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Can you spot hypermobility spectrum disorder?
Joint hypermobility syndrome, popularly known as being double-jointed, may be a common but underrecognized disorder in adults that is difficult to diagnose and often mistaken for fibromyalgia or other conditions.
So said Matthew B. Carroll, MD, a board-certified rheumatologist with Singing River Health System, Ocean Springs, Miss., during a presentation about hypermobility at the annual meeting of the American College of Physicians.
According to Dr. Carroll, the concept of a hypermobility spectrum disorder (HSD) associated with double-jointedness is relatively new and not part of the conventional nomenclature.
“One of the frustrations about HSD is that there really aren’t any good theories,” as to why some with hypermobility suffer from the syndrome while others do not, Dr. Carroll said.
Hypermobility is defined as having joints that are looser than normal. Examples of this include hyperextending the forearm at the elbow or pressing the thumb against the surface of the forearm.
Approximately 20% of the adult population has hypermobility, which affects women more than men and is more common in younger people. In children ages 3-19 years, 32% of girls and 18% of boys are hypermobile.
But the condition is not a diagnosis, “it’s a descriptor of a finding that you notice on a physical exam,” Dr. Carroll said.
When flexibility is a problem
Although hypermobility often is benign and rarely progresses to more serious health issues, HSD can cause symptoms such as recurrent dislocations, joint pain, and other degenerative changes. Recent evidence suggests that abnormal bleeding may also accompany hypermobility.
A 2013 survey in the United Kingdom found that about 3% of respondents reported pain as a consequence of their hypermobility. Dr. Carroll hypothesized that up to a quarter of those diagnosed with hypermobility have some associated pain.
“We kind of think of hypermobility as either being benign, or you kind of have it as a kid and grow out of it,” Dr. Carroll said. “But the reality is a lot of our patients keep that into adulthood and can have problems as a consequence.”
Because some of the symptoms of HSD, such as abdominal pain and fatigue, mimic other whole-body pain conditions, specifically fibromyalgia, Dr. Carroll said it likely is widely undiagnosed.
“I think a lot of these patients were diagnosed with fibromyalgia,” Dr. Carroll said. “It’s incumbent upon us to be able to start teasing some of those nuances out, or at least have rheumatology help you and other specialists figure out where you can go with these patients and their health.”
Causes of HSD
HSD can be both genetic and environmental in nature; sports injuries, spontaneous dislocations, and a fear of injury leading to a sedentary lifestyle should also be considered. The condition can overlap with Ehlers-Danlos syndromes, a rare group of inherited conditions that affect connectivity tissue.
Treating patients with HSD requires a multidisciplinary approach, including primary care, rheumatologists, geneticists, and orthopedists. If primary care physicians suspect their patient has hypermobility, they should explore this possibility before moving on to another diagnosis. Whether an adult has or had joint mobility can be determined through a series of simple questions:
- Can you bend your thumb to touch your forearm?
- As a child, did you amuse your friends by contorting your body into strange shapes?
- Do you consider yourself double-jointed?
“It gets really kind of muddy and really difficult to tease out, but I think it’s something that takes time in an iterative process to figure out,” Dr. Carroll said.
Treatment options for HSD are limited. No disease-directed pharmacologic agents exist, and interventions in general lack rigorous studies to support their use. Dr. Carroll recommends anti-inflammatory drugs and physical therapy as first-line approaches. He also stressed that lifestyle interventions – particularly exercise and weight loss – are essential. The role of surgery at this time is unclear and only used in highly selected cases. An appointment with a geneticist could also be necessary to explore family history and look for Ehlers‐Danlos syndromes.
“You’re going to need several different specialists to try to really help our patients get back up and running,” he said.
Dr. Carroll reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Joint hypermobility syndrome, popularly known as being double-jointed, may be a common but underrecognized disorder in adults that is difficult to diagnose and often mistaken for fibromyalgia or other conditions.
So said Matthew B. Carroll, MD, a board-certified rheumatologist with Singing River Health System, Ocean Springs, Miss., during a presentation about hypermobility at the annual meeting of the American College of Physicians.
According to Dr. Carroll, the concept of a hypermobility spectrum disorder (HSD) associated with double-jointedness is relatively new and not part of the conventional nomenclature.
“One of the frustrations about HSD is that there really aren’t any good theories,” as to why some with hypermobility suffer from the syndrome while others do not, Dr. Carroll said.
Hypermobility is defined as having joints that are looser than normal. Examples of this include hyperextending the forearm at the elbow or pressing the thumb against the surface of the forearm.
Approximately 20% of the adult population has hypermobility, which affects women more than men and is more common in younger people. In children ages 3-19 years, 32% of girls and 18% of boys are hypermobile.
But the condition is not a diagnosis, “it’s a descriptor of a finding that you notice on a physical exam,” Dr. Carroll said.
When flexibility is a problem
Although hypermobility often is benign and rarely progresses to more serious health issues, HSD can cause symptoms such as recurrent dislocations, joint pain, and other degenerative changes. Recent evidence suggests that abnormal bleeding may also accompany hypermobility.
A 2013 survey in the United Kingdom found that about 3% of respondents reported pain as a consequence of their hypermobility. Dr. Carroll hypothesized that up to a quarter of those diagnosed with hypermobility have some associated pain.
“We kind of think of hypermobility as either being benign, or you kind of have it as a kid and grow out of it,” Dr. Carroll said. “But the reality is a lot of our patients keep that into adulthood and can have problems as a consequence.”
Because some of the symptoms of HSD, such as abdominal pain and fatigue, mimic other whole-body pain conditions, specifically fibromyalgia, Dr. Carroll said it likely is widely undiagnosed.
“I think a lot of these patients were diagnosed with fibromyalgia,” Dr. Carroll said. “It’s incumbent upon us to be able to start teasing some of those nuances out, or at least have rheumatology help you and other specialists figure out where you can go with these patients and their health.”
Causes of HSD
HSD can be both genetic and environmental in nature; sports injuries, spontaneous dislocations, and a fear of injury leading to a sedentary lifestyle should also be considered. The condition can overlap with Ehlers-Danlos syndromes, a rare group of inherited conditions that affect connectivity tissue.
Treating patients with HSD requires a multidisciplinary approach, including primary care, rheumatologists, geneticists, and orthopedists. If primary care physicians suspect their patient has hypermobility, they should explore this possibility before moving on to another diagnosis. Whether an adult has or had joint mobility can be determined through a series of simple questions:
- Can you bend your thumb to touch your forearm?
- As a child, did you amuse your friends by contorting your body into strange shapes?
- Do you consider yourself double-jointed?
“It gets really kind of muddy and really difficult to tease out, but I think it’s something that takes time in an iterative process to figure out,” Dr. Carroll said.
Treatment options for HSD are limited. No disease-directed pharmacologic agents exist, and interventions in general lack rigorous studies to support their use. Dr. Carroll recommends anti-inflammatory drugs and physical therapy as first-line approaches. He also stressed that lifestyle interventions – particularly exercise and weight loss – are essential. The role of surgery at this time is unclear and only used in highly selected cases. An appointment with a geneticist could also be necessary to explore family history and look for Ehlers‐Danlos syndromes.
“You’re going to need several different specialists to try to really help our patients get back up and running,” he said.
Dr. Carroll reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Joint hypermobility syndrome, popularly known as being double-jointed, may be a common but underrecognized disorder in adults that is difficult to diagnose and often mistaken for fibromyalgia or other conditions.
So said Matthew B. Carroll, MD, a board-certified rheumatologist with Singing River Health System, Ocean Springs, Miss., during a presentation about hypermobility at the annual meeting of the American College of Physicians.
According to Dr. Carroll, the concept of a hypermobility spectrum disorder (HSD) associated with double-jointedness is relatively new and not part of the conventional nomenclature.
“One of the frustrations about HSD is that there really aren’t any good theories,” as to why some with hypermobility suffer from the syndrome while others do not, Dr. Carroll said.
Hypermobility is defined as having joints that are looser than normal. Examples of this include hyperextending the forearm at the elbow or pressing the thumb against the surface of the forearm.
Approximately 20% of the adult population has hypermobility, which affects women more than men and is more common in younger people. In children ages 3-19 years, 32% of girls and 18% of boys are hypermobile.
But the condition is not a diagnosis, “it’s a descriptor of a finding that you notice on a physical exam,” Dr. Carroll said.
When flexibility is a problem
Although hypermobility often is benign and rarely progresses to more serious health issues, HSD can cause symptoms such as recurrent dislocations, joint pain, and other degenerative changes. Recent evidence suggests that abnormal bleeding may also accompany hypermobility.
A 2013 survey in the United Kingdom found that about 3% of respondents reported pain as a consequence of their hypermobility. Dr. Carroll hypothesized that up to a quarter of those diagnosed with hypermobility have some associated pain.
“We kind of think of hypermobility as either being benign, or you kind of have it as a kid and grow out of it,” Dr. Carroll said. “But the reality is a lot of our patients keep that into adulthood and can have problems as a consequence.”
Because some of the symptoms of HSD, such as abdominal pain and fatigue, mimic other whole-body pain conditions, specifically fibromyalgia, Dr. Carroll said it likely is widely undiagnosed.
“I think a lot of these patients were diagnosed with fibromyalgia,” Dr. Carroll said. “It’s incumbent upon us to be able to start teasing some of those nuances out, or at least have rheumatology help you and other specialists figure out where you can go with these patients and their health.”
Causes of HSD
HSD can be both genetic and environmental in nature; sports injuries, spontaneous dislocations, and a fear of injury leading to a sedentary lifestyle should also be considered. The condition can overlap with Ehlers-Danlos syndromes, a rare group of inherited conditions that affect connectivity tissue.
Treating patients with HSD requires a multidisciplinary approach, including primary care, rheumatologists, geneticists, and orthopedists. If primary care physicians suspect their patient has hypermobility, they should explore this possibility before moving on to another diagnosis. Whether an adult has or had joint mobility can be determined through a series of simple questions:
- Can you bend your thumb to touch your forearm?
- As a child, did you amuse your friends by contorting your body into strange shapes?
- Do you consider yourself double-jointed?
“It gets really kind of muddy and really difficult to tease out, but I think it’s something that takes time in an iterative process to figure out,” Dr. Carroll said.
Treatment options for HSD are limited. No disease-directed pharmacologic agents exist, and interventions in general lack rigorous studies to support their use. Dr. Carroll recommends anti-inflammatory drugs and physical therapy as first-line approaches. He also stressed that lifestyle interventions – particularly exercise and weight loss – are essential. The role of surgery at this time is unclear and only used in highly selected cases. An appointment with a geneticist could also be necessary to explore family history and look for Ehlers‐Danlos syndromes.
“You’re going to need several different specialists to try to really help our patients get back up and running,” he said.
Dr. Carroll reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM INTERNAL MEDICINE 2023
Misoprostol only for abortion: Viable option but not ‘the best’
With a federal judge’s recent ruling clouding the future availability of mifepristone for terminating pregnancies, attention has shifted to the efficacy of another abortion drug, misoprostol.
A misoprostol-only approach also comes with more pronounced side effects.
“Misoprostol only is a good alternative; it’s not the best alternative,” Beverly Gray, MD, associate professor in the department of obstetrics and Gynecology at Duke University, Durham, N.C., said during a video conference on April 12. “The best medication would be to use mifepristone and misoprostol together because they’re efficacious with fewer side effects.”
To medically terminate a pregnancy using the two-drug regimen, patients first take the progesterone blocker mifepristone, which ends the pregnancy. That is followed 24-48 hours later with misoprostol, which causes the uterus to expel the pregnancy tissue. Used in combination, the two drugs have an efficacy rate of 98% in terminating a pregnancy.
An alternative approach is a misoprostol-only regimen. Patients take multiple doses of the drug over the course of hours until the pregnancy passes. This method is considered effective and safe, although patients may experience more nausea, vomiting, diarrhea, bleeding, and cramping.
“It’s effective, but not as effective as the combination treatment,” said Mitchell D. Creinin, MD, professor in the department of obstetrics and gynecology at University of California, Davis. “It also requires much higher doses. To get misoprostol by itself to have relatively high efficacy, you have to use multiple doses. It causes significantly more side effects, and it’s less effective.”
Dr. Creinin was part of a team that earlier this year conducted a study of misoprostol-only medical abortions. In that study, which was published in the journal Contraception, the investigators found that the misoprostol-only regimen was 78% effective at aborting completely without a procedure or unplanned additional medications. The investigators concluded that prohibiting the use of mifepristone was “senseless” but that offering misoprostol-only abortions would be a “safe, effective, and patient-centered approach.”
Both drug regimens are intended to be used during the first trimester of pregnancy, and their effectiveness is influenced by the gestation period.
Medical abortions have grown in popularity. They now account for more than half of all abortions. Last year’s U.S. Supreme Court decision in Dobbs v. Jackson Women’s Health Organization overturned the court’s 1973 ruling in Roe v. Wade, leaving it up to states to regulate abortion. Currently, nearly half of states have banned or are considering some sort of ban on the procedure, according to the Guttmacher Institute, a reproductive health advocacy group.
“Medication abortion is good for privacy in many ways,” Jolynn Dellinger, JD, a visiting lecturer at Duke Law School, said during the conference call with Dr. Gray. “It’s incredibly safe and effective and can be the very best choice for people.”
On April 7, a federal judge in Texas suspended the Food and Drug Administration approval of mifepristone. The drug has been on the market for 23 years. A federal judge in Washington State issued a competing ruling, and the Biden Administration has appealed the Texas decision.
The future of the use of mifepristone is now in the courts, but not that of misoprostol – for now. The latter is used to prevent ulcers; its use in medical abortions is secondary. Dr. Creinin said that that will make it much more difficult for antiabortion advocates to challenge.
While courts, lawmakers, and regulators at the state and federal levels work through what is allowable for medical abortions, the medical community sits and waits.
“We’re working out a variety of scenarios,” Dr. Gray said. “I think right now we’re just hoping that the legislative dust will settle enough so that we’ll have a better understanding. In the meantime, we’re creating protocols and trying to be as prepared as we can.”
A version of this article first appeared on Medscape.com.
With a federal judge’s recent ruling clouding the future availability of mifepristone for terminating pregnancies, attention has shifted to the efficacy of another abortion drug, misoprostol.
A misoprostol-only approach also comes with more pronounced side effects.
“Misoprostol only is a good alternative; it’s not the best alternative,” Beverly Gray, MD, associate professor in the department of obstetrics and Gynecology at Duke University, Durham, N.C., said during a video conference on April 12. “The best medication would be to use mifepristone and misoprostol together because they’re efficacious with fewer side effects.”
To medically terminate a pregnancy using the two-drug regimen, patients first take the progesterone blocker mifepristone, which ends the pregnancy. That is followed 24-48 hours later with misoprostol, which causes the uterus to expel the pregnancy tissue. Used in combination, the two drugs have an efficacy rate of 98% in terminating a pregnancy.
An alternative approach is a misoprostol-only regimen. Patients take multiple doses of the drug over the course of hours until the pregnancy passes. This method is considered effective and safe, although patients may experience more nausea, vomiting, diarrhea, bleeding, and cramping.
“It’s effective, but not as effective as the combination treatment,” said Mitchell D. Creinin, MD, professor in the department of obstetrics and gynecology at University of California, Davis. “It also requires much higher doses. To get misoprostol by itself to have relatively high efficacy, you have to use multiple doses. It causes significantly more side effects, and it’s less effective.”
Dr. Creinin was part of a team that earlier this year conducted a study of misoprostol-only medical abortions. In that study, which was published in the journal Contraception, the investigators found that the misoprostol-only regimen was 78% effective at aborting completely without a procedure or unplanned additional medications. The investigators concluded that prohibiting the use of mifepristone was “senseless” but that offering misoprostol-only abortions would be a “safe, effective, and patient-centered approach.”
Both drug regimens are intended to be used during the first trimester of pregnancy, and their effectiveness is influenced by the gestation period.
Medical abortions have grown in popularity. They now account for more than half of all abortions. Last year’s U.S. Supreme Court decision in Dobbs v. Jackson Women’s Health Organization overturned the court’s 1973 ruling in Roe v. Wade, leaving it up to states to regulate abortion. Currently, nearly half of states have banned or are considering some sort of ban on the procedure, according to the Guttmacher Institute, a reproductive health advocacy group.
“Medication abortion is good for privacy in many ways,” Jolynn Dellinger, JD, a visiting lecturer at Duke Law School, said during the conference call with Dr. Gray. “It’s incredibly safe and effective and can be the very best choice for people.”
On April 7, a federal judge in Texas suspended the Food and Drug Administration approval of mifepristone. The drug has been on the market for 23 years. A federal judge in Washington State issued a competing ruling, and the Biden Administration has appealed the Texas decision.
The future of the use of mifepristone is now in the courts, but not that of misoprostol – for now. The latter is used to prevent ulcers; its use in medical abortions is secondary. Dr. Creinin said that that will make it much more difficult for antiabortion advocates to challenge.
While courts, lawmakers, and regulators at the state and federal levels work through what is allowable for medical abortions, the medical community sits and waits.
“We’re working out a variety of scenarios,” Dr. Gray said. “I think right now we’re just hoping that the legislative dust will settle enough so that we’ll have a better understanding. In the meantime, we’re creating protocols and trying to be as prepared as we can.”
A version of this article first appeared on Medscape.com.
With a federal judge’s recent ruling clouding the future availability of mifepristone for terminating pregnancies, attention has shifted to the efficacy of another abortion drug, misoprostol.
A misoprostol-only approach also comes with more pronounced side effects.
“Misoprostol only is a good alternative; it’s not the best alternative,” Beverly Gray, MD, associate professor in the department of obstetrics and Gynecology at Duke University, Durham, N.C., said during a video conference on April 12. “The best medication would be to use mifepristone and misoprostol together because they’re efficacious with fewer side effects.”
To medically terminate a pregnancy using the two-drug regimen, patients first take the progesterone blocker mifepristone, which ends the pregnancy. That is followed 24-48 hours later with misoprostol, which causes the uterus to expel the pregnancy tissue. Used in combination, the two drugs have an efficacy rate of 98% in terminating a pregnancy.
An alternative approach is a misoprostol-only regimen. Patients take multiple doses of the drug over the course of hours until the pregnancy passes. This method is considered effective and safe, although patients may experience more nausea, vomiting, diarrhea, bleeding, and cramping.
“It’s effective, but not as effective as the combination treatment,” said Mitchell D. Creinin, MD, professor in the department of obstetrics and gynecology at University of California, Davis. “It also requires much higher doses. To get misoprostol by itself to have relatively high efficacy, you have to use multiple doses. It causes significantly more side effects, and it’s less effective.”
Dr. Creinin was part of a team that earlier this year conducted a study of misoprostol-only medical abortions. In that study, which was published in the journal Contraception, the investigators found that the misoprostol-only regimen was 78% effective at aborting completely without a procedure or unplanned additional medications. The investigators concluded that prohibiting the use of mifepristone was “senseless” but that offering misoprostol-only abortions would be a “safe, effective, and patient-centered approach.”
Both drug regimens are intended to be used during the first trimester of pregnancy, and their effectiveness is influenced by the gestation period.
Medical abortions have grown in popularity. They now account for more than half of all abortions. Last year’s U.S. Supreme Court decision in Dobbs v. Jackson Women’s Health Organization overturned the court’s 1973 ruling in Roe v. Wade, leaving it up to states to regulate abortion. Currently, nearly half of states have banned or are considering some sort of ban on the procedure, according to the Guttmacher Institute, a reproductive health advocacy group.
“Medication abortion is good for privacy in many ways,” Jolynn Dellinger, JD, a visiting lecturer at Duke Law School, said during the conference call with Dr. Gray. “It’s incredibly safe and effective and can be the very best choice for people.”
On April 7, a federal judge in Texas suspended the Food and Drug Administration approval of mifepristone. The drug has been on the market for 23 years. A federal judge in Washington State issued a competing ruling, and the Biden Administration has appealed the Texas decision.
The future of the use of mifepristone is now in the courts, but not that of misoprostol – for now. The latter is used to prevent ulcers; its use in medical abortions is secondary. Dr. Creinin said that that will make it much more difficult for antiabortion advocates to challenge.
While courts, lawmakers, and regulators at the state and federal levels work through what is allowable for medical abortions, the medical community sits and waits.
“We’re working out a variety of scenarios,” Dr. Gray said. “I think right now we’re just hoping that the legislative dust will settle enough so that we’ll have a better understanding. In the meantime, we’re creating protocols and trying to be as prepared as we can.”
A version of this article first appeared on Medscape.com.
Study: Prenatal supplements fail to meet nutrient needs
Although drugstore shelves might suggest otherwise,
In a new study published in the American Journal of Clinical Nutrition, investigators observed what many physicians have long suspected: Most prenatal vitamins and other supplements do not adequately make up the difference of what food-based intake of nutrients leave lacking. Despite patients believing they are getting everything they need with their product purchase, they fall short of guideline-recommended requirements.
“There is no magic pill,” said Katherine A. Sauder, PhD, an associate professor of pediatrics at the University of Colorado Anschutz Medical Campus, Aurora, and lead author of the study. “There is no easy answer here.”
The researchers analyzed 24-hour dietary intake data from 2,450 study participants across five states from 2007 to 2019. Dr. Sauder and colleagues focused on six of the more than 20 key nutrients recommended for pregnant people and determined the target dose for vitamin A, vitamin D, folate, calcium, iron, and omega-3 fatty acids.
The researchers tested more than 20,500 dietary supplements, of which 421 were prenatal products. Only 69 products – three prenatal – included all six nutrients. Just seven products – two prenatal – contained target doses for five nutrients. Only one product, which was not marketed as prenatal, contained target doses for all six nutrients but required seven tablets a serving and cost patients approximately $200 a month.
For many years, Dr. Sauder and her colleagues have struggled to identify the gold standard of vitamins for pregnant patients.
More than half of pregnant people in the United States are at risk of inadequate intake of vitamin D, folate, and iron from their diet alone, and one-third are at risk for insufficient intake of vitamin A and calcium.
Although more than 70% of pregnant women take dietary supplements, the products do not eliminate the risks for deficiencies.
The effects of inadequate nutrition during pregnancy may include neural tube defects, alterations in cardiovascular structure, and impaired neurocognitive development.
The researchers also looked at the challenges within the dietary supplement industry. The U.S. Food and Drug Administration regulates dietary supplements as foods rather than drugs and therefore does not require third-party verification that would ensure product ingredients match labels.
The researchers acknowledged the challenges in creating a one-size-fits-all nutritional supplement.
“The supplement industry is difficult, because you’re trying to create a product that works for a large, diverse group of people, but nutrition is very personal,” Dr. Sauder said.
Kendra Segura, MD, an ob.gyn. at the To Help Everyone Health and Wellness Center, Los Angeles, said she was unsurprised by the results.
“There’s no good prenatal vitamin out there,” Dr. Segura said. “There’s no ‘best.’ ”
Dr. Segura said she advises her patients to focus on increased nutritional intake with foods but added that that the lack of nutrients in diets and the need for supplements reflects the lack of availability of healthy food in some communities (known as “food deserts”), as well as poor dietary choices.
Diana Racusin, MD, an assistant professor of obstetrics, gynecology, and reproductive services at the University of Texas Health Science Center’s McGovern Medical School, Houston, also “wasn’t terribly surprised” by the findings. She stresses the importance of what patients eat more than the availability of supplements.
“What this is really showing us is we have work to do with our nutrition,” Dr. Racusin said.
Dr. Sauder’s biggest takeaway from her study is the need for more patient guidance for their nutrition beyond advising a supplement.
“We need better support for women to help them improve their diet during pregnancy so that they’re getting the nutrients they need from food,” she said, “and not having to rely on supplements as much.”
The study was supported by the Environmental Influences on Child Health Outcomes Program of the National Institutes of Health and by the nonprofit organization Autism Speaks. Dr. Sauder reports no relevant financial relationships. Two coauthors reported various conflicts of interest.
A version of this article first appeared on Medscape.com.
Although drugstore shelves might suggest otherwise,
In a new study published in the American Journal of Clinical Nutrition, investigators observed what many physicians have long suspected: Most prenatal vitamins and other supplements do not adequately make up the difference of what food-based intake of nutrients leave lacking. Despite patients believing they are getting everything they need with their product purchase, they fall short of guideline-recommended requirements.
“There is no magic pill,” said Katherine A. Sauder, PhD, an associate professor of pediatrics at the University of Colorado Anschutz Medical Campus, Aurora, and lead author of the study. “There is no easy answer here.”
The researchers analyzed 24-hour dietary intake data from 2,450 study participants across five states from 2007 to 2019. Dr. Sauder and colleagues focused on six of the more than 20 key nutrients recommended for pregnant people and determined the target dose for vitamin A, vitamin D, folate, calcium, iron, and omega-3 fatty acids.
The researchers tested more than 20,500 dietary supplements, of which 421 were prenatal products. Only 69 products – three prenatal – included all six nutrients. Just seven products – two prenatal – contained target doses for five nutrients. Only one product, which was not marketed as prenatal, contained target doses for all six nutrients but required seven tablets a serving and cost patients approximately $200 a month.
For many years, Dr. Sauder and her colleagues have struggled to identify the gold standard of vitamins for pregnant patients.
More than half of pregnant people in the United States are at risk of inadequate intake of vitamin D, folate, and iron from their diet alone, and one-third are at risk for insufficient intake of vitamin A and calcium.
Although more than 70% of pregnant women take dietary supplements, the products do not eliminate the risks for deficiencies.
The effects of inadequate nutrition during pregnancy may include neural tube defects, alterations in cardiovascular structure, and impaired neurocognitive development.
The researchers also looked at the challenges within the dietary supplement industry. The U.S. Food and Drug Administration regulates dietary supplements as foods rather than drugs and therefore does not require third-party verification that would ensure product ingredients match labels.
The researchers acknowledged the challenges in creating a one-size-fits-all nutritional supplement.
“The supplement industry is difficult, because you’re trying to create a product that works for a large, diverse group of people, but nutrition is very personal,” Dr. Sauder said.
Kendra Segura, MD, an ob.gyn. at the To Help Everyone Health and Wellness Center, Los Angeles, said she was unsurprised by the results.
“There’s no good prenatal vitamin out there,” Dr. Segura said. “There’s no ‘best.’ ”
Dr. Segura said she advises her patients to focus on increased nutritional intake with foods but added that that the lack of nutrients in diets and the need for supplements reflects the lack of availability of healthy food in some communities (known as “food deserts”), as well as poor dietary choices.
Diana Racusin, MD, an assistant professor of obstetrics, gynecology, and reproductive services at the University of Texas Health Science Center’s McGovern Medical School, Houston, also “wasn’t terribly surprised” by the findings. She stresses the importance of what patients eat more than the availability of supplements.
“What this is really showing us is we have work to do with our nutrition,” Dr. Racusin said.
Dr. Sauder’s biggest takeaway from her study is the need for more patient guidance for their nutrition beyond advising a supplement.
“We need better support for women to help them improve their diet during pregnancy so that they’re getting the nutrients they need from food,” she said, “and not having to rely on supplements as much.”
The study was supported by the Environmental Influences on Child Health Outcomes Program of the National Institutes of Health and by the nonprofit organization Autism Speaks. Dr. Sauder reports no relevant financial relationships. Two coauthors reported various conflicts of interest.
A version of this article first appeared on Medscape.com.
Although drugstore shelves might suggest otherwise,
In a new study published in the American Journal of Clinical Nutrition, investigators observed what many physicians have long suspected: Most prenatal vitamins and other supplements do not adequately make up the difference of what food-based intake of nutrients leave lacking. Despite patients believing they are getting everything they need with their product purchase, they fall short of guideline-recommended requirements.
“There is no magic pill,” said Katherine A. Sauder, PhD, an associate professor of pediatrics at the University of Colorado Anschutz Medical Campus, Aurora, and lead author of the study. “There is no easy answer here.”
The researchers analyzed 24-hour dietary intake data from 2,450 study participants across five states from 2007 to 2019. Dr. Sauder and colleagues focused on six of the more than 20 key nutrients recommended for pregnant people and determined the target dose for vitamin A, vitamin D, folate, calcium, iron, and omega-3 fatty acids.
The researchers tested more than 20,500 dietary supplements, of which 421 were prenatal products. Only 69 products – three prenatal – included all six nutrients. Just seven products – two prenatal – contained target doses for five nutrients. Only one product, which was not marketed as prenatal, contained target doses for all six nutrients but required seven tablets a serving and cost patients approximately $200 a month.
For many years, Dr. Sauder and her colleagues have struggled to identify the gold standard of vitamins for pregnant patients.
More than half of pregnant people in the United States are at risk of inadequate intake of vitamin D, folate, and iron from their diet alone, and one-third are at risk for insufficient intake of vitamin A and calcium.
Although more than 70% of pregnant women take dietary supplements, the products do not eliminate the risks for deficiencies.
The effects of inadequate nutrition during pregnancy may include neural tube defects, alterations in cardiovascular structure, and impaired neurocognitive development.
The researchers also looked at the challenges within the dietary supplement industry. The U.S. Food and Drug Administration regulates dietary supplements as foods rather than drugs and therefore does not require third-party verification that would ensure product ingredients match labels.
The researchers acknowledged the challenges in creating a one-size-fits-all nutritional supplement.
“The supplement industry is difficult, because you’re trying to create a product that works for a large, diverse group of people, but nutrition is very personal,” Dr. Sauder said.
Kendra Segura, MD, an ob.gyn. at the To Help Everyone Health and Wellness Center, Los Angeles, said she was unsurprised by the results.
“There’s no good prenatal vitamin out there,” Dr. Segura said. “There’s no ‘best.’ ”
Dr. Segura said she advises her patients to focus on increased nutritional intake with foods but added that that the lack of nutrients in diets and the need for supplements reflects the lack of availability of healthy food in some communities (known as “food deserts”), as well as poor dietary choices.
Diana Racusin, MD, an assistant professor of obstetrics, gynecology, and reproductive services at the University of Texas Health Science Center’s McGovern Medical School, Houston, also “wasn’t terribly surprised” by the findings. She stresses the importance of what patients eat more than the availability of supplements.
“What this is really showing us is we have work to do with our nutrition,” Dr. Racusin said.
Dr. Sauder’s biggest takeaway from her study is the need for more patient guidance for their nutrition beyond advising a supplement.
“We need better support for women to help them improve their diet during pregnancy so that they’re getting the nutrients they need from food,” she said, “and not having to rely on supplements as much.”
The study was supported by the Environmental Influences on Child Health Outcomes Program of the National Institutes of Health and by the nonprofit organization Autism Speaks. Dr. Sauder reports no relevant financial relationships. Two coauthors reported various conflicts of interest.
A version of this article first appeared on Medscape.com.
FROM THE AMERICAN JOURNAL OF CLINICAL NUTRITION
Spotting STIs: Vaginal swabs work best
Vaginal swabs are more effective than urine analysis in detecting certain types of sexually transmitted infections, researchers have found.
In the study, which was published online in the Annals of Family Medicine, investigators found that the diagnostic sensitivity of commercially available vaginal swabs was significantly greater than that of urine tests in detecting certain infections, including those caused by Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis.
Researchers studied chlamydia and gonorrhea, which are two of the most frequently reported STIs in the United States. Trichomoniasis is the most curable nonviral STI globally, with 156 million cases worldwide in 2016.
The Centers for Disease Control and Prevention has long recommended that vaginal swabs be used to produce optimal samples.
But despite the CDC’s recommendation, urine analysis for these STIs is more commonly used than vaginal swabs among U.S. health care providers.
“We’re using a poor sample type, and we can do better,” said Barbara Van Der Pol, PhD, a professor of medicine and public health at the University of Alabama at Birmingham and an author of the new study, a meta-analysis of 97 studies published between 1995 and 2021.
Vaginal swabs for chlamydia trachomatis had a diagnostic sensitivity of 94.1% (95% confidence interval, 93.2%-94.9%; P < .001), higher than urine testing (86.9%; 95% CI, 85.6%-88.0%; P < .001). The pooled sensitivity estimates for Neisseria gonorrhoeae were 96.5% (95% CI, 94.8%-97.7%; P < .001) for vaginal swabs and 90.7% (95% CI, 88.4%-92.5%; P < .001) for urine specimens.
The difference in pooled sensitivity estimates between vaginal swabs and urine analyses for Trichomonas vaginalis was 98% (95% CI, 97.0%-98.7%; P < .001) for vaginal swabs and 95.1% (95% CI, 93.6%-96.3%) for urine specimens.
STIs included in the study are not typically found in the urethra and appear in urine analyses only if cervical or vaginal cells have dripped into a urine sample. Dr. Van Der Pol and her colleagues estimated that the use of urine samples rather than vaginal swabs may result in more than 400,000 undiagnosed infections annually.
Undiagnosed and untreated STIs can lead to transmissions of the infection as well as infertility and can have negative effects on romantic relationships, according to Dr. Van Der Pol.
Sarah Wood, MD, an attending physician at Children’s Hospital of Philadelphia, said some health care providers may use urine analysis because patients may be more comfortable with this method. The approach also can be more convenient for medical offices: All they must do is hand a specimen container to the patient.
Conversations between clinicians and patients about vaginal swabbing may be considered “sensitive” and the swabbing more invasive, Dr. Wood, an author of an editorial accompanying the journal article, said. Clinicians may also lack awareness that the swab is a more sensitive method of detecting these STIs.
“We all want to do what’s right for our patient, but we often don’t know what’s right for the patient,” Dr. Wood said. “I don’t think people are really aware of a potential real difference in outcomes with one method over the other.”
Dr. Wood advised making STI screening using vaginal swabs more common by “offering universal opt-out screening, so not waiting until you find out if someone’s having sex but just sort of saying, ‘Hey, across our practice, we screen everybody for chlamydia. Is that something that you want to do today?’ That approach sort of takes out the piece of talking about sex, talking about sexual activity.”
Dr. Van Der Pol, who said she has worked in STI diagnostics for 40 years, said she was not surprised by the results and hopes the study changes how samples are collected and used.
“I really hope that it influences practice so that we really start using vaginal swabs, because it gives us better diagnostics for chlamydia and gonorrhea,” Dr. Van Der Pol said.
“Also, then starting to think about comprehensive women’s care in such a way that they actually order other tests on that same sample if a woman is presenting with complaints.”
A version of this article originally appeared on Medscape.com.
Vaginal swabs are more effective than urine analysis in detecting certain types of sexually transmitted infections, researchers have found.
In the study, which was published online in the Annals of Family Medicine, investigators found that the diagnostic sensitivity of commercially available vaginal swabs was significantly greater than that of urine tests in detecting certain infections, including those caused by Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis.
Researchers studied chlamydia and gonorrhea, which are two of the most frequently reported STIs in the United States. Trichomoniasis is the most curable nonviral STI globally, with 156 million cases worldwide in 2016.
The Centers for Disease Control and Prevention has long recommended that vaginal swabs be used to produce optimal samples.
But despite the CDC’s recommendation, urine analysis for these STIs is more commonly used than vaginal swabs among U.S. health care providers.
“We’re using a poor sample type, and we can do better,” said Barbara Van Der Pol, PhD, a professor of medicine and public health at the University of Alabama at Birmingham and an author of the new study, a meta-analysis of 97 studies published between 1995 and 2021.
Vaginal swabs for chlamydia trachomatis had a diagnostic sensitivity of 94.1% (95% confidence interval, 93.2%-94.9%; P < .001), higher than urine testing (86.9%; 95% CI, 85.6%-88.0%; P < .001). The pooled sensitivity estimates for Neisseria gonorrhoeae were 96.5% (95% CI, 94.8%-97.7%; P < .001) for vaginal swabs and 90.7% (95% CI, 88.4%-92.5%; P < .001) for urine specimens.
The difference in pooled sensitivity estimates between vaginal swabs and urine analyses for Trichomonas vaginalis was 98% (95% CI, 97.0%-98.7%; P < .001) for vaginal swabs and 95.1% (95% CI, 93.6%-96.3%) for urine specimens.
STIs included in the study are not typically found in the urethra and appear in urine analyses only if cervical or vaginal cells have dripped into a urine sample. Dr. Van Der Pol and her colleagues estimated that the use of urine samples rather than vaginal swabs may result in more than 400,000 undiagnosed infections annually.
Undiagnosed and untreated STIs can lead to transmissions of the infection as well as infertility and can have negative effects on romantic relationships, according to Dr. Van Der Pol.
Sarah Wood, MD, an attending physician at Children’s Hospital of Philadelphia, said some health care providers may use urine analysis because patients may be more comfortable with this method. The approach also can be more convenient for medical offices: All they must do is hand a specimen container to the patient.
Conversations between clinicians and patients about vaginal swabbing may be considered “sensitive” and the swabbing more invasive, Dr. Wood, an author of an editorial accompanying the journal article, said. Clinicians may also lack awareness that the swab is a more sensitive method of detecting these STIs.
“We all want to do what’s right for our patient, but we often don’t know what’s right for the patient,” Dr. Wood said. “I don’t think people are really aware of a potential real difference in outcomes with one method over the other.”
Dr. Wood advised making STI screening using vaginal swabs more common by “offering universal opt-out screening, so not waiting until you find out if someone’s having sex but just sort of saying, ‘Hey, across our practice, we screen everybody for chlamydia. Is that something that you want to do today?’ That approach sort of takes out the piece of talking about sex, talking about sexual activity.”
Dr. Van Der Pol, who said she has worked in STI diagnostics for 40 years, said she was not surprised by the results and hopes the study changes how samples are collected and used.
“I really hope that it influences practice so that we really start using vaginal swabs, because it gives us better diagnostics for chlamydia and gonorrhea,” Dr. Van Der Pol said.
“Also, then starting to think about comprehensive women’s care in such a way that they actually order other tests on that same sample if a woman is presenting with complaints.”
A version of this article originally appeared on Medscape.com.
Vaginal swabs are more effective than urine analysis in detecting certain types of sexually transmitted infections, researchers have found.
In the study, which was published online in the Annals of Family Medicine, investigators found that the diagnostic sensitivity of commercially available vaginal swabs was significantly greater than that of urine tests in detecting certain infections, including those caused by Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis.
Researchers studied chlamydia and gonorrhea, which are two of the most frequently reported STIs in the United States. Trichomoniasis is the most curable nonviral STI globally, with 156 million cases worldwide in 2016.
The Centers for Disease Control and Prevention has long recommended that vaginal swabs be used to produce optimal samples.
But despite the CDC’s recommendation, urine analysis for these STIs is more commonly used than vaginal swabs among U.S. health care providers.
“We’re using a poor sample type, and we can do better,” said Barbara Van Der Pol, PhD, a professor of medicine and public health at the University of Alabama at Birmingham and an author of the new study, a meta-analysis of 97 studies published between 1995 and 2021.
Vaginal swabs for chlamydia trachomatis had a diagnostic sensitivity of 94.1% (95% confidence interval, 93.2%-94.9%; P < .001), higher than urine testing (86.9%; 95% CI, 85.6%-88.0%; P < .001). The pooled sensitivity estimates for Neisseria gonorrhoeae were 96.5% (95% CI, 94.8%-97.7%; P < .001) for vaginal swabs and 90.7% (95% CI, 88.4%-92.5%; P < .001) for urine specimens.
The difference in pooled sensitivity estimates between vaginal swabs and urine analyses for Trichomonas vaginalis was 98% (95% CI, 97.0%-98.7%; P < .001) for vaginal swabs and 95.1% (95% CI, 93.6%-96.3%) for urine specimens.
STIs included in the study are not typically found in the urethra and appear in urine analyses only if cervical or vaginal cells have dripped into a urine sample. Dr. Van Der Pol and her colleagues estimated that the use of urine samples rather than vaginal swabs may result in more than 400,000 undiagnosed infections annually.
Undiagnosed and untreated STIs can lead to transmissions of the infection as well as infertility and can have negative effects on romantic relationships, according to Dr. Van Der Pol.
Sarah Wood, MD, an attending physician at Children’s Hospital of Philadelphia, said some health care providers may use urine analysis because patients may be more comfortable with this method. The approach also can be more convenient for medical offices: All they must do is hand a specimen container to the patient.
Conversations between clinicians and patients about vaginal swabbing may be considered “sensitive” and the swabbing more invasive, Dr. Wood, an author of an editorial accompanying the journal article, said. Clinicians may also lack awareness that the swab is a more sensitive method of detecting these STIs.
“We all want to do what’s right for our patient, but we often don’t know what’s right for the patient,” Dr. Wood said. “I don’t think people are really aware of a potential real difference in outcomes with one method over the other.”
Dr. Wood advised making STI screening using vaginal swabs more common by “offering universal opt-out screening, so not waiting until you find out if someone’s having sex but just sort of saying, ‘Hey, across our practice, we screen everybody for chlamydia. Is that something that you want to do today?’ That approach sort of takes out the piece of talking about sex, talking about sexual activity.”
Dr. Van Der Pol, who said she has worked in STI diagnostics for 40 years, said she was not surprised by the results and hopes the study changes how samples are collected and used.
“I really hope that it influences practice so that we really start using vaginal swabs, because it gives us better diagnostics for chlamydia and gonorrhea,” Dr. Van Der Pol said.
“Also, then starting to think about comprehensive women’s care in such a way that they actually order other tests on that same sample if a woman is presenting with complaints.”
A version of this article originally appeared on Medscape.com.