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Altered gut bacteria a biomarker of preclinical Alzheimer’s?
The findings open up the possibility of analyzing the gut microbiome to identify individuals at a higher risk for dementia and perhaps designing microbiome-altering preventive treatments to help stave off cognitive decline, researchers noted.
Study investigator Gautam Dantas, PhD, cautioned that it’s not known whether the gut is influencing the brain, or the brain is influencing the gut, “but this association is valuable to know in either case.
“It could be that the changes in the gut microbiome are just a readout of pathological changes in the brain. The other alternative is that the gut microbiome is contributing to AD, in which case, altering the gut microbiome with probiotics or fecal transfers might help change the course of the disease,” Dr. Dantas, Washington University, St. Louis, said in a news release.
The study was published online in Science Translational Medicine.
Stool test?
Multiple lines of evidence suggest a role for gut microbes in the evolution of AD pathogenesis. However, less is known about gut microbiome changes in the preclinical (presymptomatic) phase of AD.
To investigate, Dr. Dantas and colleagues studied 164 cognitively normal adults, 49 of whom had biomarker evidence of preclinical AD.
After the researchers accounted for clinical covariates and diet, those with preclinical AD had distinct gut microbial taxonomic profiles compared with their healthy controls.
The observed microbiome features correlated with amyloid and tau but not neurodegeneration biomarkers, “suggesting that the gut microbial community changes early in the disease process,” the researchers suggested.
They identified specific taxa that were associated with preclinical AD and including these microbiome features improved the accuracy, sensitivity, and specificity of machine learning classifiers for predicting preclinical AD status.
The findings suggest “markers in the stool might complement early screening measures for preclinical AD,” the researchers noted.
“The nice thing about using the gut microbiome as a screening tool is its simplicity and ease,” Beau Ances, MD, PhD, professor of neurology, at Washington University, St. Louis, said in the release.
“One day, individuals may be able to provide a stool sample and find out if they are at increased risk for developing AD. It would be much easier and less invasive and more accessible for a large proportion of the population, especially underrepresented groups, compared to brain scans or spinal taps,” Dr. Ances added.
The researchers have launched a 5-year follow-up study designed to help determine whether the differences in the gut microbiome are a cause or a result of the brain changes seen in early AD.
Caveats, cautionary notes
In a comment, Claire Sexton, DPhil, Alzheimer’s Association senior director of scientific programs and outreach, cautioned that the study design means that it’s “not possible to prove one thing causes another. What it can show is that two or more aspects are in some way related, thus setting the stage for further research.”
Dr. Sexton noted that though the authors accounted for a number of variables in their models, including age, sex, race, education, body mass index, hypertension, and diabetes, and observed no differences in intake of any major nutrient group, “it’s still not possible to rule out that additional factors beyond the variations in gut microbiome contributed to the changes in brain markers of Alzheimer’s.”
Dr. Sexton also noted that the study population is not representative of all people living with AD, with the vast majority of those with preclinical AD in the study being White.
“If these findings are replicated and confirmed in study groups that are representative of our communities, it is possible that gut microbiome signatures could be a further addition to the suite of diagnostic tools employed in certain settings,” Dr. Sexton said.
This research was supported by the Infection Disease Society of America Foundation, the National Institute on Aging, the Brennan Fund and the Paula and Rodger Riney Foundation. Dr. Dantas, Dr. Ances and Dr. Sexton have no relevant disclosures.
A version of this article first appeared on Medscape.com.
The findings open up the possibility of analyzing the gut microbiome to identify individuals at a higher risk for dementia and perhaps designing microbiome-altering preventive treatments to help stave off cognitive decline, researchers noted.
Study investigator Gautam Dantas, PhD, cautioned that it’s not known whether the gut is influencing the brain, or the brain is influencing the gut, “but this association is valuable to know in either case.
“It could be that the changes in the gut microbiome are just a readout of pathological changes in the brain. The other alternative is that the gut microbiome is contributing to AD, in which case, altering the gut microbiome with probiotics or fecal transfers might help change the course of the disease,” Dr. Dantas, Washington University, St. Louis, said in a news release.
The study was published online in Science Translational Medicine.
Stool test?
Multiple lines of evidence suggest a role for gut microbes in the evolution of AD pathogenesis. However, less is known about gut microbiome changes in the preclinical (presymptomatic) phase of AD.
To investigate, Dr. Dantas and colleagues studied 164 cognitively normal adults, 49 of whom had biomarker evidence of preclinical AD.
After the researchers accounted for clinical covariates and diet, those with preclinical AD had distinct gut microbial taxonomic profiles compared with their healthy controls.
The observed microbiome features correlated with amyloid and tau but not neurodegeneration biomarkers, “suggesting that the gut microbial community changes early in the disease process,” the researchers suggested.
They identified specific taxa that were associated with preclinical AD and including these microbiome features improved the accuracy, sensitivity, and specificity of machine learning classifiers for predicting preclinical AD status.
The findings suggest “markers in the stool might complement early screening measures for preclinical AD,” the researchers noted.
“The nice thing about using the gut microbiome as a screening tool is its simplicity and ease,” Beau Ances, MD, PhD, professor of neurology, at Washington University, St. Louis, said in the release.
“One day, individuals may be able to provide a stool sample and find out if they are at increased risk for developing AD. It would be much easier and less invasive and more accessible for a large proportion of the population, especially underrepresented groups, compared to brain scans or spinal taps,” Dr. Ances added.
The researchers have launched a 5-year follow-up study designed to help determine whether the differences in the gut microbiome are a cause or a result of the brain changes seen in early AD.
Caveats, cautionary notes
In a comment, Claire Sexton, DPhil, Alzheimer’s Association senior director of scientific programs and outreach, cautioned that the study design means that it’s “not possible to prove one thing causes another. What it can show is that two or more aspects are in some way related, thus setting the stage for further research.”
Dr. Sexton noted that though the authors accounted for a number of variables in their models, including age, sex, race, education, body mass index, hypertension, and diabetes, and observed no differences in intake of any major nutrient group, “it’s still not possible to rule out that additional factors beyond the variations in gut microbiome contributed to the changes in brain markers of Alzheimer’s.”
Dr. Sexton also noted that the study population is not representative of all people living with AD, with the vast majority of those with preclinical AD in the study being White.
“If these findings are replicated and confirmed in study groups that are representative of our communities, it is possible that gut microbiome signatures could be a further addition to the suite of diagnostic tools employed in certain settings,” Dr. Sexton said.
This research was supported by the Infection Disease Society of America Foundation, the National Institute on Aging, the Brennan Fund and the Paula and Rodger Riney Foundation. Dr. Dantas, Dr. Ances and Dr. Sexton have no relevant disclosures.
A version of this article first appeared on Medscape.com.
The findings open up the possibility of analyzing the gut microbiome to identify individuals at a higher risk for dementia and perhaps designing microbiome-altering preventive treatments to help stave off cognitive decline, researchers noted.
Study investigator Gautam Dantas, PhD, cautioned that it’s not known whether the gut is influencing the brain, or the brain is influencing the gut, “but this association is valuable to know in either case.
“It could be that the changes in the gut microbiome are just a readout of pathological changes in the brain. The other alternative is that the gut microbiome is contributing to AD, in which case, altering the gut microbiome with probiotics or fecal transfers might help change the course of the disease,” Dr. Dantas, Washington University, St. Louis, said in a news release.
The study was published online in Science Translational Medicine.
Stool test?
Multiple lines of evidence suggest a role for gut microbes in the evolution of AD pathogenesis. However, less is known about gut microbiome changes in the preclinical (presymptomatic) phase of AD.
To investigate, Dr. Dantas and colleagues studied 164 cognitively normal adults, 49 of whom had biomarker evidence of preclinical AD.
After the researchers accounted for clinical covariates and diet, those with preclinical AD had distinct gut microbial taxonomic profiles compared with their healthy controls.
The observed microbiome features correlated with amyloid and tau but not neurodegeneration biomarkers, “suggesting that the gut microbial community changes early in the disease process,” the researchers suggested.
They identified specific taxa that were associated with preclinical AD and including these microbiome features improved the accuracy, sensitivity, and specificity of machine learning classifiers for predicting preclinical AD status.
The findings suggest “markers in the stool might complement early screening measures for preclinical AD,” the researchers noted.
“The nice thing about using the gut microbiome as a screening tool is its simplicity and ease,” Beau Ances, MD, PhD, professor of neurology, at Washington University, St. Louis, said in the release.
“One day, individuals may be able to provide a stool sample and find out if they are at increased risk for developing AD. It would be much easier and less invasive and more accessible for a large proportion of the population, especially underrepresented groups, compared to brain scans or spinal taps,” Dr. Ances added.
The researchers have launched a 5-year follow-up study designed to help determine whether the differences in the gut microbiome are a cause or a result of the brain changes seen in early AD.
Caveats, cautionary notes
In a comment, Claire Sexton, DPhil, Alzheimer’s Association senior director of scientific programs and outreach, cautioned that the study design means that it’s “not possible to prove one thing causes another. What it can show is that two or more aspects are in some way related, thus setting the stage for further research.”
Dr. Sexton noted that though the authors accounted for a number of variables in their models, including age, sex, race, education, body mass index, hypertension, and diabetes, and observed no differences in intake of any major nutrient group, “it’s still not possible to rule out that additional factors beyond the variations in gut microbiome contributed to the changes in brain markers of Alzheimer’s.”
Dr. Sexton also noted that the study population is not representative of all people living with AD, with the vast majority of those with preclinical AD in the study being White.
“If these findings are replicated and confirmed in study groups that are representative of our communities, it is possible that gut microbiome signatures could be a further addition to the suite of diagnostic tools employed in certain settings,” Dr. Sexton said.
This research was supported by the Infection Disease Society of America Foundation, the National Institute on Aging, the Brennan Fund and the Paula and Rodger Riney Foundation. Dr. Dantas, Dr. Ances and Dr. Sexton have no relevant disclosures.
A version of this article first appeared on Medscape.com.
FROM SCIENCE TRANSLATIONAL MEDICINE
A new nonhormonal option for menopausal hot flashes: What prescribers should know
This transcript has been edited for clarity.
Hello. I am Dr. JoAnn Pinkerton, professor of obstetrics and gynecology at the University of Virginia and a North American Menopause Society–credentialed menopause specialist.
I am excited to tell you about a brand-new, just-approved non-estrogen therapy for treatment of menopausal symptoms. . The manufacturer, Astellas, is expected to make fezolinetant available at pharmacies before the end of this year. This medication binds to and blocks the neurokinin 3 (NK3) receptor, which plays a role in regulating body temperature, leading to a reduction in hot flashes.
For women suffering from frequent moderate to severe hot flashes, fezolinetant is an exciting breakthrough in women’s health as it is a highly effective nonhormonal treatment that reduces hot flashes and improves quality of life.
In two phase 3 clinical trials (Johnson et al. and Lederman et al.), fezolinetant 45 mg reduced the frequency of vasomotor symptoms by about 65%, significantly more than placebo, and similar to the 75% reduction seen with hormone therapy. Fezolinetant’s efficacy becomes evident within 1 week, reducing both frequency and severity of hot flashes.
With respect to side effects, 1%-2% of the menopausal women participating in clinical trials reported adverse events, including headaches, abdominal pain, diarrhea, insomnia, back pain, hot flushes, and reversible elevated hepatic transaminases. Serious adverse events were infrequent.
Subgroup analysis of data presented at ACOG’s 2023 annual meeting noted fezolinetant’s effectiveness among diverse populations, including White or Black race, body mass index of 30 or higher, those younger or older than age 55, smokers, former smokers, and never smokers, in U.S. as well as in European trial participants.
With respect to safety, a 52-week placebo-controlled safety trial confirmed safety for this time period. Adverse effects on the endometrium were neither seen nor expected, as fezolinetant is a centrally acting non–estrogen-containing medication. In addition, no loss of bone density was seen.
Prior trials of neurokinin receptor antagonists suggested the potential for hepatotoxicity. Increases in ALT or AST noted in one of the phase 3 trials of fezolinetant were described as asymptomatic, isolated, intermittent, or transient and returned to baseline during treatment or after discontinuation. However, the FDA placed a warning about liver injury potential. Package labeling recommends baseline liver function tests before starting fezolinetant and at 3, 6, and 9 months. In addition, concomitant use of moderate CYP1A2 inhibitors, including many antidepressants and cimetidine, should be avoided.
As with other recently approved medications, I am concerned that high cost could prevent appropriate candidates from having access.
Until now, the FDA had approved only one nonhormone therapy for vasomotor symptoms, 7.5 mg paroxetine salt. However, neither this formulation nor off-label use of other SSRIs, SNRIs, gabapentinoids, oxybutynin, or clonidine are as effective as hormone therapy or fezolinetant for moderate to severe vasomotor symptoms.
For women with bothersome menopausal hot flashes who can’t or choose not to use hormone therapy, including those with estrogen-sensitive breast or uterine cancers, fezolinetant offers a much-needed, highly effective, safe, nonhormone/non-estrogen option to treat their hot flashes.
The FDA approved it for treating vasomotor symptoms of menopause (hot flashes and night sweats) but it also appears to improve sleep disruption, mood, and quality of life.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
Hello. I am Dr. JoAnn Pinkerton, professor of obstetrics and gynecology at the University of Virginia and a North American Menopause Society–credentialed menopause specialist.
I am excited to tell you about a brand-new, just-approved non-estrogen therapy for treatment of menopausal symptoms. . The manufacturer, Astellas, is expected to make fezolinetant available at pharmacies before the end of this year. This medication binds to and blocks the neurokinin 3 (NK3) receptor, which plays a role in regulating body temperature, leading to a reduction in hot flashes.
For women suffering from frequent moderate to severe hot flashes, fezolinetant is an exciting breakthrough in women’s health as it is a highly effective nonhormonal treatment that reduces hot flashes and improves quality of life.
In two phase 3 clinical trials (Johnson et al. and Lederman et al.), fezolinetant 45 mg reduced the frequency of vasomotor symptoms by about 65%, significantly more than placebo, and similar to the 75% reduction seen with hormone therapy. Fezolinetant’s efficacy becomes evident within 1 week, reducing both frequency and severity of hot flashes.
With respect to side effects, 1%-2% of the menopausal women participating in clinical trials reported adverse events, including headaches, abdominal pain, diarrhea, insomnia, back pain, hot flushes, and reversible elevated hepatic transaminases. Serious adverse events were infrequent.
Subgroup analysis of data presented at ACOG’s 2023 annual meeting noted fezolinetant’s effectiveness among diverse populations, including White or Black race, body mass index of 30 or higher, those younger or older than age 55, smokers, former smokers, and never smokers, in U.S. as well as in European trial participants.
With respect to safety, a 52-week placebo-controlled safety trial confirmed safety for this time period. Adverse effects on the endometrium were neither seen nor expected, as fezolinetant is a centrally acting non–estrogen-containing medication. In addition, no loss of bone density was seen.
Prior trials of neurokinin receptor antagonists suggested the potential for hepatotoxicity. Increases in ALT or AST noted in one of the phase 3 trials of fezolinetant were described as asymptomatic, isolated, intermittent, or transient and returned to baseline during treatment or after discontinuation. However, the FDA placed a warning about liver injury potential. Package labeling recommends baseline liver function tests before starting fezolinetant and at 3, 6, and 9 months. In addition, concomitant use of moderate CYP1A2 inhibitors, including many antidepressants and cimetidine, should be avoided.
As with other recently approved medications, I am concerned that high cost could prevent appropriate candidates from having access.
Until now, the FDA had approved only one nonhormone therapy for vasomotor symptoms, 7.5 mg paroxetine salt. However, neither this formulation nor off-label use of other SSRIs, SNRIs, gabapentinoids, oxybutynin, or clonidine are as effective as hormone therapy or fezolinetant for moderate to severe vasomotor symptoms.
For women with bothersome menopausal hot flashes who can’t or choose not to use hormone therapy, including those with estrogen-sensitive breast or uterine cancers, fezolinetant offers a much-needed, highly effective, safe, nonhormone/non-estrogen option to treat their hot flashes.
The FDA approved it for treating vasomotor symptoms of menopause (hot flashes and night sweats) but it also appears to improve sleep disruption, mood, and quality of life.
A version of this article first appeared on Medscape.com.
This transcript has been edited for clarity.
Hello. I am Dr. JoAnn Pinkerton, professor of obstetrics and gynecology at the University of Virginia and a North American Menopause Society–credentialed menopause specialist.
I am excited to tell you about a brand-new, just-approved non-estrogen therapy for treatment of menopausal symptoms. . The manufacturer, Astellas, is expected to make fezolinetant available at pharmacies before the end of this year. This medication binds to and blocks the neurokinin 3 (NK3) receptor, which plays a role in regulating body temperature, leading to a reduction in hot flashes.
For women suffering from frequent moderate to severe hot flashes, fezolinetant is an exciting breakthrough in women’s health as it is a highly effective nonhormonal treatment that reduces hot flashes and improves quality of life.
In two phase 3 clinical trials (Johnson et al. and Lederman et al.), fezolinetant 45 mg reduced the frequency of vasomotor symptoms by about 65%, significantly more than placebo, and similar to the 75% reduction seen with hormone therapy. Fezolinetant’s efficacy becomes evident within 1 week, reducing both frequency and severity of hot flashes.
With respect to side effects, 1%-2% of the menopausal women participating in clinical trials reported adverse events, including headaches, abdominal pain, diarrhea, insomnia, back pain, hot flushes, and reversible elevated hepatic transaminases. Serious adverse events were infrequent.
Subgroup analysis of data presented at ACOG’s 2023 annual meeting noted fezolinetant’s effectiveness among diverse populations, including White or Black race, body mass index of 30 or higher, those younger or older than age 55, smokers, former smokers, and never smokers, in U.S. as well as in European trial participants.
With respect to safety, a 52-week placebo-controlled safety trial confirmed safety for this time period. Adverse effects on the endometrium were neither seen nor expected, as fezolinetant is a centrally acting non–estrogen-containing medication. In addition, no loss of bone density was seen.
Prior trials of neurokinin receptor antagonists suggested the potential for hepatotoxicity. Increases in ALT or AST noted in one of the phase 3 trials of fezolinetant were described as asymptomatic, isolated, intermittent, or transient and returned to baseline during treatment or after discontinuation. However, the FDA placed a warning about liver injury potential. Package labeling recommends baseline liver function tests before starting fezolinetant and at 3, 6, and 9 months. In addition, concomitant use of moderate CYP1A2 inhibitors, including many antidepressants and cimetidine, should be avoided.
As with other recently approved medications, I am concerned that high cost could prevent appropriate candidates from having access.
Until now, the FDA had approved only one nonhormone therapy for vasomotor symptoms, 7.5 mg paroxetine salt. However, neither this formulation nor off-label use of other SSRIs, SNRIs, gabapentinoids, oxybutynin, or clonidine are as effective as hormone therapy or fezolinetant for moderate to severe vasomotor symptoms.
For women with bothersome menopausal hot flashes who can’t or choose not to use hormone therapy, including those with estrogen-sensitive breast or uterine cancers, fezolinetant offers a much-needed, highly effective, safe, nonhormone/non-estrogen option to treat their hot flashes.
The FDA approved it for treating vasomotor symptoms of menopause (hot flashes and night sweats) but it also appears to improve sleep disruption, mood, and quality of life.
A version of this article first appeared on Medscape.com.
Probiotics an effective adjunct to antidepressants for major depression
By the end of the 8-week pilot study, participants who had an incomplete response to antidepressants prior to taking probiotics scored better on measures of anxiety and depression versus placebo.
“This was a pilot study, designed as an initial exploration of whether improving gut health with probiotics could act as a new pathway for supporting mood and mental health,” study investigator Viktoriya Nikolova, PhD, Institute of Psychiatry, Psychology and Neuroscience at King’s College London, said in an interview.
“While very promising and exciting, our findings are only the first step, and larger trials are needed,” she noted.
The findings were published online in JAMA Psychiatry.
Gut-brain axis
It is estimated that up to 60% of people taking antidepressants for major depressive disorder (MDD) do not achieve full response.
With an eye on the so-called gut-brain axis as a treatment target for depression, the researchers conducted a meta-analysis of seven randomized controlled trials (RCT) in 2021 and found that probiotics appeared effective in reducing depressive symptoms when taken alongside antidepressants. The studies in this meta-analysis either reported poor adherence rates or did not investigate how well study participants tolerated probiotics.
To further investigate, Dr. Nikolova and team launched a pilot RCT by recruiting study participants from primary and secondary health care services, and through general advertising in London. Data were collected from September 2019 to May 2022.
They included 49 adults diagnosed with MDD with an incomplete antidepressant response, indicated by a score of greater than 13 on the Hamilton Depression Rating Scale-17 (HAMD-17).
Half of the participants were randomly assigned to receive a widely available, proprietary, 14-strain blend probiotic supplement, and half received placebo. Both groups took their study drug four times per day during the 8-week trial.
At baseline, 4 weeks, and 8 weeks, investigators assessed the participants for depression with the HAMD-17, the Inventory of Depressive Symptomatology (IDS) Self-Report, and anxiety with the Hamilton Anxiety Rating Scale (HAMA).
The majority of participants (80%) were female with a mean age of 32 years. Adherence was high, with 97% of the doses taken as required, and no adverse events were reported.
Standardized effect sizes from linear mixed models demonstrated that, when compared with the placebo group, the probiotic group had more improvement in depressive symptoms according to the HAMD-17 (week 4: SES, 0.70; 95% confidence interval, 0.01-0.98) and IDS Self Report (week 8: SES, 0.64; 95% CI, 0.03-0.87).
When compared with the placebo group, the probiotic group also experienced greater improvements in anxiety symptoms according to the HAMA (week 4: SES, 0.67; 95% CI, 0-0.95; week 8: SES, 0.79; 95% CI, 0.06-1.05).
Dr. Nikolova said a large follow-up trial is planned to further confirm the results.
Nutritional psychiatrist Drew Ramsey, MD, author of Eat to Beat Depression and Anxiety and assistant clinical professor of psychiatry at Columbia University, New York, said in an interview: “This randomized clinical trial adds to the considerable evidence that food choices impact depression outcomes.”
He further noted that, “in nutritional psychiatry, we recommend eating fermented foods as they have been shown to improve microbiome diversity and decrease markers of inflammation.”
Dr. Ramsey noted that the RCT used the equivalent colony-forming unit of a “single serving of kombucha.”
“In our clinical group and our nutritional psychiatry course for clinicians, we recommend fermented foods over probiotics as this is the most sustainable, evidence-based way to improve microbiome diversity,” said Dr. Ramsey, citing recent research by Gardner and colleagues at Stanford (Calif.) University.
“This is an industry-funded trial that adds to the evidence base but should be interpreted by patients and clinicians as promoting consumption of more kefir, kimchi, and kombucha, not that patients should take probiotics,” he said.
A key place for probiotics in mental health
Commenting on the study, Uma Naidoo, MD, said: “As I shared throughout my first book, This is Your Brain on Food, there is a real place for the use of probiotics in mental health, including the importance of the gut-brain connection.”
Dr. Naidoo is the director of nutritional and metabolic psychiatry at Massachusetts General Hospital and of nutritional psychiatry at the MGH Academy, both in Boston.
She noted that, when a person stops using a probiotic after trying it out, the positive changes in the gut are reversed, so “remaining consistent in taking the probiotic is important if you have found it helpful for your mood.”
Dr. Naidoo added that “each person’s gut microbiome is so unique that it is likely not every human being will have the same reaction to a probiotic.”
“Eating foods with live probiotics may also benefit gut health and, therefore, mood,” she said. The same goes with eating fermented foods with live active cultures.”
The study was funded by a Medical Research Council Industrial CASE PhD Studentship with ADM Protexin (supplier of the probiotics) as the industry partner and additional support from Freya Green. Dr. Nikolova has received grants from the Medical Research Council and ADM Protexin during the conduct of the study as well as personal fees from Janssen outside the submitted work.
A version of this article first appeared on Medscape.com.
By the end of the 8-week pilot study, participants who had an incomplete response to antidepressants prior to taking probiotics scored better on measures of anxiety and depression versus placebo.
“This was a pilot study, designed as an initial exploration of whether improving gut health with probiotics could act as a new pathway for supporting mood and mental health,” study investigator Viktoriya Nikolova, PhD, Institute of Psychiatry, Psychology and Neuroscience at King’s College London, said in an interview.
“While very promising and exciting, our findings are only the first step, and larger trials are needed,” she noted.
The findings were published online in JAMA Psychiatry.
Gut-brain axis
It is estimated that up to 60% of people taking antidepressants for major depressive disorder (MDD) do not achieve full response.
With an eye on the so-called gut-brain axis as a treatment target for depression, the researchers conducted a meta-analysis of seven randomized controlled trials (RCT) in 2021 and found that probiotics appeared effective in reducing depressive symptoms when taken alongside antidepressants. The studies in this meta-analysis either reported poor adherence rates or did not investigate how well study participants tolerated probiotics.
To further investigate, Dr. Nikolova and team launched a pilot RCT by recruiting study participants from primary and secondary health care services, and through general advertising in London. Data were collected from September 2019 to May 2022.
They included 49 adults diagnosed with MDD with an incomplete antidepressant response, indicated by a score of greater than 13 on the Hamilton Depression Rating Scale-17 (HAMD-17).
Half of the participants were randomly assigned to receive a widely available, proprietary, 14-strain blend probiotic supplement, and half received placebo. Both groups took their study drug four times per day during the 8-week trial.
At baseline, 4 weeks, and 8 weeks, investigators assessed the participants for depression with the HAMD-17, the Inventory of Depressive Symptomatology (IDS) Self-Report, and anxiety with the Hamilton Anxiety Rating Scale (HAMA).
The majority of participants (80%) were female with a mean age of 32 years. Adherence was high, with 97% of the doses taken as required, and no adverse events were reported.
Standardized effect sizes from linear mixed models demonstrated that, when compared with the placebo group, the probiotic group had more improvement in depressive symptoms according to the HAMD-17 (week 4: SES, 0.70; 95% confidence interval, 0.01-0.98) and IDS Self Report (week 8: SES, 0.64; 95% CI, 0.03-0.87).
When compared with the placebo group, the probiotic group also experienced greater improvements in anxiety symptoms according to the HAMA (week 4: SES, 0.67; 95% CI, 0-0.95; week 8: SES, 0.79; 95% CI, 0.06-1.05).
Dr. Nikolova said a large follow-up trial is planned to further confirm the results.
Nutritional psychiatrist Drew Ramsey, MD, author of Eat to Beat Depression and Anxiety and assistant clinical professor of psychiatry at Columbia University, New York, said in an interview: “This randomized clinical trial adds to the considerable evidence that food choices impact depression outcomes.”
He further noted that, “in nutritional psychiatry, we recommend eating fermented foods as they have been shown to improve microbiome diversity and decrease markers of inflammation.”
Dr. Ramsey noted that the RCT used the equivalent colony-forming unit of a “single serving of kombucha.”
“In our clinical group and our nutritional psychiatry course for clinicians, we recommend fermented foods over probiotics as this is the most sustainable, evidence-based way to improve microbiome diversity,” said Dr. Ramsey, citing recent research by Gardner and colleagues at Stanford (Calif.) University.
“This is an industry-funded trial that adds to the evidence base but should be interpreted by patients and clinicians as promoting consumption of more kefir, kimchi, and kombucha, not that patients should take probiotics,” he said.
A key place for probiotics in mental health
Commenting on the study, Uma Naidoo, MD, said: “As I shared throughout my first book, This is Your Brain on Food, there is a real place for the use of probiotics in mental health, including the importance of the gut-brain connection.”
Dr. Naidoo is the director of nutritional and metabolic psychiatry at Massachusetts General Hospital and of nutritional psychiatry at the MGH Academy, both in Boston.
She noted that, when a person stops using a probiotic after trying it out, the positive changes in the gut are reversed, so “remaining consistent in taking the probiotic is important if you have found it helpful for your mood.”
Dr. Naidoo added that “each person’s gut microbiome is so unique that it is likely not every human being will have the same reaction to a probiotic.”
“Eating foods with live probiotics may also benefit gut health and, therefore, mood,” she said. The same goes with eating fermented foods with live active cultures.”
The study was funded by a Medical Research Council Industrial CASE PhD Studentship with ADM Protexin (supplier of the probiotics) as the industry partner and additional support from Freya Green. Dr. Nikolova has received grants from the Medical Research Council and ADM Protexin during the conduct of the study as well as personal fees from Janssen outside the submitted work.
A version of this article first appeared on Medscape.com.
By the end of the 8-week pilot study, participants who had an incomplete response to antidepressants prior to taking probiotics scored better on measures of anxiety and depression versus placebo.
“This was a pilot study, designed as an initial exploration of whether improving gut health with probiotics could act as a new pathway for supporting mood and mental health,” study investigator Viktoriya Nikolova, PhD, Institute of Psychiatry, Psychology and Neuroscience at King’s College London, said in an interview.
“While very promising and exciting, our findings are only the first step, and larger trials are needed,” she noted.
The findings were published online in JAMA Psychiatry.
Gut-brain axis
It is estimated that up to 60% of people taking antidepressants for major depressive disorder (MDD) do not achieve full response.
With an eye on the so-called gut-brain axis as a treatment target for depression, the researchers conducted a meta-analysis of seven randomized controlled trials (RCT) in 2021 and found that probiotics appeared effective in reducing depressive symptoms when taken alongside antidepressants. The studies in this meta-analysis either reported poor adherence rates or did not investigate how well study participants tolerated probiotics.
To further investigate, Dr. Nikolova and team launched a pilot RCT by recruiting study participants from primary and secondary health care services, and through general advertising in London. Data were collected from September 2019 to May 2022.
They included 49 adults diagnosed with MDD with an incomplete antidepressant response, indicated by a score of greater than 13 on the Hamilton Depression Rating Scale-17 (HAMD-17).
Half of the participants were randomly assigned to receive a widely available, proprietary, 14-strain blend probiotic supplement, and half received placebo. Both groups took their study drug four times per day during the 8-week trial.
At baseline, 4 weeks, and 8 weeks, investigators assessed the participants for depression with the HAMD-17, the Inventory of Depressive Symptomatology (IDS) Self-Report, and anxiety with the Hamilton Anxiety Rating Scale (HAMA).
The majority of participants (80%) were female with a mean age of 32 years. Adherence was high, with 97% of the doses taken as required, and no adverse events were reported.
Standardized effect sizes from linear mixed models demonstrated that, when compared with the placebo group, the probiotic group had more improvement in depressive symptoms according to the HAMD-17 (week 4: SES, 0.70; 95% confidence interval, 0.01-0.98) and IDS Self Report (week 8: SES, 0.64; 95% CI, 0.03-0.87).
When compared with the placebo group, the probiotic group also experienced greater improvements in anxiety symptoms according to the HAMA (week 4: SES, 0.67; 95% CI, 0-0.95; week 8: SES, 0.79; 95% CI, 0.06-1.05).
Dr. Nikolova said a large follow-up trial is planned to further confirm the results.
Nutritional psychiatrist Drew Ramsey, MD, author of Eat to Beat Depression and Anxiety and assistant clinical professor of psychiatry at Columbia University, New York, said in an interview: “This randomized clinical trial adds to the considerable evidence that food choices impact depression outcomes.”
He further noted that, “in nutritional psychiatry, we recommend eating fermented foods as they have been shown to improve microbiome diversity and decrease markers of inflammation.”
Dr. Ramsey noted that the RCT used the equivalent colony-forming unit of a “single serving of kombucha.”
“In our clinical group and our nutritional psychiatry course for clinicians, we recommend fermented foods over probiotics as this is the most sustainable, evidence-based way to improve microbiome diversity,” said Dr. Ramsey, citing recent research by Gardner and colleagues at Stanford (Calif.) University.
“This is an industry-funded trial that adds to the evidence base but should be interpreted by patients and clinicians as promoting consumption of more kefir, kimchi, and kombucha, not that patients should take probiotics,” he said.
A key place for probiotics in mental health
Commenting on the study, Uma Naidoo, MD, said: “As I shared throughout my first book, This is Your Brain on Food, there is a real place for the use of probiotics in mental health, including the importance of the gut-brain connection.”
Dr. Naidoo is the director of nutritional and metabolic psychiatry at Massachusetts General Hospital and of nutritional psychiatry at the MGH Academy, both in Boston.
She noted that, when a person stops using a probiotic after trying it out, the positive changes in the gut are reversed, so “remaining consistent in taking the probiotic is important if you have found it helpful for your mood.”
Dr. Naidoo added that “each person’s gut microbiome is so unique that it is likely not every human being will have the same reaction to a probiotic.”
“Eating foods with live probiotics may also benefit gut health and, therefore, mood,” she said. The same goes with eating fermented foods with live active cultures.”
The study was funded by a Medical Research Council Industrial CASE PhD Studentship with ADM Protexin (supplier of the probiotics) as the industry partner and additional support from Freya Green. Dr. Nikolova has received grants from the Medical Research Council and ADM Protexin during the conduct of the study as well as personal fees from Janssen outside the submitted work.
A version of this article first appeared on Medscape.com.
FROM JAMA PSYCHIATRY
‘Deprescribing’: Should some older adults shed their meds?
Joanne Lynn, MD, has lost track of the number of times in her 40 years as a geriatrician she’s seen a new patient come to her office carrying a bucket full of prescription medications – many of which they don’t need.
Dr. Lynn, who is on the faculty of George Washington University,Washington, recalled one woman who unwittingly was taking two blood pressure medications with different names.
“The risks included all the side effects overdosing carries,” Dr. Lynn said, ranging from blurred vision and crankiness to organ failure and even death.
For doctors with patients who don’t know they’re taking too much of a medication, “you wonder whether the drug is causing the health problems, and it’s a symptom of the wrong medication,” rather than a symptom of an undiagnosed illness, she said.
Patients often assume their health providers check for drug interactions or assess if a medication is no longer needed, and will catch extra prescriptions. That could be a risky assumption. Some doctors may prescribe yet another prescription to manage the side effects of an unnecessary drug, instead of doing a medication review and potentially “deprescribing” or discontinuing, a treatment that’s no longer needed.
About 57% of people age 65 years or older take five or more medications regularly – a concept known as polypharmacy, a study published in 2020 in the Journal of the American Geriatrics Society shows. While doctors prescribe drugs to help patients manage various ailments, as a list of medications grows, so do potential complications.
An older adult might forget to tell their doctor what they’re taking, or maybe they don’t even know what they’re taking or why, Dr. Lynn said.
“In some cases, a doctor just added a drug to treat something, not realizing they were already taking something else for it,” she said. “Of course, the situation of whether these patients can even afford all these drugs matters a lot, too.”
Some older adults may pick and choose which medications to take based on cost, not knowing which prescriptions are necessary, Dr. Lynn said.
Finding the ‘right balance’
Indeed, if given the option, up to 80% of older adults ages 50-80 would be open to stopping one or more of their prescribed medications, according to a 2023 poll by researchers at the University of Michigan, Ann Arbor.
“A lot of drugs that people take might have been appropriate at one point, but might have outlived their usefulness for that individual,” said Michael Steinman, MD, a professor of medicine and a geriatrician at the University of California, San Francisco, and coprincipal investigator of the U.S. Deprescribing Research Network, a doctor group focused on improving medication use for older adults.
“Having fewer medications can actually be beneficial,” he said. “You can take too many medications; you can take too few. The optimal thing is finding what is the right balance for you.”
Defining how many medications is too many depends on each person, which is why caregivers and older adults can ask their doctor for a review of medications that have multiplied over time.
By reevaluating their medications, older adults can actually lower their chances of potentially harmful side effects, and avoid the spiral of being prescribed even more medications, said Sarah Vordenberg, PharmD, MPH, a clinical associate professor at the University of Michigan’s College of Pharmacy, Ann Arbor.
“It’s not really the number of medications, it’s [about] are they inappropriate or unnecessary medications for a patient,” she said.
Patients and caregivers can ask for an honest conversation with their doctor. The University of Michigan poll found that more than 90% of older adults who took prescription medications expected their health care provider to review their medicines during a regular visit.
But doctors often need prompting from patients to start a review.
“The clinical inertia, or maintaining the status quo, unfortunately is a lot of times easier than having time-intensive conversations,” Dr. Vordenberg said.
Ask questions
Sara Merwin spent many years helping manage her parents’ medical appointments and health as they transitioned from living independently in Colorado to a retirement community and finally a nursing home. Ms. Merwin, coauthor of “The Informed Patient,” said her father was taking a long list of medications, and she often asked his primary care doctor for a medication review.
“I felt that my father at his age and his frailty didn’t need as many meds as he was on,” said Ms. Merwin, who lives in Long Island, N.Y. “So we went over his meds, and I asked, ‘Does he really need to be on this?’ ‘Does he really need to be on that?’ ”
She questioned one medication in particular, a statin to lower his cholesterol and risk of a heart attack.
“I thought possibly the statin was causing some myalgia, some muscle aches in his legs, which is why I advocated for coming off it,” she said.
The primary care doctor discontinued the anticholesterol drug.
Local pharmacies can also serve as a starting point for older adults and caregivers, where a pharmacist can give them more information on whether a particular combination of the medications taken may be harmful. In states that allow for pharmacists to prescribe some medications, pharmacists may be able to consolidate some of the medications or advise that a patient stop taking one or more, Dr. Vordenberg said.
“All pharmacists have the training to do a comprehensive medication review,” she said. “All pharmacists have the ability to follow up with the patient to find out how the deprescribing is going.”
Ms. Merwin’s parents received their prescriptions from a “small mom-and-pop pharmacy, where they were on a first-name basis with the pharmacist who really looked out for them. So they had that expertise available to them,” she said.
With information in hand on potentially unnecessary medications, the work of shedding medications should be done along with health care providers, some of whom prescribed the medications in the first place.
Many older adults live in geographically isolated areas without pharmacies, or receive prescriptions from mail-order pharmacies. In this case, Medicare plans offer free medication reviews with a doctor or pharmacist – known as a medication therapy management program – and provide recommendations for taking each drug.
Ms. Merwin’s father died in early 2020. She sometimes questions whether he should have stayed on the statin for longer, or if the doctor agreed too quickly without doing more research. But overall, she doesn’t regret raising the question with his health care providers, and she advises other caregivers and older adults to pay attention to medication lists.
“It’s dangerous to be passive when it comes to one’s health care now,” Ms. Merwin said. “That’s a difficult message for older adults to hear because they have grown up with the primacy of the doctor and the authority of the doctor, as opposed to it being a collaborative relationship.”
A version of this article first appeared on WebMD.com.
Joanne Lynn, MD, has lost track of the number of times in her 40 years as a geriatrician she’s seen a new patient come to her office carrying a bucket full of prescription medications – many of which they don’t need.
Dr. Lynn, who is on the faculty of George Washington University,Washington, recalled one woman who unwittingly was taking two blood pressure medications with different names.
“The risks included all the side effects overdosing carries,” Dr. Lynn said, ranging from blurred vision and crankiness to organ failure and even death.
For doctors with patients who don’t know they’re taking too much of a medication, “you wonder whether the drug is causing the health problems, and it’s a symptom of the wrong medication,” rather than a symptom of an undiagnosed illness, she said.
Patients often assume their health providers check for drug interactions or assess if a medication is no longer needed, and will catch extra prescriptions. That could be a risky assumption. Some doctors may prescribe yet another prescription to manage the side effects of an unnecessary drug, instead of doing a medication review and potentially “deprescribing” or discontinuing, a treatment that’s no longer needed.
About 57% of people age 65 years or older take five or more medications regularly – a concept known as polypharmacy, a study published in 2020 in the Journal of the American Geriatrics Society shows. While doctors prescribe drugs to help patients manage various ailments, as a list of medications grows, so do potential complications.
An older adult might forget to tell their doctor what they’re taking, or maybe they don’t even know what they’re taking or why, Dr. Lynn said.
“In some cases, a doctor just added a drug to treat something, not realizing they were already taking something else for it,” she said. “Of course, the situation of whether these patients can even afford all these drugs matters a lot, too.”
Some older adults may pick and choose which medications to take based on cost, not knowing which prescriptions are necessary, Dr. Lynn said.
Finding the ‘right balance’
Indeed, if given the option, up to 80% of older adults ages 50-80 would be open to stopping one or more of their prescribed medications, according to a 2023 poll by researchers at the University of Michigan, Ann Arbor.
“A lot of drugs that people take might have been appropriate at one point, but might have outlived their usefulness for that individual,” said Michael Steinman, MD, a professor of medicine and a geriatrician at the University of California, San Francisco, and coprincipal investigator of the U.S. Deprescribing Research Network, a doctor group focused on improving medication use for older adults.
“Having fewer medications can actually be beneficial,” he said. “You can take too many medications; you can take too few. The optimal thing is finding what is the right balance for you.”
Defining how many medications is too many depends on each person, which is why caregivers and older adults can ask their doctor for a review of medications that have multiplied over time.
By reevaluating their medications, older adults can actually lower their chances of potentially harmful side effects, and avoid the spiral of being prescribed even more medications, said Sarah Vordenberg, PharmD, MPH, a clinical associate professor at the University of Michigan’s College of Pharmacy, Ann Arbor.
“It’s not really the number of medications, it’s [about] are they inappropriate or unnecessary medications for a patient,” she said.
Patients and caregivers can ask for an honest conversation with their doctor. The University of Michigan poll found that more than 90% of older adults who took prescription medications expected their health care provider to review their medicines during a regular visit.
But doctors often need prompting from patients to start a review.
“The clinical inertia, or maintaining the status quo, unfortunately is a lot of times easier than having time-intensive conversations,” Dr. Vordenberg said.
Ask questions
Sara Merwin spent many years helping manage her parents’ medical appointments and health as they transitioned from living independently in Colorado to a retirement community and finally a nursing home. Ms. Merwin, coauthor of “The Informed Patient,” said her father was taking a long list of medications, and she often asked his primary care doctor for a medication review.
“I felt that my father at his age and his frailty didn’t need as many meds as he was on,” said Ms. Merwin, who lives in Long Island, N.Y. “So we went over his meds, and I asked, ‘Does he really need to be on this?’ ‘Does he really need to be on that?’ ”
She questioned one medication in particular, a statin to lower his cholesterol and risk of a heart attack.
“I thought possibly the statin was causing some myalgia, some muscle aches in his legs, which is why I advocated for coming off it,” she said.
The primary care doctor discontinued the anticholesterol drug.
Local pharmacies can also serve as a starting point for older adults and caregivers, where a pharmacist can give them more information on whether a particular combination of the medications taken may be harmful. In states that allow for pharmacists to prescribe some medications, pharmacists may be able to consolidate some of the medications or advise that a patient stop taking one or more, Dr. Vordenberg said.
“All pharmacists have the training to do a comprehensive medication review,” she said. “All pharmacists have the ability to follow up with the patient to find out how the deprescribing is going.”
Ms. Merwin’s parents received their prescriptions from a “small mom-and-pop pharmacy, where they were on a first-name basis with the pharmacist who really looked out for them. So they had that expertise available to them,” she said.
With information in hand on potentially unnecessary medications, the work of shedding medications should be done along with health care providers, some of whom prescribed the medications in the first place.
Many older adults live in geographically isolated areas without pharmacies, or receive prescriptions from mail-order pharmacies. In this case, Medicare plans offer free medication reviews with a doctor or pharmacist – known as a medication therapy management program – and provide recommendations for taking each drug.
Ms. Merwin’s father died in early 2020. She sometimes questions whether he should have stayed on the statin for longer, or if the doctor agreed too quickly without doing more research. But overall, she doesn’t regret raising the question with his health care providers, and she advises other caregivers and older adults to pay attention to medication lists.
“It’s dangerous to be passive when it comes to one’s health care now,” Ms. Merwin said. “That’s a difficult message for older adults to hear because they have grown up with the primacy of the doctor and the authority of the doctor, as opposed to it being a collaborative relationship.”
A version of this article first appeared on WebMD.com.
Joanne Lynn, MD, has lost track of the number of times in her 40 years as a geriatrician she’s seen a new patient come to her office carrying a bucket full of prescription medications – many of which they don’t need.
Dr. Lynn, who is on the faculty of George Washington University,Washington, recalled one woman who unwittingly was taking two blood pressure medications with different names.
“The risks included all the side effects overdosing carries,” Dr. Lynn said, ranging from blurred vision and crankiness to organ failure and even death.
For doctors with patients who don’t know they’re taking too much of a medication, “you wonder whether the drug is causing the health problems, and it’s a symptom of the wrong medication,” rather than a symptom of an undiagnosed illness, she said.
Patients often assume their health providers check for drug interactions or assess if a medication is no longer needed, and will catch extra prescriptions. That could be a risky assumption. Some doctors may prescribe yet another prescription to manage the side effects of an unnecessary drug, instead of doing a medication review and potentially “deprescribing” or discontinuing, a treatment that’s no longer needed.
About 57% of people age 65 years or older take five or more medications regularly – a concept known as polypharmacy, a study published in 2020 in the Journal of the American Geriatrics Society shows. While doctors prescribe drugs to help patients manage various ailments, as a list of medications grows, so do potential complications.
An older adult might forget to tell their doctor what they’re taking, or maybe they don’t even know what they’re taking or why, Dr. Lynn said.
“In some cases, a doctor just added a drug to treat something, not realizing they were already taking something else for it,” she said. “Of course, the situation of whether these patients can even afford all these drugs matters a lot, too.”
Some older adults may pick and choose which medications to take based on cost, not knowing which prescriptions are necessary, Dr. Lynn said.
Finding the ‘right balance’
Indeed, if given the option, up to 80% of older adults ages 50-80 would be open to stopping one or more of their prescribed medications, according to a 2023 poll by researchers at the University of Michigan, Ann Arbor.
“A lot of drugs that people take might have been appropriate at one point, but might have outlived their usefulness for that individual,” said Michael Steinman, MD, a professor of medicine and a geriatrician at the University of California, San Francisco, and coprincipal investigator of the U.S. Deprescribing Research Network, a doctor group focused on improving medication use for older adults.
“Having fewer medications can actually be beneficial,” he said. “You can take too many medications; you can take too few. The optimal thing is finding what is the right balance for you.”
Defining how many medications is too many depends on each person, which is why caregivers and older adults can ask their doctor for a review of medications that have multiplied over time.
By reevaluating their medications, older adults can actually lower their chances of potentially harmful side effects, and avoid the spiral of being prescribed even more medications, said Sarah Vordenberg, PharmD, MPH, a clinical associate professor at the University of Michigan’s College of Pharmacy, Ann Arbor.
“It’s not really the number of medications, it’s [about] are they inappropriate or unnecessary medications for a patient,” she said.
Patients and caregivers can ask for an honest conversation with their doctor. The University of Michigan poll found that more than 90% of older adults who took prescription medications expected their health care provider to review their medicines during a regular visit.
But doctors often need prompting from patients to start a review.
“The clinical inertia, or maintaining the status quo, unfortunately is a lot of times easier than having time-intensive conversations,” Dr. Vordenberg said.
Ask questions
Sara Merwin spent many years helping manage her parents’ medical appointments and health as they transitioned from living independently in Colorado to a retirement community and finally a nursing home. Ms. Merwin, coauthor of “The Informed Patient,” said her father was taking a long list of medications, and she often asked his primary care doctor for a medication review.
“I felt that my father at his age and his frailty didn’t need as many meds as he was on,” said Ms. Merwin, who lives in Long Island, N.Y. “So we went over his meds, and I asked, ‘Does he really need to be on this?’ ‘Does he really need to be on that?’ ”
She questioned one medication in particular, a statin to lower his cholesterol and risk of a heart attack.
“I thought possibly the statin was causing some myalgia, some muscle aches in his legs, which is why I advocated for coming off it,” she said.
The primary care doctor discontinued the anticholesterol drug.
Local pharmacies can also serve as a starting point for older adults and caregivers, where a pharmacist can give them more information on whether a particular combination of the medications taken may be harmful. In states that allow for pharmacists to prescribe some medications, pharmacists may be able to consolidate some of the medications or advise that a patient stop taking one or more, Dr. Vordenberg said.
“All pharmacists have the training to do a comprehensive medication review,” she said. “All pharmacists have the ability to follow up with the patient to find out how the deprescribing is going.”
Ms. Merwin’s parents received their prescriptions from a “small mom-and-pop pharmacy, where they were on a first-name basis with the pharmacist who really looked out for them. So they had that expertise available to them,” she said.
With information in hand on potentially unnecessary medications, the work of shedding medications should be done along with health care providers, some of whom prescribed the medications in the first place.
Many older adults live in geographically isolated areas without pharmacies, or receive prescriptions from mail-order pharmacies. In this case, Medicare plans offer free medication reviews with a doctor or pharmacist – known as a medication therapy management program – and provide recommendations for taking each drug.
Ms. Merwin’s father died in early 2020. She sometimes questions whether he should have stayed on the statin for longer, or if the doctor agreed too quickly without doing more research. But overall, she doesn’t regret raising the question with his health care providers, and she advises other caregivers and older adults to pay attention to medication lists.
“It’s dangerous to be passive when it comes to one’s health care now,” Ms. Merwin said. “That’s a difficult message for older adults to hear because they have grown up with the primacy of the doctor and the authority of the doctor, as opposed to it being a collaborative relationship.”
A version of this article first appeared on WebMD.com.
Syncope not associated with increased risk for car crash
In a case-crossover study that examined health and driving data for about 3,000 drivers in British Columbia, researchers found similar rates of ED visits for syncope before the dates of car crashes (1.6%) and before control dates (1.2%).
“An emergency visit for syncope did not appear to increase the risk of subsequent traffic crash,” lead author John A. Staples, MD, MPH, clinical associate professor of general internal medicine at the University of British Columbia, Vancouver, said in an interview.
The findings were published online in the Canadian Journal of Cardiology.
Case-crossover study
Syncope prompts more than 1 million visits to EDs in the United States each year. About 9% of patients with syncope have recurrence within 1 year.
Some jurisdictions legally require clinicians to advise patients at higher risk for syncope recurrence to stop driving temporarily. But guidelines about when and whom to restrict are not standardized, said Dr. Staples.
“I came to this topic because I work as a physician in a hospital and, a few years ago, I advised a young woman who suffered a serious injury after she passed out while driving and crashed her car,” he added. “She wanted to know if she could drive again and when. I found out that there wasn’t much evidence that could guide my advice to her. That is what planted the seed that eventually grew into this study.”
The researchers examined driving data from the Insurance Corporation of British Columbia and detailed ED visit data from regional health authorities. They included licensed drivers who were diagnosed with syncope and collapse at an ED between 2010 and 2015 in their study. The researchers focused on eligible participants who were involved in a motor vehicle collision between August 2011 and December 2015.
For each patient, the date of the crash was used to establish three control dates without crashes. The control dates were 26 weeks, 52 weeks, and 78 weeks before the crash. The investigators compared the rate of emergency visit for syncope in the 28 days before the crash with the rate of emergency visit for syncope in the 28 days before each control date.
An emergency visit for syncope occurred in 47 of 3,026 precrash intervals and 112 of 9,078 control intervals. This result indicated that syncope was not significantly associated with subsequent crash (adjusted odds ratio, 1.27; P = .18).
In addition, there was no significant association between syncope and crash in subgroups considered to be at higher risk for adverse outcomes after syncope, such as patients older than 65 years and patients with cardiovascular disease or cardiac syncope.
Gaps in data
“It’s a complicated study design but one that’s helpful to understand the temporal relationship between syncope and crash,” said Dr. Staples. “If we had found that the syncope visit was more likely to occur in the 4 weeks before the crash than in earlier matched 4-week control periods, we would have concluded that syncope transiently increases crash risk.”
Dr. Staples emphasized that this was a real-world study and that some patients with syncope at higher risk for a car crash likely stopped driving. “This study doesn’t say there’s no relationship between syncope and subsequent crash, just that our current practices, including current driving restrictions, seem to do an acceptable job of preventing some crashes.”
Limitations of the study influence the interpretation of the results. For example, the data sources did not indicate how patients modified their driving, said Dr. Staples.
Also lacking is information about how physicians identified which patients were at heightened risk for another syncope episode and advised those patients not to drive. “Now would be a good time to start to think about what other studies are needed to better tailor driving restrictions for the right patient,” said Dr. Staples.
‘A messy situation’
In a comment, Deepak L. Bhatt, MD, MPH, professor of cardiovascular medicine at Icahn School of Medicine at Mount Sinai, New York, called the conclusions “well thought out.” He said the study addressed a common, often perplexing problem in a practical way. Dr. Bhatt was not involved in the research.
“This study is trying to address the issue of what to do with people who have had syncope or fainting and have had a car crash. In general, we don’t really know what to do with those people, but there’s a lot of concern for many reasons, for both the patient and the public. There are potential legal liabilities, and the whole thing, generally speaking, tends to be a messy situation. Usually, the default position physicians take is to be very cautious and conservative, and restrict driving,” said Dr. Bhatt.
The study is reassuring, he added. “The authors have contextualized this risk very nicely. Physicians worry a lot about patients who have had an episode of syncope while driving and restrict their patients’ driving, at least temporarily. But as a society, we are much more permissive about people who drive drunk or under the influence, or who drive without seat belts, or who speed, or text while driving. So, within that larger context, we are extremely worried about this one source of risk that is probably less than these other sources of risk.”
Most of the time, the cause of the syncope is benign, said Dr. Bhatt. “We rule out the bad things, like a heart attack or cardiac arrest, seizure, and arrhythmia. Afterwards, the risk from driving is relatively small.” The study results support current practices and suggest “that we probably don’t need to be excessive with our restrictions.
“There is going to be a wide variation in practice, with some physicians wanting to be more restrictive, but there is a lot of subjectivity in how these recommendations are acted on in real life. That’s why I think this study really should reassure physicians that it’s okay to use common sense and good medical judgment when giving advice on driving to their patients,” Dr. Bhatt concluded.
The study was supported by the Canadian Institutes of Health Research and the Heart and Stroke Foundation Canada. Dr. Staples and Dr. Bhatt reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
In a case-crossover study that examined health and driving data for about 3,000 drivers in British Columbia, researchers found similar rates of ED visits for syncope before the dates of car crashes (1.6%) and before control dates (1.2%).
“An emergency visit for syncope did not appear to increase the risk of subsequent traffic crash,” lead author John A. Staples, MD, MPH, clinical associate professor of general internal medicine at the University of British Columbia, Vancouver, said in an interview.
The findings were published online in the Canadian Journal of Cardiology.
Case-crossover study
Syncope prompts more than 1 million visits to EDs in the United States each year. About 9% of patients with syncope have recurrence within 1 year.
Some jurisdictions legally require clinicians to advise patients at higher risk for syncope recurrence to stop driving temporarily. But guidelines about when and whom to restrict are not standardized, said Dr. Staples.
“I came to this topic because I work as a physician in a hospital and, a few years ago, I advised a young woman who suffered a serious injury after she passed out while driving and crashed her car,” he added. “She wanted to know if she could drive again and when. I found out that there wasn’t much evidence that could guide my advice to her. That is what planted the seed that eventually grew into this study.”
The researchers examined driving data from the Insurance Corporation of British Columbia and detailed ED visit data from regional health authorities. They included licensed drivers who were diagnosed with syncope and collapse at an ED between 2010 and 2015 in their study. The researchers focused on eligible participants who were involved in a motor vehicle collision between August 2011 and December 2015.
For each patient, the date of the crash was used to establish three control dates without crashes. The control dates were 26 weeks, 52 weeks, and 78 weeks before the crash. The investigators compared the rate of emergency visit for syncope in the 28 days before the crash with the rate of emergency visit for syncope in the 28 days before each control date.
An emergency visit for syncope occurred in 47 of 3,026 precrash intervals and 112 of 9,078 control intervals. This result indicated that syncope was not significantly associated with subsequent crash (adjusted odds ratio, 1.27; P = .18).
In addition, there was no significant association between syncope and crash in subgroups considered to be at higher risk for adverse outcomes after syncope, such as patients older than 65 years and patients with cardiovascular disease or cardiac syncope.
Gaps in data
“It’s a complicated study design but one that’s helpful to understand the temporal relationship between syncope and crash,” said Dr. Staples. “If we had found that the syncope visit was more likely to occur in the 4 weeks before the crash than in earlier matched 4-week control periods, we would have concluded that syncope transiently increases crash risk.”
Dr. Staples emphasized that this was a real-world study and that some patients with syncope at higher risk for a car crash likely stopped driving. “This study doesn’t say there’s no relationship between syncope and subsequent crash, just that our current practices, including current driving restrictions, seem to do an acceptable job of preventing some crashes.”
Limitations of the study influence the interpretation of the results. For example, the data sources did not indicate how patients modified their driving, said Dr. Staples.
Also lacking is information about how physicians identified which patients were at heightened risk for another syncope episode and advised those patients not to drive. “Now would be a good time to start to think about what other studies are needed to better tailor driving restrictions for the right patient,” said Dr. Staples.
‘A messy situation’
In a comment, Deepak L. Bhatt, MD, MPH, professor of cardiovascular medicine at Icahn School of Medicine at Mount Sinai, New York, called the conclusions “well thought out.” He said the study addressed a common, often perplexing problem in a practical way. Dr. Bhatt was not involved in the research.
“This study is trying to address the issue of what to do with people who have had syncope or fainting and have had a car crash. In general, we don’t really know what to do with those people, but there’s a lot of concern for many reasons, for both the patient and the public. There are potential legal liabilities, and the whole thing, generally speaking, tends to be a messy situation. Usually, the default position physicians take is to be very cautious and conservative, and restrict driving,” said Dr. Bhatt.
The study is reassuring, he added. “The authors have contextualized this risk very nicely. Physicians worry a lot about patients who have had an episode of syncope while driving and restrict their patients’ driving, at least temporarily. But as a society, we are much more permissive about people who drive drunk or under the influence, or who drive without seat belts, or who speed, or text while driving. So, within that larger context, we are extremely worried about this one source of risk that is probably less than these other sources of risk.”
Most of the time, the cause of the syncope is benign, said Dr. Bhatt. “We rule out the bad things, like a heart attack or cardiac arrest, seizure, and arrhythmia. Afterwards, the risk from driving is relatively small.” The study results support current practices and suggest “that we probably don’t need to be excessive with our restrictions.
“There is going to be a wide variation in practice, with some physicians wanting to be more restrictive, but there is a lot of subjectivity in how these recommendations are acted on in real life. That’s why I think this study really should reassure physicians that it’s okay to use common sense and good medical judgment when giving advice on driving to their patients,” Dr. Bhatt concluded.
The study was supported by the Canadian Institutes of Health Research and the Heart and Stroke Foundation Canada. Dr. Staples and Dr. Bhatt reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
In a case-crossover study that examined health and driving data for about 3,000 drivers in British Columbia, researchers found similar rates of ED visits for syncope before the dates of car crashes (1.6%) and before control dates (1.2%).
“An emergency visit for syncope did not appear to increase the risk of subsequent traffic crash,” lead author John A. Staples, MD, MPH, clinical associate professor of general internal medicine at the University of British Columbia, Vancouver, said in an interview.
The findings were published online in the Canadian Journal of Cardiology.
Case-crossover study
Syncope prompts more than 1 million visits to EDs in the United States each year. About 9% of patients with syncope have recurrence within 1 year.
Some jurisdictions legally require clinicians to advise patients at higher risk for syncope recurrence to stop driving temporarily. But guidelines about when and whom to restrict are not standardized, said Dr. Staples.
“I came to this topic because I work as a physician in a hospital and, a few years ago, I advised a young woman who suffered a serious injury after she passed out while driving and crashed her car,” he added. “She wanted to know if she could drive again and when. I found out that there wasn’t much evidence that could guide my advice to her. That is what planted the seed that eventually grew into this study.”
The researchers examined driving data from the Insurance Corporation of British Columbia and detailed ED visit data from regional health authorities. They included licensed drivers who were diagnosed with syncope and collapse at an ED between 2010 and 2015 in their study. The researchers focused on eligible participants who were involved in a motor vehicle collision between August 2011 and December 2015.
For each patient, the date of the crash was used to establish three control dates without crashes. The control dates were 26 weeks, 52 weeks, and 78 weeks before the crash. The investigators compared the rate of emergency visit for syncope in the 28 days before the crash with the rate of emergency visit for syncope in the 28 days before each control date.
An emergency visit for syncope occurred in 47 of 3,026 precrash intervals and 112 of 9,078 control intervals. This result indicated that syncope was not significantly associated with subsequent crash (adjusted odds ratio, 1.27; P = .18).
In addition, there was no significant association between syncope and crash in subgroups considered to be at higher risk for adverse outcomes after syncope, such as patients older than 65 years and patients with cardiovascular disease or cardiac syncope.
Gaps in data
“It’s a complicated study design but one that’s helpful to understand the temporal relationship between syncope and crash,” said Dr. Staples. “If we had found that the syncope visit was more likely to occur in the 4 weeks before the crash than in earlier matched 4-week control periods, we would have concluded that syncope transiently increases crash risk.”
Dr. Staples emphasized that this was a real-world study and that some patients with syncope at higher risk for a car crash likely stopped driving. “This study doesn’t say there’s no relationship between syncope and subsequent crash, just that our current practices, including current driving restrictions, seem to do an acceptable job of preventing some crashes.”
Limitations of the study influence the interpretation of the results. For example, the data sources did not indicate how patients modified their driving, said Dr. Staples.
Also lacking is information about how physicians identified which patients were at heightened risk for another syncope episode and advised those patients not to drive. “Now would be a good time to start to think about what other studies are needed to better tailor driving restrictions for the right patient,” said Dr. Staples.
‘A messy situation’
In a comment, Deepak L. Bhatt, MD, MPH, professor of cardiovascular medicine at Icahn School of Medicine at Mount Sinai, New York, called the conclusions “well thought out.” He said the study addressed a common, often perplexing problem in a practical way. Dr. Bhatt was not involved in the research.
“This study is trying to address the issue of what to do with people who have had syncope or fainting and have had a car crash. In general, we don’t really know what to do with those people, but there’s a lot of concern for many reasons, for both the patient and the public. There are potential legal liabilities, and the whole thing, generally speaking, tends to be a messy situation. Usually, the default position physicians take is to be very cautious and conservative, and restrict driving,” said Dr. Bhatt.
The study is reassuring, he added. “The authors have contextualized this risk very nicely. Physicians worry a lot about patients who have had an episode of syncope while driving and restrict their patients’ driving, at least temporarily. But as a society, we are much more permissive about people who drive drunk or under the influence, or who drive without seat belts, or who speed, or text while driving. So, within that larger context, we are extremely worried about this one source of risk that is probably less than these other sources of risk.”
Most of the time, the cause of the syncope is benign, said Dr. Bhatt. “We rule out the bad things, like a heart attack or cardiac arrest, seizure, and arrhythmia. Afterwards, the risk from driving is relatively small.” The study results support current practices and suggest “that we probably don’t need to be excessive with our restrictions.
“There is going to be a wide variation in practice, with some physicians wanting to be more restrictive, but there is a lot of subjectivity in how these recommendations are acted on in real life. That’s why I think this study really should reassure physicians that it’s okay to use common sense and good medical judgment when giving advice on driving to their patients,” Dr. Bhatt concluded.
The study was supported by the Canadian Institutes of Health Research and the Heart and Stroke Foundation Canada. Dr. Staples and Dr. Bhatt reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM THE CANADIAN JOURNAL OF CARDIOLOGY
Are you a physician ... or a vending machine?
When we address this problem with patients, some become immediately defensive, making it difficult to modify treatment regimens. It’s almost as if people believe that they have a “right” to their medications and nobody should dare take them away. Even when I think the interaction goes relatively smoothly, the outcome usually shows otherwise.
I will decrease gabapentin from 3,200 mg per day and they will come back with cyclobenzaprine from the urgent care center down the block.
I try to stop an abused amphetamine and dextroamphetamine, and not only do the drugs show up in the urine toxicology test a month later (from the brother’s girlfriend’s sister) but the screening will be positive for cocaine (from the sister’s boyfriend’s brother) and probably alprazolam, too.
People want what they want, and I believe what they want is the overwhelming need not to feel, and especially to not feel our natural and uncomfortable states of pain, sadness, anxiety, fatigue, and discomfort (sometimes all at once). They will use anything orally or intravenously or nasally to make those feelings go away.
I am an addiction specialist so I write this commentary out of care and concern and recognition of how much, pain both physical and psychic, people suffer.
Perhaps we as physicians are conditioned to believe that we must prescribe “something” to the patient who is uncomfortable and sitting in front of us. In general we are sympathetic to the needs of those who come to us in distress, and we try our best to help reduce their symptoms.
I know that we cannot simply “fire” people, because these patients are ours to take care of; they are our responsibility, though this is our overused response to “difficult” patients.
And I know that we have insufficient replacements for these medications. We stopped prescribing oxycodone and now people are on gabapentin in the highest doses, diversion is up, and so is its abuse.
Many of us regularly teach about breathing and mindfulness. I discuss trauma and talk therapy. I order physical therapy and walking regimens and podcasts. But our relationship is transactional, and in prescribing a medication, I have shown them that I am hearing them. I hate this feeling of being trapped.
I spend much of my day negotiating and drive home at night feeling like nothing more than a vending machine.
Dr. Hambright is with the department of addiction medicine at Samaritan Daytop Village, Ellenville, N.Y., and Samadhi Recovery Community Outreach Center, Kingston, N.Y. She disclosed no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
When we address this problem with patients, some become immediately defensive, making it difficult to modify treatment regimens. It’s almost as if people believe that they have a “right” to their medications and nobody should dare take them away. Even when I think the interaction goes relatively smoothly, the outcome usually shows otherwise.
I will decrease gabapentin from 3,200 mg per day and they will come back with cyclobenzaprine from the urgent care center down the block.
I try to stop an abused amphetamine and dextroamphetamine, and not only do the drugs show up in the urine toxicology test a month later (from the brother’s girlfriend’s sister) but the screening will be positive for cocaine (from the sister’s boyfriend’s brother) and probably alprazolam, too.
People want what they want, and I believe what they want is the overwhelming need not to feel, and especially to not feel our natural and uncomfortable states of pain, sadness, anxiety, fatigue, and discomfort (sometimes all at once). They will use anything orally or intravenously or nasally to make those feelings go away.
I am an addiction specialist so I write this commentary out of care and concern and recognition of how much, pain both physical and psychic, people suffer.
Perhaps we as physicians are conditioned to believe that we must prescribe “something” to the patient who is uncomfortable and sitting in front of us. In general we are sympathetic to the needs of those who come to us in distress, and we try our best to help reduce their symptoms.
I know that we cannot simply “fire” people, because these patients are ours to take care of; they are our responsibility, though this is our overused response to “difficult” patients.
And I know that we have insufficient replacements for these medications. We stopped prescribing oxycodone and now people are on gabapentin in the highest doses, diversion is up, and so is its abuse.
Many of us regularly teach about breathing and mindfulness. I discuss trauma and talk therapy. I order physical therapy and walking regimens and podcasts. But our relationship is transactional, and in prescribing a medication, I have shown them that I am hearing them. I hate this feeling of being trapped.
I spend much of my day negotiating and drive home at night feeling like nothing more than a vending machine.
Dr. Hambright is with the department of addiction medicine at Samaritan Daytop Village, Ellenville, N.Y., and Samadhi Recovery Community Outreach Center, Kingston, N.Y. She disclosed no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
When we address this problem with patients, some become immediately defensive, making it difficult to modify treatment regimens. It’s almost as if people believe that they have a “right” to their medications and nobody should dare take them away. Even when I think the interaction goes relatively smoothly, the outcome usually shows otherwise.
I will decrease gabapentin from 3,200 mg per day and they will come back with cyclobenzaprine from the urgent care center down the block.
I try to stop an abused amphetamine and dextroamphetamine, and not only do the drugs show up in the urine toxicology test a month later (from the brother’s girlfriend’s sister) but the screening will be positive for cocaine (from the sister’s boyfriend’s brother) and probably alprazolam, too.
People want what they want, and I believe what they want is the overwhelming need not to feel, and especially to not feel our natural and uncomfortable states of pain, sadness, anxiety, fatigue, and discomfort (sometimes all at once). They will use anything orally or intravenously or nasally to make those feelings go away.
I am an addiction specialist so I write this commentary out of care and concern and recognition of how much, pain both physical and psychic, people suffer.
Perhaps we as physicians are conditioned to believe that we must prescribe “something” to the patient who is uncomfortable and sitting in front of us. In general we are sympathetic to the needs of those who come to us in distress, and we try our best to help reduce their symptoms.
I know that we cannot simply “fire” people, because these patients are ours to take care of; they are our responsibility, though this is our overused response to “difficult” patients.
And I know that we have insufficient replacements for these medications. We stopped prescribing oxycodone and now people are on gabapentin in the highest doses, diversion is up, and so is its abuse.
Many of us regularly teach about breathing and mindfulness. I discuss trauma and talk therapy. I order physical therapy and walking regimens and podcasts. But our relationship is transactional, and in prescribing a medication, I have shown them that I am hearing them. I hate this feeling of being trapped.
I spend much of my day negotiating and drive home at night feeling like nothing more than a vending machine.
Dr. Hambright is with the department of addiction medicine at Samaritan Daytop Village, Ellenville, N.Y., and Samadhi Recovery Community Outreach Center, Kingston, N.Y. She disclosed no relevant conflicts of interest.
A version of this article first appeared on Medscape.com.
BMI ‘vastly underestimates’ true obesity
CHICAGO – , a finding that highlights the shortcomings of BMI and adds to the growing case that BMI alone should not be the default gauge for obesity.
“BMI vastly underestimates true obesity,” Aayush Visaria, MD, said at the annual meeting of the Endocrine Society.
His findings highlight that “BMI should be supplemented with other measures of obesity” for the management of individual patients, with assessments that could include a bioelectrical impedance scale or waist circumference, said Dr. Visaria, a researcher at Rutgers Robert Wood Johnson Medical School in New Brunswick, N.J.
Dr. Visaria cited a new policy issued by the American Medical Association a couple of days before his presentation, which advises that BMI “be used in conjunction with other valid measures of risk such as, but not limited to, measurements of visceral fat, body adiposity index, body composition, relative fat mass, waist circumference, and genetic/metabolic factors.”
“We’re at the start of the end of BMI,” Dr. Visaria declared during a press briefing at the meeting.
He said DEXA is not practical or cost-effective for obesity screening in routine practice. Therefore, he predicts that waist circumference, often expressed as waist-to-height ratio, will be measured more often, although he acknowledged that waist measurement can be difficult. However, better physician training on the measure should help it become the norm.
Another useful tool for obesity measurement he foresees quickly becoming widespread is bathroom scales that record both weight and body fat percentage using a small electric current to make a bioelectrical impedance measure of adiposity.
Bioimpedance scales will provide more standardized measurements than waist circumference and “revolutionize how we measure obesity,” Dr. Visaria predicted. They are “very accessible and cheap,” he noted, with many models sold for less than $100.
Obesity prevalence of 74%
The study by Dr. Visaria and colleagues used data from 9,784 U.S. adults aged 20-59 years (average age, 39 years) collected in several National Health and Nutrition Examination Surveys during 2011-2018. All these participants underwent DEXA assessment of their total body fat as well as a BMI calculation.
Using standard obesity cutoffs for both BMI and total body fat, Dr. Visaria found that DEXA rated 74% of participants as having obesity based on body fat compared with 36% based on BMI.
Among the 64% of the study group who were not obese by BMI, DEXA scans showed 53% of this subgroup did have obesity based on body fat content. Among those with a normal BMI, 43% had obesity by DEXA result.
Further analysis showed that when Dr. Visaria added waist circumference to BMI to enlarge the diagnostic net for obesity it cut the percentage of adults missed as having obesity by BMI alone nearly in half.
Additional analyses showed that the rate of missed diagnoses of obesity by BMI was most common only among people of Hispanic or Asian ethnicity, with both groups showing a 49% rate of obesity by DEXA among those with normal-range BMIs.
The rate of missed obesity diagnoses was highest among all women, with a 59% prevalence of obesity by DEXA among women with a normal-range BMI.
The study received no commercial funding. Dr. Visaria has reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
CHICAGO – , a finding that highlights the shortcomings of BMI and adds to the growing case that BMI alone should not be the default gauge for obesity.
“BMI vastly underestimates true obesity,” Aayush Visaria, MD, said at the annual meeting of the Endocrine Society.
His findings highlight that “BMI should be supplemented with other measures of obesity” for the management of individual patients, with assessments that could include a bioelectrical impedance scale or waist circumference, said Dr. Visaria, a researcher at Rutgers Robert Wood Johnson Medical School in New Brunswick, N.J.
Dr. Visaria cited a new policy issued by the American Medical Association a couple of days before his presentation, which advises that BMI “be used in conjunction with other valid measures of risk such as, but not limited to, measurements of visceral fat, body adiposity index, body composition, relative fat mass, waist circumference, and genetic/metabolic factors.”
“We’re at the start of the end of BMI,” Dr. Visaria declared during a press briefing at the meeting.
He said DEXA is not practical or cost-effective for obesity screening in routine practice. Therefore, he predicts that waist circumference, often expressed as waist-to-height ratio, will be measured more often, although he acknowledged that waist measurement can be difficult. However, better physician training on the measure should help it become the norm.
Another useful tool for obesity measurement he foresees quickly becoming widespread is bathroom scales that record both weight and body fat percentage using a small electric current to make a bioelectrical impedance measure of adiposity.
Bioimpedance scales will provide more standardized measurements than waist circumference and “revolutionize how we measure obesity,” Dr. Visaria predicted. They are “very accessible and cheap,” he noted, with many models sold for less than $100.
Obesity prevalence of 74%
The study by Dr. Visaria and colleagues used data from 9,784 U.S. adults aged 20-59 years (average age, 39 years) collected in several National Health and Nutrition Examination Surveys during 2011-2018. All these participants underwent DEXA assessment of their total body fat as well as a BMI calculation.
Using standard obesity cutoffs for both BMI and total body fat, Dr. Visaria found that DEXA rated 74% of participants as having obesity based on body fat compared with 36% based on BMI.
Among the 64% of the study group who were not obese by BMI, DEXA scans showed 53% of this subgroup did have obesity based on body fat content. Among those with a normal BMI, 43% had obesity by DEXA result.
Further analysis showed that when Dr. Visaria added waist circumference to BMI to enlarge the diagnostic net for obesity it cut the percentage of adults missed as having obesity by BMI alone nearly in half.
Additional analyses showed that the rate of missed diagnoses of obesity by BMI was most common only among people of Hispanic or Asian ethnicity, with both groups showing a 49% rate of obesity by DEXA among those with normal-range BMIs.
The rate of missed obesity diagnoses was highest among all women, with a 59% prevalence of obesity by DEXA among women with a normal-range BMI.
The study received no commercial funding. Dr. Visaria has reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
CHICAGO – , a finding that highlights the shortcomings of BMI and adds to the growing case that BMI alone should not be the default gauge for obesity.
“BMI vastly underestimates true obesity,” Aayush Visaria, MD, said at the annual meeting of the Endocrine Society.
His findings highlight that “BMI should be supplemented with other measures of obesity” for the management of individual patients, with assessments that could include a bioelectrical impedance scale or waist circumference, said Dr. Visaria, a researcher at Rutgers Robert Wood Johnson Medical School in New Brunswick, N.J.
Dr. Visaria cited a new policy issued by the American Medical Association a couple of days before his presentation, which advises that BMI “be used in conjunction with other valid measures of risk such as, but not limited to, measurements of visceral fat, body adiposity index, body composition, relative fat mass, waist circumference, and genetic/metabolic factors.”
“We’re at the start of the end of BMI,” Dr. Visaria declared during a press briefing at the meeting.
He said DEXA is not practical or cost-effective for obesity screening in routine practice. Therefore, he predicts that waist circumference, often expressed as waist-to-height ratio, will be measured more often, although he acknowledged that waist measurement can be difficult. However, better physician training on the measure should help it become the norm.
Another useful tool for obesity measurement he foresees quickly becoming widespread is bathroom scales that record both weight and body fat percentage using a small electric current to make a bioelectrical impedance measure of adiposity.
Bioimpedance scales will provide more standardized measurements than waist circumference and “revolutionize how we measure obesity,” Dr. Visaria predicted. They are “very accessible and cheap,” he noted, with many models sold for less than $100.
Obesity prevalence of 74%
The study by Dr. Visaria and colleagues used data from 9,784 U.S. adults aged 20-59 years (average age, 39 years) collected in several National Health and Nutrition Examination Surveys during 2011-2018. All these participants underwent DEXA assessment of their total body fat as well as a BMI calculation.
Using standard obesity cutoffs for both BMI and total body fat, Dr. Visaria found that DEXA rated 74% of participants as having obesity based on body fat compared with 36% based on BMI.
Among the 64% of the study group who were not obese by BMI, DEXA scans showed 53% of this subgroup did have obesity based on body fat content. Among those with a normal BMI, 43% had obesity by DEXA result.
Further analysis showed that when Dr. Visaria added waist circumference to BMI to enlarge the diagnostic net for obesity it cut the percentage of adults missed as having obesity by BMI alone nearly in half.
Additional analyses showed that the rate of missed diagnoses of obesity by BMI was most common only among people of Hispanic or Asian ethnicity, with both groups showing a 49% rate of obesity by DEXA among those with normal-range BMIs.
The rate of missed obesity diagnoses was highest among all women, with a 59% prevalence of obesity by DEXA among women with a normal-range BMI.
The study received no commercial funding. Dr. Visaria has reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
AT ENDO 2023
Sarcopenia prevalence and risk in older RA patients
Key clinical point: Patients with rheumatoid arthritis (RA) who were ≥65 years old had a significantly increased risk of developing sarcopenia, particularly if they were men with poor nutritional status and long-standing disease.
Major finding: Sarcopenia was diagnosed in a higher proportion of patients with RA vs control individuals without RA (15.8% vs 3.9%; P = .014). Male sex (P = .042), longer disease duration (P = .012), and poorer nutritional status (P = .042) were significant risk factors for the development of sarcopenia in older patients with RA.
Study details: Findings are from a cross-sectional study including 76 patients age ≥ 65 years with RA and 76 age- and sex-matched control individuals without RA.
Disclosures: This study was funded by Redes de Investigación Cooperativa Orientadas a Resultados en Salud, Spain, and other sources. The authors declared no conflicts of interest.
Source: Cano-García L et al. Sarcopenia and nutrition in elderly rheumatoid arthritis patients: A cross-sectional study to determine prevalence and risk factors. Nutrients. 2023;15:2440 (May 24). doi: 10.3390/nu15112440
Key clinical point: Patients with rheumatoid arthritis (RA) who were ≥65 years old had a significantly increased risk of developing sarcopenia, particularly if they were men with poor nutritional status and long-standing disease.
Major finding: Sarcopenia was diagnosed in a higher proportion of patients with RA vs control individuals without RA (15.8% vs 3.9%; P = .014). Male sex (P = .042), longer disease duration (P = .012), and poorer nutritional status (P = .042) were significant risk factors for the development of sarcopenia in older patients with RA.
Study details: Findings are from a cross-sectional study including 76 patients age ≥ 65 years with RA and 76 age- and sex-matched control individuals without RA.
Disclosures: This study was funded by Redes de Investigación Cooperativa Orientadas a Resultados en Salud, Spain, and other sources. The authors declared no conflicts of interest.
Source: Cano-García L et al. Sarcopenia and nutrition in elderly rheumatoid arthritis patients: A cross-sectional study to determine prevalence and risk factors. Nutrients. 2023;15:2440 (May 24). doi: 10.3390/nu15112440
Key clinical point: Patients with rheumatoid arthritis (RA) who were ≥65 years old had a significantly increased risk of developing sarcopenia, particularly if they were men with poor nutritional status and long-standing disease.
Major finding: Sarcopenia was diagnosed in a higher proportion of patients with RA vs control individuals without RA (15.8% vs 3.9%; P = .014). Male sex (P = .042), longer disease duration (P = .012), and poorer nutritional status (P = .042) were significant risk factors for the development of sarcopenia in older patients with RA.
Study details: Findings are from a cross-sectional study including 76 patients age ≥ 65 years with RA and 76 age- and sex-matched control individuals without RA.
Disclosures: This study was funded by Redes de Investigación Cooperativa Orientadas a Resultados en Salud, Spain, and other sources. The authors declared no conflicts of interest.
Source: Cano-García L et al. Sarcopenia and nutrition in elderly rheumatoid arthritis patients: A cross-sectional study to determine prevalence and risk factors. Nutrients. 2023;15:2440 (May 24). doi: 10.3390/nu15112440
Progressing joint damage: An indication to consider intensive treatment in RA patients in remission or LDA
Key clinical point: Intensive treatment more effectively suppressed joint damage progression than the current treatment in patients with rheumatoid arthritis (RA) who showed joint damage progression and had low disease activity (LDA) or were in remission.
Major finding: At 1 year of treatment, intensive vs current treatment was associated with a smaller change in the van der Heijde modified total Sharp score (ΔTSS; 0.67 vs 1.79; P < .001) and joint space narrowing scores (0.57 vs 1.41; P < .001) and a larger proportion of patients achieved a ΔTSS of ≤0.5 (66.7% vs 32.4%; P = .010).
Study details: This retrospective study included 89 patients with RA in remission or with LDA who showed joint damage progression and were assigned to either receive intensive treatment or continue the current treatment.
Disclosures: This study did not declare the funding source. T Mochizuki, K Yano, and K Ikari declared receiving lecture honoraria from various sources. The other authors declared no conflicts of interest.
Source: Mochizuki T et al. Intensive treatment for the progression of joint damage in rheumatoid arthritis patients with low disease activity or remission. Mod Rheumatol. 2023 (Jun 2). doi: 10.1093/mr/road041
Key clinical point: Intensive treatment more effectively suppressed joint damage progression than the current treatment in patients with rheumatoid arthritis (RA) who showed joint damage progression and had low disease activity (LDA) or were in remission.
Major finding: At 1 year of treatment, intensive vs current treatment was associated with a smaller change in the van der Heijde modified total Sharp score (ΔTSS; 0.67 vs 1.79; P < .001) and joint space narrowing scores (0.57 vs 1.41; P < .001) and a larger proportion of patients achieved a ΔTSS of ≤0.5 (66.7% vs 32.4%; P = .010).
Study details: This retrospective study included 89 patients with RA in remission or with LDA who showed joint damage progression and were assigned to either receive intensive treatment or continue the current treatment.
Disclosures: This study did not declare the funding source. T Mochizuki, K Yano, and K Ikari declared receiving lecture honoraria from various sources. The other authors declared no conflicts of interest.
Source: Mochizuki T et al. Intensive treatment for the progression of joint damage in rheumatoid arthritis patients with low disease activity or remission. Mod Rheumatol. 2023 (Jun 2). doi: 10.1093/mr/road041
Key clinical point: Intensive treatment more effectively suppressed joint damage progression than the current treatment in patients with rheumatoid arthritis (RA) who showed joint damage progression and had low disease activity (LDA) or were in remission.
Major finding: At 1 year of treatment, intensive vs current treatment was associated with a smaller change in the van der Heijde modified total Sharp score (ΔTSS; 0.67 vs 1.79; P < .001) and joint space narrowing scores (0.57 vs 1.41; P < .001) and a larger proportion of patients achieved a ΔTSS of ≤0.5 (66.7% vs 32.4%; P = .010).
Study details: This retrospective study included 89 patients with RA in remission or with LDA who showed joint damage progression and were assigned to either receive intensive treatment or continue the current treatment.
Disclosures: This study did not declare the funding source. T Mochizuki, K Yano, and K Ikari declared receiving lecture honoraria from various sources. The other authors declared no conflicts of interest.
Source: Mochizuki T et al. Intensive treatment for the progression of joint damage in rheumatoid arthritis patients with low disease activity or remission. Mod Rheumatol. 2023 (Jun 2). doi: 10.1093/mr/road041
Ultrasound detects subclinical inflammation in RA patients with low or no disease activity
Key clinical point: Ultrasound detected subclinical inflammation in the wrist joints of most patients with rheumatoid arthritis (RA) in clinical remission or with lower disease activity, with the risk for subclinical inflammation being lower among those using biologic therapy.
Major finding: Overall, subclinical inflammation was detected in 57.4% of the patients in complete remission or with lower disease activity. Factors negatively associated with subclinical inflammation included the use of biologic therapy (odds ratio [OR] 0.59; P = .001), methotrexate (OR 0.83; P = .020), and glucocorticoids (OR 0.60; P = .001) and alcohol consumption (OR 0.55; P = .006).
Study details: This cross-sectional study included 1248 patients with RA who underwent gray scale and power Doppler ultrasound assessments of the dorsal radiolunate joints of both wrists.
Disclosures: This study was supported by the Kaohsiung Chang Gung Memorial Hospital, Taiwan, and other sources. The authors declared no conflicts of interest.
Source: Wang YW et al. Factors associated with subclinical inflammation of wrist joints in rheumatoid arthritis patients with low or no disease activity—A RA ultrasound registry study. BMC Musculoskelet Disord. 2023;24:438 (May 30). doi: 10.1186/s12891-023-06521-8
Key clinical point: Ultrasound detected subclinical inflammation in the wrist joints of most patients with rheumatoid arthritis (RA) in clinical remission or with lower disease activity, with the risk for subclinical inflammation being lower among those using biologic therapy.
Major finding: Overall, subclinical inflammation was detected in 57.4% of the patients in complete remission or with lower disease activity. Factors negatively associated with subclinical inflammation included the use of biologic therapy (odds ratio [OR] 0.59; P = .001), methotrexate (OR 0.83; P = .020), and glucocorticoids (OR 0.60; P = .001) and alcohol consumption (OR 0.55; P = .006).
Study details: This cross-sectional study included 1248 patients with RA who underwent gray scale and power Doppler ultrasound assessments of the dorsal radiolunate joints of both wrists.
Disclosures: This study was supported by the Kaohsiung Chang Gung Memorial Hospital, Taiwan, and other sources. The authors declared no conflicts of interest.
Source: Wang YW et al. Factors associated with subclinical inflammation of wrist joints in rheumatoid arthritis patients with low or no disease activity—A RA ultrasound registry study. BMC Musculoskelet Disord. 2023;24:438 (May 30). doi: 10.1186/s12891-023-06521-8
Key clinical point: Ultrasound detected subclinical inflammation in the wrist joints of most patients with rheumatoid arthritis (RA) in clinical remission or with lower disease activity, with the risk for subclinical inflammation being lower among those using biologic therapy.
Major finding: Overall, subclinical inflammation was detected in 57.4% of the patients in complete remission or with lower disease activity. Factors negatively associated with subclinical inflammation included the use of biologic therapy (odds ratio [OR] 0.59; P = .001), methotrexate (OR 0.83; P = .020), and glucocorticoids (OR 0.60; P = .001) and alcohol consumption (OR 0.55; P = .006).
Study details: This cross-sectional study included 1248 patients with RA who underwent gray scale and power Doppler ultrasound assessments of the dorsal radiolunate joints of both wrists.
Disclosures: This study was supported by the Kaohsiung Chang Gung Memorial Hospital, Taiwan, and other sources. The authors declared no conflicts of interest.
Source: Wang YW et al. Factors associated with subclinical inflammation of wrist joints in rheumatoid arthritis patients with low or no disease activity—A RA ultrasound registry study. BMC Musculoskelet Disord. 2023;24:438 (May 30). doi: 10.1186/s12891-023-06521-8