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Brews, Bubbles, & Booze: Stroke Risk and Patients’ Favorite Drinks
This research roundup reviews the latest findings, highlighting both promising insights and remaining uncertainties to help guide discussions with your patients.
Coffee and Tea: Good or Bad?
In the INTERSTROKE study, high coffee consumption (> 4 cups daily) was associated with an significantly increased risk for all strokes (odds ratio [OR], 1.37) or ischemic stroke (OR, 1.31), while low to moderate coffee had no link to increased stroke risk. In contrast, tea consumption was associated with lower odds of all stroke (OR, 0.81 for highest intake) or ischemic stroke (OR, 0.81).
In a recent UK Biobank study, consumption of coffee or tea was associated with reduced risk for stroke and dementia, with the biggest benefit associated with consuming both beverages.
Specifically, the investigators found that individuals who drank two to three cups of coffee and two to three cups of tea per day had a 30% decrease in incidence of stroke and a 28% lower risk for dementia versus those who did not.
A recent systematic review and dose-response meta-analysis showed that each daily cup increase in tea was associated with an average 4% reduced risk for stroke and a 2% reduced risk for cardiovascular disease (CVD) events.
The protective effect of coffee and tea on stroke risk may be driven, in part, by flavonoids, which have antioxidant and anti-inflammatory properties, as well as positive effects on vascular function.
“The advice to patients should be that coffee and tea may protect against stroke, but that sweetening either beverage with sugar probably should be minimized,” said Cheryl Bushnell, MD, MHS, of Wake Forest University School of Medicine in Winston-Salem, North Carolina, and chair of the American Stroke Association (ASA) 2024 Guideline for the Primary Prevention of Stroke.
Taylor Wallace, PhD, a certified food scientist, said, “most people should consume a cup or two of unsweetened tea per day in moderation for cardiometabolic health. It is an easy step in the right direction for good health but not a cure-all.”
When it comes to coffee, adults who like it should drink it “in moderation — just lay off the cream and sugar,” said Wallace, adjunct associate professor at George Washington University, Washington, DC, and Tufts University, Boston, Massachusetts.
“A cup or two of black coffee with low-fat or nonfat milk with breakfast is a healthy way to start the day, especially when you’re like me and have an 8-year-old that is full of energy!” Wallace said.
The Skinny on Soda
When it comes to sugar-sweetened and diet beverages, data from the Nurses’ Health Study and Health Professionals Follow-Up Study, showed a 16% increased risk for stroke with one or more daily servings of sugar-sweetened or low-calorie soda per day (vs none), independent of established dietary and nondietary cardiovascular risk factors.
In the Women’s Health Initiative Observational Study of postmenopausal women, a higher intake of artificially sweetened beverages was associated with increased risk for all stroke (adjusted hazard ratio [aHR], 1.23), ischemic stroke (aHR, 1.31), coronary heart disease (aHR, 1.29) and all-cause mortality (aHR, 1.16).
In the Framingham Heart Study Offspring cohort, consumption of one can of diet soda or more each day (vs none) was associated with a nearly threefold increased risk for stroke and dementia over a 10-year follow-up period.
A separate French study showed that total artificial sweetener intake from all sources was associated with increased overall risk for cardiovascular and cerebrovascular disease.
However, given the limitations of these studies, it’s hard to draw any firm conclusions, Wallace cautioned.
“We know that sugar-sweetened beverages are correlated with weight gain and cardiometabolic dysfunction promotion in children and adults,” he said.
Yet, “there really isn’t any convincing evidence that diet soda has much impact on human health at all. Most observational studies are mixed and likely very confounded by other diet and lifestyle factors. That doesn’t mean go overboard; a daily diet soda is probably fine, but that doesn’t mean go drink 10 of them every day,” he added.
Alcohol: Moderation or Abstinence?
Evidence on alcohol use and stroke risk have been mixed over the years. For decades, the evidence was suggestive that a moderate amount of alcohol daily (one to two drinks in men and one drink in women) may be beneficial at reducing major vascular outcomes.
Yet, over the past few years, some research has found no evidence of benefit with moderate alcohol intake. And the detrimental effects of excessive alcohol use are clear.
A large meta-analysis showed that light to moderate alcohol consumption (up to one drink per day) was associated with a reduced risk for ischemic stroke. However, heavy drinking (more than two drinks per day) significantly increased the risk for both ischemic and hemorrhagic stroke.
A separate study showed young adults who are moderate to heavy drinkers are at increased risk for stroke — and the risk increases with more years of imbibing.
In the INTERSTROKE study, high to moderate alcohol consumption was associated with increased stroke risk, whereas low alcohol consumption conferred no increased risk.
However, Bushnell pointed out that the study data was derived from based on self-report, and that other healthy behaviors may counteract the risk for alcohol consumption.
“For alcohol, regardless of stroke risk, the most important data shows that any alcohol consumption is associated with worse cognitive function, so generally, the lower the alcohol consumption the better,” Bushnell said.
She noted that, currently, the American Heart Association (AHA)/ASA recommend a maximum of two drinks per day for men and one drink per day for women to reduce stroke risk.
“However, the data for the risk for cognitive impairment with any alcohol is convincing and should be kept in mind in addition to the maximum alcohol recommended by the AHA/ASA,” Bushnell advised.
“We know excessive intake puts you at major risk for CVD, cancer, cognitive decline, and a whole host of other health ailments — no question there,” said Wallace.
The impact of moderate intake, on the other hand, is less clear. “Alcohol is a highly biased and political issue and the evidence (or lack thereof) on both sides is shoddy at best,” Wallace added.
A key challenge is that accurate self-reporting of alcohol intake is difficult, even for scientists, and most studies rely on self-reported data from observational cohorts. These often include limited dietary assessments, which provide only a partial picture of long-term consumption patterns, Wallace noted.
“The short answer is we don’t know if moderation is beneficial, detrimental, or null with respect to health,” he said.
Bushnell reports no relevant disclosures. Wallace (www.drtaylorwallace.com) is CEO of Think Healthy Group; editor of The Journal of Dietary Supplements, deputy editor of The Journal of the American Nutrition Association (www.nutrition.org), nutrition section editor of Annals of Medicine, and an advisory board member with Forbes Health.
A version of this article appeared on Medscape.com.
This research roundup reviews the latest findings, highlighting both promising insights and remaining uncertainties to help guide discussions with your patients.
Coffee and Tea: Good or Bad?
In the INTERSTROKE study, high coffee consumption (> 4 cups daily) was associated with an significantly increased risk for all strokes (odds ratio [OR], 1.37) or ischemic stroke (OR, 1.31), while low to moderate coffee had no link to increased stroke risk. In contrast, tea consumption was associated with lower odds of all stroke (OR, 0.81 for highest intake) or ischemic stroke (OR, 0.81).
In a recent UK Biobank study, consumption of coffee or tea was associated with reduced risk for stroke and dementia, with the biggest benefit associated with consuming both beverages.
Specifically, the investigators found that individuals who drank two to three cups of coffee and two to three cups of tea per day had a 30% decrease in incidence of stroke and a 28% lower risk for dementia versus those who did not.
A recent systematic review and dose-response meta-analysis showed that each daily cup increase in tea was associated with an average 4% reduced risk for stroke and a 2% reduced risk for cardiovascular disease (CVD) events.
The protective effect of coffee and tea on stroke risk may be driven, in part, by flavonoids, which have antioxidant and anti-inflammatory properties, as well as positive effects on vascular function.
“The advice to patients should be that coffee and tea may protect against stroke, but that sweetening either beverage with sugar probably should be minimized,” said Cheryl Bushnell, MD, MHS, of Wake Forest University School of Medicine in Winston-Salem, North Carolina, and chair of the American Stroke Association (ASA) 2024 Guideline for the Primary Prevention of Stroke.
Taylor Wallace, PhD, a certified food scientist, said, “most people should consume a cup or two of unsweetened tea per day in moderation for cardiometabolic health. It is an easy step in the right direction for good health but not a cure-all.”
When it comes to coffee, adults who like it should drink it “in moderation — just lay off the cream and sugar,” said Wallace, adjunct associate professor at George Washington University, Washington, DC, and Tufts University, Boston, Massachusetts.
“A cup or two of black coffee with low-fat or nonfat milk with breakfast is a healthy way to start the day, especially when you’re like me and have an 8-year-old that is full of energy!” Wallace said.
The Skinny on Soda
When it comes to sugar-sweetened and diet beverages, data from the Nurses’ Health Study and Health Professionals Follow-Up Study, showed a 16% increased risk for stroke with one or more daily servings of sugar-sweetened or low-calorie soda per day (vs none), independent of established dietary and nondietary cardiovascular risk factors.
In the Women’s Health Initiative Observational Study of postmenopausal women, a higher intake of artificially sweetened beverages was associated with increased risk for all stroke (adjusted hazard ratio [aHR], 1.23), ischemic stroke (aHR, 1.31), coronary heart disease (aHR, 1.29) and all-cause mortality (aHR, 1.16).
In the Framingham Heart Study Offspring cohort, consumption of one can of diet soda or more each day (vs none) was associated with a nearly threefold increased risk for stroke and dementia over a 10-year follow-up period.
A separate French study showed that total artificial sweetener intake from all sources was associated with increased overall risk for cardiovascular and cerebrovascular disease.
However, given the limitations of these studies, it’s hard to draw any firm conclusions, Wallace cautioned.
“We know that sugar-sweetened beverages are correlated with weight gain and cardiometabolic dysfunction promotion in children and adults,” he said.
Yet, “there really isn’t any convincing evidence that diet soda has much impact on human health at all. Most observational studies are mixed and likely very confounded by other diet and lifestyle factors. That doesn’t mean go overboard; a daily diet soda is probably fine, but that doesn’t mean go drink 10 of them every day,” he added.
Alcohol: Moderation or Abstinence?
Evidence on alcohol use and stroke risk have been mixed over the years. For decades, the evidence was suggestive that a moderate amount of alcohol daily (one to two drinks in men and one drink in women) may be beneficial at reducing major vascular outcomes.
Yet, over the past few years, some research has found no evidence of benefit with moderate alcohol intake. And the detrimental effects of excessive alcohol use are clear.
A large meta-analysis showed that light to moderate alcohol consumption (up to one drink per day) was associated with a reduced risk for ischemic stroke. However, heavy drinking (more than two drinks per day) significantly increased the risk for both ischemic and hemorrhagic stroke.
A separate study showed young adults who are moderate to heavy drinkers are at increased risk for stroke — and the risk increases with more years of imbibing.
In the INTERSTROKE study, high to moderate alcohol consumption was associated with increased stroke risk, whereas low alcohol consumption conferred no increased risk.
However, Bushnell pointed out that the study data was derived from based on self-report, and that other healthy behaviors may counteract the risk for alcohol consumption.
“For alcohol, regardless of stroke risk, the most important data shows that any alcohol consumption is associated with worse cognitive function, so generally, the lower the alcohol consumption the better,” Bushnell said.
She noted that, currently, the American Heart Association (AHA)/ASA recommend a maximum of two drinks per day for men and one drink per day for women to reduce stroke risk.
“However, the data for the risk for cognitive impairment with any alcohol is convincing and should be kept in mind in addition to the maximum alcohol recommended by the AHA/ASA,” Bushnell advised.
“We know excessive intake puts you at major risk for CVD, cancer, cognitive decline, and a whole host of other health ailments — no question there,” said Wallace.
The impact of moderate intake, on the other hand, is less clear. “Alcohol is a highly biased and political issue and the evidence (or lack thereof) on both sides is shoddy at best,” Wallace added.
A key challenge is that accurate self-reporting of alcohol intake is difficult, even for scientists, and most studies rely on self-reported data from observational cohorts. These often include limited dietary assessments, which provide only a partial picture of long-term consumption patterns, Wallace noted.
“The short answer is we don’t know if moderation is beneficial, detrimental, or null with respect to health,” he said.
Bushnell reports no relevant disclosures. Wallace (www.drtaylorwallace.com) is CEO of Think Healthy Group; editor of The Journal of Dietary Supplements, deputy editor of The Journal of the American Nutrition Association (www.nutrition.org), nutrition section editor of Annals of Medicine, and an advisory board member with Forbes Health.
A version of this article appeared on Medscape.com.
This research roundup reviews the latest findings, highlighting both promising insights and remaining uncertainties to help guide discussions with your patients.
Coffee and Tea: Good or Bad?
In the INTERSTROKE study, high coffee consumption (> 4 cups daily) was associated with an significantly increased risk for all strokes (odds ratio [OR], 1.37) or ischemic stroke (OR, 1.31), while low to moderate coffee had no link to increased stroke risk. In contrast, tea consumption was associated with lower odds of all stroke (OR, 0.81 for highest intake) or ischemic stroke (OR, 0.81).
In a recent UK Biobank study, consumption of coffee or tea was associated with reduced risk for stroke and dementia, with the biggest benefit associated with consuming both beverages.
Specifically, the investigators found that individuals who drank two to three cups of coffee and two to three cups of tea per day had a 30% decrease in incidence of stroke and a 28% lower risk for dementia versus those who did not.
A recent systematic review and dose-response meta-analysis showed that each daily cup increase in tea was associated with an average 4% reduced risk for stroke and a 2% reduced risk for cardiovascular disease (CVD) events.
The protective effect of coffee and tea on stroke risk may be driven, in part, by flavonoids, which have antioxidant and anti-inflammatory properties, as well as positive effects on vascular function.
“The advice to patients should be that coffee and tea may protect against stroke, but that sweetening either beverage with sugar probably should be minimized,” said Cheryl Bushnell, MD, MHS, of Wake Forest University School of Medicine in Winston-Salem, North Carolina, and chair of the American Stroke Association (ASA) 2024 Guideline for the Primary Prevention of Stroke.
Taylor Wallace, PhD, a certified food scientist, said, “most people should consume a cup or two of unsweetened tea per day in moderation for cardiometabolic health. It is an easy step in the right direction for good health but not a cure-all.”
When it comes to coffee, adults who like it should drink it “in moderation — just lay off the cream and sugar,” said Wallace, adjunct associate professor at George Washington University, Washington, DC, and Tufts University, Boston, Massachusetts.
“A cup or two of black coffee with low-fat or nonfat milk with breakfast is a healthy way to start the day, especially when you’re like me and have an 8-year-old that is full of energy!” Wallace said.
The Skinny on Soda
When it comes to sugar-sweetened and diet beverages, data from the Nurses’ Health Study and Health Professionals Follow-Up Study, showed a 16% increased risk for stroke with one or more daily servings of sugar-sweetened or low-calorie soda per day (vs none), independent of established dietary and nondietary cardiovascular risk factors.
In the Women’s Health Initiative Observational Study of postmenopausal women, a higher intake of artificially sweetened beverages was associated with increased risk for all stroke (adjusted hazard ratio [aHR], 1.23), ischemic stroke (aHR, 1.31), coronary heart disease (aHR, 1.29) and all-cause mortality (aHR, 1.16).
In the Framingham Heart Study Offspring cohort, consumption of one can of diet soda or more each day (vs none) was associated with a nearly threefold increased risk for stroke and dementia over a 10-year follow-up period.
A separate French study showed that total artificial sweetener intake from all sources was associated with increased overall risk for cardiovascular and cerebrovascular disease.
However, given the limitations of these studies, it’s hard to draw any firm conclusions, Wallace cautioned.
“We know that sugar-sweetened beverages are correlated with weight gain and cardiometabolic dysfunction promotion in children and adults,” he said.
Yet, “there really isn’t any convincing evidence that diet soda has much impact on human health at all. Most observational studies are mixed and likely very confounded by other diet and lifestyle factors. That doesn’t mean go overboard; a daily diet soda is probably fine, but that doesn’t mean go drink 10 of them every day,” he added.
Alcohol: Moderation or Abstinence?
Evidence on alcohol use and stroke risk have been mixed over the years. For decades, the evidence was suggestive that a moderate amount of alcohol daily (one to two drinks in men and one drink in women) may be beneficial at reducing major vascular outcomes.
Yet, over the past few years, some research has found no evidence of benefit with moderate alcohol intake. And the detrimental effects of excessive alcohol use are clear.
A large meta-analysis showed that light to moderate alcohol consumption (up to one drink per day) was associated with a reduced risk for ischemic stroke. However, heavy drinking (more than two drinks per day) significantly increased the risk for both ischemic and hemorrhagic stroke.
A separate study showed young adults who are moderate to heavy drinkers are at increased risk for stroke — and the risk increases with more years of imbibing.
In the INTERSTROKE study, high to moderate alcohol consumption was associated with increased stroke risk, whereas low alcohol consumption conferred no increased risk.
However, Bushnell pointed out that the study data was derived from based on self-report, and that other healthy behaviors may counteract the risk for alcohol consumption.
“For alcohol, regardless of stroke risk, the most important data shows that any alcohol consumption is associated with worse cognitive function, so generally, the lower the alcohol consumption the better,” Bushnell said.
She noted that, currently, the American Heart Association (AHA)/ASA recommend a maximum of two drinks per day for men and one drink per day for women to reduce stroke risk.
“However, the data for the risk for cognitive impairment with any alcohol is convincing and should be kept in mind in addition to the maximum alcohol recommended by the AHA/ASA,” Bushnell advised.
“We know excessive intake puts you at major risk for CVD, cancer, cognitive decline, and a whole host of other health ailments — no question there,” said Wallace.
The impact of moderate intake, on the other hand, is less clear. “Alcohol is a highly biased and political issue and the evidence (or lack thereof) on both sides is shoddy at best,” Wallace added.
A key challenge is that accurate self-reporting of alcohol intake is difficult, even for scientists, and most studies rely on self-reported data from observational cohorts. These often include limited dietary assessments, which provide only a partial picture of long-term consumption patterns, Wallace noted.
“The short answer is we don’t know if moderation is beneficial, detrimental, or null with respect to health,” he said.
Bushnell reports no relevant disclosures. Wallace (www.drtaylorwallace.com) is CEO of Think Healthy Group; editor of The Journal of Dietary Supplements, deputy editor of The Journal of the American Nutrition Association (www.nutrition.org), nutrition section editor of Annals of Medicine, and an advisory board member with Forbes Health.
A version of this article appeared on Medscape.com.
Silent Epidemic: Loneliness a Serious Threat to Both Brain and Body
In a world that is more connected than ever, a silent epidemic is taking its toll. Overall, one in three US adults report chronic loneliness — a condition so detrimental that it rivals smoking and obesity with respect to its negative effect on health and well-being. From anxiety and depression to life-threatening conditions like cardiovascular disease, stroke, and Alzheimer’s and Parkinson’s diseases, loneliness is more than an emotion — it’s a serious threat to both the brain and body.
In 2023, a US Surgeon General advisory raised the alarm about the national problem of loneliness and isolation, describing it as an epidemic.
“Given the significant health consequences of loneliness and isolation, we must prioritize building social connection in the same way we have prioritized other critical public health issues such as tobacco, obesity, and substance use disorders. Together, we can build a country that’s healthier, more resilient, less lonely, and more connected,” the report concluded.
But how, exactly, does chronic loneliness affect the physiology and function of the brain? What does the latest research reveal about the link between loneliness and neurologic and psychiatric illness, and what can clinicians do to address the issue?
This news organization spoke to multiple experts in the field to explore these issues.
A Major Risk Factor
Anna Finley, PhD, assistant professor of psychology at North Dakota State University, Fargo, explained that loneliness and social isolation are different entities. Social isolation is an objective measure of the number of people someone interacts with on a regular basis, whereas loneliness is a subjective feeling that occurs when close connections are lacking.
“These two things are not actually as related as you think they would be. People can feel lonely in a crowd or feel well connected with only a few friendships. It’s more about the quality of the connection and the quality of your perception of it. So someone could be in some very supportive relationships but still feel that there’s something missing,” she said in an interview.
So what do we know about how loneliness affects health? Evidence supporting the hypothesis that loneliness is an emerging risk factor for many diseases is steadily building.
Recently, the American Heart Association published a statement summarizing the evidence for a direct association between social isolation and loneliness and coronary heart disease and stroke mortality.
In addition, many studies have shown that individuals experiencing social isolation or loneliness have an increased risk for anxiety and depression, dementia, infectious disease, hospitalization, and all-cause death, even after adjusting for age and many other traditional risk factors.
One study revealed that eliminating loneliness has the potential to prevent nearly 20% of cases of depression in adults aged 50 years or older.
Indu Subramanian, MD, professor of neurology at the University of California, Los Angeles, and colleagues conducted a study involving patients with Parkinson’s disease, which showed that the negative impact of loneliness on disease severity was as significant as the positive effects of 30 minutes of daily exercise.
“The importance of loneliness is under-recognized and undervalued, and it poses a major risk for health outcomes and quality of life,” said Subramanian.
Subramanian noted that loneliness is stigmatizing, causing people to feel unlikable and blame themselves, which prevents them from opening up to doctors or loved ones about their struggle. At the same time, healthcare providers may not think to ask about loneliness or know about potential interventions. She emphasized that much more work is needed to address this issue.
Early Mortality Risk
Julianne Holt-Lunstad, PhD, professor of psychology and neuroscience at Brigham Young University in Provo, Utah, is the author of two large meta-analyses that suggest loneliness, social isolation, or living alone are independent risk factors for early mortality, increasing this risk by about a third — the equivalent to the risk of smoking 15 cigarettes per day.
“We have quite robust evidence across a number of health outcomes implicating the harmful effects of loneliness and social isolation. While these are observational studies and show mainly associations, we do have evidence from longitudinal studies that show lacking social connection, whether that be loneliness or social isolation, predicts subsequent worse outcomes, and most of these studies have adjusted for alternative kinds of explanations, like age, initial health status, lifestyle factors,” Holt-Lunstad said.
There is some evidence to suggest that isolation is more predictive of physical health outcomes, whereas loneliness is more predictive of mental health outcomes. That said, both isolation and loneliness have significant effects on mental and physical health outcomes, she noted.
There is also the question of whether loneliness is causing poor health or whether people who are in poor health feel lonely because poor health can lead to social isolation.
Finley said there’s probably a bit of both going on, but longitudinal studies, where loneliness is measured at a fixed timepoint then health outcomes are reported a few years later, suggest that loneliness is contributing to these adverse outcomes.
She added that there is also some evidence in animal models to suggest that loneliness is a causal risk factor for adverse health outcomes. “But you can’t ask a mouse or rat how lonely they’re feeling. All you can do is house them individually — removing them from social connection. This isn’t necessarily the same thing as loneliness in humans.”
Finley is studying mechanisms in the brain that may be involved in mediating the adverse health consequences of loneliness.
“What I’ve been seeing in the data so far is that it tends to be the self-report of how lonely folks are feeling that has the associations with differences in the brain, as opposed to the number of social connections people have. It does seem to be the more subjective, emotional perception of loneliness that is important.”
In a review of potential mechanisms involved, she concluded that it is dysregulated emotions and altered perceptions of social interactions that has profound impacts on the brain, suggesting that people who are lonely may have a tendency to interpret social cues in a negative way, preventing them from forming productive positive relationships.
Lack of Trust
One researcher who has studied this phenomenon is Dirk Scheele, PhD, professor of social neuroscience at Ruhr University Bochum in Germany.
“We were interested to find out why people remained lonely,” he said in an interview. “Loneliness is an unpleasant experience, and there are so many opportunities for social contacts nowadays, it’s not really clear at first sight why people are chronically lonely.”
To examine this question, Scheele and his team conducted a study in which functional MRI was used to examine the brain in otherwise healthy individuals with high or low loneliness scores while they played a trust game.
They also simulated a positive social interaction between participants and researchers, in which they talked about plans for a fictitious lottery win, and about their hobbies and interests, during which mood was measured with questionnaires, and saliva samples were collected to measure hormone levels.
Results showed that the high-lonely individuals had reduced activation in the insula cortex during the trust decisions. “This area of the brain is involved in the processing of bodily signals, such as ‘gut feelings.’ So reduced activity here could be interpreted as fewer gut feelings on who can be trusted,” Scheele explained.
The high-lonely individuals also had reduced responsiveness to the positive social interaction with a lower release of oxytocin and a smaller elevation in mood compared with the control individuals.
Scheele pointed out that there is some evidence that oxytocin might increase trust, and there is reduced release of endogenous oxytocin in high loneliness.
“Our results are consistent with the idea that loneliness is associated with negative biases about other people. So if we expect negative things from other people — for instance, that they cannot be trusted — then that would hamper further social interactions and could lead to loneliness,” he added.
A Role for Oxytocin?
In another study, the same researchers tested short-term (five weekly sessions) group psychotherapy to reduce loneliness using established techniques to target these negative biases. They also investigated whether the effects of this group psychotherapy could be augmented by administering intranasal oxytocin (vs placebo) before the group psychotherapy sessions.
Results showed that the group psychotherapy intervention reduced trait loneliness (loneliness experienced over a prolonged period). The oxytocin did not show a significant effect on trait loneliness, but there was a suggestion that it may enhance the reduction in state loneliness (how someone is feeling at a specific time) brought about by the psychotherapy sessions.
“We found that bonding within the groups was experienced as more positive in the oxytocin treated groups. It is possible that a longer intervention would be helpful for longer-term results,” Scheele concluded. “It’s not going to be a quick fix for loneliness, but there may be a role for oxytocin as an adjunct to psychotherapy.”
A Basic Human Need
Another loneliness researcher, Livia Tomova, PhD, assistant professor of psychology at Cardiff University in Wales, has used social isolation to induce loneliness in young people and found that this intervention was linked to brain patterns similar to those associated with hunger.
“We know that the drive to eat food is a very basic human need. We know quite well how it is represented in the brain,” she explained.
The researchers tested how the brains of the participants responded to seeing pictures of social interactions after they underwent a prolonged period of social isolation. In a subsequent session, the same people were asked to undergo food fasting and then underwent brain scans when looking at pictures of food. Results showed that the neural patterns were similar in the two situations with increased activity in the substantia nigra area within the midbrain.
“This area of the brain processes rewards and motivation. It consists primarily of dopamine neurons and increased activity corresponds to a feeling of craving something. So this area of the brain that controls essential homeostatic needs is activated when people feel lonely, suggesting that our need for social contact with others is potentially a very basic need similar to eating,” Tomova said.
Lower Gray Matter Volumes in Key Brain Areas
And another group from Germany has found that higher loneliness scores are negatively associated with specific brain regions responsible for memory, emotion regulation, and social processing.
Sandra Düzel, PhD, and colleagues from the Max Planck Institute for Human Development and the Charité – Universitätsmedizin Berlin, both in Berlin, Germany, reported a study in which individuals who reported higher loneliness had smaller gray matter volumes in brain regions such as the left amygdala, anterior hippocampus, and cerebellum, regions which are crucial for both emotional regulation and higher-order cognitive processes, such as self-reflection and executive function.
Düzel believes that possible mechanisms behind the link between loneliness and brain volume differences could include stress-related damage, with prolonged loneliness associated with elevated levels of stress hormones, which can damage the hippocampus over time, and reduced cognitive and social stimulation, which may contribute to brain volume reductions in regions critical for memory and emotional processing.
“Loneliness is often characterized by reduced social and environmental diversity, leading to less engagement with novel experiences and potentially lower hippocampal-striatal connectivity.
Since novelty-seeking and environmental diversity are associated with positive emotional states, individuals experiencing loneliness might benefit from increased exposure to new environments which could stimulate the brain’s reward circuits, fostering positive affect and potentially mitigating the emotional burden of loneliness,” she said.
Is Social Prescribing the Answer?
So are there enough data now to act and attempt to develop interventions to reduce loneliness? Most of these researchers believe so.
“I think we have enough information to act on this now. There are a number of national academies consensus reports, which suggest that, while certainly there are still gaps in our evidence and more to be learned, there is sufficient evidence that a concerning portion of the population seems to lack connection, and that the consequences are serious enough that we need to do something about it,” said Holt-Lunstad.
Some countries have introduced social prescribing where doctors can prescribe a group activity or a regular visit or telephone conversation with a supportive person.
Subramanian pointed out that it’s easier to implement in countries with national health services and may be more difficult to embrace in the US healthcare system.
“We are not so encouraged from a financial perspective to think about preventive care in the US. We don’t have an easy way to recognize in any tangible way the downstream of such activities in terms of preventing future problems. That is something we need to work on,” she said.
Finley cautioned that to work well, social prescribing will require an understanding of each person’s individual situation.
“Some people may only receive benefit of interacting with others if they are also getting some sort of support to address the social and emotional concerns that are tagging along with loneliness. I’m not sure that just telling people to go join their local gardening club or whatever will be the correct answer for everyone.”
She pointed out that many people will have issues in their life that are making it hard for them to be social. These could be mobility or financial challenges, care responsibilities, or concerns about illnesses or life events. “We need to figure out what would have the most bang for the person’s buck, so to speak, as an intervention. That could mean connecting them to a group relevant to their individual situation.”
Opportunity to Connect Not Enough?
Tomova believes that training people in social skills may be a better option. “It appears that some people who are chronically lonely seem to struggle to make relationships with others. So just encouraging them to interact with others more will not necessarily help. We need to better understand the pathways involved and who are the people who become ill. We can then develop and target better interventions and teach people coping strategies for that situation.”
Scheele agreed. “While just giving people the opportunity to connect may work for some, others who are experiencing really chronic loneliness may not benefit very much from this unless their negative belief systems are addressed.” He suggested some sort of psychotherapy may be helpful in this situation.
But at least all seem to agree that healthcare providers need to be more aware of loneliness as a health risk factor, try to identify people at risk, and to think about how best to support them.
Holt-Lunstad noted that one of the recommendations in the US Surgeon General’s advisory was to increase the education, training, and resources on loneliness for healthcare providers.
“If we want this to be addressed, we need to give healthcare providers the time, resources, and training in order to do that, otherwise, we are adding one more thing to an already overburdened system. They need to understand how important it is, and how it might help them take care of the patient.”
“Our hope is that we can start to reverse some of the trends that we are seeing, both in terms of the prevalence rates of loneliness, but also that we could start seeing improvements in health and other kinds of outcomes,” she concluded.
Progress is being made in increasing awareness about the dangers of chronic loneliness. It’s now recognized as a serious health risk, but there are actionable steps that can help. Loneliness doesn’t have to be a permanent condition for anyone, said Scheele.
Holt-Lunstad served as an adviser for Foundation for Social Connection, Global Initiative on Loneliness and Connection, and Nextdoor Neighborhood Vitality Board and received research grants/income from Templeton Foundation, Eventbrite, Foundation for Social Connection, and Triple-S Foundation. Subramanian served as a speaker bureau for Acorda Pharma. The other researchers reported no disclosures.
A version of this article first appeared on Medscape.com.
In a world that is more connected than ever, a silent epidemic is taking its toll. Overall, one in three US adults report chronic loneliness — a condition so detrimental that it rivals smoking and obesity with respect to its negative effect on health and well-being. From anxiety and depression to life-threatening conditions like cardiovascular disease, stroke, and Alzheimer’s and Parkinson’s diseases, loneliness is more than an emotion — it’s a serious threat to both the brain and body.
In 2023, a US Surgeon General advisory raised the alarm about the national problem of loneliness and isolation, describing it as an epidemic.
“Given the significant health consequences of loneliness and isolation, we must prioritize building social connection in the same way we have prioritized other critical public health issues such as tobacco, obesity, and substance use disorders. Together, we can build a country that’s healthier, more resilient, less lonely, and more connected,” the report concluded.
But how, exactly, does chronic loneliness affect the physiology and function of the brain? What does the latest research reveal about the link between loneliness and neurologic and psychiatric illness, and what can clinicians do to address the issue?
This news organization spoke to multiple experts in the field to explore these issues.
A Major Risk Factor
Anna Finley, PhD, assistant professor of psychology at North Dakota State University, Fargo, explained that loneliness and social isolation are different entities. Social isolation is an objective measure of the number of people someone interacts with on a regular basis, whereas loneliness is a subjective feeling that occurs when close connections are lacking.
“These two things are not actually as related as you think they would be. People can feel lonely in a crowd or feel well connected with only a few friendships. It’s more about the quality of the connection and the quality of your perception of it. So someone could be in some very supportive relationships but still feel that there’s something missing,” she said in an interview.
So what do we know about how loneliness affects health? Evidence supporting the hypothesis that loneliness is an emerging risk factor for many diseases is steadily building.
Recently, the American Heart Association published a statement summarizing the evidence for a direct association between social isolation and loneliness and coronary heart disease and stroke mortality.
In addition, many studies have shown that individuals experiencing social isolation or loneliness have an increased risk for anxiety and depression, dementia, infectious disease, hospitalization, and all-cause death, even after adjusting for age and many other traditional risk factors.
One study revealed that eliminating loneliness has the potential to prevent nearly 20% of cases of depression in adults aged 50 years or older.
Indu Subramanian, MD, professor of neurology at the University of California, Los Angeles, and colleagues conducted a study involving patients with Parkinson’s disease, which showed that the negative impact of loneliness on disease severity was as significant as the positive effects of 30 minutes of daily exercise.
“The importance of loneliness is under-recognized and undervalued, and it poses a major risk for health outcomes and quality of life,” said Subramanian.
Subramanian noted that loneliness is stigmatizing, causing people to feel unlikable and blame themselves, which prevents them from opening up to doctors or loved ones about their struggle. At the same time, healthcare providers may not think to ask about loneliness or know about potential interventions. She emphasized that much more work is needed to address this issue.
Early Mortality Risk
Julianne Holt-Lunstad, PhD, professor of psychology and neuroscience at Brigham Young University in Provo, Utah, is the author of two large meta-analyses that suggest loneliness, social isolation, or living alone are independent risk factors for early mortality, increasing this risk by about a third — the equivalent to the risk of smoking 15 cigarettes per day.
“We have quite robust evidence across a number of health outcomes implicating the harmful effects of loneliness and social isolation. While these are observational studies and show mainly associations, we do have evidence from longitudinal studies that show lacking social connection, whether that be loneliness or social isolation, predicts subsequent worse outcomes, and most of these studies have adjusted for alternative kinds of explanations, like age, initial health status, lifestyle factors,” Holt-Lunstad said.
There is some evidence to suggest that isolation is more predictive of physical health outcomes, whereas loneliness is more predictive of mental health outcomes. That said, both isolation and loneliness have significant effects on mental and physical health outcomes, she noted.
There is also the question of whether loneliness is causing poor health or whether people who are in poor health feel lonely because poor health can lead to social isolation.
Finley said there’s probably a bit of both going on, but longitudinal studies, where loneliness is measured at a fixed timepoint then health outcomes are reported a few years later, suggest that loneliness is contributing to these adverse outcomes.
She added that there is also some evidence in animal models to suggest that loneliness is a causal risk factor for adverse health outcomes. “But you can’t ask a mouse or rat how lonely they’re feeling. All you can do is house them individually — removing them from social connection. This isn’t necessarily the same thing as loneliness in humans.”
Finley is studying mechanisms in the brain that may be involved in mediating the adverse health consequences of loneliness.
“What I’ve been seeing in the data so far is that it tends to be the self-report of how lonely folks are feeling that has the associations with differences in the brain, as opposed to the number of social connections people have. It does seem to be the more subjective, emotional perception of loneliness that is important.”
In a review of potential mechanisms involved, she concluded that it is dysregulated emotions and altered perceptions of social interactions that has profound impacts on the brain, suggesting that people who are lonely may have a tendency to interpret social cues in a negative way, preventing them from forming productive positive relationships.
Lack of Trust
One researcher who has studied this phenomenon is Dirk Scheele, PhD, professor of social neuroscience at Ruhr University Bochum in Germany.
“We were interested to find out why people remained lonely,” he said in an interview. “Loneliness is an unpleasant experience, and there are so many opportunities for social contacts nowadays, it’s not really clear at first sight why people are chronically lonely.”
To examine this question, Scheele and his team conducted a study in which functional MRI was used to examine the brain in otherwise healthy individuals with high or low loneliness scores while they played a trust game.
They also simulated a positive social interaction between participants and researchers, in which they talked about plans for a fictitious lottery win, and about their hobbies and interests, during which mood was measured with questionnaires, and saliva samples were collected to measure hormone levels.
Results showed that the high-lonely individuals had reduced activation in the insula cortex during the trust decisions. “This area of the brain is involved in the processing of bodily signals, such as ‘gut feelings.’ So reduced activity here could be interpreted as fewer gut feelings on who can be trusted,” Scheele explained.
The high-lonely individuals also had reduced responsiveness to the positive social interaction with a lower release of oxytocin and a smaller elevation in mood compared with the control individuals.
Scheele pointed out that there is some evidence that oxytocin might increase trust, and there is reduced release of endogenous oxytocin in high loneliness.
“Our results are consistent with the idea that loneliness is associated with negative biases about other people. So if we expect negative things from other people — for instance, that they cannot be trusted — then that would hamper further social interactions and could lead to loneliness,” he added.
A Role for Oxytocin?
In another study, the same researchers tested short-term (five weekly sessions) group psychotherapy to reduce loneliness using established techniques to target these negative biases. They also investigated whether the effects of this group psychotherapy could be augmented by administering intranasal oxytocin (vs placebo) before the group psychotherapy sessions.
Results showed that the group psychotherapy intervention reduced trait loneliness (loneliness experienced over a prolonged period). The oxytocin did not show a significant effect on trait loneliness, but there was a suggestion that it may enhance the reduction in state loneliness (how someone is feeling at a specific time) brought about by the psychotherapy sessions.
“We found that bonding within the groups was experienced as more positive in the oxytocin treated groups. It is possible that a longer intervention would be helpful for longer-term results,” Scheele concluded. “It’s not going to be a quick fix for loneliness, but there may be a role for oxytocin as an adjunct to psychotherapy.”
A Basic Human Need
Another loneliness researcher, Livia Tomova, PhD, assistant professor of psychology at Cardiff University in Wales, has used social isolation to induce loneliness in young people and found that this intervention was linked to brain patterns similar to those associated with hunger.
“We know that the drive to eat food is a very basic human need. We know quite well how it is represented in the brain,” she explained.
The researchers tested how the brains of the participants responded to seeing pictures of social interactions after they underwent a prolonged period of social isolation. In a subsequent session, the same people were asked to undergo food fasting and then underwent brain scans when looking at pictures of food. Results showed that the neural patterns were similar in the two situations with increased activity in the substantia nigra area within the midbrain.
“This area of the brain processes rewards and motivation. It consists primarily of dopamine neurons and increased activity corresponds to a feeling of craving something. So this area of the brain that controls essential homeostatic needs is activated when people feel lonely, suggesting that our need for social contact with others is potentially a very basic need similar to eating,” Tomova said.
Lower Gray Matter Volumes in Key Brain Areas
And another group from Germany has found that higher loneliness scores are negatively associated with specific brain regions responsible for memory, emotion regulation, and social processing.
Sandra Düzel, PhD, and colleagues from the Max Planck Institute for Human Development and the Charité – Universitätsmedizin Berlin, both in Berlin, Germany, reported a study in which individuals who reported higher loneliness had smaller gray matter volumes in brain regions such as the left amygdala, anterior hippocampus, and cerebellum, regions which are crucial for both emotional regulation and higher-order cognitive processes, such as self-reflection and executive function.
Düzel believes that possible mechanisms behind the link between loneliness and brain volume differences could include stress-related damage, with prolonged loneliness associated with elevated levels of stress hormones, which can damage the hippocampus over time, and reduced cognitive and social stimulation, which may contribute to brain volume reductions in regions critical for memory and emotional processing.
“Loneliness is often characterized by reduced social and environmental diversity, leading to less engagement with novel experiences and potentially lower hippocampal-striatal connectivity.
Since novelty-seeking and environmental diversity are associated with positive emotional states, individuals experiencing loneliness might benefit from increased exposure to new environments which could stimulate the brain’s reward circuits, fostering positive affect and potentially mitigating the emotional burden of loneliness,” she said.
Is Social Prescribing the Answer?
So are there enough data now to act and attempt to develop interventions to reduce loneliness? Most of these researchers believe so.
“I think we have enough information to act on this now. There are a number of national academies consensus reports, which suggest that, while certainly there are still gaps in our evidence and more to be learned, there is sufficient evidence that a concerning portion of the population seems to lack connection, and that the consequences are serious enough that we need to do something about it,” said Holt-Lunstad.
Some countries have introduced social prescribing where doctors can prescribe a group activity or a regular visit or telephone conversation with a supportive person.
Subramanian pointed out that it’s easier to implement in countries with national health services and may be more difficult to embrace in the US healthcare system.
“We are not so encouraged from a financial perspective to think about preventive care in the US. We don’t have an easy way to recognize in any tangible way the downstream of such activities in terms of preventing future problems. That is something we need to work on,” she said.
Finley cautioned that to work well, social prescribing will require an understanding of each person’s individual situation.
“Some people may only receive benefit of interacting with others if they are also getting some sort of support to address the social and emotional concerns that are tagging along with loneliness. I’m not sure that just telling people to go join their local gardening club or whatever will be the correct answer for everyone.”
She pointed out that many people will have issues in their life that are making it hard for them to be social. These could be mobility or financial challenges, care responsibilities, or concerns about illnesses or life events. “We need to figure out what would have the most bang for the person’s buck, so to speak, as an intervention. That could mean connecting them to a group relevant to their individual situation.”
Opportunity to Connect Not Enough?
Tomova believes that training people in social skills may be a better option. “It appears that some people who are chronically lonely seem to struggle to make relationships with others. So just encouraging them to interact with others more will not necessarily help. We need to better understand the pathways involved and who are the people who become ill. We can then develop and target better interventions and teach people coping strategies for that situation.”
Scheele agreed. “While just giving people the opportunity to connect may work for some, others who are experiencing really chronic loneliness may not benefit very much from this unless their negative belief systems are addressed.” He suggested some sort of psychotherapy may be helpful in this situation.
But at least all seem to agree that healthcare providers need to be more aware of loneliness as a health risk factor, try to identify people at risk, and to think about how best to support them.
Holt-Lunstad noted that one of the recommendations in the US Surgeon General’s advisory was to increase the education, training, and resources on loneliness for healthcare providers.
“If we want this to be addressed, we need to give healthcare providers the time, resources, and training in order to do that, otherwise, we are adding one more thing to an already overburdened system. They need to understand how important it is, and how it might help them take care of the patient.”
“Our hope is that we can start to reverse some of the trends that we are seeing, both in terms of the prevalence rates of loneliness, but also that we could start seeing improvements in health and other kinds of outcomes,” she concluded.
Progress is being made in increasing awareness about the dangers of chronic loneliness. It’s now recognized as a serious health risk, but there are actionable steps that can help. Loneliness doesn’t have to be a permanent condition for anyone, said Scheele.
Holt-Lunstad served as an adviser for Foundation for Social Connection, Global Initiative on Loneliness and Connection, and Nextdoor Neighborhood Vitality Board and received research grants/income from Templeton Foundation, Eventbrite, Foundation for Social Connection, and Triple-S Foundation. Subramanian served as a speaker bureau for Acorda Pharma. The other researchers reported no disclosures.
A version of this article first appeared on Medscape.com.
In a world that is more connected than ever, a silent epidemic is taking its toll. Overall, one in three US adults report chronic loneliness — a condition so detrimental that it rivals smoking and obesity with respect to its negative effect on health and well-being. From anxiety and depression to life-threatening conditions like cardiovascular disease, stroke, and Alzheimer’s and Parkinson’s diseases, loneliness is more than an emotion — it’s a serious threat to both the brain and body.
In 2023, a US Surgeon General advisory raised the alarm about the national problem of loneliness and isolation, describing it as an epidemic.
“Given the significant health consequences of loneliness and isolation, we must prioritize building social connection in the same way we have prioritized other critical public health issues such as tobacco, obesity, and substance use disorders. Together, we can build a country that’s healthier, more resilient, less lonely, and more connected,” the report concluded.
But how, exactly, does chronic loneliness affect the physiology and function of the brain? What does the latest research reveal about the link between loneliness and neurologic and psychiatric illness, and what can clinicians do to address the issue?
This news organization spoke to multiple experts in the field to explore these issues.
A Major Risk Factor
Anna Finley, PhD, assistant professor of psychology at North Dakota State University, Fargo, explained that loneliness and social isolation are different entities. Social isolation is an objective measure of the number of people someone interacts with on a regular basis, whereas loneliness is a subjective feeling that occurs when close connections are lacking.
“These two things are not actually as related as you think they would be. People can feel lonely in a crowd or feel well connected with only a few friendships. It’s more about the quality of the connection and the quality of your perception of it. So someone could be in some very supportive relationships but still feel that there’s something missing,” she said in an interview.
So what do we know about how loneliness affects health? Evidence supporting the hypothesis that loneliness is an emerging risk factor for many diseases is steadily building.
Recently, the American Heart Association published a statement summarizing the evidence for a direct association between social isolation and loneliness and coronary heart disease and stroke mortality.
In addition, many studies have shown that individuals experiencing social isolation or loneliness have an increased risk for anxiety and depression, dementia, infectious disease, hospitalization, and all-cause death, even after adjusting for age and many other traditional risk factors.
One study revealed that eliminating loneliness has the potential to prevent nearly 20% of cases of depression in adults aged 50 years or older.
Indu Subramanian, MD, professor of neurology at the University of California, Los Angeles, and colleagues conducted a study involving patients with Parkinson’s disease, which showed that the negative impact of loneliness on disease severity was as significant as the positive effects of 30 minutes of daily exercise.
“The importance of loneliness is under-recognized and undervalued, and it poses a major risk for health outcomes and quality of life,” said Subramanian.
Subramanian noted that loneliness is stigmatizing, causing people to feel unlikable and blame themselves, which prevents them from opening up to doctors or loved ones about their struggle. At the same time, healthcare providers may not think to ask about loneliness or know about potential interventions. She emphasized that much more work is needed to address this issue.
Early Mortality Risk
Julianne Holt-Lunstad, PhD, professor of psychology and neuroscience at Brigham Young University in Provo, Utah, is the author of two large meta-analyses that suggest loneliness, social isolation, or living alone are independent risk factors for early mortality, increasing this risk by about a third — the equivalent to the risk of smoking 15 cigarettes per day.
“We have quite robust evidence across a number of health outcomes implicating the harmful effects of loneliness and social isolation. While these are observational studies and show mainly associations, we do have evidence from longitudinal studies that show lacking social connection, whether that be loneliness or social isolation, predicts subsequent worse outcomes, and most of these studies have adjusted for alternative kinds of explanations, like age, initial health status, lifestyle factors,” Holt-Lunstad said.
There is some evidence to suggest that isolation is more predictive of physical health outcomes, whereas loneliness is more predictive of mental health outcomes. That said, both isolation and loneliness have significant effects on mental and physical health outcomes, she noted.
There is also the question of whether loneliness is causing poor health or whether people who are in poor health feel lonely because poor health can lead to social isolation.
Finley said there’s probably a bit of both going on, but longitudinal studies, where loneliness is measured at a fixed timepoint then health outcomes are reported a few years later, suggest that loneliness is contributing to these adverse outcomes.
She added that there is also some evidence in animal models to suggest that loneliness is a causal risk factor for adverse health outcomes. “But you can’t ask a mouse or rat how lonely they’re feeling. All you can do is house them individually — removing them from social connection. This isn’t necessarily the same thing as loneliness in humans.”
Finley is studying mechanisms in the brain that may be involved in mediating the adverse health consequences of loneliness.
“What I’ve been seeing in the data so far is that it tends to be the self-report of how lonely folks are feeling that has the associations with differences in the brain, as opposed to the number of social connections people have. It does seem to be the more subjective, emotional perception of loneliness that is important.”
In a review of potential mechanisms involved, she concluded that it is dysregulated emotions and altered perceptions of social interactions that has profound impacts on the brain, suggesting that people who are lonely may have a tendency to interpret social cues in a negative way, preventing them from forming productive positive relationships.
Lack of Trust
One researcher who has studied this phenomenon is Dirk Scheele, PhD, professor of social neuroscience at Ruhr University Bochum in Germany.
“We were interested to find out why people remained lonely,” he said in an interview. “Loneliness is an unpleasant experience, and there are so many opportunities for social contacts nowadays, it’s not really clear at first sight why people are chronically lonely.”
To examine this question, Scheele and his team conducted a study in which functional MRI was used to examine the brain in otherwise healthy individuals with high or low loneliness scores while they played a trust game.
They also simulated a positive social interaction between participants and researchers, in which they talked about plans for a fictitious lottery win, and about their hobbies and interests, during which mood was measured with questionnaires, and saliva samples were collected to measure hormone levels.
Results showed that the high-lonely individuals had reduced activation in the insula cortex during the trust decisions. “This area of the brain is involved in the processing of bodily signals, such as ‘gut feelings.’ So reduced activity here could be interpreted as fewer gut feelings on who can be trusted,” Scheele explained.
The high-lonely individuals also had reduced responsiveness to the positive social interaction with a lower release of oxytocin and a smaller elevation in mood compared with the control individuals.
Scheele pointed out that there is some evidence that oxytocin might increase trust, and there is reduced release of endogenous oxytocin in high loneliness.
“Our results are consistent with the idea that loneliness is associated with negative biases about other people. So if we expect negative things from other people — for instance, that they cannot be trusted — then that would hamper further social interactions and could lead to loneliness,” he added.
A Role for Oxytocin?
In another study, the same researchers tested short-term (five weekly sessions) group psychotherapy to reduce loneliness using established techniques to target these negative biases. They also investigated whether the effects of this group psychotherapy could be augmented by administering intranasal oxytocin (vs placebo) before the group psychotherapy sessions.
Results showed that the group psychotherapy intervention reduced trait loneliness (loneliness experienced over a prolonged period). The oxytocin did not show a significant effect on trait loneliness, but there was a suggestion that it may enhance the reduction in state loneliness (how someone is feeling at a specific time) brought about by the psychotherapy sessions.
“We found that bonding within the groups was experienced as more positive in the oxytocin treated groups. It is possible that a longer intervention would be helpful for longer-term results,” Scheele concluded. “It’s not going to be a quick fix for loneliness, but there may be a role for oxytocin as an adjunct to psychotherapy.”
A Basic Human Need
Another loneliness researcher, Livia Tomova, PhD, assistant professor of psychology at Cardiff University in Wales, has used social isolation to induce loneliness in young people and found that this intervention was linked to brain patterns similar to those associated with hunger.
“We know that the drive to eat food is a very basic human need. We know quite well how it is represented in the brain,” she explained.
The researchers tested how the brains of the participants responded to seeing pictures of social interactions after they underwent a prolonged period of social isolation. In a subsequent session, the same people were asked to undergo food fasting and then underwent brain scans when looking at pictures of food. Results showed that the neural patterns were similar in the two situations with increased activity in the substantia nigra area within the midbrain.
“This area of the brain processes rewards and motivation. It consists primarily of dopamine neurons and increased activity corresponds to a feeling of craving something. So this area of the brain that controls essential homeostatic needs is activated when people feel lonely, suggesting that our need for social contact with others is potentially a very basic need similar to eating,” Tomova said.
Lower Gray Matter Volumes in Key Brain Areas
And another group from Germany has found that higher loneliness scores are negatively associated with specific brain regions responsible for memory, emotion regulation, and social processing.
Sandra Düzel, PhD, and colleagues from the Max Planck Institute for Human Development and the Charité – Universitätsmedizin Berlin, both in Berlin, Germany, reported a study in which individuals who reported higher loneliness had smaller gray matter volumes in brain regions such as the left amygdala, anterior hippocampus, and cerebellum, regions which are crucial for both emotional regulation and higher-order cognitive processes, such as self-reflection and executive function.
Düzel believes that possible mechanisms behind the link between loneliness and brain volume differences could include stress-related damage, with prolonged loneliness associated with elevated levels of stress hormones, which can damage the hippocampus over time, and reduced cognitive and social stimulation, which may contribute to brain volume reductions in regions critical for memory and emotional processing.
“Loneliness is often characterized by reduced social and environmental diversity, leading to less engagement with novel experiences and potentially lower hippocampal-striatal connectivity.
Since novelty-seeking and environmental diversity are associated with positive emotional states, individuals experiencing loneliness might benefit from increased exposure to new environments which could stimulate the brain’s reward circuits, fostering positive affect and potentially mitigating the emotional burden of loneliness,” she said.
Is Social Prescribing the Answer?
So are there enough data now to act and attempt to develop interventions to reduce loneliness? Most of these researchers believe so.
“I think we have enough information to act on this now. There are a number of national academies consensus reports, which suggest that, while certainly there are still gaps in our evidence and more to be learned, there is sufficient evidence that a concerning portion of the population seems to lack connection, and that the consequences are serious enough that we need to do something about it,” said Holt-Lunstad.
Some countries have introduced social prescribing where doctors can prescribe a group activity or a regular visit or telephone conversation with a supportive person.
Subramanian pointed out that it’s easier to implement in countries with national health services and may be more difficult to embrace in the US healthcare system.
“We are not so encouraged from a financial perspective to think about preventive care in the US. We don’t have an easy way to recognize in any tangible way the downstream of such activities in terms of preventing future problems. That is something we need to work on,” she said.
Finley cautioned that to work well, social prescribing will require an understanding of each person’s individual situation.
“Some people may only receive benefit of interacting with others if they are also getting some sort of support to address the social and emotional concerns that are tagging along with loneliness. I’m not sure that just telling people to go join their local gardening club or whatever will be the correct answer for everyone.”
She pointed out that many people will have issues in their life that are making it hard for them to be social. These could be mobility or financial challenges, care responsibilities, or concerns about illnesses or life events. “We need to figure out what would have the most bang for the person’s buck, so to speak, as an intervention. That could mean connecting them to a group relevant to their individual situation.”
Opportunity to Connect Not Enough?
Tomova believes that training people in social skills may be a better option. “It appears that some people who are chronically lonely seem to struggle to make relationships with others. So just encouraging them to interact with others more will not necessarily help. We need to better understand the pathways involved and who are the people who become ill. We can then develop and target better interventions and teach people coping strategies for that situation.”
Scheele agreed. “While just giving people the opportunity to connect may work for some, others who are experiencing really chronic loneliness may not benefit very much from this unless their negative belief systems are addressed.” He suggested some sort of psychotherapy may be helpful in this situation.
But at least all seem to agree that healthcare providers need to be more aware of loneliness as a health risk factor, try to identify people at risk, and to think about how best to support them.
Holt-Lunstad noted that one of the recommendations in the US Surgeon General’s advisory was to increase the education, training, and resources on loneliness for healthcare providers.
“If we want this to be addressed, we need to give healthcare providers the time, resources, and training in order to do that, otherwise, we are adding one more thing to an already overburdened system. They need to understand how important it is, and how it might help them take care of the patient.”
“Our hope is that we can start to reverse some of the trends that we are seeing, both in terms of the prevalence rates of loneliness, but also that we could start seeing improvements in health and other kinds of outcomes,” she concluded.
Progress is being made in increasing awareness about the dangers of chronic loneliness. It’s now recognized as a serious health risk, but there are actionable steps that can help. Loneliness doesn’t have to be a permanent condition for anyone, said Scheele.
Holt-Lunstad served as an adviser for Foundation for Social Connection, Global Initiative on Loneliness and Connection, and Nextdoor Neighborhood Vitality Board and received research grants/income from Templeton Foundation, Eventbrite, Foundation for Social Connection, and Triple-S Foundation. Subramanian served as a speaker bureau for Acorda Pharma. The other researchers reported no disclosures.
A version of this article first appeared on Medscape.com.
ATA: Updates on Risk, Diagnosis, and Treatment of Thyroid Cancer
The study, presented by Juan Brito Campana, MBBS, of the Mayo Clinic in Rochester, Minnesota, used Medicare records to perform a secondary analysis of 41,000 adults with type 2 diabetes and moderate cardiovascular risk who were new users of GLP-1 receptor agonists, compared to users of other diabetes medications.
“We took the innovative approach of applying the methodological rigor of a randomized clinical trial to the very large dataset of observational studies,” said Brito Campana.
The results showed a low absolute risk of thyroid cancer, with only 0.17% of patients in the GLP-1 group developing the disease. However, the data also showed a potential relative increase in risk during the first year of GLP-1 receptor agonist use.
“This is likely due to increased detection rather than true incidence, as the latency period for thyroid cancer development is typically longer,” Brito Campana said.
“We also note the limitations of the observational study design, including the short follow-up period and lack of detailed histological data. However, we believe the benefits of GLP-1 receptor agonists likely outweigh the risk of thyroid cancer.”
Malignancy in Bethesda III and IV Thyroid Nodules
At the same ATA session, Sapir Nachum Goldberg, MD, of the University of Pennsylvania, Philadelphia, presented the results of a retrospective record review that examined the prevalence of malignancy in Bethesda III and IV thyroid nodules with negative Thyrogen Receptor Signaling (ThyroSeq) version 3 molecular testing results.
Goldberg reported that 87% of patients with ThyroSeq negative subtype results were managed nonoperatively. “Based on our data, the true prevalence of malignancy likely lies between our low and high estimates of 3% and 23%,” she said. “We believe that the prevalence of malignancy may be higher in real-world practice than validation studies.”
Additionally, nodules with “currently negative” or “negative but limited” ThyroSeq results had a higher prevalence of malignancy (7%), compared with those with a “negative” result (2%). Factors like immediate vs delayed surgery, nodule size, and ultrasound pattern did not significantly impact malignancy prevalence.
The study results also indicated that surveillance ultrasonography is not routinely performed in up to one-third of patients, Goldberg said.
She closed by suggesting that colleagues consider the negative subtype in clinical decision-making. For “negative but limited” nodules, repeat the fine needle aspiration and, for “negative” and “currently negative” nodules, consider ultrasound follow-up as per ATA guidelines for Bethesda II cytology, she said.
RET-Mutated Medullary Thyroid Cancer
For patients with RET-mutated medullary thyroid cancer, Julien Hadoux, MD, PhD, of Institut de Cancérologie Gustave Roussy, Villejuif, France, presented a combined analysis of the efficacy of the RET inhibitor selpercatinib from the phase 1/2 LIBRETTO-001 and phase 3 LIBRETTO-531 trials.
This post hoc analysis used a combined cohort of 509 patients with RET-mutated advanced or metastatic medullary thyroid cancer who had received selpercatinib in the two trials.
Hadoux reported that robust and durable responses were seen across all mutation groups, including M918T, extracellular cysteine, and an “other” group composed of various uncommon RET mutations. “The median [progression-free survival] PFS was not reached for either the M918T or extracellular groups and it was 51.4 months for the Other group,” he said.
“Selpercatinib showed superior median PFS vs control, regardless of the RET mutation. This analysis constitutes the largest catalog of RET mutations in medullary thyroid cancers treated with RET-specific inhibitors.”
TRK-Fusion Differentiated Thyroid Cancer
Steven Waguespack, MD, of the University of Texas MD Anderson Cancer Center, Houston, shared updated efficacy and safety data from three phase 1/2 pooled clinical trials of the tropomyosin kinase receptor (TRK) inhibitor larotrectinib in thyroid cancer. These data updated results initially published in 2022.
“Larotrectinib continues to demonstrate rapid and durable responses, extended survival, and offers a favorable safety profile in patients with TRK fusion differentiated thyroid cancer, with limited activity in anaplastic thyroid cancer,” Waguespack said.
“Additionally, in a subset of patients, we identified some acquired on-target NTRK mutations and off-target GNAS and TP53 mutations that may give further insight into mechanisms of resistance.”
The primary endpoint was the investigator-assessed objective response rate (ORR); at 48 months, the ORR was 79% by independent review. The median PFS in patients with TRK fusion differentiated thyroid cancer was 44 months, while the median duration of response was 41 months. The 4-year overall survival rate was 86%.
Waguespack closed with a cautionary note to colleagues: “While circulating tumor DNA next-generation sequencing (NGS) analysis can be used to test for NTRK gene fusions, negative results should be followed up with tissue-based NGS,” he said.
Brito Campana and Goldberg disclosed no relevant financial relationships. Hadoux reported receiving honoraria for speaker engagements, advisory roles, or funding for CME from Eli Lilly, AAA, IPSEN, Roche, Pharma Mar, and EISAI, and research grants from Novartis, Sanofi, and Eli Lilly.
A version of this article appeared on Medscape.com.
The study, presented by Juan Brito Campana, MBBS, of the Mayo Clinic in Rochester, Minnesota, used Medicare records to perform a secondary analysis of 41,000 adults with type 2 diabetes and moderate cardiovascular risk who were new users of GLP-1 receptor agonists, compared to users of other diabetes medications.
“We took the innovative approach of applying the methodological rigor of a randomized clinical trial to the very large dataset of observational studies,” said Brito Campana.
The results showed a low absolute risk of thyroid cancer, with only 0.17% of patients in the GLP-1 group developing the disease. However, the data also showed a potential relative increase in risk during the first year of GLP-1 receptor agonist use.
“This is likely due to increased detection rather than true incidence, as the latency period for thyroid cancer development is typically longer,” Brito Campana said.
“We also note the limitations of the observational study design, including the short follow-up period and lack of detailed histological data. However, we believe the benefits of GLP-1 receptor agonists likely outweigh the risk of thyroid cancer.”
Malignancy in Bethesda III and IV Thyroid Nodules
At the same ATA session, Sapir Nachum Goldberg, MD, of the University of Pennsylvania, Philadelphia, presented the results of a retrospective record review that examined the prevalence of malignancy in Bethesda III and IV thyroid nodules with negative Thyrogen Receptor Signaling (ThyroSeq) version 3 molecular testing results.
Goldberg reported that 87% of patients with ThyroSeq negative subtype results were managed nonoperatively. “Based on our data, the true prevalence of malignancy likely lies between our low and high estimates of 3% and 23%,” she said. “We believe that the prevalence of malignancy may be higher in real-world practice than validation studies.”
Additionally, nodules with “currently negative” or “negative but limited” ThyroSeq results had a higher prevalence of malignancy (7%), compared with those with a “negative” result (2%). Factors like immediate vs delayed surgery, nodule size, and ultrasound pattern did not significantly impact malignancy prevalence.
The study results also indicated that surveillance ultrasonography is not routinely performed in up to one-third of patients, Goldberg said.
She closed by suggesting that colleagues consider the negative subtype in clinical decision-making. For “negative but limited” nodules, repeat the fine needle aspiration and, for “negative” and “currently negative” nodules, consider ultrasound follow-up as per ATA guidelines for Bethesda II cytology, she said.
RET-Mutated Medullary Thyroid Cancer
For patients with RET-mutated medullary thyroid cancer, Julien Hadoux, MD, PhD, of Institut de Cancérologie Gustave Roussy, Villejuif, France, presented a combined analysis of the efficacy of the RET inhibitor selpercatinib from the phase 1/2 LIBRETTO-001 and phase 3 LIBRETTO-531 trials.
This post hoc analysis used a combined cohort of 509 patients with RET-mutated advanced or metastatic medullary thyroid cancer who had received selpercatinib in the two trials.
Hadoux reported that robust and durable responses were seen across all mutation groups, including M918T, extracellular cysteine, and an “other” group composed of various uncommon RET mutations. “The median [progression-free survival] PFS was not reached for either the M918T or extracellular groups and it was 51.4 months for the Other group,” he said.
“Selpercatinib showed superior median PFS vs control, regardless of the RET mutation. This analysis constitutes the largest catalog of RET mutations in medullary thyroid cancers treated with RET-specific inhibitors.”
TRK-Fusion Differentiated Thyroid Cancer
Steven Waguespack, MD, of the University of Texas MD Anderson Cancer Center, Houston, shared updated efficacy and safety data from three phase 1/2 pooled clinical trials of the tropomyosin kinase receptor (TRK) inhibitor larotrectinib in thyroid cancer. These data updated results initially published in 2022.
“Larotrectinib continues to demonstrate rapid and durable responses, extended survival, and offers a favorable safety profile in patients with TRK fusion differentiated thyroid cancer, with limited activity in anaplastic thyroid cancer,” Waguespack said.
“Additionally, in a subset of patients, we identified some acquired on-target NTRK mutations and off-target GNAS and TP53 mutations that may give further insight into mechanisms of resistance.”
The primary endpoint was the investigator-assessed objective response rate (ORR); at 48 months, the ORR was 79% by independent review. The median PFS in patients with TRK fusion differentiated thyroid cancer was 44 months, while the median duration of response was 41 months. The 4-year overall survival rate was 86%.
Waguespack closed with a cautionary note to colleagues: “While circulating tumor DNA next-generation sequencing (NGS) analysis can be used to test for NTRK gene fusions, negative results should be followed up with tissue-based NGS,” he said.
Brito Campana and Goldberg disclosed no relevant financial relationships. Hadoux reported receiving honoraria for speaker engagements, advisory roles, or funding for CME from Eli Lilly, AAA, IPSEN, Roche, Pharma Mar, and EISAI, and research grants from Novartis, Sanofi, and Eli Lilly.
A version of this article appeared on Medscape.com.
The study, presented by Juan Brito Campana, MBBS, of the Mayo Clinic in Rochester, Minnesota, used Medicare records to perform a secondary analysis of 41,000 adults with type 2 diabetes and moderate cardiovascular risk who were new users of GLP-1 receptor agonists, compared to users of other diabetes medications.
“We took the innovative approach of applying the methodological rigor of a randomized clinical trial to the very large dataset of observational studies,” said Brito Campana.
The results showed a low absolute risk of thyroid cancer, with only 0.17% of patients in the GLP-1 group developing the disease. However, the data also showed a potential relative increase in risk during the first year of GLP-1 receptor agonist use.
“This is likely due to increased detection rather than true incidence, as the latency period for thyroid cancer development is typically longer,” Brito Campana said.
“We also note the limitations of the observational study design, including the short follow-up period and lack of detailed histological data. However, we believe the benefits of GLP-1 receptor agonists likely outweigh the risk of thyroid cancer.”
Malignancy in Bethesda III and IV Thyroid Nodules
At the same ATA session, Sapir Nachum Goldberg, MD, of the University of Pennsylvania, Philadelphia, presented the results of a retrospective record review that examined the prevalence of malignancy in Bethesda III and IV thyroid nodules with negative Thyrogen Receptor Signaling (ThyroSeq) version 3 molecular testing results.
Goldberg reported that 87% of patients with ThyroSeq negative subtype results were managed nonoperatively. “Based on our data, the true prevalence of malignancy likely lies between our low and high estimates of 3% and 23%,” she said. “We believe that the prevalence of malignancy may be higher in real-world practice than validation studies.”
Additionally, nodules with “currently negative” or “negative but limited” ThyroSeq results had a higher prevalence of malignancy (7%), compared with those with a “negative” result (2%). Factors like immediate vs delayed surgery, nodule size, and ultrasound pattern did not significantly impact malignancy prevalence.
The study results also indicated that surveillance ultrasonography is not routinely performed in up to one-third of patients, Goldberg said.
She closed by suggesting that colleagues consider the negative subtype in clinical decision-making. For “negative but limited” nodules, repeat the fine needle aspiration and, for “negative” and “currently negative” nodules, consider ultrasound follow-up as per ATA guidelines for Bethesda II cytology, she said.
RET-Mutated Medullary Thyroid Cancer
For patients with RET-mutated medullary thyroid cancer, Julien Hadoux, MD, PhD, of Institut de Cancérologie Gustave Roussy, Villejuif, France, presented a combined analysis of the efficacy of the RET inhibitor selpercatinib from the phase 1/2 LIBRETTO-001 and phase 3 LIBRETTO-531 trials.
This post hoc analysis used a combined cohort of 509 patients with RET-mutated advanced or metastatic medullary thyroid cancer who had received selpercatinib in the two trials.
Hadoux reported that robust and durable responses were seen across all mutation groups, including M918T, extracellular cysteine, and an “other” group composed of various uncommon RET mutations. “The median [progression-free survival] PFS was not reached for either the M918T or extracellular groups and it was 51.4 months for the Other group,” he said.
“Selpercatinib showed superior median PFS vs control, regardless of the RET mutation. This analysis constitutes the largest catalog of RET mutations in medullary thyroid cancers treated with RET-specific inhibitors.”
TRK-Fusion Differentiated Thyroid Cancer
Steven Waguespack, MD, of the University of Texas MD Anderson Cancer Center, Houston, shared updated efficacy and safety data from three phase 1/2 pooled clinical trials of the tropomyosin kinase receptor (TRK) inhibitor larotrectinib in thyroid cancer. These data updated results initially published in 2022.
“Larotrectinib continues to demonstrate rapid and durable responses, extended survival, and offers a favorable safety profile in patients with TRK fusion differentiated thyroid cancer, with limited activity in anaplastic thyroid cancer,” Waguespack said.
“Additionally, in a subset of patients, we identified some acquired on-target NTRK mutations and off-target GNAS and TP53 mutations that may give further insight into mechanisms of resistance.”
The primary endpoint was the investigator-assessed objective response rate (ORR); at 48 months, the ORR was 79% by independent review. The median PFS in patients with TRK fusion differentiated thyroid cancer was 44 months, while the median duration of response was 41 months. The 4-year overall survival rate was 86%.
Waguespack closed with a cautionary note to colleagues: “While circulating tumor DNA next-generation sequencing (NGS) analysis can be used to test for NTRK gene fusions, negative results should be followed up with tissue-based NGS,” he said.
Brito Campana and Goldberg disclosed no relevant financial relationships. Hadoux reported receiving honoraria for speaker engagements, advisory roles, or funding for CME from Eli Lilly, AAA, IPSEN, Roche, Pharma Mar, and EISAI, and research grants from Novartis, Sanofi, and Eli Lilly.
A version of this article appeared on Medscape.com.
FROM ATA 2024
Lifestyle Medicine Trends to Keep an Eye On
Our current healthcare system, which is a costly and unending cycle of merely managing chronic disease symptoms, is failing us. What we truly need is a patient-centered approach that restores health by addressing not just diagnoses but also the physical, emotional, and social needs of each individual. This is the essence of whole-person health, and transformation toward this model of care is already underway.
This shift underscores why clinicians like me support placing lifestyle medicine at the foundation of health and healthcare. Evidence-based lifestyle medicine — which applies interventions in nutrition, physical activity, restorative sleep, stress management, positive social connections, and avoidance of risky substances to prevent, treat, and when used intensively, even reverse lifestyle-related chronic disease — is a medical specialty equipped to successfully address patients’ whole-person health in an effective, high-value clinical care delivery model.
As this transformation continues, here are four key lifestyle medicine trends for 2025.
Lifestyle Medicine Becomes More Ingrained in Primary Care
The 2021 National Academies of Science, Engineering, and Medicine report, “Implementing High-Quality Primary Care” sounded the alarm about the state of primary care and outlined a comprehensive approach to transform it. Lifestyle medicine emerged as a solution as clinicians found innovative ways to integrate lifestyle behavior interventions into existing care models in a financially sustainable, scalable manner. Examples include Blue Zones Health, a new delivery model that aligns lifestyle medicine–certified clinicians with community and payers in California, and the University of Pittsburgh Medical Center lifestyle medicine program, where primary care patients are referred to virtual group coaching, a teaching kitchen, and classes on food as medicine, obesity, type 2 diabetes, and more.
Organizations dedicated to advancing primary care are paying close attention to the potential of lifestyle medicine. Currently, The Primary Care Collaborative has launched a new multi-year initiative on whole-person care and lifestyle medicine. This initiative aims to broaden the primary care community’s understanding of whole health and lifestyle medicine concepts and the evidence behind them, as well as lay the groundwork for future work to promote whole-person primary care and lifestyle medicine among an engaged and committed community of members.
Digital Tools and AI Spark Lifestyle Medicine Innovations
American College of Lifestyle Medicine partner organizations are increasingly utilizing digital tools, such as health apps tailored to lifestyle behavior interventions, to expand access to care and support behavior change. One of the biggest challenges in lifestyle interventions is the limited time during patient encounters. But artificial intelligence (AI) tools can record (with patient permission) and summarize encounters, enabling clinicians to turn away from their keyboards and be more present to learn about the unique living, environmental, and societal factors that impact every individual’s lifestyle choices. AI tools can create individualized whole-food, plant-predominant meal plans or physical activity schedules for patients in just a few seconds. The potential for AI in lifestyle medicine is vast, and its applications were further explored at the American College of Lifestyle Medicine’s annual conference in October.
Behavior Change and Sustainability of the Food-as-Medicine Movement
Significant investments have been made in food as medicine to address diet-related chronic diseases. But merely providing medically tailored meals or produce prescriptions is not enough because once the prescriptions end, so will the health benefits. Clinicians certified in lifestyle medicine are prepared to coach patients into long-term behavior change, supporting them with education and information to shop for and prepare tasty, nutritious, and affordable food. The same applies to the use of glucagon-like peptide 1 drugs. Although the initial weight loss offers motivation, lifestyle changes are necessary to sustain long-term health benefits beyond medications.
Lifestyle Medicine Emerges as a Strategy to Achieve Health Equity
Lifestyle behavior interventions have the unique ability to address health status and social drivers of health. For example, food as medicine affects an individual’s health while also addressing nutrition security. Certainly, no medication can both improve health status and feed someone. The addition of payment for the screening of social drivers of health to the 2024 Medicare Physician Fee Schedule is an important step toward connecting clinicians with community health–based organizations that can address factors that influence patients’ ability to adhere to lifestyle behavior care plans. Lifestyle medicine clinicians are poised to lead this effort because they are already having conversations with patients about their environment, living conditions, and access to nutritious food.
The changes coming to our healthcare system are exciting and long overdue. Lifestyle medicine is positioned to be at the forefront of this transformation now and in the future.
Dr. Patel, president of the American College of Lifestyle Medicine in St. Louis, has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
Our current healthcare system, which is a costly and unending cycle of merely managing chronic disease symptoms, is failing us. What we truly need is a patient-centered approach that restores health by addressing not just diagnoses but also the physical, emotional, and social needs of each individual. This is the essence of whole-person health, and transformation toward this model of care is already underway.
This shift underscores why clinicians like me support placing lifestyle medicine at the foundation of health and healthcare. Evidence-based lifestyle medicine — which applies interventions in nutrition, physical activity, restorative sleep, stress management, positive social connections, and avoidance of risky substances to prevent, treat, and when used intensively, even reverse lifestyle-related chronic disease — is a medical specialty equipped to successfully address patients’ whole-person health in an effective, high-value clinical care delivery model.
As this transformation continues, here are four key lifestyle medicine trends for 2025.
Lifestyle Medicine Becomes More Ingrained in Primary Care
The 2021 National Academies of Science, Engineering, and Medicine report, “Implementing High-Quality Primary Care” sounded the alarm about the state of primary care and outlined a comprehensive approach to transform it. Lifestyle medicine emerged as a solution as clinicians found innovative ways to integrate lifestyle behavior interventions into existing care models in a financially sustainable, scalable manner. Examples include Blue Zones Health, a new delivery model that aligns lifestyle medicine–certified clinicians with community and payers in California, and the University of Pittsburgh Medical Center lifestyle medicine program, where primary care patients are referred to virtual group coaching, a teaching kitchen, and classes on food as medicine, obesity, type 2 diabetes, and more.
Organizations dedicated to advancing primary care are paying close attention to the potential of lifestyle medicine. Currently, The Primary Care Collaborative has launched a new multi-year initiative on whole-person care and lifestyle medicine. This initiative aims to broaden the primary care community’s understanding of whole health and lifestyle medicine concepts and the evidence behind them, as well as lay the groundwork for future work to promote whole-person primary care and lifestyle medicine among an engaged and committed community of members.
Digital Tools and AI Spark Lifestyle Medicine Innovations
American College of Lifestyle Medicine partner organizations are increasingly utilizing digital tools, such as health apps tailored to lifestyle behavior interventions, to expand access to care and support behavior change. One of the biggest challenges in lifestyle interventions is the limited time during patient encounters. But artificial intelligence (AI) tools can record (with patient permission) and summarize encounters, enabling clinicians to turn away from their keyboards and be more present to learn about the unique living, environmental, and societal factors that impact every individual’s lifestyle choices. AI tools can create individualized whole-food, plant-predominant meal plans or physical activity schedules for patients in just a few seconds. The potential for AI in lifestyle medicine is vast, and its applications were further explored at the American College of Lifestyle Medicine’s annual conference in October.
Behavior Change and Sustainability of the Food-as-Medicine Movement
Significant investments have been made in food as medicine to address diet-related chronic diseases. But merely providing medically tailored meals or produce prescriptions is not enough because once the prescriptions end, so will the health benefits. Clinicians certified in lifestyle medicine are prepared to coach patients into long-term behavior change, supporting them with education and information to shop for and prepare tasty, nutritious, and affordable food. The same applies to the use of glucagon-like peptide 1 drugs. Although the initial weight loss offers motivation, lifestyle changes are necessary to sustain long-term health benefits beyond medications.
Lifestyle Medicine Emerges as a Strategy to Achieve Health Equity
Lifestyle behavior interventions have the unique ability to address health status and social drivers of health. For example, food as medicine affects an individual’s health while also addressing nutrition security. Certainly, no medication can both improve health status and feed someone. The addition of payment for the screening of social drivers of health to the 2024 Medicare Physician Fee Schedule is an important step toward connecting clinicians with community health–based organizations that can address factors that influence patients’ ability to adhere to lifestyle behavior care plans. Lifestyle medicine clinicians are poised to lead this effort because they are already having conversations with patients about their environment, living conditions, and access to nutritious food.
The changes coming to our healthcare system are exciting and long overdue. Lifestyle medicine is positioned to be at the forefront of this transformation now and in the future.
Dr. Patel, president of the American College of Lifestyle Medicine in St. Louis, has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
Our current healthcare system, which is a costly and unending cycle of merely managing chronic disease symptoms, is failing us. What we truly need is a patient-centered approach that restores health by addressing not just diagnoses but also the physical, emotional, and social needs of each individual. This is the essence of whole-person health, and transformation toward this model of care is already underway.
This shift underscores why clinicians like me support placing lifestyle medicine at the foundation of health and healthcare. Evidence-based lifestyle medicine — which applies interventions in nutrition, physical activity, restorative sleep, stress management, positive social connections, and avoidance of risky substances to prevent, treat, and when used intensively, even reverse lifestyle-related chronic disease — is a medical specialty equipped to successfully address patients’ whole-person health in an effective, high-value clinical care delivery model.
As this transformation continues, here are four key lifestyle medicine trends for 2025.
Lifestyle Medicine Becomes More Ingrained in Primary Care
The 2021 National Academies of Science, Engineering, and Medicine report, “Implementing High-Quality Primary Care” sounded the alarm about the state of primary care and outlined a comprehensive approach to transform it. Lifestyle medicine emerged as a solution as clinicians found innovative ways to integrate lifestyle behavior interventions into existing care models in a financially sustainable, scalable manner. Examples include Blue Zones Health, a new delivery model that aligns lifestyle medicine–certified clinicians with community and payers in California, and the University of Pittsburgh Medical Center lifestyle medicine program, where primary care patients are referred to virtual group coaching, a teaching kitchen, and classes on food as medicine, obesity, type 2 diabetes, and more.
Organizations dedicated to advancing primary care are paying close attention to the potential of lifestyle medicine. Currently, The Primary Care Collaborative has launched a new multi-year initiative on whole-person care and lifestyle medicine. This initiative aims to broaden the primary care community’s understanding of whole health and lifestyle medicine concepts and the evidence behind them, as well as lay the groundwork for future work to promote whole-person primary care and lifestyle medicine among an engaged and committed community of members.
Digital Tools and AI Spark Lifestyle Medicine Innovations
American College of Lifestyle Medicine partner organizations are increasingly utilizing digital tools, such as health apps tailored to lifestyle behavior interventions, to expand access to care and support behavior change. One of the biggest challenges in lifestyle interventions is the limited time during patient encounters. But artificial intelligence (AI) tools can record (with patient permission) and summarize encounters, enabling clinicians to turn away from their keyboards and be more present to learn about the unique living, environmental, and societal factors that impact every individual’s lifestyle choices. AI tools can create individualized whole-food, plant-predominant meal plans or physical activity schedules for patients in just a few seconds. The potential for AI in lifestyle medicine is vast, and its applications were further explored at the American College of Lifestyle Medicine’s annual conference in October.
Behavior Change and Sustainability of the Food-as-Medicine Movement
Significant investments have been made in food as medicine to address diet-related chronic diseases. But merely providing medically tailored meals or produce prescriptions is not enough because once the prescriptions end, so will the health benefits. Clinicians certified in lifestyle medicine are prepared to coach patients into long-term behavior change, supporting them with education and information to shop for and prepare tasty, nutritious, and affordable food. The same applies to the use of glucagon-like peptide 1 drugs. Although the initial weight loss offers motivation, lifestyle changes are necessary to sustain long-term health benefits beyond medications.
Lifestyle Medicine Emerges as a Strategy to Achieve Health Equity
Lifestyle behavior interventions have the unique ability to address health status and social drivers of health. For example, food as medicine affects an individual’s health while also addressing nutrition security. Certainly, no medication can both improve health status and feed someone. The addition of payment for the screening of social drivers of health to the 2024 Medicare Physician Fee Schedule is an important step toward connecting clinicians with community health–based organizations that can address factors that influence patients’ ability to adhere to lifestyle behavior care plans. Lifestyle medicine clinicians are poised to lead this effort because they are already having conversations with patients about their environment, living conditions, and access to nutritious food.
The changes coming to our healthcare system are exciting and long overdue. Lifestyle medicine is positioned to be at the forefront of this transformation now and in the future.
Dr. Patel, president of the American College of Lifestyle Medicine in St. Louis, has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
Social Adversity Increases Mortality Risk in Patients With Pulmonary Hypertension
BOSTON — Social adversity is associated with worse survival among patients with pulmonary hypertension (PH), according to a new retrospective study of a New York City population.
A sub-analysis of both HIV+ and HIV– patients showed worse mortality outcomes with social adversity in both groups.
“Almost the majority of patients that we treat have either some social adversity or no insurance or are undocumented, so as a group of residents, we decided to study the impact of these factors on their health and the care that can be provided. We started using the two cohorts and now we keep it going with every new resident,” said Luca Biavati, MD, who presented the study at the CHEST Annual Meeting.
“The presence of any form of socioeconomic disadvantage is negatively impacting care and for a large part of the population, there are some factors that could probably be addressed by either an institutional or hospital policy,” said Dr. Biavati, who is an internal medicine resident at Jacobi Medical Center, New York.
Other factors are more difficult to address, such as lack of education. “[Some patients] don’t understand the gravity of their issue and medical condition until it’s too late, and then they’re not fit enough for the treatment, or just because of the social situation, they cannot qualify for advanced therapies,” said Dr. Biavati.
The researchers established two cohorts: One consisting of patients with HIV and heart failure who may or may not have had PH and one comprising patients with PH with or without HIV and heart failure. In the HIV/heart failure group, PH without social adversity was associated with a nearly threefold increase in all-cause mortality (hazard ratio [HR], 2.83; P = .004), whereas PH with social adversity was linked to a more than sevenfold increase in all-cause mortality (HR, 7.14; P < .001). Social adversity without PA was associated with a more than fourfold increase (HR, 4.47; P < .001).
Within the PH cohort, social adversity was associated with lower survival (P < .001). When the researchers broke down the results by types of social adversity, they found statistically significant relationships between greater mortality risk and economic instability within the HIV+ population (HR, 2.59; P = .040), transportation issues within the HIV– population (HR, 12.8; P < .001), and lack of social or family support within both the HIV– (HR, 5.49; P < .001) and the HIV+ population (HR, 2.03; P = .028).
The research has prompted interventions, which are now being studied at the institution, according to Dr. Biavati. “We have a policy of giving medications in bags when we discharge a patient with a social adversity. We literally go to the pharmacy, bring up the bag of medication, and we [put it] in their hands before they leave the hospital. They get a 1- or 3-month supply, depending on the medication, and then we usually discharge them with a clinical appointment already scheduled with either a pulmonary or primary care provider, and we usually call them before every appointment to confirm that they’re coming. That increases the chances of some success, but there’s still a very long way to go,” said Dr. Biavati.
Dr. Biavati was blinded to the results of the intervention, so he could not report on whether it was working. “But I can tell you that I’ve had busier clinics, so hopefully that means that they’re showing up more,” he said.
The problem is complex, according to Sandeep Jain, MD, who moderated the session. “Social adversity means lack of education. Lack of education means lack of compliance. Lack of compliance means what can you do if people are not taking medications? So it’s all matched together. It’s all lack of education and lack of money, lack of family support. And these drugs they have to take every single day. It’s not that easy. It’s very easy for us to say I had antiretroviral treatment for 6 months. It is almost impossible to continue regular treatment for that long [for a patient with social adversity]. You can’t blame them if they aren’t taking treatments. It’s very difficult for them,” said Dr. Jain.
That underscores the need for interventions that can address the needs of patients with social adversity. “We have to [practice] medicine considering the social situation of the patient and not just the medicine that we study in books. That’s kind of what we are faced with every day. We have therapies, and then life happens. It’s much harder to care for those patients,” said Dr. Biavati.
Dr. Biavati and Dr. Jain reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
BOSTON — Social adversity is associated with worse survival among patients with pulmonary hypertension (PH), according to a new retrospective study of a New York City population.
A sub-analysis of both HIV+ and HIV– patients showed worse mortality outcomes with social adversity in both groups.
“Almost the majority of patients that we treat have either some social adversity or no insurance or are undocumented, so as a group of residents, we decided to study the impact of these factors on their health and the care that can be provided. We started using the two cohorts and now we keep it going with every new resident,” said Luca Biavati, MD, who presented the study at the CHEST Annual Meeting.
“The presence of any form of socioeconomic disadvantage is negatively impacting care and for a large part of the population, there are some factors that could probably be addressed by either an institutional or hospital policy,” said Dr. Biavati, who is an internal medicine resident at Jacobi Medical Center, New York.
Other factors are more difficult to address, such as lack of education. “[Some patients] don’t understand the gravity of their issue and medical condition until it’s too late, and then they’re not fit enough for the treatment, or just because of the social situation, they cannot qualify for advanced therapies,” said Dr. Biavati.
The researchers established two cohorts: One consisting of patients with HIV and heart failure who may or may not have had PH and one comprising patients with PH with or without HIV and heart failure. In the HIV/heart failure group, PH without social adversity was associated with a nearly threefold increase in all-cause mortality (hazard ratio [HR], 2.83; P = .004), whereas PH with social adversity was linked to a more than sevenfold increase in all-cause mortality (HR, 7.14; P < .001). Social adversity without PA was associated with a more than fourfold increase (HR, 4.47; P < .001).
Within the PH cohort, social adversity was associated with lower survival (P < .001). When the researchers broke down the results by types of social adversity, they found statistically significant relationships between greater mortality risk and economic instability within the HIV+ population (HR, 2.59; P = .040), transportation issues within the HIV– population (HR, 12.8; P < .001), and lack of social or family support within both the HIV– (HR, 5.49; P < .001) and the HIV+ population (HR, 2.03; P = .028).
The research has prompted interventions, which are now being studied at the institution, according to Dr. Biavati. “We have a policy of giving medications in bags when we discharge a patient with a social adversity. We literally go to the pharmacy, bring up the bag of medication, and we [put it] in their hands before they leave the hospital. They get a 1- or 3-month supply, depending on the medication, and then we usually discharge them with a clinical appointment already scheduled with either a pulmonary or primary care provider, and we usually call them before every appointment to confirm that they’re coming. That increases the chances of some success, but there’s still a very long way to go,” said Dr. Biavati.
Dr. Biavati was blinded to the results of the intervention, so he could not report on whether it was working. “But I can tell you that I’ve had busier clinics, so hopefully that means that they’re showing up more,” he said.
The problem is complex, according to Sandeep Jain, MD, who moderated the session. “Social adversity means lack of education. Lack of education means lack of compliance. Lack of compliance means what can you do if people are not taking medications? So it’s all matched together. It’s all lack of education and lack of money, lack of family support. And these drugs they have to take every single day. It’s not that easy. It’s very easy for us to say I had antiretroviral treatment for 6 months. It is almost impossible to continue regular treatment for that long [for a patient with social adversity]. You can’t blame them if they aren’t taking treatments. It’s very difficult for them,” said Dr. Jain.
That underscores the need for interventions that can address the needs of patients with social adversity. “We have to [practice] medicine considering the social situation of the patient and not just the medicine that we study in books. That’s kind of what we are faced with every day. We have therapies, and then life happens. It’s much harder to care for those patients,” said Dr. Biavati.
Dr. Biavati and Dr. Jain reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
BOSTON — Social adversity is associated with worse survival among patients with pulmonary hypertension (PH), according to a new retrospective study of a New York City population.
A sub-analysis of both HIV+ and HIV– patients showed worse mortality outcomes with social adversity in both groups.
“Almost the majority of patients that we treat have either some social adversity or no insurance or are undocumented, so as a group of residents, we decided to study the impact of these factors on their health and the care that can be provided. We started using the two cohorts and now we keep it going with every new resident,” said Luca Biavati, MD, who presented the study at the CHEST Annual Meeting.
“The presence of any form of socioeconomic disadvantage is negatively impacting care and for a large part of the population, there are some factors that could probably be addressed by either an institutional or hospital policy,” said Dr. Biavati, who is an internal medicine resident at Jacobi Medical Center, New York.
Other factors are more difficult to address, such as lack of education. “[Some patients] don’t understand the gravity of their issue and medical condition until it’s too late, and then they’re not fit enough for the treatment, or just because of the social situation, they cannot qualify for advanced therapies,” said Dr. Biavati.
The researchers established two cohorts: One consisting of patients with HIV and heart failure who may or may not have had PH and one comprising patients with PH with or without HIV and heart failure. In the HIV/heart failure group, PH without social adversity was associated with a nearly threefold increase in all-cause mortality (hazard ratio [HR], 2.83; P = .004), whereas PH with social adversity was linked to a more than sevenfold increase in all-cause mortality (HR, 7.14; P < .001). Social adversity without PA was associated with a more than fourfold increase (HR, 4.47; P < .001).
Within the PH cohort, social adversity was associated with lower survival (P < .001). When the researchers broke down the results by types of social adversity, they found statistically significant relationships between greater mortality risk and economic instability within the HIV+ population (HR, 2.59; P = .040), transportation issues within the HIV– population (HR, 12.8; P < .001), and lack of social or family support within both the HIV– (HR, 5.49; P < .001) and the HIV+ population (HR, 2.03; P = .028).
The research has prompted interventions, which are now being studied at the institution, according to Dr. Biavati. “We have a policy of giving medications in bags when we discharge a patient with a social adversity. We literally go to the pharmacy, bring up the bag of medication, and we [put it] in their hands before they leave the hospital. They get a 1- or 3-month supply, depending on the medication, and then we usually discharge them with a clinical appointment already scheduled with either a pulmonary or primary care provider, and we usually call them before every appointment to confirm that they’re coming. That increases the chances of some success, but there’s still a very long way to go,” said Dr. Biavati.
Dr. Biavati was blinded to the results of the intervention, so he could not report on whether it was working. “But I can tell you that I’ve had busier clinics, so hopefully that means that they’re showing up more,” he said.
The problem is complex, according to Sandeep Jain, MD, who moderated the session. “Social adversity means lack of education. Lack of education means lack of compliance. Lack of compliance means what can you do if people are not taking medications? So it’s all matched together. It’s all lack of education and lack of money, lack of family support. And these drugs they have to take every single day. It’s not that easy. It’s very easy for us to say I had antiretroviral treatment for 6 months. It is almost impossible to continue regular treatment for that long [for a patient with social adversity]. You can’t blame them if they aren’t taking treatments. It’s very difficult for them,” said Dr. Jain.
That underscores the need for interventions that can address the needs of patients with social adversity. “We have to [practice] medicine considering the social situation of the patient and not just the medicine that we study in books. That’s kind of what we are faced with every day. We have therapies, and then life happens. It’s much harder to care for those patients,” said Dr. Biavati.
Dr. Biavati and Dr. Jain reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM CHEST 2024
AF Burden Increases Around Time of COPD Hospitalizations
BOSTON — Patients with COPD who have exacerbations requiring hospitalization should be monitored for cardiac arrhythmias, investigators said.
This recommendation is based on results of a study of medical records showing that among more than 20,000 hospitalizations for patients with COPD without concurrent heart failure (HF), 40% patients had at least 6 minutes of daily atrial fibrillation (AF) burden, and nearly half of these patients had at least an hour of daily AF burden; patients with COPD and concurrent HF had similar daily AF burdens, reported Trent Fischer, MD, MS, senior principal scientist at Medtronic in Minneapolis.
“We can conclude that AF burden increases in the weeks after a hospitalization for COPD if they don’t have a concurrent diagnosis of heart failure. Also, having concurrent heart failure increases the risk of atrial fibrillation and increases the atrial fibrillation burden around the time of COPD hospitalization,” he said in a rapid-fire oral abstract session at the CHEST Annual Meeting.
The findings indicated a need for increased vigilance for AF around the time of a serious COPD exacerbation and may explain at least some of the increased risks for stroke observed in patients who are hospitalized for COPD exacerbations, he said.
Retrospective Study
They drew data from 2007 through 2021 on patients with implantable cardioverter defibrillators, cardiac resynchronization therapy devices, pacemakers, and implantable cardiac monitors, using the Optum de-identified electronic health record dataset linked with Medtronic’s CareLink database to conduct a retrospective analysis.
They looked at admissions for COPD linked to available device diagnostic parameters between 30 days prior to and 60 days after admission for COPD.
They identified a total of 20,056 COPD hospitalizations for patients with concurrent HF and 3877 for those without HF.
Among patients with HF, 43% had a daily AF burden of at least 6 minutes, and 22% had at least 1 hour of irregular rhythms. Among patients without HF, 40% had at least 6 minutes of irregular rhythms daily, and 18% had at least 1 hour.
Among patients with HF, the daily average AF burden increased from a baseline of 158 min/d 30 days before an admission to 170 min/d at admission, returning to baseline by 20 days after hospitalization.
For patients without HF, the AF burden increased from 107 min/d at baseline to 113 min/d during hospitalization and returned to baseline by 20 days after hospitalization.
Confounding Factor?
In the Q&A, session moderator Krishna Sundar, MBBS, MD, FCCP, a pulmonary, sleep medicine, and critical care medicine specialist at St. John’s Medical Center in Jackson, Wyoming, said that when patients with HF get admitted for COPD exacerbations, their HF typically worsens and asked Dr. Fischer how he could tell the difference.
“I know there’s a lot of interaction between heart failure and COPD. They’re well-know comorbidities, and the exacerbation of one can bring on worsening of the other. At least with this database, we can’t really tease out any sort of differences,” Dr. Fischer replied.
“I think that a diagnosis of COPD exacerbation is pretty well laid out, but it’s sometimes difficult to separate worsening of heart failure in these patients, and often these patients get treated for both problems. It’s clear that it’s the heart failure patients who are having more atrial fibrillation episodes, which is not surprising, but the question is how much is the COPD exacerbation contributing to the atrial fibrillation?” said Dr. Sundar.
The study was supported by Medtronic. Dr. Fischer is employed by the company. Dr. Sundar reported no relevant financial relationships.
A version of this article appeared on Medscape.com.
BOSTON — Patients with COPD who have exacerbations requiring hospitalization should be monitored for cardiac arrhythmias, investigators said.
This recommendation is based on results of a study of medical records showing that among more than 20,000 hospitalizations for patients with COPD without concurrent heart failure (HF), 40% patients had at least 6 minutes of daily atrial fibrillation (AF) burden, and nearly half of these patients had at least an hour of daily AF burden; patients with COPD and concurrent HF had similar daily AF burdens, reported Trent Fischer, MD, MS, senior principal scientist at Medtronic in Minneapolis.
“We can conclude that AF burden increases in the weeks after a hospitalization for COPD if they don’t have a concurrent diagnosis of heart failure. Also, having concurrent heart failure increases the risk of atrial fibrillation and increases the atrial fibrillation burden around the time of COPD hospitalization,” he said in a rapid-fire oral abstract session at the CHEST Annual Meeting.
The findings indicated a need for increased vigilance for AF around the time of a serious COPD exacerbation and may explain at least some of the increased risks for stroke observed in patients who are hospitalized for COPD exacerbations, he said.
Retrospective Study
They drew data from 2007 through 2021 on patients with implantable cardioverter defibrillators, cardiac resynchronization therapy devices, pacemakers, and implantable cardiac monitors, using the Optum de-identified electronic health record dataset linked with Medtronic’s CareLink database to conduct a retrospective analysis.
They looked at admissions for COPD linked to available device diagnostic parameters between 30 days prior to and 60 days after admission for COPD.
They identified a total of 20,056 COPD hospitalizations for patients with concurrent HF and 3877 for those without HF.
Among patients with HF, 43% had a daily AF burden of at least 6 minutes, and 22% had at least 1 hour of irregular rhythms. Among patients without HF, 40% had at least 6 minutes of irregular rhythms daily, and 18% had at least 1 hour.
Among patients with HF, the daily average AF burden increased from a baseline of 158 min/d 30 days before an admission to 170 min/d at admission, returning to baseline by 20 days after hospitalization.
For patients without HF, the AF burden increased from 107 min/d at baseline to 113 min/d during hospitalization and returned to baseline by 20 days after hospitalization.
Confounding Factor?
In the Q&A, session moderator Krishna Sundar, MBBS, MD, FCCP, a pulmonary, sleep medicine, and critical care medicine specialist at St. John’s Medical Center in Jackson, Wyoming, said that when patients with HF get admitted for COPD exacerbations, their HF typically worsens and asked Dr. Fischer how he could tell the difference.
“I know there’s a lot of interaction between heart failure and COPD. They’re well-know comorbidities, and the exacerbation of one can bring on worsening of the other. At least with this database, we can’t really tease out any sort of differences,” Dr. Fischer replied.
“I think that a diagnosis of COPD exacerbation is pretty well laid out, but it’s sometimes difficult to separate worsening of heart failure in these patients, and often these patients get treated for both problems. It’s clear that it’s the heart failure patients who are having more atrial fibrillation episodes, which is not surprising, but the question is how much is the COPD exacerbation contributing to the atrial fibrillation?” said Dr. Sundar.
The study was supported by Medtronic. Dr. Fischer is employed by the company. Dr. Sundar reported no relevant financial relationships.
A version of this article appeared on Medscape.com.
BOSTON — Patients with COPD who have exacerbations requiring hospitalization should be monitored for cardiac arrhythmias, investigators said.
This recommendation is based on results of a study of medical records showing that among more than 20,000 hospitalizations for patients with COPD without concurrent heart failure (HF), 40% patients had at least 6 minutes of daily atrial fibrillation (AF) burden, and nearly half of these patients had at least an hour of daily AF burden; patients with COPD and concurrent HF had similar daily AF burdens, reported Trent Fischer, MD, MS, senior principal scientist at Medtronic in Minneapolis.
“We can conclude that AF burden increases in the weeks after a hospitalization for COPD if they don’t have a concurrent diagnosis of heart failure. Also, having concurrent heart failure increases the risk of atrial fibrillation and increases the atrial fibrillation burden around the time of COPD hospitalization,” he said in a rapid-fire oral abstract session at the CHEST Annual Meeting.
The findings indicated a need for increased vigilance for AF around the time of a serious COPD exacerbation and may explain at least some of the increased risks for stroke observed in patients who are hospitalized for COPD exacerbations, he said.
Retrospective Study
They drew data from 2007 through 2021 on patients with implantable cardioverter defibrillators, cardiac resynchronization therapy devices, pacemakers, and implantable cardiac monitors, using the Optum de-identified electronic health record dataset linked with Medtronic’s CareLink database to conduct a retrospective analysis.
They looked at admissions for COPD linked to available device diagnostic parameters between 30 days prior to and 60 days after admission for COPD.
They identified a total of 20,056 COPD hospitalizations for patients with concurrent HF and 3877 for those without HF.
Among patients with HF, 43% had a daily AF burden of at least 6 minutes, and 22% had at least 1 hour of irregular rhythms. Among patients without HF, 40% had at least 6 minutes of irregular rhythms daily, and 18% had at least 1 hour.
Among patients with HF, the daily average AF burden increased from a baseline of 158 min/d 30 days before an admission to 170 min/d at admission, returning to baseline by 20 days after hospitalization.
For patients without HF, the AF burden increased from 107 min/d at baseline to 113 min/d during hospitalization and returned to baseline by 20 days after hospitalization.
Confounding Factor?
In the Q&A, session moderator Krishna Sundar, MBBS, MD, FCCP, a pulmonary, sleep medicine, and critical care medicine specialist at St. John’s Medical Center in Jackson, Wyoming, said that when patients with HF get admitted for COPD exacerbations, their HF typically worsens and asked Dr. Fischer how he could tell the difference.
“I know there’s a lot of interaction between heart failure and COPD. They’re well-know comorbidities, and the exacerbation of one can bring on worsening of the other. At least with this database, we can’t really tease out any sort of differences,” Dr. Fischer replied.
“I think that a diagnosis of COPD exacerbation is pretty well laid out, but it’s sometimes difficult to separate worsening of heart failure in these patients, and often these patients get treated for both problems. It’s clear that it’s the heart failure patients who are having more atrial fibrillation episodes, which is not surprising, but the question is how much is the COPD exacerbation contributing to the atrial fibrillation?” said Dr. Sundar.
The study was supported by Medtronic. Dr. Fischer is employed by the company. Dr. Sundar reported no relevant financial relationships.
A version of this article appeared on Medscape.com.
FROM CHEST 2024
Semiannual Time Changes Linked to Accidents, Heart Attacks
As people turn their clocks back an hour on November 3 to mark the end of daylight saving time and return to standard time, they should remain aware of their sleep health and of potential risks associated with shifts in sleep patterns, according to a University of Calgary psychology professor who researches circadian cycles.
said Michael Antle, PhD, head of the psychology department and member of the Hotchkiss Brain Institute at the Cumming School of Medicine, University of Calgary, Alberta, Canada.
In an interview, Antle explained the science behind the health risks associated with time changes, offered tips to prepare for the shift, and discussed scientists’ suggestion to move to year-round standard time. This interview has been condensed and edited for clarity.
Why is it important to pay attention to circadian rhythms?
Circadian rhythms are patterns of physiologic and behavioral changes that affect everything inside the body and everything we do, including when hormones are secreted, digestive juices are ready to digest, and growth hormones are released at night. The body is a carefully coordinated orchestra, and everything has to happen at the right time.
When we start messing with those rhythms, that’s when states of disease start coming on and we don’t feel well. You’ve probably experienced it — when you try to stay up late, eat at the wrong times, or have jet lag. Flying across one or two time zones is usually tolerable, but if you fly across the world, it can be profound and make you feel bad, even up to a week. Similar shifts happen with the time changes.
How do the time changes affect health risks?
The wintertime change is generally more tolerable, and you’ll hear people talk about “gaining an hour” of sleep. It’s better than that, because we’re realigning our social clocks — such as our work schedules and school schedules — with daylight. We tend to go to bed relative to the sun but wake up based on when our boss says to be at our desk, so an earlier sunset helps us to fall asleep earlier and is healthier for our body.
In the spring, the opposite happens, and the time change affects us much more than just one bad night of sleep. For some people, it can feel like losing an hour of sleep every day for weeks, and that abrupt change can lead to car accidents, workplace injuries, heart attacks, and strokes. Our body experiences extra strain when we’re not awake and ready for the day.
What does your research show?
Most of my work focuses on preclinical models to understand what’s going on in the brain and body. Because we can’t study this ethically in humans, we learn a lot from animal models, especially mice. In a recent study looking at mild circadian disruption — where we raised mice on days that were about 75 minutes shorter — we saw they started developing diabetes, heart disease, and insulin resistance within in a few months, or about the time they were a young adult.
Oftentimes, people think about their sleep rhythm as an arbitrary choice, but in fact, it does affect your health. We know that if your human circadian clock runs slow, morning light can help fix that and reset it, whereas evening light moves us in the other direction and makes it harder to get up in the morning.
Some people want to switch to one year-round time. What do you advocate?
In most cases, the standard time (or winter time) is the more natural time that fits better with our body cycle. If we follow a time where we get up before sunrise or have a later sunset, then it’s linked to more social jet lag, where people are less attentive at work, don’t learn as well at school, and have more accidents.
Instead of picking what sounds good or chasing the name — such as “daylight saving time” — we need to think about the right time for us and our circadian clock. Some places, such as Maine in the United States, would actually fit better with the Atlantic time zone or the Maritime provinces in Canada, whereas some parts of Alberta are geographically west of Los Angeles based on longitude and would fit better with the Pacific time zone. Sticking with a year-round daylight saving time in some cities in Alberta would mean people wouldn’t see the sun until 10:30 AM in the winter, which is really late and could affect activities such as skiing and hockey.
The Canadian Society for Chronobiology advocates for year-round standard time to align our social clocks with our biological clocks. Sleep and circadian rhythm experts in the US and globally have issued similar position statements.
What tips do you suggest to help people adjust their circadian clocks in November?
For people who know their bodies and that it will affect them more, give yourself extra time. If your schedule permits, plan ahead and change your clocks sooner, especially if you’re able to do so over the weekend. Don’t rush around while tired — rushing when you’re not ready leads to those increased accidents on the road or on the job. Know that the sun will still be mismatched for a bit and your body clock will take time to adjust, so you might feel out of sorts for a few days.
Antle reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
As people turn their clocks back an hour on November 3 to mark the end of daylight saving time and return to standard time, they should remain aware of their sleep health and of potential risks associated with shifts in sleep patterns, according to a University of Calgary psychology professor who researches circadian cycles.
said Michael Antle, PhD, head of the psychology department and member of the Hotchkiss Brain Institute at the Cumming School of Medicine, University of Calgary, Alberta, Canada.
In an interview, Antle explained the science behind the health risks associated with time changes, offered tips to prepare for the shift, and discussed scientists’ suggestion to move to year-round standard time. This interview has been condensed and edited for clarity.
Why is it important to pay attention to circadian rhythms?
Circadian rhythms are patterns of physiologic and behavioral changes that affect everything inside the body and everything we do, including when hormones are secreted, digestive juices are ready to digest, and growth hormones are released at night. The body is a carefully coordinated orchestra, and everything has to happen at the right time.
When we start messing with those rhythms, that’s when states of disease start coming on and we don’t feel well. You’ve probably experienced it — when you try to stay up late, eat at the wrong times, or have jet lag. Flying across one or two time zones is usually tolerable, but if you fly across the world, it can be profound and make you feel bad, even up to a week. Similar shifts happen with the time changes.
How do the time changes affect health risks?
The wintertime change is generally more tolerable, and you’ll hear people talk about “gaining an hour” of sleep. It’s better than that, because we’re realigning our social clocks — such as our work schedules and school schedules — with daylight. We tend to go to bed relative to the sun but wake up based on when our boss says to be at our desk, so an earlier sunset helps us to fall asleep earlier and is healthier for our body.
In the spring, the opposite happens, and the time change affects us much more than just one bad night of sleep. For some people, it can feel like losing an hour of sleep every day for weeks, and that abrupt change can lead to car accidents, workplace injuries, heart attacks, and strokes. Our body experiences extra strain when we’re not awake and ready for the day.
What does your research show?
Most of my work focuses on preclinical models to understand what’s going on in the brain and body. Because we can’t study this ethically in humans, we learn a lot from animal models, especially mice. In a recent study looking at mild circadian disruption — where we raised mice on days that were about 75 minutes shorter — we saw they started developing diabetes, heart disease, and insulin resistance within in a few months, or about the time they were a young adult.
Oftentimes, people think about their sleep rhythm as an arbitrary choice, but in fact, it does affect your health. We know that if your human circadian clock runs slow, morning light can help fix that and reset it, whereas evening light moves us in the other direction and makes it harder to get up in the morning.
Some people want to switch to one year-round time. What do you advocate?
In most cases, the standard time (or winter time) is the more natural time that fits better with our body cycle. If we follow a time where we get up before sunrise or have a later sunset, then it’s linked to more social jet lag, where people are less attentive at work, don’t learn as well at school, and have more accidents.
Instead of picking what sounds good or chasing the name — such as “daylight saving time” — we need to think about the right time for us and our circadian clock. Some places, such as Maine in the United States, would actually fit better with the Atlantic time zone or the Maritime provinces in Canada, whereas some parts of Alberta are geographically west of Los Angeles based on longitude and would fit better with the Pacific time zone. Sticking with a year-round daylight saving time in some cities in Alberta would mean people wouldn’t see the sun until 10:30 AM in the winter, which is really late and could affect activities such as skiing and hockey.
The Canadian Society for Chronobiology advocates for year-round standard time to align our social clocks with our biological clocks. Sleep and circadian rhythm experts in the US and globally have issued similar position statements.
What tips do you suggest to help people adjust their circadian clocks in November?
For people who know their bodies and that it will affect them more, give yourself extra time. If your schedule permits, plan ahead and change your clocks sooner, especially if you’re able to do so over the weekend. Don’t rush around while tired — rushing when you’re not ready leads to those increased accidents on the road or on the job. Know that the sun will still be mismatched for a bit and your body clock will take time to adjust, so you might feel out of sorts for a few days.
Antle reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
As people turn their clocks back an hour on November 3 to mark the end of daylight saving time and return to standard time, they should remain aware of their sleep health and of potential risks associated with shifts in sleep patterns, according to a University of Calgary psychology professor who researches circadian cycles.
said Michael Antle, PhD, head of the psychology department and member of the Hotchkiss Brain Institute at the Cumming School of Medicine, University of Calgary, Alberta, Canada.
In an interview, Antle explained the science behind the health risks associated with time changes, offered tips to prepare for the shift, and discussed scientists’ suggestion to move to year-round standard time. This interview has been condensed and edited for clarity.
Why is it important to pay attention to circadian rhythms?
Circadian rhythms are patterns of physiologic and behavioral changes that affect everything inside the body and everything we do, including when hormones are secreted, digestive juices are ready to digest, and growth hormones are released at night. The body is a carefully coordinated orchestra, and everything has to happen at the right time.
When we start messing with those rhythms, that’s when states of disease start coming on and we don’t feel well. You’ve probably experienced it — when you try to stay up late, eat at the wrong times, or have jet lag. Flying across one or two time zones is usually tolerable, but if you fly across the world, it can be profound and make you feel bad, even up to a week. Similar shifts happen with the time changes.
How do the time changes affect health risks?
The wintertime change is generally more tolerable, and you’ll hear people talk about “gaining an hour” of sleep. It’s better than that, because we’re realigning our social clocks — such as our work schedules and school schedules — with daylight. We tend to go to bed relative to the sun but wake up based on when our boss says to be at our desk, so an earlier sunset helps us to fall asleep earlier and is healthier for our body.
In the spring, the opposite happens, and the time change affects us much more than just one bad night of sleep. For some people, it can feel like losing an hour of sleep every day for weeks, and that abrupt change can lead to car accidents, workplace injuries, heart attacks, and strokes. Our body experiences extra strain when we’re not awake and ready for the day.
What does your research show?
Most of my work focuses on preclinical models to understand what’s going on in the brain and body. Because we can’t study this ethically in humans, we learn a lot from animal models, especially mice. In a recent study looking at mild circadian disruption — where we raised mice on days that were about 75 minutes shorter — we saw they started developing diabetes, heart disease, and insulin resistance within in a few months, or about the time they were a young adult.
Oftentimes, people think about their sleep rhythm as an arbitrary choice, but in fact, it does affect your health. We know that if your human circadian clock runs slow, morning light can help fix that and reset it, whereas evening light moves us in the other direction and makes it harder to get up in the morning.
Some people want to switch to one year-round time. What do you advocate?
In most cases, the standard time (or winter time) is the more natural time that fits better with our body cycle. If we follow a time where we get up before sunrise or have a later sunset, then it’s linked to more social jet lag, where people are less attentive at work, don’t learn as well at school, and have more accidents.
Instead of picking what sounds good or chasing the name — such as “daylight saving time” — we need to think about the right time for us and our circadian clock. Some places, such as Maine in the United States, would actually fit better with the Atlantic time zone or the Maritime provinces in Canada, whereas some parts of Alberta are geographically west of Los Angeles based on longitude and would fit better with the Pacific time zone. Sticking with a year-round daylight saving time in some cities in Alberta would mean people wouldn’t see the sun until 10:30 AM in the winter, which is really late and could affect activities such as skiing and hockey.
The Canadian Society for Chronobiology advocates for year-round standard time to align our social clocks with our biological clocks. Sleep and circadian rhythm experts in the US and globally have issued similar position statements.
What tips do you suggest to help people adjust their circadian clocks in November?
For people who know their bodies and that it will affect them more, give yourself extra time. If your schedule permits, plan ahead and change your clocks sooner, especially if you’re able to do so over the weekend. Don’t rush around while tired — rushing when you’re not ready leads to those increased accidents on the road or on the job. Know that the sun will still be mismatched for a bit and your body clock will take time to adjust, so you might feel out of sorts for a few days.
Antle reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Which Specialists Should Lead BP Control Efforts?
Current efforts to control high blood pressure (BP) are failing in the United States and globally.
The first World Health Organization (WHO) global report on hypertension found that only 54% of adults with hypertension are diagnosed, 42% get treatment, and just 21% have their hypertension controlled.
In the United States, almost half (48%) of adults have high BP, defined as a systolic BP > 130 mm Hg, or a diastolic BP > 80 mm Hg, or are taking medication for high BP, according to the Centers for Disease Control and Prevention. Only about one in four adults (22.5%) with high BP have their BP under control.
High BP is a major risk factor for coronary heart disease, heart failure, and stroke, and the problem of controlling it is only getting worse. In 2024, the American Heart Association estimates that, “among adults, prevalence of hypertension will increase from 51.2% in 2020 to 61.0% in 2050.”
Pharmacists Most Effective
Though many factors contribute to hypertension, researchers have found that the kind of specialist leading the hypertension team may play a role in success. Currently, most BP control teams are led by physicians in primary care.
In a recent meta-analysis involving 100 randomized controlled trials and more than 90,000 patients in Circulation, Katherine T. Mills, PhD, School of Public Health, Tulane University, New Orleans, Louisiana, and colleagues found that, while all the groups studied who led BP control efforts were successful in reducing BP, pharmacist- and community health worker–led teams saw the biggest reductions.
Those groups’ efforts resulted in the greatest systolic BP drops: −7.3 mm Hg (pharmacists) and −7.1 mm Hg (community health workers). Groups led by nurses and physicians saw systolic changes of −3 and −2.4 mm Hg, respectively.
Similarly, pharmacist- and community health worker–led efforts saw the greatest diastolic BP reductions (−3.8 and −3.1 mm Hg), compared with nurse-led (−1.6) and physician-led (−1.2) efforts.
Reductions Enough to Cut Cardiovascular Disease Risk
The reduction numbers for pharmacists are clinically meaningful, Mills said in an interview. “It’s greater than a lot of what we see from individual lifestyle changes,” such as reducing sodium intake or increasing physical activity.
“It’s a big enough blood pressure change to have meaningful reduction in risk of cardiovascular disease,” she said.
This evidence that the leader of the team matters is particularly important because the treatment of hypertension is not in doubt. Something else is not working the way it should.
“We have basically all the scientific evidence we need in terms of what interventions work. But there’s a big gap between that and what’s actually being done in the real world,” she said.
Mills said she was not surprised that pharmacists got the best results “because so much of it has to do with titrating medications and finding the right kind of medications for each patient.”
Additionally, BP management and control falls right into pharmacists’ wheelhouse, Mills noted, including evaluating medication side effects and talking to patients about medication adherence.
Why Pharmacists May Be More Successful
In an accompanying editorial, Ross T. Tsuyuki, PharmD, with the EPICORE Centre, Division of Cardiology, University of Alberta in Edmonton, Canada, and coauthors said the Mills study provides further data to support pharmacists leading BP control efforts, but it’s not the data that have been keeping the model from changing. The barriers include turf wars and lack of legislative change.
The editorialists also said having pharmacist-led BP teams is only the first step. “We need pharmacists to independently prescribe,” they wrote.
“Since individual states govern the scope of practice of pharmacists,” the editorialists wrote, “we have the enormous task of changing regulations to allow pharmacists to independently prescribe for hypertension. But it can be done. The Canadian province of Alberta allows pharmacists to prescribe. And more recently, Idaho. While most states allow some sort of collaborative (dependent) prescribing, that is only a first step.”
Allowing pharmacists to independently prescribe will help populations who do not have a physician or can’t get access to a physician, the editorialists wrote. But changing state legislation would be a lengthy and complex effort.
Physician-Led BP Control Model ‘Seems to Fail Miserably’
Coauthor of the editorial, Florian Rader, MD, MSc, medical director of the Hypertension Center of Excellence at Cedars-Sinai Medical Center in Los Angeles, California, said in an interview that, currently, physician-led teams are the norm, “and that model seems to fail miserably.”
He offered several key reasons for that. In primary care, patients with hypertension often have other problems — they may have high cholesterol or diabetes. “They may have acute illnesses that bother them as well as hypertension that doesn’t bother them,” he said.
Physicians tend to find excuses not to increase or add BP medications, Rader said. “We tend then to blame ‘white coat effect’ or say ‘you’re just nervous today.’ ”
Pharmacists, comparatively, are more protocol driven, he said. “They essentially look at blood pressure and they have an algorithm in their mind. If the blood pressure hits the guideline-stated bar, start this medication. If it hits another bar, increase or add another medication.”
Rader said turf wars are also keeping physician-led teams from changing, fueled by fears that patients will seek care from pharmacists instead of physicians.
“I don’t think the pharmacists will steal a single patient,” Rader said. “If a physician had a healthcare partner like a pharmacist to optimize blood pressure, then [patients] come back to the physician with normalized BP on the right medications. I think it’s a total win-win. I think we just have to get over that.”
Pharmacist-led warfarin clinics are very well established, Rader said, “but for whatever reason, when it comes to blood pressure, physicians are a little bit more hesitant.”
Collaboration Yes, Independent No
Hypertension expert Donald J. DiPette, MD, Health Sciences Distinguished Professor in the Department of Internal Medicine at University of South Carolina, Columbia, said he completely agrees with Mills and colleagues’ conclusion. “Pharmacists and community health workers are most effective at leading BP intervention implementation and should be prioritized in future hypertension control efforts.”
The conclusion “is in line with the thinking of major organizations,” said DiPette, who helped develop the WHO’s most recent pharmacological treatment of hypertension guidelines. “WHO suggests that pharmacological treatment of hypertension can be provided by nonphysician professionals such as pharmacists and nurses as long as the following conditions are met: Proper training, prescribing authority, specific management protocols, and physician oversight.”
DiPette strongly believes BP control efforts should be supervised by a physician, but that could come in different ways. He suggested a collaborative but physician-supervised development of a protocol. Everyone contributes, but the physician signs off on it.
As for the Idaho example of independent practice for pharmacists, DiPette said he doesn’t think that will make a big difference in control rates. “That’s still not team-based care.”
Community Health Workers Key
He said he was also glad to see community healthcare workers emerge as the next-most-effective group after pharmacists to lead BP control teams. This is particularly important as BP control efforts globally need to consider the cultural experience of individual communities. “The community worker is on the ground, and can help overcome some of the cultural barriers,” he said.
“The key is to focus on team-based care and moving away from silo practice,” DiPette said.
Physicians, he said, often fall into “clinical or therapeutic inertia,” where BP is concerned. “We fail to titrate or add additional hypertensive medications even when they’re clearly indicated by the blood pressure. This is a problem not with the individual patient or the healthcare system, this is on us as physicians.”
Nonphysicians are more aligned with following protocols and guidelines, irrespective of the dynamics of what’s going on, he said.
And following protocols rigidly is a good thing for hypertension. “We’re not overtreating hypertension,” he emphasized. “We’re undertreating it.”
Reversing the trend on hypertension will take a sea change in medicine — changing institutions, systems, and individuals who have been doing things the same way for decades, he said.
“Our hypertension control rates are dismal,” DiPette said. “What’s more alarming is they’re going down. That’s the urgency. That’s the burning platform. We must strongly consider doing something different.”
Tsuyuki has received investigator-initiated arm’s length research grants from Merck, Pfizer, AstraZeneca, and Sanofi. He has been a speaker/consultant for Merck, Emergent BioSolutions, and Shoppers Drug Mart/Loblaw Companies Limited. Rader has been a consultant for Bristol Meyers Squibb, Cytokinetics, Idorsia, Medtronic, and ReCor Medical. Mills and coauthors reported no relevant financial relationships. DiPette declared no relevant financial relationships. He was part of a leadership team that developed WHO guidelines on hypertension.
A version of this article first appeared on Medscape.com.
Current efforts to control high blood pressure (BP) are failing in the United States and globally.
The first World Health Organization (WHO) global report on hypertension found that only 54% of adults with hypertension are diagnosed, 42% get treatment, and just 21% have their hypertension controlled.
In the United States, almost half (48%) of adults have high BP, defined as a systolic BP > 130 mm Hg, or a diastolic BP > 80 mm Hg, or are taking medication for high BP, according to the Centers for Disease Control and Prevention. Only about one in four adults (22.5%) with high BP have their BP under control.
High BP is a major risk factor for coronary heart disease, heart failure, and stroke, and the problem of controlling it is only getting worse. In 2024, the American Heart Association estimates that, “among adults, prevalence of hypertension will increase from 51.2% in 2020 to 61.0% in 2050.”
Pharmacists Most Effective
Though many factors contribute to hypertension, researchers have found that the kind of specialist leading the hypertension team may play a role in success. Currently, most BP control teams are led by physicians in primary care.
In a recent meta-analysis involving 100 randomized controlled trials and more than 90,000 patients in Circulation, Katherine T. Mills, PhD, School of Public Health, Tulane University, New Orleans, Louisiana, and colleagues found that, while all the groups studied who led BP control efforts were successful in reducing BP, pharmacist- and community health worker–led teams saw the biggest reductions.
Those groups’ efforts resulted in the greatest systolic BP drops: −7.3 mm Hg (pharmacists) and −7.1 mm Hg (community health workers). Groups led by nurses and physicians saw systolic changes of −3 and −2.4 mm Hg, respectively.
Similarly, pharmacist- and community health worker–led efforts saw the greatest diastolic BP reductions (−3.8 and −3.1 mm Hg), compared with nurse-led (−1.6) and physician-led (−1.2) efforts.
Reductions Enough to Cut Cardiovascular Disease Risk
The reduction numbers for pharmacists are clinically meaningful, Mills said in an interview. “It’s greater than a lot of what we see from individual lifestyle changes,” such as reducing sodium intake or increasing physical activity.
“It’s a big enough blood pressure change to have meaningful reduction in risk of cardiovascular disease,” she said.
This evidence that the leader of the team matters is particularly important because the treatment of hypertension is not in doubt. Something else is not working the way it should.
“We have basically all the scientific evidence we need in terms of what interventions work. But there’s a big gap between that and what’s actually being done in the real world,” she said.
Mills said she was not surprised that pharmacists got the best results “because so much of it has to do with titrating medications and finding the right kind of medications for each patient.”
Additionally, BP management and control falls right into pharmacists’ wheelhouse, Mills noted, including evaluating medication side effects and talking to patients about medication adherence.
Why Pharmacists May Be More Successful
In an accompanying editorial, Ross T. Tsuyuki, PharmD, with the EPICORE Centre, Division of Cardiology, University of Alberta in Edmonton, Canada, and coauthors said the Mills study provides further data to support pharmacists leading BP control efforts, but it’s not the data that have been keeping the model from changing. The barriers include turf wars and lack of legislative change.
The editorialists also said having pharmacist-led BP teams is only the first step. “We need pharmacists to independently prescribe,” they wrote.
“Since individual states govern the scope of practice of pharmacists,” the editorialists wrote, “we have the enormous task of changing regulations to allow pharmacists to independently prescribe for hypertension. But it can be done. The Canadian province of Alberta allows pharmacists to prescribe. And more recently, Idaho. While most states allow some sort of collaborative (dependent) prescribing, that is only a first step.”
Allowing pharmacists to independently prescribe will help populations who do not have a physician or can’t get access to a physician, the editorialists wrote. But changing state legislation would be a lengthy and complex effort.
Physician-Led BP Control Model ‘Seems to Fail Miserably’
Coauthor of the editorial, Florian Rader, MD, MSc, medical director of the Hypertension Center of Excellence at Cedars-Sinai Medical Center in Los Angeles, California, said in an interview that, currently, physician-led teams are the norm, “and that model seems to fail miserably.”
He offered several key reasons for that. In primary care, patients with hypertension often have other problems — they may have high cholesterol or diabetes. “They may have acute illnesses that bother them as well as hypertension that doesn’t bother them,” he said.
Physicians tend to find excuses not to increase or add BP medications, Rader said. “We tend then to blame ‘white coat effect’ or say ‘you’re just nervous today.’ ”
Pharmacists, comparatively, are more protocol driven, he said. “They essentially look at blood pressure and they have an algorithm in their mind. If the blood pressure hits the guideline-stated bar, start this medication. If it hits another bar, increase or add another medication.”
Rader said turf wars are also keeping physician-led teams from changing, fueled by fears that patients will seek care from pharmacists instead of physicians.
“I don’t think the pharmacists will steal a single patient,” Rader said. “If a physician had a healthcare partner like a pharmacist to optimize blood pressure, then [patients] come back to the physician with normalized BP on the right medications. I think it’s a total win-win. I think we just have to get over that.”
Pharmacist-led warfarin clinics are very well established, Rader said, “but for whatever reason, when it comes to blood pressure, physicians are a little bit more hesitant.”
Collaboration Yes, Independent No
Hypertension expert Donald J. DiPette, MD, Health Sciences Distinguished Professor in the Department of Internal Medicine at University of South Carolina, Columbia, said he completely agrees with Mills and colleagues’ conclusion. “Pharmacists and community health workers are most effective at leading BP intervention implementation and should be prioritized in future hypertension control efforts.”
The conclusion “is in line with the thinking of major organizations,” said DiPette, who helped develop the WHO’s most recent pharmacological treatment of hypertension guidelines. “WHO suggests that pharmacological treatment of hypertension can be provided by nonphysician professionals such as pharmacists and nurses as long as the following conditions are met: Proper training, prescribing authority, specific management protocols, and physician oversight.”
DiPette strongly believes BP control efforts should be supervised by a physician, but that could come in different ways. He suggested a collaborative but physician-supervised development of a protocol. Everyone contributes, but the physician signs off on it.
As for the Idaho example of independent practice for pharmacists, DiPette said he doesn’t think that will make a big difference in control rates. “That’s still not team-based care.”
Community Health Workers Key
He said he was also glad to see community healthcare workers emerge as the next-most-effective group after pharmacists to lead BP control teams. This is particularly important as BP control efforts globally need to consider the cultural experience of individual communities. “The community worker is on the ground, and can help overcome some of the cultural barriers,” he said.
“The key is to focus on team-based care and moving away from silo practice,” DiPette said.
Physicians, he said, often fall into “clinical or therapeutic inertia,” where BP is concerned. “We fail to titrate or add additional hypertensive medications even when they’re clearly indicated by the blood pressure. This is a problem not with the individual patient or the healthcare system, this is on us as physicians.”
Nonphysicians are more aligned with following protocols and guidelines, irrespective of the dynamics of what’s going on, he said.
And following protocols rigidly is a good thing for hypertension. “We’re not overtreating hypertension,” he emphasized. “We’re undertreating it.”
Reversing the trend on hypertension will take a sea change in medicine — changing institutions, systems, and individuals who have been doing things the same way for decades, he said.
“Our hypertension control rates are dismal,” DiPette said. “What’s more alarming is they’re going down. That’s the urgency. That’s the burning platform. We must strongly consider doing something different.”
Tsuyuki has received investigator-initiated arm’s length research grants from Merck, Pfizer, AstraZeneca, and Sanofi. He has been a speaker/consultant for Merck, Emergent BioSolutions, and Shoppers Drug Mart/Loblaw Companies Limited. Rader has been a consultant for Bristol Meyers Squibb, Cytokinetics, Idorsia, Medtronic, and ReCor Medical. Mills and coauthors reported no relevant financial relationships. DiPette declared no relevant financial relationships. He was part of a leadership team that developed WHO guidelines on hypertension.
A version of this article first appeared on Medscape.com.
Current efforts to control high blood pressure (BP) are failing in the United States and globally.
The first World Health Organization (WHO) global report on hypertension found that only 54% of adults with hypertension are diagnosed, 42% get treatment, and just 21% have their hypertension controlled.
In the United States, almost half (48%) of adults have high BP, defined as a systolic BP > 130 mm Hg, or a diastolic BP > 80 mm Hg, or are taking medication for high BP, according to the Centers for Disease Control and Prevention. Only about one in four adults (22.5%) with high BP have their BP under control.
High BP is a major risk factor for coronary heart disease, heart failure, and stroke, and the problem of controlling it is only getting worse. In 2024, the American Heart Association estimates that, “among adults, prevalence of hypertension will increase from 51.2% in 2020 to 61.0% in 2050.”
Pharmacists Most Effective
Though many factors contribute to hypertension, researchers have found that the kind of specialist leading the hypertension team may play a role in success. Currently, most BP control teams are led by physicians in primary care.
In a recent meta-analysis involving 100 randomized controlled trials and more than 90,000 patients in Circulation, Katherine T. Mills, PhD, School of Public Health, Tulane University, New Orleans, Louisiana, and colleagues found that, while all the groups studied who led BP control efforts were successful in reducing BP, pharmacist- and community health worker–led teams saw the biggest reductions.
Those groups’ efforts resulted in the greatest systolic BP drops: −7.3 mm Hg (pharmacists) and −7.1 mm Hg (community health workers). Groups led by nurses and physicians saw systolic changes of −3 and −2.4 mm Hg, respectively.
Similarly, pharmacist- and community health worker–led efforts saw the greatest diastolic BP reductions (−3.8 and −3.1 mm Hg), compared with nurse-led (−1.6) and physician-led (−1.2) efforts.
Reductions Enough to Cut Cardiovascular Disease Risk
The reduction numbers for pharmacists are clinically meaningful, Mills said in an interview. “It’s greater than a lot of what we see from individual lifestyle changes,” such as reducing sodium intake or increasing physical activity.
“It’s a big enough blood pressure change to have meaningful reduction in risk of cardiovascular disease,” she said.
This evidence that the leader of the team matters is particularly important because the treatment of hypertension is not in doubt. Something else is not working the way it should.
“We have basically all the scientific evidence we need in terms of what interventions work. But there’s a big gap between that and what’s actually being done in the real world,” she said.
Mills said she was not surprised that pharmacists got the best results “because so much of it has to do with titrating medications and finding the right kind of medications for each patient.”
Additionally, BP management and control falls right into pharmacists’ wheelhouse, Mills noted, including evaluating medication side effects and talking to patients about medication adherence.
Why Pharmacists May Be More Successful
In an accompanying editorial, Ross T. Tsuyuki, PharmD, with the EPICORE Centre, Division of Cardiology, University of Alberta in Edmonton, Canada, and coauthors said the Mills study provides further data to support pharmacists leading BP control efforts, but it’s not the data that have been keeping the model from changing. The barriers include turf wars and lack of legislative change.
The editorialists also said having pharmacist-led BP teams is only the first step. “We need pharmacists to independently prescribe,” they wrote.
“Since individual states govern the scope of practice of pharmacists,” the editorialists wrote, “we have the enormous task of changing regulations to allow pharmacists to independently prescribe for hypertension. But it can be done. The Canadian province of Alberta allows pharmacists to prescribe. And more recently, Idaho. While most states allow some sort of collaborative (dependent) prescribing, that is only a first step.”
Allowing pharmacists to independently prescribe will help populations who do not have a physician or can’t get access to a physician, the editorialists wrote. But changing state legislation would be a lengthy and complex effort.
Physician-Led BP Control Model ‘Seems to Fail Miserably’
Coauthor of the editorial, Florian Rader, MD, MSc, medical director of the Hypertension Center of Excellence at Cedars-Sinai Medical Center in Los Angeles, California, said in an interview that, currently, physician-led teams are the norm, “and that model seems to fail miserably.”
He offered several key reasons for that. In primary care, patients with hypertension often have other problems — they may have high cholesterol or diabetes. “They may have acute illnesses that bother them as well as hypertension that doesn’t bother them,” he said.
Physicians tend to find excuses not to increase or add BP medications, Rader said. “We tend then to blame ‘white coat effect’ or say ‘you’re just nervous today.’ ”
Pharmacists, comparatively, are more protocol driven, he said. “They essentially look at blood pressure and they have an algorithm in their mind. If the blood pressure hits the guideline-stated bar, start this medication. If it hits another bar, increase or add another medication.”
Rader said turf wars are also keeping physician-led teams from changing, fueled by fears that patients will seek care from pharmacists instead of physicians.
“I don’t think the pharmacists will steal a single patient,” Rader said. “If a physician had a healthcare partner like a pharmacist to optimize blood pressure, then [patients] come back to the physician with normalized BP on the right medications. I think it’s a total win-win. I think we just have to get over that.”
Pharmacist-led warfarin clinics are very well established, Rader said, “but for whatever reason, when it comes to blood pressure, physicians are a little bit more hesitant.”
Collaboration Yes, Independent No
Hypertension expert Donald J. DiPette, MD, Health Sciences Distinguished Professor in the Department of Internal Medicine at University of South Carolina, Columbia, said he completely agrees with Mills and colleagues’ conclusion. “Pharmacists and community health workers are most effective at leading BP intervention implementation and should be prioritized in future hypertension control efforts.”
The conclusion “is in line with the thinking of major organizations,” said DiPette, who helped develop the WHO’s most recent pharmacological treatment of hypertension guidelines. “WHO suggests that pharmacological treatment of hypertension can be provided by nonphysician professionals such as pharmacists and nurses as long as the following conditions are met: Proper training, prescribing authority, specific management protocols, and physician oversight.”
DiPette strongly believes BP control efforts should be supervised by a physician, but that could come in different ways. He suggested a collaborative but physician-supervised development of a protocol. Everyone contributes, but the physician signs off on it.
As for the Idaho example of independent practice for pharmacists, DiPette said he doesn’t think that will make a big difference in control rates. “That’s still not team-based care.”
Community Health Workers Key
He said he was also glad to see community healthcare workers emerge as the next-most-effective group after pharmacists to lead BP control teams. This is particularly important as BP control efforts globally need to consider the cultural experience of individual communities. “The community worker is on the ground, and can help overcome some of the cultural barriers,” he said.
“The key is to focus on team-based care and moving away from silo practice,” DiPette said.
Physicians, he said, often fall into “clinical or therapeutic inertia,” where BP is concerned. “We fail to titrate or add additional hypertensive medications even when they’re clearly indicated by the blood pressure. This is a problem not with the individual patient or the healthcare system, this is on us as physicians.”
Nonphysicians are more aligned with following protocols and guidelines, irrespective of the dynamics of what’s going on, he said.
And following protocols rigidly is a good thing for hypertension. “We’re not overtreating hypertension,” he emphasized. “We’re undertreating it.”
Reversing the trend on hypertension will take a sea change in medicine — changing institutions, systems, and individuals who have been doing things the same way for decades, he said.
“Our hypertension control rates are dismal,” DiPette said. “What’s more alarming is they’re going down. That’s the urgency. That’s the burning platform. We must strongly consider doing something different.”
Tsuyuki has received investigator-initiated arm’s length research grants from Merck, Pfizer, AstraZeneca, and Sanofi. He has been a speaker/consultant for Merck, Emergent BioSolutions, and Shoppers Drug Mart/Loblaw Companies Limited. Rader has been a consultant for Bristol Meyers Squibb, Cytokinetics, Idorsia, Medtronic, and ReCor Medical. Mills and coauthors reported no relevant financial relationships. DiPette declared no relevant financial relationships. He was part of a leadership team that developed WHO guidelines on hypertension.
A version of this article first appeared on Medscape.com.
Cardiovascular Disease 2050: No, GLP-1s Won’t Save the Day
This transcript has been edited for clarity .
Robert A. Harrington, MD: I’m here in London at the European Society of Cardiology meetings, at theheart.org | Medscape Cardiology booth, using the meetings as an opportunity to meet with colleagues to talk about recent things that they’ve been writing about.
Today I’m joined by a good friend and colleague, Dr. Dhruv Kazi from Beth Israel Deaconess in Boston. Thanks for joining us.
Dhruv S. Kazi, MD, MS: Thank you for having me.
Harrington: Dr. Kazi is an associate professor of medicine at Harvard Medical School. He’s also the associate director of the Smith Center, which is an outcomes research center at the Beth Israel Deaconess. Thanks for joining us.
Kazi: Excited to be here.
Harrington: The topic I think you know that I want to discuss is a really important paper. There are two papers. They’re part of the American Heart Association’s 100th anniversary celebration, if you will. Many of the papers looked back at where science taken us.
With your coauthor, Karen Joynt Maddox, your papers are looking forward. They’re about the burden of cardiovascular disease in 2050. One paper really focused on what I would call the clinical and public health issues. Yours is focused on the economics. Is that a good description?
Kazi: Perfect.
Harrington: Tell us what you, Karen, and the other writers set out to do. What were you asked to do?
Kazi: As you know, the American Heart Association is entering its second century. Part of this was an exercise to say, where will the country be in 2050, which is a long enough time horizon for us to start planning for the future.
We looked back and said, if prior trends remain the same, where will we be in 2050, accounting for changes in demographics, changes in the composition of the population, and knowing that some of the cardiovascular risk factors are getting worse?
Harrington: For me, what was really striking is that, when I first saw the title and read “2050,” I thought, Oh, that’s a long way away. Then as I started reading it, I realized that this is not so far away.
Kazi: Absolutely.
Harrington: If we’re going to make a difference, it might take us 25 years.
Kazi: Especially if we set ourselves ambitious goals, we›re going to have to dig deep. Business-as-usual is not going to get us there.
Harrington: No. What I think has happened is we›ve spent so much time taking care of acute illness. Case fatality rates are fantastic. I was actually making the comment yesterday to a colleague that when I was an intern, the 30-day death rate from acute myocardial infarction was about 20%.
Kazi: Oh, wow.
Harrington: Now it’s 5%. That’s a big difference in a career.
Trends in the Wrong Direction
Kazi: There are fundamental trends. The decline in case fatalities is a really positive development, and I would hope that, going forward, that would continue. Those are risk-adjusted death rates and what is happening is that risk is going up. This is a function of the fact that the US population is aging; 2030 will be the first year that all the baby boomers will be over the age of 65.
By the mid-2030s, we’ll have more adults over the age of 65 than kids. That aging of the population is going to increase risk. The second is — and this is a positive development — we are a more diverse population, but the populations that are minoritized have higher cardiovascular risk, for a variety of reasons.
As the population of Asian Americans increases and doubles, in fact, as the population of Hispanic Americans doubles, we’re going to see an increase in risk related to cardiovascular disease. The third is that, over the past decade, there are some risk factors that are going in the wrong direction.
Harrington: Let’s talk about that because that’s humbling. I’m involved, as you know, with the American Heart Association, as are you. Despite all the work on Life’s Simple 7 and now Life’s Essential 8, we still have some issues.
Kazi: The big ones that come to mind are hypertension, diabetes, and obesity, all of which are trending in the wrong direction. Hypertension, we were gaining traction; and then over the past decade, we’ve slipped again. As you know, national blood pressure control rates have declined in many populations.
Harrington: Rather substantially.
Kazi: Substantially so, which has implications, in particular, for stroke rates in the future and stroke rates in young adults in the future. Obesity is a problem that we have very little control over. We’re already at 40% on average, which means that some populations are already in the 60% range.
Harrington: We also have obesity in kids — the burden, I’ll call it, of obesity. It’s not that you become obese in your thirties or your forties; you›re becoming obese as a teenager or even younger.
Kazi: Exactly. Since the 1990s, obesity in US adults has doubled, but obesity in US children has quadrupled. It’s starting from a lower base, but it’s very much an escalating problem.
Harrington: Diabetes is tightly linked to it but not totally explained.
Kazi: Exactly. The increase in diabetes is largely driven by obesity, but it›s probably also driven by changes in diet and lifestyle that don›t go through obesity.
Harrington: Yeah, it’s interesting. I think I have this figure correctly. It used to be rare that you saw a child with type 2 diabetes or what we call type 2 diabetes.
Kazi: Yeah.
Harrington: Now, the vast majority of kids with diabetes have type 2 diabetes.
Kazi: In the adolescents/young adults age group, most of it is type 2.
Harrington: Diabetes going up, obesity up, hypertension not well controlled, smoking combustible cigarettes way down.
Kazi: Yeah.
Harrington: Cholesterol levels. I was surprised. Cholesterol looked better. You said — because I was at a meeting where somebody asked you — that’s not explained by treatment.
Kazi: No, it’s not, at least going back to the ‘70s, but likely even sooner. I think that can only be attributed to substantial dietary changes. We are consuming less fat and less trans-fat. It’s possible that those collectively are improving our cholesterol levels, possibly at the expense of our glucose levels, because we basically substituted fats in our diet with more carbs at a population level.
Cigarettes and Vaping
Harrington: Some things certainly trend in the right direction but others in a really difficult direction. It’s going to lead to pretty large changes in risk for coronary disease, atrial fibrillation, and heart failure.
Kazi: I want to go back to the tobacco point. There are definitely marked declines in tobacco, still tightly related to income in the country. You see much higher prevalence of tobacco use in lower-income populations, but it’s unclear to me where it’s going in kids. We know that combustible tobacco use is going down but e-cigarettes went up. What that leads to over the next 30 years is unclear to me.
Harrington: That is a really important comment that’s worth sidebarring. The vaping use has been a terrible epidemic among our high schoolers. What is that going to lead to? Is it going to lead to the use of combustible cigarettes and we’re going to see that go back up? It remains to be seen.
Kazi: Yes, it remains to be seen. Going back to your point about this change in risk factors and this change in demographics, both aging and becoming a more diverse population means that we have large increases in some healthcare conditions.
Coronary heart disease goes up some, there›s a big jump in stroke — nearly a doubling in stroke — which is related to hypertension, obesity, an aging population, and a more diverse population. There are changes in stroke in the young, and atrial fibrillation related to, again, hypertension. We’re seeing these projections, and with them come these pretty large projections in changes in healthcare spending.
Healthcare Spending Not Sustainable
Harrington: Big. I mean, it’s not sustainable. Give the audience the number — it’s pretty frightening.
Kazi: We’re talking about a quadrupling of healthcare costs related to cardiovascular disease over 25 years. We’ve gotten used to the narrative that healthcare in the US is expensive and drugs are expensive, but this is an enormous problem — an unsustainable problem, like you called it.
It’s a doubling as a proportion of the economy. I was looking this up this morning. If the US healthcare economy were its own economy, it would be the fourth largest economy in the world.
Harrington: Healthcare as it is today, is it 21% of our economy?
Kazi: It’s 17% now. If it were its own economy, it would be the fourth largest in the world. We are spending more on healthcare than all but two other countries’ total economies. It’s kind of crazy.
Harrington: We’re talking about a quadrupling.
Kazi: Within that, the cardiovascular piece is a big piece, and we›re talking about a quadrupling.
Harrington: That’s both direct and indirect costs.
Kazi: The quadrupling of costs is just the direct costs. Indirect costs, for the listeners, refer to costs unrelated to healthcare but changes in productivity, either because people are disabled and unable to participate fully in the workforce or they die early.
The productivity costs are also increased substantially as a result. If you look at both healthcare and productivity, that goes up threefold. These are very large changes.
Harrington: Let’s now get to what we can do about it. I made the comment to you when I first read the papers that I was very depressed. Then, after I went through my Kübler-Ross stages of depression, death, and dying, I came to acceptance.
What are we going to do about it? This is a focus on policy, but also a focus on how we deliver healthcare, how we think about healthcare, and how we develop drugs and devices.
The drug question is going to be the one the audience is thinking about. They say, well, what about GLP-1 agonists? Aren’t those going to save the day?
Kazi: Yes and no. I’ll say that, early in my career, I used to be very attracted to simple solutions to complex problems. I’ve come to realize that simple solutions are elegant, attractive, and wrong. We›re dealing with a very complex issue and I think we’re going to need a multipronged approach.
The way I think about it is that there was a group of people who are at very high risk today. How do we help those individuals? Then how do we help the future generation so that they’re not dealing with the projections that we’re talking about.
My colleague, Karen Joynt Maddox, who led one of the papers, as you mentioned, has an elegant line in the paper where she says projections are not destiny. These are things we can change.
Harrington: If nothing changes, this is what it’s going to look like.
Kazi: This is where we’re headed.
Harrington: We can change. We’ve got some time to change, but we don’t have forever.
Kazi: Yes, exactly. We picked the 25-year timeline instead of a “let’s plan for the next century” timeline because we want something concrete and actionable. It’s close enough to be meaningful but far enough to give us the runway we need to act.
Harrington: Give me two things from the policy perspective, because it’s mostly policy.
Kazi: There are policy and clinical interventions. From the policy perspective, if I had to list two things, one is expansion of access to care. As we talk about this big increase in the burden of disease and risk factors, if you have a large proportion of your population that has hypertension or diabetes, you’re going to have to expand access to care to ensure that people get treated so they can get access to this care before they develop the complications that we worry about, like stroke and heart disease, that are very expensive to treat downstream.
The second, more broadly related to access to care, is the access to medications that are effective. You bring up GLP-1s. I think we need a real strategy for how we can give people access to GLP-1s at a price that is affordable to individuals but also affordable to the health system, and to help them stay on the drugs.
GLP-1s are transformative in what they do for weight loss and for diabetes, but more than 50% of people who start one are off it at 12 months. There’s something fundamentally wrong about how we’re delivering GLP-1s today. It’s not just about the cost of the drugs but the support system people need to stay on.
Harrington: I’ve made the comment, in many forms now, that we know the drugs work. We have to figure out how to use them.
Kazi: Exactly, yes.
Harrington: Using them includes chronicity. This is a chronic condition. Some people can come off the drugs, but many can’t. We’re going to have to figure this out, and maybe the newer generations of drugs will help us address what people call the off-ramping. How are we going to do that? I think you’re spot-on. Those are critically important questions.
Kazi: As we looked at this modeling, I’ll tell you — I had a come-to-Jesus moment where I was like, there is no way to fix cardiovascular disease in the US without going through obesity and diabetes. We have to address obesity in the US. We can’t just treat our way out of it. Obesity is fundamentally a food problem and we’ve got to engage again with food policy in a meaningful way.
Harrington: As you know, with the American Heart Association, we›re doing a large amount of work now on food as medicine and food is medicine. We are trying to figure out what the levers are that we can pull to actually help people eat healthier diets.
Kazi: Yes. Rather than framing it as an individual choice that people are eating poorly, it’s, how do we make healthy diets the default in the environment?
Harrington: This is where you get to the children as well.
Kazi: Exactly.
Harrington: I could talk about this all day. I’ve had the benefit of reading the papers now a few times and talking to you on several occasions. Thank you for joining us.
Kazi: Thank you.
Dr. Harrington, Stephen and Suzanne Weiss Dean, Weill Cornell Medicine; Provost for Medical Affairs, Cornell University, New York, NY, disclosed ties with Baim Institute (DSMB); CSL (RCT Executive Committee); Janssen (RCT Char), NHLBI (RCT Executive Committee, DSMB Chair); PCORI (RCT Co-Chair); DCRI, Atropos Health; Bitterroot Bio; Bristol Myers Squibb; BridgeBio; Element Science; Edwards Lifesciences; Foresite Labs; Medscape/WebMD Board of Directors for: American Heart Association; College of the Holy Cross; and Cytokinetics. Dr. Kazi, Associate Director, Smith Center for Outcomes Research, Associate Professor, Department of Medicine (Cardiology), Harvard Medical School, Director, Department of Cardiac Critical Care Unit, Beth Israel Deaconess Medical Center, Boston, Massachusetts, has disclosed receiving a research grant from Boston Scientific (grant to examine the economics of stroke prevention).
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity .
Robert A. Harrington, MD: I’m here in London at the European Society of Cardiology meetings, at theheart.org | Medscape Cardiology booth, using the meetings as an opportunity to meet with colleagues to talk about recent things that they’ve been writing about.
Today I’m joined by a good friend and colleague, Dr. Dhruv Kazi from Beth Israel Deaconess in Boston. Thanks for joining us.
Dhruv S. Kazi, MD, MS: Thank you for having me.
Harrington: Dr. Kazi is an associate professor of medicine at Harvard Medical School. He’s also the associate director of the Smith Center, which is an outcomes research center at the Beth Israel Deaconess. Thanks for joining us.
Kazi: Excited to be here.
Harrington: The topic I think you know that I want to discuss is a really important paper. There are two papers. They’re part of the American Heart Association’s 100th anniversary celebration, if you will. Many of the papers looked back at where science taken us.
With your coauthor, Karen Joynt Maddox, your papers are looking forward. They’re about the burden of cardiovascular disease in 2050. One paper really focused on what I would call the clinical and public health issues. Yours is focused on the economics. Is that a good description?
Kazi: Perfect.
Harrington: Tell us what you, Karen, and the other writers set out to do. What were you asked to do?
Kazi: As you know, the American Heart Association is entering its second century. Part of this was an exercise to say, where will the country be in 2050, which is a long enough time horizon for us to start planning for the future.
We looked back and said, if prior trends remain the same, where will we be in 2050, accounting for changes in demographics, changes in the composition of the population, and knowing that some of the cardiovascular risk factors are getting worse?
Harrington: For me, what was really striking is that, when I first saw the title and read “2050,” I thought, Oh, that’s a long way away. Then as I started reading it, I realized that this is not so far away.
Kazi: Absolutely.
Harrington: If we’re going to make a difference, it might take us 25 years.
Kazi: Especially if we set ourselves ambitious goals, we›re going to have to dig deep. Business-as-usual is not going to get us there.
Harrington: No. What I think has happened is we›ve spent so much time taking care of acute illness. Case fatality rates are fantastic. I was actually making the comment yesterday to a colleague that when I was an intern, the 30-day death rate from acute myocardial infarction was about 20%.
Kazi: Oh, wow.
Harrington: Now it’s 5%. That’s a big difference in a career.
Trends in the Wrong Direction
Kazi: There are fundamental trends. The decline in case fatalities is a really positive development, and I would hope that, going forward, that would continue. Those are risk-adjusted death rates and what is happening is that risk is going up. This is a function of the fact that the US population is aging; 2030 will be the first year that all the baby boomers will be over the age of 65.
By the mid-2030s, we’ll have more adults over the age of 65 than kids. That aging of the population is going to increase risk. The second is — and this is a positive development — we are a more diverse population, but the populations that are minoritized have higher cardiovascular risk, for a variety of reasons.
As the population of Asian Americans increases and doubles, in fact, as the population of Hispanic Americans doubles, we’re going to see an increase in risk related to cardiovascular disease. The third is that, over the past decade, there are some risk factors that are going in the wrong direction.
Harrington: Let’s talk about that because that’s humbling. I’m involved, as you know, with the American Heart Association, as are you. Despite all the work on Life’s Simple 7 and now Life’s Essential 8, we still have some issues.
Kazi: The big ones that come to mind are hypertension, diabetes, and obesity, all of which are trending in the wrong direction. Hypertension, we were gaining traction; and then over the past decade, we’ve slipped again. As you know, national blood pressure control rates have declined in many populations.
Harrington: Rather substantially.
Kazi: Substantially so, which has implications, in particular, for stroke rates in the future and stroke rates in young adults in the future. Obesity is a problem that we have very little control over. We’re already at 40% on average, which means that some populations are already in the 60% range.
Harrington: We also have obesity in kids — the burden, I’ll call it, of obesity. It’s not that you become obese in your thirties or your forties; you›re becoming obese as a teenager or even younger.
Kazi: Exactly. Since the 1990s, obesity in US adults has doubled, but obesity in US children has quadrupled. It’s starting from a lower base, but it’s very much an escalating problem.
Harrington: Diabetes is tightly linked to it but not totally explained.
Kazi: Exactly. The increase in diabetes is largely driven by obesity, but it›s probably also driven by changes in diet and lifestyle that don›t go through obesity.
Harrington: Yeah, it’s interesting. I think I have this figure correctly. It used to be rare that you saw a child with type 2 diabetes or what we call type 2 diabetes.
Kazi: Yeah.
Harrington: Now, the vast majority of kids with diabetes have type 2 diabetes.
Kazi: In the adolescents/young adults age group, most of it is type 2.
Harrington: Diabetes going up, obesity up, hypertension not well controlled, smoking combustible cigarettes way down.
Kazi: Yeah.
Harrington: Cholesterol levels. I was surprised. Cholesterol looked better. You said — because I was at a meeting where somebody asked you — that’s not explained by treatment.
Kazi: No, it’s not, at least going back to the ‘70s, but likely even sooner. I think that can only be attributed to substantial dietary changes. We are consuming less fat and less trans-fat. It’s possible that those collectively are improving our cholesterol levels, possibly at the expense of our glucose levels, because we basically substituted fats in our diet with more carbs at a population level.
Cigarettes and Vaping
Harrington: Some things certainly trend in the right direction but others in a really difficult direction. It’s going to lead to pretty large changes in risk for coronary disease, atrial fibrillation, and heart failure.
Kazi: I want to go back to the tobacco point. There are definitely marked declines in tobacco, still tightly related to income in the country. You see much higher prevalence of tobacco use in lower-income populations, but it’s unclear to me where it’s going in kids. We know that combustible tobacco use is going down but e-cigarettes went up. What that leads to over the next 30 years is unclear to me.
Harrington: That is a really important comment that’s worth sidebarring. The vaping use has been a terrible epidemic among our high schoolers. What is that going to lead to? Is it going to lead to the use of combustible cigarettes and we’re going to see that go back up? It remains to be seen.
Kazi: Yes, it remains to be seen. Going back to your point about this change in risk factors and this change in demographics, both aging and becoming a more diverse population means that we have large increases in some healthcare conditions.
Coronary heart disease goes up some, there›s a big jump in stroke — nearly a doubling in stroke — which is related to hypertension, obesity, an aging population, and a more diverse population. There are changes in stroke in the young, and atrial fibrillation related to, again, hypertension. We’re seeing these projections, and with them come these pretty large projections in changes in healthcare spending.
Healthcare Spending Not Sustainable
Harrington: Big. I mean, it’s not sustainable. Give the audience the number — it’s pretty frightening.
Kazi: We’re talking about a quadrupling of healthcare costs related to cardiovascular disease over 25 years. We’ve gotten used to the narrative that healthcare in the US is expensive and drugs are expensive, but this is an enormous problem — an unsustainable problem, like you called it.
It’s a doubling as a proportion of the economy. I was looking this up this morning. If the US healthcare economy were its own economy, it would be the fourth largest economy in the world.
Harrington: Healthcare as it is today, is it 21% of our economy?
Kazi: It’s 17% now. If it were its own economy, it would be the fourth largest in the world. We are spending more on healthcare than all but two other countries’ total economies. It’s kind of crazy.
Harrington: We’re talking about a quadrupling.
Kazi: Within that, the cardiovascular piece is a big piece, and we›re talking about a quadrupling.
Harrington: That’s both direct and indirect costs.
Kazi: The quadrupling of costs is just the direct costs. Indirect costs, for the listeners, refer to costs unrelated to healthcare but changes in productivity, either because people are disabled and unable to participate fully in the workforce or they die early.
The productivity costs are also increased substantially as a result. If you look at both healthcare and productivity, that goes up threefold. These are very large changes.
Harrington: Let’s now get to what we can do about it. I made the comment to you when I first read the papers that I was very depressed. Then, after I went through my Kübler-Ross stages of depression, death, and dying, I came to acceptance.
What are we going to do about it? This is a focus on policy, but also a focus on how we deliver healthcare, how we think about healthcare, and how we develop drugs and devices.
The drug question is going to be the one the audience is thinking about. They say, well, what about GLP-1 agonists? Aren’t those going to save the day?
Kazi: Yes and no. I’ll say that, early in my career, I used to be very attracted to simple solutions to complex problems. I’ve come to realize that simple solutions are elegant, attractive, and wrong. We›re dealing with a very complex issue and I think we’re going to need a multipronged approach.
The way I think about it is that there was a group of people who are at very high risk today. How do we help those individuals? Then how do we help the future generation so that they’re not dealing with the projections that we’re talking about.
My colleague, Karen Joynt Maddox, who led one of the papers, as you mentioned, has an elegant line in the paper where she says projections are not destiny. These are things we can change.
Harrington: If nothing changes, this is what it’s going to look like.
Kazi: This is where we’re headed.
Harrington: We can change. We’ve got some time to change, but we don’t have forever.
Kazi: Yes, exactly. We picked the 25-year timeline instead of a “let’s plan for the next century” timeline because we want something concrete and actionable. It’s close enough to be meaningful but far enough to give us the runway we need to act.
Harrington: Give me two things from the policy perspective, because it’s mostly policy.
Kazi: There are policy and clinical interventions. From the policy perspective, if I had to list two things, one is expansion of access to care. As we talk about this big increase in the burden of disease and risk factors, if you have a large proportion of your population that has hypertension or diabetes, you’re going to have to expand access to care to ensure that people get treated so they can get access to this care before they develop the complications that we worry about, like stroke and heart disease, that are very expensive to treat downstream.
The second, more broadly related to access to care, is the access to medications that are effective. You bring up GLP-1s. I think we need a real strategy for how we can give people access to GLP-1s at a price that is affordable to individuals but also affordable to the health system, and to help them stay on the drugs.
GLP-1s are transformative in what they do for weight loss and for diabetes, but more than 50% of people who start one are off it at 12 months. There’s something fundamentally wrong about how we’re delivering GLP-1s today. It’s not just about the cost of the drugs but the support system people need to stay on.
Harrington: I’ve made the comment, in many forms now, that we know the drugs work. We have to figure out how to use them.
Kazi: Exactly, yes.
Harrington: Using them includes chronicity. This is a chronic condition. Some people can come off the drugs, but many can’t. We’re going to have to figure this out, and maybe the newer generations of drugs will help us address what people call the off-ramping. How are we going to do that? I think you’re spot-on. Those are critically important questions.
Kazi: As we looked at this modeling, I’ll tell you — I had a come-to-Jesus moment where I was like, there is no way to fix cardiovascular disease in the US without going through obesity and diabetes. We have to address obesity in the US. We can’t just treat our way out of it. Obesity is fundamentally a food problem and we’ve got to engage again with food policy in a meaningful way.
Harrington: As you know, with the American Heart Association, we›re doing a large amount of work now on food as medicine and food is medicine. We are trying to figure out what the levers are that we can pull to actually help people eat healthier diets.
Kazi: Yes. Rather than framing it as an individual choice that people are eating poorly, it’s, how do we make healthy diets the default in the environment?
Harrington: This is where you get to the children as well.
Kazi: Exactly.
Harrington: I could talk about this all day. I’ve had the benefit of reading the papers now a few times and talking to you on several occasions. Thank you for joining us.
Kazi: Thank you.
Dr. Harrington, Stephen and Suzanne Weiss Dean, Weill Cornell Medicine; Provost for Medical Affairs, Cornell University, New York, NY, disclosed ties with Baim Institute (DSMB); CSL (RCT Executive Committee); Janssen (RCT Char), NHLBI (RCT Executive Committee, DSMB Chair); PCORI (RCT Co-Chair); DCRI, Atropos Health; Bitterroot Bio; Bristol Myers Squibb; BridgeBio; Element Science; Edwards Lifesciences; Foresite Labs; Medscape/WebMD Board of Directors for: American Heart Association; College of the Holy Cross; and Cytokinetics. Dr. Kazi, Associate Director, Smith Center for Outcomes Research, Associate Professor, Department of Medicine (Cardiology), Harvard Medical School, Director, Department of Cardiac Critical Care Unit, Beth Israel Deaconess Medical Center, Boston, Massachusetts, has disclosed receiving a research grant from Boston Scientific (grant to examine the economics of stroke prevention).
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity .
Robert A. Harrington, MD: I’m here in London at the European Society of Cardiology meetings, at theheart.org | Medscape Cardiology booth, using the meetings as an opportunity to meet with colleagues to talk about recent things that they’ve been writing about.
Today I’m joined by a good friend and colleague, Dr. Dhruv Kazi from Beth Israel Deaconess in Boston. Thanks for joining us.
Dhruv S. Kazi, MD, MS: Thank you for having me.
Harrington: Dr. Kazi is an associate professor of medicine at Harvard Medical School. He’s also the associate director of the Smith Center, which is an outcomes research center at the Beth Israel Deaconess. Thanks for joining us.
Kazi: Excited to be here.
Harrington: The topic I think you know that I want to discuss is a really important paper. There are two papers. They’re part of the American Heart Association’s 100th anniversary celebration, if you will. Many of the papers looked back at where science taken us.
With your coauthor, Karen Joynt Maddox, your papers are looking forward. They’re about the burden of cardiovascular disease in 2050. One paper really focused on what I would call the clinical and public health issues. Yours is focused on the economics. Is that a good description?
Kazi: Perfect.
Harrington: Tell us what you, Karen, and the other writers set out to do. What were you asked to do?
Kazi: As you know, the American Heart Association is entering its second century. Part of this was an exercise to say, where will the country be in 2050, which is a long enough time horizon for us to start planning for the future.
We looked back and said, if prior trends remain the same, where will we be in 2050, accounting for changes in demographics, changes in the composition of the population, and knowing that some of the cardiovascular risk factors are getting worse?
Harrington: For me, what was really striking is that, when I first saw the title and read “2050,” I thought, Oh, that’s a long way away. Then as I started reading it, I realized that this is not so far away.
Kazi: Absolutely.
Harrington: If we’re going to make a difference, it might take us 25 years.
Kazi: Especially if we set ourselves ambitious goals, we›re going to have to dig deep. Business-as-usual is not going to get us there.
Harrington: No. What I think has happened is we›ve spent so much time taking care of acute illness. Case fatality rates are fantastic. I was actually making the comment yesterday to a colleague that when I was an intern, the 30-day death rate from acute myocardial infarction was about 20%.
Kazi: Oh, wow.
Harrington: Now it’s 5%. That’s a big difference in a career.
Trends in the Wrong Direction
Kazi: There are fundamental trends. The decline in case fatalities is a really positive development, and I would hope that, going forward, that would continue. Those are risk-adjusted death rates and what is happening is that risk is going up. This is a function of the fact that the US population is aging; 2030 will be the first year that all the baby boomers will be over the age of 65.
By the mid-2030s, we’ll have more adults over the age of 65 than kids. That aging of the population is going to increase risk. The second is — and this is a positive development — we are a more diverse population, but the populations that are minoritized have higher cardiovascular risk, for a variety of reasons.
As the population of Asian Americans increases and doubles, in fact, as the population of Hispanic Americans doubles, we’re going to see an increase in risk related to cardiovascular disease. The third is that, over the past decade, there are some risk factors that are going in the wrong direction.
Harrington: Let’s talk about that because that’s humbling. I’m involved, as you know, with the American Heart Association, as are you. Despite all the work on Life’s Simple 7 and now Life’s Essential 8, we still have some issues.
Kazi: The big ones that come to mind are hypertension, diabetes, and obesity, all of which are trending in the wrong direction. Hypertension, we were gaining traction; and then over the past decade, we’ve slipped again. As you know, national blood pressure control rates have declined in many populations.
Harrington: Rather substantially.
Kazi: Substantially so, which has implications, in particular, for stroke rates in the future and stroke rates in young adults in the future. Obesity is a problem that we have very little control over. We’re already at 40% on average, which means that some populations are already in the 60% range.
Harrington: We also have obesity in kids — the burden, I’ll call it, of obesity. It’s not that you become obese in your thirties or your forties; you›re becoming obese as a teenager or even younger.
Kazi: Exactly. Since the 1990s, obesity in US adults has doubled, but obesity in US children has quadrupled. It’s starting from a lower base, but it’s very much an escalating problem.
Harrington: Diabetes is tightly linked to it but not totally explained.
Kazi: Exactly. The increase in diabetes is largely driven by obesity, but it›s probably also driven by changes in diet and lifestyle that don›t go through obesity.
Harrington: Yeah, it’s interesting. I think I have this figure correctly. It used to be rare that you saw a child with type 2 diabetes or what we call type 2 diabetes.
Kazi: Yeah.
Harrington: Now, the vast majority of kids with diabetes have type 2 diabetes.
Kazi: In the adolescents/young adults age group, most of it is type 2.
Harrington: Diabetes going up, obesity up, hypertension not well controlled, smoking combustible cigarettes way down.
Kazi: Yeah.
Harrington: Cholesterol levels. I was surprised. Cholesterol looked better. You said — because I was at a meeting where somebody asked you — that’s not explained by treatment.
Kazi: No, it’s not, at least going back to the ‘70s, but likely even sooner. I think that can only be attributed to substantial dietary changes. We are consuming less fat and less trans-fat. It’s possible that those collectively are improving our cholesterol levels, possibly at the expense of our glucose levels, because we basically substituted fats in our diet with more carbs at a population level.
Cigarettes and Vaping
Harrington: Some things certainly trend in the right direction but others in a really difficult direction. It’s going to lead to pretty large changes in risk for coronary disease, atrial fibrillation, and heart failure.
Kazi: I want to go back to the tobacco point. There are definitely marked declines in tobacco, still tightly related to income in the country. You see much higher prevalence of tobacco use in lower-income populations, but it’s unclear to me where it’s going in kids. We know that combustible tobacco use is going down but e-cigarettes went up. What that leads to over the next 30 years is unclear to me.
Harrington: That is a really important comment that’s worth sidebarring. The vaping use has been a terrible epidemic among our high schoolers. What is that going to lead to? Is it going to lead to the use of combustible cigarettes and we’re going to see that go back up? It remains to be seen.
Kazi: Yes, it remains to be seen. Going back to your point about this change in risk factors and this change in demographics, both aging and becoming a more diverse population means that we have large increases in some healthcare conditions.
Coronary heart disease goes up some, there›s a big jump in stroke — nearly a doubling in stroke — which is related to hypertension, obesity, an aging population, and a more diverse population. There are changes in stroke in the young, and atrial fibrillation related to, again, hypertension. We’re seeing these projections, and with them come these pretty large projections in changes in healthcare spending.
Healthcare Spending Not Sustainable
Harrington: Big. I mean, it’s not sustainable. Give the audience the number — it’s pretty frightening.
Kazi: We’re talking about a quadrupling of healthcare costs related to cardiovascular disease over 25 years. We’ve gotten used to the narrative that healthcare in the US is expensive and drugs are expensive, but this is an enormous problem — an unsustainable problem, like you called it.
It’s a doubling as a proportion of the economy. I was looking this up this morning. If the US healthcare economy were its own economy, it would be the fourth largest economy in the world.
Harrington: Healthcare as it is today, is it 21% of our economy?
Kazi: It’s 17% now. If it were its own economy, it would be the fourth largest in the world. We are spending more on healthcare than all but two other countries’ total economies. It’s kind of crazy.
Harrington: We’re talking about a quadrupling.
Kazi: Within that, the cardiovascular piece is a big piece, and we›re talking about a quadrupling.
Harrington: That’s both direct and indirect costs.
Kazi: The quadrupling of costs is just the direct costs. Indirect costs, for the listeners, refer to costs unrelated to healthcare but changes in productivity, either because people are disabled and unable to participate fully in the workforce or they die early.
The productivity costs are also increased substantially as a result. If you look at both healthcare and productivity, that goes up threefold. These are very large changes.
Harrington: Let’s now get to what we can do about it. I made the comment to you when I first read the papers that I was very depressed. Then, after I went through my Kübler-Ross stages of depression, death, and dying, I came to acceptance.
What are we going to do about it? This is a focus on policy, but also a focus on how we deliver healthcare, how we think about healthcare, and how we develop drugs and devices.
The drug question is going to be the one the audience is thinking about. They say, well, what about GLP-1 agonists? Aren’t those going to save the day?
Kazi: Yes and no. I’ll say that, early in my career, I used to be very attracted to simple solutions to complex problems. I’ve come to realize that simple solutions are elegant, attractive, and wrong. We›re dealing with a very complex issue and I think we’re going to need a multipronged approach.
The way I think about it is that there was a group of people who are at very high risk today. How do we help those individuals? Then how do we help the future generation so that they’re not dealing with the projections that we’re talking about.
My colleague, Karen Joynt Maddox, who led one of the papers, as you mentioned, has an elegant line in the paper where she says projections are not destiny. These are things we can change.
Harrington: If nothing changes, this is what it’s going to look like.
Kazi: This is where we’re headed.
Harrington: We can change. We’ve got some time to change, but we don’t have forever.
Kazi: Yes, exactly. We picked the 25-year timeline instead of a “let’s plan for the next century” timeline because we want something concrete and actionable. It’s close enough to be meaningful but far enough to give us the runway we need to act.
Harrington: Give me two things from the policy perspective, because it’s mostly policy.
Kazi: There are policy and clinical interventions. From the policy perspective, if I had to list two things, one is expansion of access to care. As we talk about this big increase in the burden of disease and risk factors, if you have a large proportion of your population that has hypertension or diabetes, you’re going to have to expand access to care to ensure that people get treated so they can get access to this care before they develop the complications that we worry about, like stroke and heart disease, that are very expensive to treat downstream.
The second, more broadly related to access to care, is the access to medications that are effective. You bring up GLP-1s. I think we need a real strategy for how we can give people access to GLP-1s at a price that is affordable to individuals but also affordable to the health system, and to help them stay on the drugs.
GLP-1s are transformative in what they do for weight loss and for diabetes, but more than 50% of people who start one are off it at 12 months. There’s something fundamentally wrong about how we’re delivering GLP-1s today. It’s not just about the cost of the drugs but the support system people need to stay on.
Harrington: I’ve made the comment, in many forms now, that we know the drugs work. We have to figure out how to use them.
Kazi: Exactly, yes.
Harrington: Using them includes chronicity. This is a chronic condition. Some people can come off the drugs, but many can’t. We’re going to have to figure this out, and maybe the newer generations of drugs will help us address what people call the off-ramping. How are we going to do that? I think you’re spot-on. Those are critically important questions.
Kazi: As we looked at this modeling, I’ll tell you — I had a come-to-Jesus moment where I was like, there is no way to fix cardiovascular disease in the US without going through obesity and diabetes. We have to address obesity in the US. We can’t just treat our way out of it. Obesity is fundamentally a food problem and we’ve got to engage again with food policy in a meaningful way.
Harrington: As you know, with the American Heart Association, we›re doing a large amount of work now on food as medicine and food is medicine. We are trying to figure out what the levers are that we can pull to actually help people eat healthier diets.
Kazi: Yes. Rather than framing it as an individual choice that people are eating poorly, it’s, how do we make healthy diets the default in the environment?
Harrington: This is where you get to the children as well.
Kazi: Exactly.
Harrington: I could talk about this all day. I’ve had the benefit of reading the papers now a few times and talking to you on several occasions. Thank you for joining us.
Kazi: Thank you.
Dr. Harrington, Stephen and Suzanne Weiss Dean, Weill Cornell Medicine; Provost for Medical Affairs, Cornell University, New York, NY, disclosed ties with Baim Institute (DSMB); CSL (RCT Executive Committee); Janssen (RCT Char), NHLBI (RCT Executive Committee, DSMB Chair); PCORI (RCT Co-Chair); DCRI, Atropos Health; Bitterroot Bio; Bristol Myers Squibb; BridgeBio; Element Science; Edwards Lifesciences; Foresite Labs; Medscape/WebMD Board of Directors for: American Heart Association; College of the Holy Cross; and Cytokinetics. Dr. Kazi, Associate Director, Smith Center for Outcomes Research, Associate Professor, Department of Medicine (Cardiology), Harvard Medical School, Director, Department of Cardiac Critical Care Unit, Beth Israel Deaconess Medical Center, Boston, Massachusetts, has disclosed receiving a research grant from Boston Scientific (grant to examine the economics of stroke prevention).
A version of this article appeared on Medscape.com.
Rising Stroke Rates in Californians With Sickle Cell Disease
TOPLINE:
METHODOLOGY:
- Researchers analyzed data from the California Department of Health Care Access and Innovation (HCAI), covering emergency department and hospitalization records from 1991 to 2019.
- A total of 7636 patients with SCD were included in the study cohort.
- Cumulative incidence and rates for primary and recurrent strokes and transient ischemic attacks (TIAs) were determined pre- and post STOP trial.
- Patients with SCD were identified using ICD-9 and ICD-10 codes, with specific criteria for inclusion based on hospitalization records.
- The study utilized Fine and Gray methodology to calculate cumulative incidence functions, accounting for the competing risk for death.
TAKEAWAY:
- The cumulative incidence of first ischemic stroke in patients with SCD was 2.1% by age 20 and 13.5% by age 60.
- Ischemic stroke rates increased significantly in children and adults in the 2010-2019 period, compared with the preceding decade.
- Risk factors for stroke and TIA included increasing age, hypertension, and hyperlipidemia.
- The study found a significant increase in rates of intracranial hemorrhage in adults aged 18-30 years and TIAs in children younger than 18 years from 2010 to 2019, compared with the prior decade.
IN PRACTICE:
“Neurovascular complications, including strokes and transient ischemic attacks (TIAs), are common and cause significant morbidity in individuals with sickle cell disease (SCD). The STOP trial (1998) established chronic transfusions as the standard of care for children with SCD at high risk for stroke,” the study’s authors wrote.
SOURCE:
This study was led by Olubusola B. Oluwole, MD, MS, University of Pittsburgh in Pennsylvania, and was published online in Blood.
LIMITATIONS:
This study’s reliance on administrative data may have introduced systematic errors, particularly with the transition from ICD-9 to ICD-10 codes. The lack of laboratory results and medication data in the HCAI database limited the ability to fully assess patient conditions and treatments. Additionally, the methodology changes in 2014 likely underreported death rates in people without PDD/EDU encounters in the calendar year preceding their death.
DISCLOSURES:
The authors reported no relevant conflicts of interest.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- Researchers analyzed data from the California Department of Health Care Access and Innovation (HCAI), covering emergency department and hospitalization records from 1991 to 2019.
- A total of 7636 patients with SCD were included in the study cohort.
- Cumulative incidence and rates for primary and recurrent strokes and transient ischemic attacks (TIAs) were determined pre- and post STOP trial.
- Patients with SCD were identified using ICD-9 and ICD-10 codes, with specific criteria for inclusion based on hospitalization records.
- The study utilized Fine and Gray methodology to calculate cumulative incidence functions, accounting for the competing risk for death.
TAKEAWAY:
- The cumulative incidence of first ischemic stroke in patients with SCD was 2.1% by age 20 and 13.5% by age 60.
- Ischemic stroke rates increased significantly in children and adults in the 2010-2019 period, compared with the preceding decade.
- Risk factors for stroke and TIA included increasing age, hypertension, and hyperlipidemia.
- The study found a significant increase in rates of intracranial hemorrhage in adults aged 18-30 years and TIAs in children younger than 18 years from 2010 to 2019, compared with the prior decade.
IN PRACTICE:
“Neurovascular complications, including strokes and transient ischemic attacks (TIAs), are common and cause significant morbidity in individuals with sickle cell disease (SCD). The STOP trial (1998) established chronic transfusions as the standard of care for children with SCD at high risk for stroke,” the study’s authors wrote.
SOURCE:
This study was led by Olubusola B. Oluwole, MD, MS, University of Pittsburgh in Pennsylvania, and was published online in Blood.
LIMITATIONS:
This study’s reliance on administrative data may have introduced systematic errors, particularly with the transition from ICD-9 to ICD-10 codes. The lack of laboratory results and medication data in the HCAI database limited the ability to fully assess patient conditions and treatments. Additionally, the methodology changes in 2014 likely underreported death rates in people without PDD/EDU encounters in the calendar year preceding their death.
DISCLOSURES:
The authors reported no relevant conflicts of interest.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
TOPLINE:
METHODOLOGY:
- Researchers analyzed data from the California Department of Health Care Access and Innovation (HCAI), covering emergency department and hospitalization records from 1991 to 2019.
- A total of 7636 patients with SCD were included in the study cohort.
- Cumulative incidence and rates for primary and recurrent strokes and transient ischemic attacks (TIAs) were determined pre- and post STOP trial.
- Patients with SCD were identified using ICD-9 and ICD-10 codes, with specific criteria for inclusion based on hospitalization records.
- The study utilized Fine and Gray methodology to calculate cumulative incidence functions, accounting for the competing risk for death.
TAKEAWAY:
- The cumulative incidence of first ischemic stroke in patients with SCD was 2.1% by age 20 and 13.5% by age 60.
- Ischemic stroke rates increased significantly in children and adults in the 2010-2019 period, compared with the preceding decade.
- Risk factors for stroke and TIA included increasing age, hypertension, and hyperlipidemia.
- The study found a significant increase in rates of intracranial hemorrhage in adults aged 18-30 years and TIAs in children younger than 18 years from 2010 to 2019, compared with the prior decade.
IN PRACTICE:
“Neurovascular complications, including strokes and transient ischemic attacks (TIAs), are common and cause significant morbidity in individuals with sickle cell disease (SCD). The STOP trial (1998) established chronic transfusions as the standard of care for children with SCD at high risk for stroke,” the study’s authors wrote.
SOURCE:
This study was led by Olubusola B. Oluwole, MD, MS, University of Pittsburgh in Pennsylvania, and was published online in Blood.
LIMITATIONS:
This study’s reliance on administrative data may have introduced systematic errors, particularly with the transition from ICD-9 to ICD-10 codes. The lack of laboratory results and medication data in the HCAI database limited the ability to fully assess patient conditions and treatments. Additionally, the methodology changes in 2014 likely underreported death rates in people without PDD/EDU encounters in the calendar year preceding their death.
DISCLOSURES:
The authors reported no relevant conflicts of interest.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.