they don’t yet feel comfortable doing so at school). Research so far shows that prepubertal children who are allowed to socially transition have levels of anxiety and depression nearly indistinguishable from their cisgender peers.⁴ While some in the past have raised the question of whether a social transition increases a child’s degree of gender incongruence and thus their likelihood to “persist” in a transgender identity, research has suggested this is not the case, and that gender identity does not meaningfully differ before and after a social transition.⁵ It’s worth noting, that “desistance” of a young person’s transgender identity is generally not considered an ethical goal and that gender identity conversion efforts (that is, attempts to force transgender people to be cisgender) have been labeled unethical by the American Academy of Child & Adolescent Psychiatry.

Sadly, transgender children are victims of bullying at high rates in their schools and communities. Creating safe and affirming school and community environments can be some of the highest yield ways in which providers can support the mental health of gender-diverse youth at this stage. Gender Spectrum is an excellent nonprofit that provides resources to help families and communities with some of these nonmedical supports.

 

Early adolescence and pubertal suppression

The earliest gender-affirming medical intervention that may be considered is pubertal suppression. Pubertal suppression is achieved with gonadotropin-releasing hormone agonists. This class of medications is Food and Drug Administration approved in pediatrics for precocious puberty – a condition in which young people enter puberty much earlier than expected (sometimes as early as age 3). For that condition, the rationale is to delay puberty until the patient reaches a more developmentally normative age for puberty to begin. The rationale for pubertal suppression for adolescent gender dysphoria is somewhat similar – these medications allow for the temporary pausing of puberty, which can be particularly helpful for adolescents who are having severe negative psychological reactions to the ways in which their bodies are developing. The major advantage here is that pubertal suppression can be reversed (if the medication is stopped, endogenous puberty will proceed), whereas puberty itself cannot be easily reversed (resulting in adult transgender people needing surgery and other interventions later in life, if these changes can be fully undone at all). As with all medications, puberty blockers do carry known side effects, including falling behind on bone density (sex hormones are needed to mineralize bones). Because of this, it is generally recommended that adolescents have their bone density monitored during treatment, pursue avenues to improve bone health (for example, exercise), and either stop the puberty blocker to undergo endogenous puberty or start gender-affirming hormones (estrogen or testosterone) by around age 16. 

It is also important to note that, under current guidelines, an adolescent must first undergo a comprehensive biopsychosocial mental health evaluation prior to starting pubertal suppression to ensure the clinical team has a comprehensive understanding of the adolescent’s mental health, that all potential gender supports that are needed are put into place, and that the adolescent and their guardians have a strong understanding of the medical intervention, its risks, side effects, and potential benefits. In addition, consent must be provided by parents or legal guardians, whereas adolescents themselves provide assent. Several studies have linked access to pubertal suppression, when indicated for gender dysphoria, to improved mental health outcomes (for example, van der Miesen and colleagues, Turban and colleagues, de Vries and colleagues, and Costa and colleagues).^6-9

 

Later adolescence and gender-affirming hormones

Later in adolescence, transgender youth may be candidates for gender-affirming hormone treatment (for example, estrogen or testosterone) to induce pubertal changes that align with their gender identities. Once again, under current guidelines, a comprehensive mental health biopsychosocial evaluation must be conducted prior to initiation of these treatments. Part of this evaluation includes fertility counseling and consideration of fertility preservation (for example, oocyte or semen cryopreservation), given the potential for these medications to impact fertility. It also involves discussion of several of the physiologic changes from these medications that can be irreversible (for example, voice changes from testosterone are particularly difficult to reverse in the future). Tables of the physical changes from these medications, when they begin after starting, and when they generally reach their maximum are available in the Endocrine Society guidelines.² The past endocrine society guidelines recommended not initiating gender-affirming hormones until age 16. The most recent guidelines note that there may be instances in which providers may consider starting them as early as age 13 (for example, to reduce risk of falling behind on bone density, or if a patient is having psychological distress related to their peers going through puberty while they are still in a prepubertal state). The latest World Professional Association for Transgender Health Standards of Care removed specific age cutoffs, highlighting the importance of a multidisciplinary team of mental health and hormone prescribing providers working together to understand the best course of action for a particular patient. As with pubertal suppression, several studies have linked access to gender-affirming hormones to improve mental health for adolescents with gender dysphoria (for example, Turban and colleagues, Chen and colleagues, de Vries and colleagues, Allen and colleagues, and Tordoff and colleagues).^10-14

Gender-affirming surgeries

The vast majority of gender-affirming surgeries are not considered until adulthood. The most notable exception to this is masculinizing top surgery for trans masculine and nonbinary adolescents. As with all surgeries, this is a major decision, and requires agreement from a mental health provider, a medical provider, and the surgeon. Early research suggests such surgeries result in improved chest dysphoria and that regret rates appear to be low.^15,16 While the latest World Professional Association for Transgender Health similarly removed strict age cutoffs for gender-affirming surgery, again noting the importance of individualized care, I suspect most will read this change in the context of the Endocrine Society guidelines and past WPATH guidelines that noted gender-affirming genital surgeries are not offered until adulthood (a rare exception perhaps being someone pursuing a gender-affirming vaginoplasty at say age 17 in the summer prior to college to avoid needing to take off from school for surgical recovery). Gender-affirming genital surgeries are generally much more involved surgeries with prolonged recovery times. 

Given the substantial proportion of young people who openly identify as transgender,¹⁷ and the proliferation of misinformation, political rhetoric, and legislation that can impact gender-affirming care for adolescents with gender dysphoria,¹⁸ it is essential that providers have accurate, up-to-date information on what this care entails and how it is provided.

Dr. Turban is director of the gender psychiatry program at the University of California, San Francisco, where he is an assistant professor of child & adolescent psychiatry and affiliate faculty at the Philip R. Lee Institute for Health Policy Studies. He is on Twitter @jack_turban.
 

References

1. Malta M et al. Lancet Public Health. 2020 Apr;5(4):e178-9.

2. Hembree WC et al. J Clin Endocrinol Metab. 2017 Nov 1;102(11):3869-903.

3. Coleman E et al. Int J Transgend Health. 2022 Sep 6;23(Suppl 1):S1-259.

4. Durwood L et al. J Am Acad Child Adolesc Psychiatry. 2017 Feb;56(2):116-23.e2.

5. Rae JR et al. Psychol Sci. 2019 May;30(5):669-81.

6. van der Miesen AIR et al. J Adolesc Health. 2020 Jun;66(6):699-704.

7. Turban JL et al. Pediatrics. 2020 Feb;145(2):e20191725.

8. de Vries ALC et al. J Sex Med. 2011 Aug;8(8):2276-83.

9. Costa R et al. J Sex Med. 2015 Nov;12(11):2206-14.

10. Turban JL et al. PLoS One. 2022 Jan 12;17(1):e0261039.

11. Chen D et al. N Engl J Med. 2023;388:240-50.

12. de Vries ALC et al. Pediatrics. 2014 Oct;134(4):696-70.

13. Allen LR et al. Clin Pract Pediatr Psychol. 2019. doi: 10.1037/cpp0000288.

14. Tordoff DM et al. JAMA Netw Open. 2022 Feb 1;5(2):e220978.

15. Olson-Kennedy J et al. JAMA Pediatr. 2018;172(5):431-6.

16. Tang A et al. Ann Plast Surg. 2022 May;88(4 Suppl):S325-31

17. Johns MM et al. Morb Mortal Wkly Rep. 2019 Jan 25;68(3):67-71.

18. Turban JL et al. JAMA. 2021;325(22):2251-2.

For as long as we’ve had official recommendations for exercise, those recommendations have focused on effort.

Do at least 150 minutes a week of “moderate to vigorous” physical activity, public health guidelines say. That could be anything from brisk walking (moderate) to competitive mountain-bike racing (vigorous). 

But as broad as that spectrum is, it still leaves out a lot. Like washing dishes. Or changing a diaper. Or birdwatching in the park. Or giving a PowerPoint presentation. 

All those tasks are “light” physical activities. We don’t think of them as exercise, and public health guidelines don’t account for them.

But at least one researcher believes we should take them more seriously. 

“Light physical activity appears to be the key to almost universal success regarding health,” said  Andrew Agbaje, MD, a clinical epidemiologist at the University of Eastern Finland.
 

The high cost of not moving

Any parent, teacher, or caregiver can tell you that children slow down as they age. Youngsters who were bouncing off walls at 11 may move very little at 24. But it’s not necessarily their fault. 

“We are more or less forcing them into sedentary behavior,” Dr. Agbaje said, pointing to things such as school, homework, and all the other situations that require young people to sit still. Their free time, in turn, increasingly involves screens, which keep them sitting even longer.

“We’re playing with a time bomb,” Dr. Agbaje said. 

In a recent study of nearly 800 children, Dr. Agbaje measured how the children’s activity changed between the ages of 11 and 24.

The goal was to see how those changes affected their C-reactive protein.

Several findings stand out:

• The children’s moderate-to-vigorous activity was unchanged over time. It was about 60 minutes a day for males and 45 minutes a day for females at 11 and 24 years old.
• Light physical activity declined by about 3.5 hours a day.
• Sedentary behaviors – sitting, sleeping, or otherwise barely moving – increased by almost 3 hours a day.
• C-reactive protein increased significantly from age 15, when it was first measured, to 24. It nearly doubled in males and tripled in females. 

While sedentariness was strongly linked to rising C-reactive protein, activity at any intensity was associated with lower inflammation.

But here’s an interesting wrinkle: The more body fat participants had, the less effective physical activity was in fighting inflammation. Body fat reduced the benefit of moderate-to-vigorous activity by close to 80%. 

That wasn’t the case for light physical activity. Body fat mitigated just 30% of the benefit.  

“Light physical activity looks like an unsung hero, which is surprising and new,” Dr. Agbaje said. “We might need to focus on that in this generation.”
 

The time-intensity continuum

That said, there are good reasons for public health guidelines to focus on higher intensities.

Take, for example, a study of Swedish military conscripts who underwent a battery of fitness tests in the early 1970s, when they were 18. Four decades later, those who had the highest exercise capacity in their late teens were 19% less likely to have subclinical levels of arterial plaque. 

Higher exercise capacity is usually the result of higher-intensity exercise. 

“The relationship between physical activity and exercise capacity is bidirectional and dynamic,” said study author Melony Fortuin-de Smidt, PhD, a postdoctoral researcher at Umeå University in Sweden. 

In other words, what you can do now reflects what you did in the past, and what you do now will affect what you can do in the future – for better or for worse.

That’s not to say you can’t get the same benefit from lower-intensity activities. But there’s a catch: “You will need to do more,” Dr. Fortuin-de Smidt said. 

In another recent study, Dr. Fortuin-de Smidt and coauthors calculated that you’d need 60 minutes of walking at a “normal” pace to get the same reduction in cardiovascular disease risk as you’d get from 40 minutes of brisk walking.

But those figures “should be interpreted cautiously,” since they include self-reported data, she said. 

A 2019 study that used data from activity trackers came up with starkly different estimates: To get maximum protection from the risk of early death, you’d need 24 minutes a day of moderate-to-vigorous activity or 6-plus hours of light activity – “15 times longer to reap the same mortality benefits,” Dr. Fortuin-de Smidt said. 

Notably, that study includes an in-between category the authors call “high” light physical activity. That could include low-intensity yoga or calisthenics, cooking or cleaning, and shopping or gardening. For those activities, you’d need just 75 minutes a day to get the same health benefits as 24 minutes of moderate-to-vigorous activity. 

It’s worth mentioning that any of those activities could also be regular light or even moderate-to-vigorous, depending on how quickly or slowly you do them. Intensity is not about the activity type – it’s about the effort you put into doing it.


 

When light makes right

The message isn’t to obsessively categorize every movement into vigorous, moderate, “high” light, or regular light. Most of our activities probably include some combination.

The goal is to take more steps. 

“Every move and every step counts towards better health,” Dr. Fortuin-de Smidt said. 

Dr. Agbaje compares exercise to medicine. Each of us needs to adjust the exercise dose to fit our needs, goals, and abilities. 

A tough workout for an average adult might qualify as a warm-up for a well-trained athlete, while the athlete’s warm-up might be dangerous for someone who’s not prepared for it.

That, Dr. Agbaje said, is the best argument for moving more whenever possible, even if it doesn’t feel like exercise. 

“For everybody, light physical activity is safe,” he said. “Just go for a walk.”
 

A version of this article first appeared on WebMD.com.

For as long as we’ve had official recommendations for exercise, those recommendations have focused on effort.

Do at least 150 minutes a week of “moderate to vigorous” physical activity, public health guidelines say. That could be anything from brisk walking (moderate) to competitive mountain-bike racing (vigorous). 

But as broad as that spectrum is, it still leaves out a lot. Like washing dishes. Or changing a diaper. Or birdwatching in the park. Or giving a PowerPoint presentation. 

All those tasks are “light” physical activities. We don’t think of them as exercise, and public health guidelines don’t account for them.

But at least one researcher believes we should take them more seriously. 

“Light physical activity appears to be the key to almost universal success regarding health,” said  Andrew Agbaje, MD, a clinical epidemiologist at the University of Eastern Finland.
 

The high cost of not moving

Any parent, teacher, or caregiver can tell you that children slow down as they age. Youngsters who were bouncing off walls at 11 may move very little at 24. But it’s not necessarily their fault. 

“We are more or less forcing them into sedentary behavior,” Dr. Agbaje said, pointing to things such as school, homework, and all the other situations that require young people to sit still. Their free time, in turn, increasingly involves screens, which keep them sitting even longer.

“We’re playing with a time bomb,” Dr. Agbaje said. 

In a recent study of nearly 800 children, Dr. Agbaje measured how the children’s activity changed between the ages of 11 and 24.

The goal was to see how those changes affected their C-reactive protein.

Several findings stand out:

• The children’s moderate-to-vigorous activity was unchanged over time. It was about 60 minutes a day for males and 45 minutes a day for females at 11 and 24 years old.
• Light physical activity declined by about 3.5 hours a day.
• Sedentary behaviors – sitting, sleeping, or otherwise barely moving – increased by almost 3 hours a day.
• C-reactive protein increased significantly from age 15, when it was first measured, to 24. It nearly doubled in males and tripled in females. 

While sedentariness was strongly linked to rising C-reactive protein, activity at any intensity was associated with lower inflammation.

But here’s an interesting wrinkle: The more body fat participants had, the less effective physical activity was in fighting inflammation. Body fat reduced the benefit of moderate-to-vigorous activity by close to 80%. 

That wasn’t the case for light physical activity. Body fat mitigated just 30% of the benefit.  

“Light physical activity looks like an unsung hero, which is surprising and new,” Dr. Agbaje said. “We might need to focus on that in this generation.”
 

The time-intensity continuum

That said, there are good reasons for public health guidelines to focus on higher intensities.

Take, for example, a study of Swedish military conscripts who underwent a battery of fitness tests in the early 1970s, when they were 18. Four decades later, those who had the highest exercise capacity in their late teens were 19% less likely to have subclinical levels of arterial plaque. 

Higher exercise capacity is usually the result of higher-intensity exercise. 

“The relationship between physical activity and exercise capacity is bidirectional and dynamic,” said study author Melony Fortuin-de Smidt, PhD, a postdoctoral researcher at Umeå University in Sweden. 

In other words, what you can do now reflects what you did in the past, and what you do now will affect what you can do in the future – for better or for worse.

That’s not to say you can’t get the same benefit from lower-intensity activities. But there’s a catch: “You will need to do more,” Dr. Fortuin-de Smidt said. 

In another recent study, Dr. Fortuin-de Smidt and coauthors calculated that you’d need 60 minutes of walking at a “normal” pace to get the same reduction in cardiovascular disease risk as you’d get from 40 minutes of brisk walking.

But those figures “should be interpreted cautiously,” since they include self-reported data, she said. 

A 2019 study that used data from activity trackers came up with starkly different estimates: To get maximum protection from the risk of early death, you’d need 24 minutes a day of moderate-to-vigorous activity or 6-plus hours of light activity – “15 times longer to reap the same mortality benefits,” Dr. Fortuin-de Smidt said. 

Notably, that study includes an in-between category the authors call “high” light physical activity. That could include low-intensity yoga or calisthenics, cooking or cleaning, and shopping or gardening. For those activities, you’d need just 75 minutes a day to get the same health benefits as 24 minutes of moderate-to-vigorous activity. 

It’s worth mentioning that any of those activities could also be regular light or even moderate-to-vigorous, depending on how quickly or slowly you do them. Intensity is not about the activity type – it’s about the effort you put into doing it.


 

When light makes right

The message isn’t to obsessively categorize every movement into vigorous, moderate, “high” light, or regular light. Most of our activities probably include some combination.

The goal is to take more steps. 

“Every move and every step counts towards better health,” Dr. Fortuin-de Smidt said. 

Dr. Agbaje compares exercise to medicine. Each of us needs to adjust the exercise dose to fit our needs, goals, and abilities. 

A tough workout for an average adult might qualify as a warm-up for a well-trained athlete, while the athlete’s warm-up might be dangerous for someone who’s not prepared for it.

That, Dr. Agbaje said, is the best argument for moving more whenever possible, even if it doesn’t feel like exercise. 

“For everybody, light physical activity is safe,” he said. “Just go for a walk.”
 

A version of this article first appeared on WebMD.com.

For as long as we’ve had official recommendations for exercise, those recommendations have focused on effort.

Do at least 150 minutes a week of “moderate to vigorous” physical activity, public health guidelines say. That could be anything from brisk walking (moderate) to competitive mountain-bike racing (vigorous). 

But as broad as that spectrum is, it still leaves out a lot. Like washing dishes. Or changing a diaper. Or birdwatching in the park. Or giving a PowerPoint presentation. 

All those tasks are “light” physical activities. We don’t think of them as exercise, and public health guidelines don’t account for them.

But at least one researcher believes we should take them more seriously. 

“Light physical activity appears to be the key to almost universal success regarding health,” said  Andrew Agbaje, MD, a clinical epidemiologist at the University of Eastern Finland.
 

The high cost of not moving

Any parent, teacher, or caregiver can tell you that children slow down as they age. Youngsters who were bouncing off walls at 11 may move very little at 24. But it’s not necessarily their fault. 

“We are more or less forcing them into sedentary behavior,” Dr. Agbaje said, pointing to things such as school, homework, and all the other situations that require young people to sit still. Their free time, in turn, increasingly involves screens, which keep them sitting even longer.

“We’re playing with a time bomb,” Dr. Agbaje said. 

In a recent study of nearly 800 children, Dr. Agbaje measured how the children’s activity changed between the ages of 11 and 24.

The goal was to see how those changes affected their C-reactive protein.

Several findings stand out:

• The children’s moderate-to-vigorous activity was unchanged over time. It was about 60 minutes a day for males and 45 minutes a day for females at 11 and 24 years old.
• Light physical activity declined by about 3.5 hours a day.
• Sedentary behaviors – sitting, sleeping, or otherwise barely moving – increased by almost 3 hours a day.
• C-reactive protein increased significantly from age 15, when it was first measured, to 24. It nearly doubled in males and tripled in females. 

While sedentariness was strongly linked to rising C-reactive protein, activity at any intensity was associated with lower inflammation.

But here’s an interesting wrinkle: The more body fat participants had, the less effective physical activity was in fighting inflammation. Body fat reduced the benefit of moderate-to-vigorous activity by close to 80%. 

That wasn’t the case for light physical activity. Body fat mitigated just 30% of the benefit.  

“Light physical activity looks like an unsung hero, which is surprising and new,” Dr. Agbaje said. “We might need to focus on that in this generation.”
 

The time-intensity continuum

That said, there are good reasons for public health guidelines to focus on higher intensities.

Take, for example, a study of Swedish military conscripts who underwent a battery of fitness tests in the early 1970s, when they were 18. Four decades later, those who had the highest exercise capacity in their late teens were 19% less likely to have subclinical levels of arterial plaque. 

Higher exercise capacity is usually the result of higher-intensity exercise. 

“The relationship between physical activity and exercise capacity is bidirectional and dynamic,” said study author Melony Fortuin-de Smidt, PhD, a postdoctoral researcher at Umeå University in Sweden. 

In other words, what you can do now reflects what you did in the past, and what you do now will affect what you can do in the future – for better or for worse.

That’s not to say you can’t get the same benefit from lower-intensity activities. But there’s a catch: “You will need to do more,” Dr. Fortuin-de Smidt said. 

In another recent study, Dr. Fortuin-de Smidt and coauthors calculated that you’d need 60 minutes of walking at a “normal” pace to get the same reduction in cardiovascular disease risk as you’d get from 40 minutes of brisk walking.

But those figures “should be interpreted cautiously,” since they include self-reported data, she said. 

A 2019 study that used data from activity trackers came up with starkly different estimates: To get maximum protection from the risk of early death, you’d need 24 minutes a day of moderate-to-vigorous activity or 6-plus hours of light activity – “15 times longer to reap the same mortality benefits,” Dr. Fortuin-de Smidt said. 

Notably, that study includes an in-between category the authors call “high” light physical activity. That could include low-intensity yoga or calisthenics, cooking or cleaning, and shopping or gardening. For those activities, you’d need just 75 minutes a day to get the same health benefits as 24 minutes of moderate-to-vigorous activity. 

It’s worth mentioning that any of those activities could also be regular light or even moderate-to-vigorous, depending on how quickly or slowly you do them. Intensity is not about the activity type – it’s about the effort you put into doing it.


 

When light makes right

The message isn’t to obsessively categorize every movement into vigorous, moderate, “high” light, or regular light. Most of our activities probably include some combination.

The goal is to take more steps. 

“Every move and every step counts towards better health,” Dr. Fortuin-de Smidt said. 

Dr. Agbaje compares exercise to medicine. Each of us needs to adjust the exercise dose to fit our needs, goals, and abilities. 

A tough workout for an average adult might qualify as a warm-up for a well-trained athlete, while the athlete’s warm-up might be dangerous for someone who’s not prepared for it.

That, Dr. Agbaje said, is the best argument for moving more whenever possible, even if it doesn’t feel like exercise. 

“For everybody, light physical activity is safe,” he said. “Just go for a walk.”
 

A version of this article first appeared on WebMD.com.

In recent years, many disease-modifying therapies (DMTs) have been approved for the treatment of multiple sclerosis (MS). DMTs are not a cure for MS, but they have been proven to alter the course of the disease, reduce relapses, slow its progression, and alleviate symptoms. DMTs function by surpressing immune activity. This, in turn, diminishes the intensity of the inflammatory attack responsible for driving this disorder.  

Dr Lauren Krupp, a neurologist at NYU Langone Health in New York, NY, presents an overview of the mechanisms of action (MOA) for the various DMTs and their effects on the immune system, including the potential to increase risk for infection and alter response to vaccination.  

Dr Krupp notes that DMTs can be administered orally, by injection, and by infusion, depending on the drug prescribed. She further explains that because there are now more DMT options, it is important to understand how best to tailor therapy decisions to individual patients.  

--

Lauren Krupp, MD, Professor, Department of Neurology, NYU Grossman School of Medicine; Director, NYU Langone Comprehensive Care Center, Deaprtment of Neurology, NYU Langone Health, New York, NY 

Lauren Krupp, MD, has disclosed the following relevant financial relationships: 

Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Novartis; Biogen; Bristol-Myers Squibb 

Received research grant from: Biogen; Novartis 

In recent years, many disease-modifying therapies (DMTs) have been approved for the treatment of multiple sclerosis (MS). DMTs are not a cure for MS, but they have been proven to alter the course of the disease, reduce relapses, slow its progression, and alleviate symptoms. DMTs function by surpressing immune activity. This, in turn, diminishes the intensity of the inflammatory attack responsible for driving this disorder.  

Dr Lauren Krupp, a neurologist at NYU Langone Health in New York, NY, presents an overview of the mechanisms of action (MOA) for the various DMTs and their effects on the immune system, including the potential to increase risk for infection and alter response to vaccination.  

Dr Krupp notes that DMTs can be administered orally, by injection, and by infusion, depending on the drug prescribed. She further explains that because there are now more DMT options, it is important to understand how best to tailor therapy decisions to individual patients.  

--

Lauren Krupp, MD, Professor, Department of Neurology, NYU Grossman School of Medicine; Director, NYU Langone Comprehensive Care Center, Deaprtment of Neurology, NYU Langone Health, New York, NY 

Lauren Krupp, MD, has disclosed the following relevant financial relationships: 

Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Novartis; Biogen; Bristol-Myers Squibb 

Received research grant from: Biogen; Novartis 

In recent years, many disease-modifying therapies (DMTs) have been approved for the treatment of multiple sclerosis (MS). DMTs are not a cure for MS, but they have been proven to alter the course of the disease, reduce relapses, slow its progression, and alleviate symptoms. DMTs function by surpressing immune activity. This, in turn, diminishes the intensity of the inflammatory attack responsible for driving this disorder.  

Dr Lauren Krupp, a neurologist at NYU Langone Health in New York, NY, presents an overview of the mechanisms of action (MOA) for the various DMTs and their effects on the immune system, including the potential to increase risk for infection and alter response to vaccination.  

Dr Krupp notes that DMTs can be administered orally, by injection, and by infusion, depending on the drug prescribed. She further explains that because there are now more DMT options, it is important to understand how best to tailor therapy decisions to individual patients.  

--

Lauren Krupp, MD, Professor, Department of Neurology, NYU Grossman School of Medicine; Director, NYU Langone Comprehensive Care Center, Deaprtment of Neurology, NYU Langone Health, New York, NY 

Lauren Krupp, MD, has disclosed the following relevant financial relationships: 

Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Novartis; Biogen; Bristol-Myers Squibb 

Received research grant from: Biogen; Novartis 

Eastern and southeastern areas of the United States have the highest rates of Alzheimer’s disease (AD), new research shows.

Investigators at Rush University in Chicago found AD prevalence was highest in Maryland, New York, Mississippi, and Florida. At the county level, Miami-Dade in Florida, Baltimore city, and Bronx County in New York were among the U.S. counties with the highest prevalence of the disease.

Such geographical variations may be caused by the unique make-up of regional populations, study investigator Kumar Rajan, PhD, professor of medicine and director of Rush Institute for Healthy Aging, Rush University Medical Center, Chicago, said in an interview.

Dr. Rajan presented the research at the Alzheimer’s Association International Conference.
 

High-impact research

An estimated 6.7 million Americans are living with AD, a figure that’s expected to double by 2050. Estimating the prevalence of Alzheimer’s across states’ counties can provide a better understanding of region-specific disease burden and have policy implications for resource allocation, Dr. Rajan noted.

To determine the state- and county-specific prevalence of AD, the researchers applied AD data from the Chicago Health and Aging Project, a population-based study that’s about 60% African American, to county- and state-level data from the National Center for Health Statistics.

“We used estimates in our study in Chicago, which began in the 1990s and has approximately 10,800 people, and projected those estimates to county-level populations to see what the variations look like,” said Dr. Rajan.

Of 3,142 counties in 50 states, the East and Southeastern regions of the United States had the highest AD prevalence. For states, the highest rates were in Maryland (12.9%), New York (12.7%), Mississippi (12.5%), and Florida (12.5%).

California and Illinois were also among the top 10 states with the highest prevalence of Alzheimer’s.

California had the highest number of residents, with 719,000 (95% confidence interval, 665,000-774,400), followed by Florida with 579,000 (95% CI, 539,900 to 620,000), and Texas with 459,000 (95% CI, 422,700 to 496,000).

The three counties with the highest prevalence, all with 16.6%, were Miami-Dade County, Baltimore city, and Bronx County.

One county in the top 10 for AD prevalence was El Paso, Tex., which Dr. Rajan found “a bit surprising,” as Texas was not among the top four states with the highest prevalence.

In addition to older age, what’s likely driving elevated AD prevalence in these areas is the substantially larger proportion of minority populations who are at higher risk for AD, possibly due to health disparities, said Dr. Rajan.

Determining local-level estimates of AD should have “a very high impact” on public health programs aimed at AD prevention, detection, and treatment, he said. In addition, as more AD drugs are approved, there will likely be county-level and even state-level implications for Medicare coverage.

In addition, these new findings could help physicians treating or caring for minority populations “understand the landscape of what the disease looks like,” said Dr. Rajan.

A limitation of the study was that it was based on data from a single study, he noted.

The next step is to expand this research. Dr. Rajan and others are establishing the Regional and Ethnic Variations in Alzheimer’s and Cognitive Health Consortium, with the goal of gaining a better understanding of AD prevalence across six U.S. regions.
 

Optimal resource distribution

In a comment, Percy Griffin, PhD, director of scientific engagement, Alzheimer’s Association, said the research provides useful information about AD prevalence at the local level.

“We need to understand how specific demographics and characteristics can help explain some of the high prevalence in certain areas.”

Compared with White Americans, Dr. Griffin noted that Black Americans are twice as likely to have AD, and older Hispanic Americans are 1.5 times as likely.

This new data will help pinpoint areas of high risk and high need so that funding, staffing, and other resources for those with AD and other dementias can be optimally distributed, he said.

“It gives us that kind of geographic specificity in terms of the prevalence so we can dig deeper and better allocate resources on a county level,” he added.

The Alzheimer’s Association “is fully committed to working with local agencies and being in the communities to assist them in their efforts to intervene in this disease.”

The study also highlights the need for more research to determine what factors other than age and race – such as potential environmental factors – might affect regional AD prevalence, he said.

The study received funding from the National Institutes of Health. Dr. Rajan and Dr. Griffin reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Eastern and southeastern areas of the United States have the highest rates of Alzheimer’s disease (AD), new research shows.

Investigators at Rush University in Chicago found AD prevalence was highest in Maryland, New York, Mississippi, and Florida. At the county level, Miami-Dade in Florida, Baltimore city, and Bronx County in New York were among the U.S. counties with the highest prevalence of the disease.

Such geographical variations may be caused by the unique make-up of regional populations, study investigator Kumar Rajan, PhD, professor of medicine and director of Rush Institute for Healthy Aging, Rush University Medical Center, Chicago, said in an interview.

Dr. Rajan presented the research at the Alzheimer’s Association International Conference.
 

High-impact research

An estimated 6.7 million Americans are living with AD, a figure that’s expected to double by 2050. Estimating the prevalence of Alzheimer’s across states’ counties can provide a better understanding of region-specific disease burden and have policy implications for resource allocation, Dr. Rajan noted.

To determine the state- and county-specific prevalence of AD, the researchers applied AD data from the Chicago Health and Aging Project, a population-based study that’s about 60% African American, to county- and state-level data from the National Center for Health Statistics.

“We used estimates in our study in Chicago, which began in the 1990s and has approximately 10,800 people, and projected those estimates to county-level populations to see what the variations look like,” said Dr. Rajan.

Of 3,142 counties in 50 states, the East and Southeastern regions of the United States had the highest AD prevalence. For states, the highest rates were in Maryland (12.9%), New York (12.7%), Mississippi (12.5%), and Florida (12.5%).

California and Illinois were also among the top 10 states with the highest prevalence of Alzheimer’s.

California had the highest number of residents, with 719,000 (95% confidence interval, 665,000-774,400), followed by Florida with 579,000 (95% CI, 539,900 to 620,000), and Texas with 459,000 (95% CI, 422,700 to 496,000).

The three counties with the highest prevalence, all with 16.6%, were Miami-Dade County, Baltimore city, and Bronx County.

One county in the top 10 for AD prevalence was El Paso, Tex., which Dr. Rajan found “a bit surprising,” as Texas was not among the top four states with the highest prevalence.

In addition to older age, what’s likely driving elevated AD prevalence in these areas is the substantially larger proportion of minority populations who are at higher risk for AD, possibly due to health disparities, said Dr. Rajan.

Determining local-level estimates of AD should have “a very high impact” on public health programs aimed at AD prevention, detection, and treatment, he said. In addition, as more AD drugs are approved, there will likely be county-level and even state-level implications for Medicare coverage.

In addition, these new findings could help physicians treating or caring for minority populations “understand the landscape of what the disease looks like,” said Dr. Rajan.

A limitation of the study was that it was based on data from a single study, he noted.

The next step is to expand this research. Dr. Rajan and others are establishing the Regional and Ethnic Variations in Alzheimer’s and Cognitive Health Consortium, with the goal of gaining a better understanding of AD prevalence across six U.S. regions.
 

Optimal resource distribution

In a comment, Percy Griffin, PhD, director of scientific engagement, Alzheimer’s Association, said the research provides useful information about AD prevalence at the local level.

“We need to understand how specific demographics and characteristics can help explain some of the high prevalence in certain areas.”

Compared with White Americans, Dr. Griffin noted that Black Americans are twice as likely to have AD, and older Hispanic Americans are 1.5 times as likely.

This new data will help pinpoint areas of high risk and high need so that funding, staffing, and other resources for those with AD and other dementias can be optimally distributed, he said.

“It gives us that kind of geographic specificity in terms of the prevalence so we can dig deeper and better allocate resources on a county level,” he added.

The Alzheimer’s Association “is fully committed to working with local agencies and being in the communities to assist them in their efforts to intervene in this disease.”

The study also highlights the need for more research to determine what factors other than age and race – such as potential environmental factors – might affect regional AD prevalence, he said.

The study received funding from the National Institutes of Health. Dr. Rajan and Dr. Griffin reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Eastern and southeastern areas of the United States have the highest rates of Alzheimer’s disease (AD), new research shows.

Investigators at Rush University in Chicago found AD prevalence was highest in Maryland, New York, Mississippi, and Florida. At the county level, Miami-Dade in Florida, Baltimore city, and Bronx County in New York were among the U.S. counties with the highest prevalence of the disease.

Such geographical variations may be caused by the unique make-up of regional populations, study investigator Kumar Rajan, PhD, professor of medicine and director of Rush Institute for Healthy Aging, Rush University Medical Center, Chicago, said in an interview.

Dr. Rajan presented the research at the Alzheimer’s Association International Conference.
 

High-impact research

An estimated 6.7 million Americans are living with AD, a figure that’s expected to double by 2050. Estimating the prevalence of Alzheimer’s across states’ counties can provide a better understanding of region-specific disease burden and have policy implications for resource allocation, Dr. Rajan noted.

To determine the state- and county-specific prevalence of AD, the researchers applied AD data from the Chicago Health and Aging Project, a population-based study that’s about 60% African American, to county- and state-level data from the National Center for Health Statistics.

“We used estimates in our study in Chicago, which began in the 1990s and has approximately 10,800 people, and projected those estimates to county-level populations to see what the variations look like,” said Dr. Rajan.

Of 3,142 counties in 50 states, the East and Southeastern regions of the United States had the highest AD prevalence. For states, the highest rates were in Maryland (12.9%), New York (12.7%), Mississippi (12.5%), and Florida (12.5%).

California and Illinois were also among the top 10 states with the highest prevalence of Alzheimer’s.

California had the highest number of residents, with 719,000 (95% confidence interval, 665,000-774,400), followed by Florida with 579,000 (95% CI, 539,900 to 620,000), and Texas with 459,000 (95% CI, 422,700 to 496,000).

The three counties with the highest prevalence, all with 16.6%, were Miami-Dade County, Baltimore city, and Bronx County.

One county in the top 10 for AD prevalence was El Paso, Tex., which Dr. Rajan found “a bit surprising,” as Texas was not among the top four states with the highest prevalence.

In addition to older age, what’s likely driving elevated AD prevalence in these areas is the substantially larger proportion of minority populations who are at higher risk for AD, possibly due to health disparities, said Dr. Rajan.

Determining local-level estimates of AD should have “a very high impact” on public health programs aimed at AD prevention, detection, and treatment, he said. In addition, as more AD drugs are approved, there will likely be county-level and even state-level implications for Medicare coverage.

In addition, these new findings could help physicians treating or caring for minority populations “understand the landscape of what the disease looks like,” said Dr. Rajan.

A limitation of the study was that it was based on data from a single study, he noted.

The next step is to expand this research. Dr. Rajan and others are establishing the Regional and Ethnic Variations in Alzheimer’s and Cognitive Health Consortium, with the goal of gaining a better understanding of AD prevalence across six U.S. regions.
 

Optimal resource distribution

In a comment, Percy Griffin, PhD, director of scientific engagement, Alzheimer’s Association, said the research provides useful information about AD prevalence at the local level.

“We need to understand how specific demographics and characteristics can help explain some of the high prevalence in certain areas.”

Compared with White Americans, Dr. Griffin noted that Black Americans are twice as likely to have AD, and older Hispanic Americans are 1.5 times as likely.

This new data will help pinpoint areas of high risk and high need so that funding, staffing, and other resources for those with AD and other dementias can be optimally distributed, he said.

“It gives us that kind of geographic specificity in terms of the prevalence so we can dig deeper and better allocate resources on a county level,” he added.

The Alzheimer’s Association “is fully committed to working with local agencies and being in the communities to assist them in their efforts to intervene in this disease.”

The study also highlights the need for more research to determine what factors other than age and race – such as potential environmental factors – might affect regional AD prevalence, he said.

The study received funding from the National Institutes of Health. Dr. Rajan and Dr. Griffin reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Are there medical conditions other than obesity where physicians, if even inadvertently, regularly sabotage their patients’ efforts at managing them? Because for patients with obesity, their physicians, sometimes even before they walk into the examining room to meet them, do and say things that may quash their weight loss efforts.

No doubt this list will be nonexhaustive, but here are what I see as the top 10 ways doctors sabotage their patients’ weight loss journeys.

• 1. Having an office that is anxiety provoking, exclusionary, and/or fat phobic for people with obesity, which in turn may remove trust and preclude conversation. Examples of this would be offices without chairs in the waiting room that are suitable for people with obesity; with reading materials such as glossy magazines like Men’s Health and Shape, glorifying unhealthy dieting and body ideals; or where the scale is in a nonprivate area or has a very narrow platform, or maxes out at a weight lower than many patients’.
• 2. Not taking an actual history. Meaning, physicians regularly launch into a “you should really lose weight” speech without exploring a patient’s history of weight loss and social determinants of health. In some cases, that patient may have a history of disordered eating or body dysmorphia, and then this discussion needs to be approached carefully with those facts underwriting its tenor and direction. In other cases, patients’ social determinants of health would make intentional behavior change efforts in the name of weight management an impossible luxury. And sometimes that same patient may in fact be maintaining a clinically meaningful weight loss from their peak weight already. In all cases, not speaking with your patients and instead speaking at your patients will not increase their likelihood to trust or follow or seek your advice.
• 3. Pushing useless diet advice. The most common and most useless are some variation on needing to just eat less and move more. That’s about as useful as telling someone that making money requires them to buy low and sell high. Or telling someone with depression that they should just cheer up and look at the bright side of things.
• 4. Pushing specific diet advice (intermittent fasting, keto, low carb, vegan, low fat, whatever) as if it’s the only way or the best way to lose weight. The research is clear: There is no one best dietary approach, and one person’s best diet is another person’s worst. Yet, some clinicians are themselves diet zealots and preach one diet over all others. Of course, many of their patients may well have already tried that approach, while others won’t enjoy it, and so promoting it above all others will fail a great many people.
• 5. Refusing to prescribe medications to patients who meet the clinical criteria for use, especially now that there are truly effective and useful medications. Do these same clinicians refuse to prescribe antihypertensives or oral hypoglycemics to patients whose blood pressures or blood sugars are risking their health? Related would be those clinicians who don’t bother to learn enough about pharmaceutical options for obesity to feel comfortable prescribing them. This, despite the fact that statistically, well over 30% of their patients have obesity, and polls suggest that at least half of those embark on weight loss efforts annually. If a patient meets clinical criteria for a medication’s approved indication and a doctor won’t prescribe it because of their personal beliefs, in my opinion that’s grounds for a regulatory complaint.
• 6. Fearmongering around medications regarding adverse or unknown effects. The media’s coverage of new antiobesity medications is alarmist, to say the least, and for reasons I can’t fathom, given how well tolerated these medications are when dose titration is slow, monitored, and adjusted appropriately. Many physicians are not only buying into media narratives but are also spreading them.
• 7. Stopping medications for obesity when weight is lost. Do you also stop blood pressure medications when they normalize a patient’s blood pressure? Chronic conditions require ongoing long-term treatment. And yet I hear about this in my practice regularly.
• 8. Prescribing medications that cause weight gain rather than alternatives that don’t, or without discussion of same, or without the concomitant prescription of medication to counter it. From atypical antipsychotics to antidepressants to certain antiseizure medications to some blood pressure medications, there are those that have been shown to lead to, at times, dramatic weight gain. Yet, physicians will still regularly prescribe them to patients with obesity without first trying patients on available alternatives that don’t lead to weight gain, or without at least monitoring and then considering the prescription of an antiobesity medication to try to mitigate iatrogenic gain.
• 9. Setting ridiculous and unrealistic weight loss goals with patients. Without medication, the average person may lose 10% of their weight with purely behavioral efforts, 15%-20% with the addition of medications to those behavioral efforts, and 30% with the addition of bariatric surgery to their behavioral efforts. So why do so many physicians suggest goals that greatly exceed those averages? Imagine being committed to learning to run and having your running coach tell you at your training outset that your goal is to run a marathon within a Boston Marathon qualifying time. The goal should be whatever weight a person reaches living the healthiest life that they can honestly enjoy, not the Boston Marathon of weight loss.
• 10. Not discussing all options with all patients. Yes, food and fitness levers can affect weight, but that doesn’t mean that patients who meet the medical criteria for antiobesity medication or bariatric surgery shouldn’t be informed of their options. Our job as physicians is to fully inform our patients about the risks and benefits of all treatment options and then to support our patients’ decisions as to what option they want to pursue (including none, by the way). Our job is not to exclude discussion of proven and available options because our weight biases see us personally not believing in them – or worse, thinking that patients haven’t tried food and fitness umpteen times before, and that we require them to fail those efforts yet again before we stop gatekeeping their access to effective adjunctive therapeutic interventions.

Until recently, underwriting weight bias in medicine has been the dearth of effective treatments which in turn probably contributed to the overall lack of education for physicians in obesity management despite its extremely high prevalence. The times, though, are definitely a-changin’. Consequent to these new generations of medications rapidly coming online, by necessity we will see improvements in medical education around obesity management. Meanwhile, their efficacy will help dispel the bias that underlies much of this list. A decade or 2 from now, we will see obesity treated as we do every other chronic noncommunicable disease with lifestyle levers – with patient-centered care free from judgment and blame, and with a myriad of therapeutic options that physicians objectively, not subjectively, inform and prescribe to their patients.

Dr. Freedhoff is associate professor, department of family medicine, University of Ottawa, and medical director, Bariatric Medical Institute, also in Ottawa. He reported conflicts of interest with Constant Health and Novo Nordisk.
 

A version of this article first appeared on Medscape.com.

Are there medical conditions other than obesity where physicians, if even inadvertently, regularly sabotage their patients’ efforts at managing them? Because for patients with obesity, their physicians, sometimes even before they walk into the examining room to meet them, do and say things that may quash their weight loss efforts.

No doubt this list will be nonexhaustive, but here are what I see as the top 10 ways doctors sabotage their patients’ weight loss journeys.

• 1. Having an office that is anxiety provoking, exclusionary, and/or fat phobic for people with obesity, which in turn may remove trust and preclude conversation. Examples of this would be offices without chairs in the waiting room that are suitable for people with obesity; with reading materials such as glossy magazines like Men’s Health and Shape, glorifying unhealthy dieting and body ideals; or where the scale is in a nonprivate area or has a very narrow platform, or maxes out at a weight lower than many patients’.
• 2. Not taking an actual history. Meaning, physicians regularly launch into a “you should really lose weight” speech without exploring a patient’s history of weight loss and social determinants of health. In some cases, that patient may have a history of disordered eating or body dysmorphia, and then this discussion needs to be approached carefully with those facts underwriting its tenor and direction. In other cases, patients’ social determinants of health would make intentional behavior change efforts in the name of weight management an impossible luxury. And sometimes that same patient may in fact be maintaining a clinically meaningful weight loss from their peak weight already. In all cases, not speaking with your patients and instead speaking at your patients will not increase their likelihood to trust or follow or seek your advice.
• 3. Pushing useless diet advice. The most common and most useless are some variation on needing to just eat less and move more. That’s about as useful as telling someone that making money requires them to buy low and sell high. Or telling someone with depression that they should just cheer up and look at the bright side of things.
• 4. Pushing specific diet advice (intermittent fasting, keto, low carb, vegan, low fat, whatever) as if it’s the only way or the best way to lose weight. The research is clear: There is no one best dietary approach, and one person’s best diet is another person’s worst. Yet, some clinicians are themselves diet zealots and preach one diet over all others. Of course, many of their patients may well have already tried that approach, while others won’t enjoy it, and so promoting it above all others will fail a great many people.
• 5. Refusing to prescribe medications to patients who meet the clinical criteria for use, especially now that there are truly effective and useful medications. Do these same clinicians refuse to prescribe antihypertensives or oral hypoglycemics to patients whose blood pressures or blood sugars are risking their health? Related would be those clinicians who don’t bother to learn enough about pharmaceutical options for obesity to feel comfortable prescribing them. This, despite the fact that statistically, well over 30% of their patients have obesity, and polls suggest that at least half of those embark on weight loss efforts annually. If a patient meets clinical criteria for a medication’s approved indication and a doctor won’t prescribe it because of their personal beliefs, in my opinion that’s grounds for a regulatory complaint.
• 6. Fearmongering around medications regarding adverse or unknown effects. The media’s coverage of new antiobesity medications is alarmist, to say the least, and for reasons I can’t fathom, given how well tolerated these medications are when dose titration is slow, monitored, and adjusted appropriately. Many physicians are not only buying into media narratives but are also spreading them.
• 7. Stopping medications for obesity when weight is lost. Do you also stop blood pressure medications when they normalize a patient’s blood pressure? Chronic conditions require ongoing long-term treatment. And yet I hear about this in my practice regularly.
• 8. Prescribing medications that cause weight gain rather than alternatives that don’t, or without discussion of same, or without the concomitant prescription of medication to counter it. From atypical antipsychotics to antidepressants to certain antiseizure medications to some blood pressure medications, there are those that have been shown to lead to, at times, dramatic weight gain. Yet, physicians will still regularly prescribe them to patients with obesity without first trying patients on available alternatives that don’t lead to weight gain, or without at least monitoring and then considering the prescription of an antiobesity medication to try to mitigate iatrogenic gain.
• 9. Setting ridiculous and unrealistic weight loss goals with patients. Without medication, the average person may lose 10% of their weight with purely behavioral efforts, 15%-20% with the addition of medications to those behavioral efforts, and 30% with the addition of bariatric surgery to their behavioral efforts. So why do so many physicians suggest goals that greatly exceed those averages? Imagine being committed to learning to run and having your running coach tell you at your training outset that your goal is to run a marathon within a Boston Marathon qualifying time. The goal should be whatever weight a person reaches living the healthiest life that they can honestly enjoy, not the Boston Marathon of weight loss.
• 10. Not discussing all options with all patients. Yes, food and fitness levers can affect weight, but that doesn’t mean that patients who meet the medical criteria for antiobesity medication or bariatric surgery shouldn’t be informed of their options. Our job as physicians is to fully inform our patients about the risks and benefits of all treatment options and then to support our patients’ decisions as to what option they want to pursue (including none, by the way). Our job is not to exclude discussion of proven and available options because our weight biases see us personally not believing in them – or worse, thinking that patients haven’t tried food and fitness umpteen times before, and that we require them to fail those efforts yet again before we stop gatekeeping their access to effective adjunctive therapeutic interventions.

Until recently, underwriting weight bias in medicine has been the dearth of effective treatments which in turn probably contributed to the overall lack of education for physicians in obesity management despite its extremely high prevalence. The times, though, are definitely a-changin’. Consequent to these new generations of medications rapidly coming online, by necessity we will see improvements in medical education around obesity management. Meanwhile, their efficacy will help dispel the bias that underlies much of this list. A decade or 2 from now, we will see obesity treated as we do every other chronic noncommunicable disease with lifestyle levers – with patient-centered care free from judgment and blame, and with a myriad of therapeutic options that physicians objectively, not subjectively, inform and prescribe to their patients.

Dr. Freedhoff is associate professor, department of family medicine, University of Ottawa, and medical director, Bariatric Medical Institute, also in Ottawa. He reported conflicts of interest with Constant Health and Novo Nordisk.
 

A version of this article first appeared on Medscape.com.

Are there medical conditions other than obesity where physicians, if even inadvertently, regularly sabotage their patients’ efforts at managing them? Because for patients with obesity, their physicians, sometimes even before they walk into the examining room to meet them, do and say things that may quash their weight loss efforts.

No doubt this list will be nonexhaustive, but here are what I see as the top 10 ways doctors sabotage their patients’ weight loss journeys.

• 1. Having an office that is anxiety provoking, exclusionary, and/or fat phobic for people with obesity, which in turn may remove trust and preclude conversation. Examples of this would be offices without chairs in the waiting room that are suitable for people with obesity; with reading materials such as glossy magazines like Men’s Health and Shape, glorifying unhealthy dieting and body ideals; or where the scale is in a nonprivate area or has a very narrow platform, or maxes out at a weight lower than many patients’.
• 2. Not taking an actual history. Meaning, physicians regularly launch into a “you should really lose weight” speech without exploring a patient’s history of weight loss and social determinants of health. In some cases, that patient may have a history of disordered eating or body dysmorphia, and then this discussion needs to be approached carefully with those facts underwriting its tenor and direction. In other cases, patients’ social determinants of health would make intentional behavior change efforts in the name of weight management an impossible luxury. And sometimes that same patient may in fact be maintaining a clinically meaningful weight loss from their peak weight already. In all cases, not speaking with your patients and instead speaking at your patients will not increase their likelihood to trust or follow or seek your advice.
• 3. Pushing useless diet advice. The most common and most useless are some variation on needing to just eat less and move more. That’s about as useful as telling someone that making money requires them to buy low and sell high. Or telling someone with depression that they should just cheer up and look at the bright side of things.
• 4. Pushing specific diet advice (intermittent fasting, keto, low carb, vegan, low fat, whatever) as if it’s the only way or the best way to lose weight. The research is clear: There is no one best dietary approach, and one person’s best diet is another person’s worst. Yet, some clinicians are themselves diet zealots and preach one diet over all others. Of course, many of their patients may well have already tried that approach, while others won’t enjoy it, and so promoting it above all others will fail a great many people.
• 5. Refusing to prescribe medications to patients who meet the clinical criteria for use, especially now that there are truly effective and useful medications. Do these same clinicians refuse to prescribe antihypertensives or oral hypoglycemics to patients whose blood pressures or blood sugars are risking their health? Related would be those clinicians who don’t bother to learn enough about pharmaceutical options for obesity to feel comfortable prescribing them. This, despite the fact that statistically, well over 30% of their patients have obesity, and polls suggest that at least half of those embark on weight loss efforts annually. If a patient meets clinical criteria for a medication’s approved indication and a doctor won’t prescribe it because of their personal beliefs, in my opinion that’s grounds for a regulatory complaint.
• 6. Fearmongering around medications regarding adverse or unknown effects. The media’s coverage of new antiobesity medications is alarmist, to say the least, and for reasons I can’t fathom, given how well tolerated these medications are when dose titration is slow, monitored, and adjusted appropriately. Many physicians are not only buying into media narratives but are also spreading them.
• 7. Stopping medications for obesity when weight is lost. Do you also stop blood pressure medications when they normalize a patient’s blood pressure? Chronic conditions require ongoing long-term treatment. And yet I hear about this in my practice regularly.
• 8. Prescribing medications that cause weight gain rather than alternatives that don’t, or without discussion of same, or without the concomitant prescription of medication to counter it. From atypical antipsychotics to antidepressants to certain antiseizure medications to some blood pressure medications, there are those that have been shown to lead to, at times, dramatic weight gain. Yet, physicians will still regularly prescribe them to patients with obesity without first trying patients on available alternatives that don’t lead to weight gain, or without at least monitoring and then considering the prescription of an antiobesity medication to try to mitigate iatrogenic gain.
• 9. Setting ridiculous and unrealistic weight loss goals with patients. Without medication, the average person may lose 10% of their weight with purely behavioral efforts, 15%-20% with the addition of medications to those behavioral efforts, and 30% with the addition of bariatric surgery to their behavioral efforts. So why do so many physicians suggest goals that greatly exceed those averages? Imagine being committed to learning to run and having your running coach tell you at your training outset that your goal is to run a marathon within a Boston Marathon qualifying time. The goal should be whatever weight a person reaches living the healthiest life that they can honestly enjoy, not the Boston Marathon of weight loss.
• 10. Not discussing all options with all patients. Yes, food and fitness levers can affect weight, but that doesn’t mean that patients who meet the medical criteria for antiobesity medication or bariatric surgery shouldn’t be informed of their options. Our job as physicians is to fully inform our patients about the risks and benefits of all treatment options and then to support our patients’ decisions as to what option they want to pursue (including none, by the way). Our job is not to exclude discussion of proven and available options because our weight biases see us personally not believing in them – or worse, thinking that patients haven’t tried food and fitness umpteen times before, and that we require them to fail those efforts yet again before we stop gatekeeping their access to effective adjunctive therapeutic interventions.

Until recently, underwriting weight bias in medicine has been the dearth of effective treatments which in turn probably contributed to the overall lack of education for physicians in obesity management despite its extremely high prevalence. The times, though, are definitely a-changin’. Consequent to these new generations of medications rapidly coming online, by necessity we will see improvements in medical education around obesity management. Meanwhile, their efficacy will help dispel the bias that underlies much of this list. A decade or 2 from now, we will see obesity treated as we do every other chronic noncommunicable disease with lifestyle levers – with patient-centered care free from judgment and blame, and with a myriad of therapeutic options that physicians objectively, not subjectively, inform and prescribe to their patients.

Dr. Freedhoff is associate professor, department of family medicine, University of Ottawa, and medical director, Bariatric Medical Institute, also in Ottawa. He reported conflicts of interest with Constant Health and Novo Nordisk.
 

A version of this article first appeared on Medscape.com.

This last week I quietly reached a milestone. I didn’t do anything special about it; it was just another office day.

I passed 25 years since I first began seeing patients as an attending physician. That’s a pretty decent chunk of time.

I was terrified that day. For the first time in my medical career I was working without a net. I even remember the first one, a fellow with back pain. I saw five to six patients that day that I recall, including a work-in from the fellowship I’d completed 2 weeks earlier. I also had my first hospital consult when the oncologist I was subleasing from asked me to have a look at a lady he was admitting for new-onset diplopia.

That’s a good chuck of a career behind me, when you consider the beginnings of it. College, MCATs, waiting by the mailbox (yeah, kids, a mailbox, waiting for a printed letter, delivered by the postman). Moving halfway across the country for 4 years. Somehow, to my own amazement, graduating. Moving back. Internship. Residency. Fellowship.

Then my first day as an attending, now a quarter-century gone. Looking at my charts I’ve seen roughly 18,000 individual patients over time between my office and the hospital.

But that’s another change – after 22 years in the trenches, I stopped doing hospital work over 3 years ago. Inpatient work, at least to me now, seems more like a younger person’s game. In my late 50s, I don’t think I qualify as one anymore.

On day 1, also in the Phoenix summer, I wore a long-sleeved shirt, tie, slacks, and neatly polished shoes. In 2006 I moved to Hawaiian shirts, shorts, and sneakers.

I don’t plan on doing this in another 25 years. I still like it, but by then I will have passed the baton to another generation and will be off on a cruise ship having boat drinks in the afternoon.

But that’s not to say it hasn’t been fun. For all the frustrations, stresses, and aggravations, I have no regrets over the road I’ve taken, and hopefully I will always feel that way.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

This last week I quietly reached a milestone. I didn’t do anything special about it; it was just another office day.

I passed 25 years since I first began seeing patients as an attending physician. That’s a pretty decent chunk of time.

I was terrified that day. For the first time in my medical career I was working without a net. I even remember the first one, a fellow with back pain. I saw five to six patients that day that I recall, including a work-in from the fellowship I’d completed 2 weeks earlier. I also had my first hospital consult when the oncologist I was subleasing from asked me to have a look at a lady he was admitting for new-onset diplopia.

That’s a good chuck of a career behind me, when you consider the beginnings of it. College, MCATs, waiting by the mailbox (yeah, kids, a mailbox, waiting for a printed letter, delivered by the postman). Moving halfway across the country for 4 years. Somehow, to my own amazement, graduating. Moving back. Internship. Residency. Fellowship.

Then my first day as an attending, now a quarter-century gone. Looking at my charts I’ve seen roughly 18,000 individual patients over time between my office and the hospital.

But that’s another change – after 22 years in the trenches, I stopped doing hospital work over 3 years ago. Inpatient work, at least to me now, seems more like a younger person’s game. In my late 50s, I don’t think I qualify as one anymore.

On day 1, also in the Phoenix summer, I wore a long-sleeved shirt, tie, slacks, and neatly polished shoes. In 2006 I moved to Hawaiian shirts, shorts, and sneakers.

I don’t plan on doing this in another 25 years. I still like it, but by then I will have passed the baton to another generation and will be off on a cruise ship having boat drinks in the afternoon.

But that’s not to say it hasn’t been fun. For all the frustrations, stresses, and aggravations, I have no regrets over the road I’ve taken, and hopefully I will always feel that way.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

This last week I quietly reached a milestone. I didn’t do anything special about it; it was just another office day.

I passed 25 years since I first began seeing patients as an attending physician. That’s a pretty decent chunk of time.

I was terrified that day. For the first time in my medical career I was working without a net. I even remember the first one, a fellow with back pain. I saw five to six patients that day that I recall, including a work-in from the fellowship I’d completed 2 weeks earlier. I also had my first hospital consult when the oncologist I was subleasing from asked me to have a look at a lady he was admitting for new-onset diplopia.

That’s a good chuck of a career behind me, when you consider the beginnings of it. College, MCATs, waiting by the mailbox (yeah, kids, a mailbox, waiting for a printed letter, delivered by the postman). Moving halfway across the country for 4 years. Somehow, to my own amazement, graduating. Moving back. Internship. Residency. Fellowship.

Then my first day as an attending, now a quarter-century gone. Looking at my charts I’ve seen roughly 18,000 individual patients over time between my office and the hospital.

But that’s another change – after 22 years in the trenches, I stopped doing hospital work over 3 years ago. Inpatient work, at least to me now, seems more like a younger person’s game. In my late 50s, I don’t think I qualify as one anymore.

On day 1, also in the Phoenix summer, I wore a long-sleeved shirt, tie, slacks, and neatly polished shoes. In 2006 I moved to Hawaiian shirts, shorts, and sneakers.

I don’t plan on doing this in another 25 years. I still like it, but by then I will have passed the baton to another generation and will be off on a cruise ship having boat drinks in the afternoon.

But that’s not to say it hasn’t been fun. For all the frustrations, stresses, and aggravations, I have no regrets over the road I’ve taken, and hopefully I will always feel that way.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.