Clinician Reviews

TOPLINE: 

Hypertension, atrial fibrillation, and smoking are more strongly linked to increased risk for severe stroke than nonsevere stroke, whereas a high waist-to-hip ratio is more closely associated with nonsevere stroke, a global study shows.

METHODOLOGY:

• The INTERSTROKE case-control study included nearly 27,000 participants, half of whom had a first acute stroke (ischemic or hemorrhagic) and the other half acting as age- and sex-matched controls.
• Participants (mean age, 62 years; 40% women) were recruited across 142 centers in 32 countries between 2007 and 2015. Baseline demographics and lifestyle risk factors for stroke were gathered using standardized questionnaires
• Modified Rankin Scale (mRS) scores measured within 72 hours of hospital admission were used to classify stroke severity (0-3, nonsevere stroke; 4-6, severe stroke).

TAKEAWAY:

• Among the participants with acute stroke, 64% had nonsevere stroke and 36% had severe stroke, based on the mRS.
• Hypertension, atrial fibrillation, and smoking showed a significantly stronger association with severe stroke than with nonsevere stroke (odds ratios [ORs], 3.21 vs 2.87, 4.70 vs 3.61, and 1.87 vs 1.65, respectively; all P < .001).
• A high waist-to-hip ratio showed a stronger association with nonsevere stroke than with severe stroke (OR, 1.37 vs 1.11, respectively; P < .001).
• Diabetes, poor diet, physical inactivity, and stress were linked to increased odds of both severe and nonsevere stroke, whereas alcohol consumption and high apolipoprotein B levels were linked to higher odds of only nonsevere stroke. No significant differences in odds were observed between stroke severities in matched individuals.

IN PRACTICE:

“Our findings emphasize the importance of controlling high blood pressure, which is the most important modifiable risk factor for stroke globally,” lead author Catriona Reddin, MB BCh, BAO, MSc, School of Medicine, University of Galway, in Ireland, said in a press release.

SOURCE:

The study was published online in Neurology.

LIMITATIONS:

The study limitations included potential unmeasured confounders; reliance on the mRS score, which may have underestimated stroke severity; and challenges with recruiting patients with severe stroke in a case-control study. Smoking-related comorbidities and regional or sex-related variations in alcohol intake may also have influenced the results.

DISCLOSURES:

The study was funded by various organizations, including health research councils and foundations from Canada, Sweden, and Scotland, and pharmaceutical companies such as AstraZeneca, Boehringer Ingelheim, Pfizer, and MSD. One investigator reported receiving funding from the Irish Clinical Academic Training Programme, the Wellcome Trust and the Health Research Board, the Health Service Executive, National Doctors Training and Planning, and the Health and Social Care, Research and Development Division in Northern Ireland. No other conflicts of interest were reported.

 

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 appeared on Medscape.com.

TOPLINE: 

Hypertension, atrial fibrillation, and smoking are more strongly linked to increased risk for severe stroke than nonsevere stroke, whereas a high waist-to-hip ratio is more closely associated with nonsevere stroke, a global study shows.

METHODOLOGY:

• The INTERSTROKE case-control study included nearly 27,000 participants, half of whom had a first acute stroke (ischemic or hemorrhagic) and the other half acting as age- and sex-matched controls.
• Participants (mean age, 62 years; 40% women) were recruited across 142 centers in 32 countries between 2007 and 2015. Baseline demographics and lifestyle risk factors for stroke were gathered using standardized questionnaires
• Modified Rankin Scale (mRS) scores measured within 72 hours of hospital admission were used to classify stroke severity (0-3, nonsevere stroke; 4-6, severe stroke).

TAKEAWAY:

• Among the participants with acute stroke, 64% had nonsevere stroke and 36% had severe stroke, based on the mRS.
• Hypertension, atrial fibrillation, and smoking showed a significantly stronger association with severe stroke than with nonsevere stroke (odds ratios [ORs], 3.21 vs 2.87, 4.70 vs 3.61, and 1.87 vs 1.65, respectively; all P < .001).
• A high waist-to-hip ratio showed a stronger association with nonsevere stroke than with severe stroke (OR, 1.37 vs 1.11, respectively; P < .001).
• Diabetes, poor diet, physical inactivity, and stress were linked to increased odds of both severe and nonsevere stroke, whereas alcohol consumption and high apolipoprotein B levels were linked to higher odds of only nonsevere stroke. No significant differences in odds were observed between stroke severities in matched individuals.

IN PRACTICE:

“Our findings emphasize the importance of controlling high blood pressure, which is the most important modifiable risk factor for stroke globally,” lead author Catriona Reddin, MB BCh, BAO, MSc, School of Medicine, University of Galway, in Ireland, said in a press release.

SOURCE:

The study was published online in Neurology.

LIMITATIONS:

The study limitations included potential unmeasured confounders; reliance on the mRS score, which may have underestimated stroke severity; and challenges with recruiting patients with severe stroke in a case-control study. Smoking-related comorbidities and regional or sex-related variations in alcohol intake may also have influenced the results.

DISCLOSURES:

The study was funded by various organizations, including health research councils and foundations from Canada, Sweden, and Scotland, and pharmaceutical companies such as AstraZeneca, Boehringer Ingelheim, Pfizer, and MSD. One investigator reported receiving funding from the Irish Clinical Academic Training Programme, the Wellcome Trust and the Health Research Board, the Health Service Executive, National Doctors Training and Planning, and the Health and Social Care, Research and Development Division in Northern Ireland. No other conflicts of interest were reported.

 

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 appeared on Medscape.com.

TOPLINE: 

Hypertension, atrial fibrillation, and smoking are more strongly linked to increased risk for severe stroke than nonsevere stroke, whereas a high waist-to-hip ratio is more closely associated with nonsevere stroke, a global study shows.

METHODOLOGY:

• The INTERSTROKE case-control study included nearly 27,000 participants, half of whom had a first acute stroke (ischemic or hemorrhagic) and the other half acting as age- and sex-matched controls.
• Participants (mean age, 62 years; 40% women) were recruited across 142 centers in 32 countries between 2007 and 2015. Baseline demographics and lifestyle risk factors for stroke were gathered using standardized questionnaires
• Modified Rankin Scale (mRS) scores measured within 72 hours of hospital admission were used to classify stroke severity (0-3, nonsevere stroke; 4-6, severe stroke).

TAKEAWAY:

• Among the participants with acute stroke, 64% had nonsevere stroke and 36% had severe stroke, based on the mRS.
• Hypertension, atrial fibrillation, and smoking showed a significantly stronger association with severe stroke than with nonsevere stroke (odds ratios [ORs], 3.21 vs 2.87, 4.70 vs 3.61, and 1.87 vs 1.65, respectively; all P < .001).
• A high waist-to-hip ratio showed a stronger association with nonsevere stroke than with severe stroke (OR, 1.37 vs 1.11, respectively; P < .001).
• Diabetes, poor diet, physical inactivity, and stress were linked to increased odds of both severe and nonsevere stroke, whereas alcohol consumption and high apolipoprotein B levels were linked to higher odds of only nonsevere stroke. No significant differences in odds were observed between stroke severities in matched individuals.

IN PRACTICE:

“Our findings emphasize the importance of controlling high blood pressure, which is the most important modifiable risk factor for stroke globally,” lead author Catriona Reddin, MB BCh, BAO, MSc, School of Medicine, University of Galway, in Ireland, said in a press release.

SOURCE:

The study was published online in Neurology.

LIMITATIONS:

The study limitations included potential unmeasured confounders; reliance on the mRS score, which may have underestimated stroke severity; and challenges with recruiting patients with severe stroke in a case-control study. Smoking-related comorbidities and regional or sex-related variations in alcohol intake may also have influenced the results.

DISCLOSURES:

The study was funded by various organizations, including health research councils and foundations from Canada, Sweden, and Scotland, and pharmaceutical companies such as AstraZeneca, Boehringer Ingelheim, Pfizer, and MSD. One investigator reported receiving funding from the Irish Clinical Academic Training Programme, the Wellcome Trust and the Health Research Board, the Health Service Executive, National Doctors Training and Planning, and the Health and Social Care, Research and Development Division in Northern Ireland. No other conflicts of interest were reported.

 

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 appeared on Medscape.com.

TOPLINE:

Elevated levels of plasma F2-isoprostanes, a reliable marker of oxidative stress, are associated with an increased risk for fractures in older ambulatory patients with type 2 diabetes (T2D) independently of bone density.

METHODOLOGY:

• Patients with T2D face an increased risk for fractures at any given bone mineral density; oxidative stress levels (reflected in circulating F2-isoprostanes), which are elevated in T2D, are associated with other T2D complications, and may weaken bone integrity.
• Researchers analyzed data from an observational cohort study to investigate the association between the levels of circulating F2-isoprostanes and the risk for clinical fractures in older patients with T2D.
• The data included 703 older ambulatory adults (baseline age, 70-79 years; about half White individuals and half Black individuals ; about half men and half women) from the Health, Aging and Body Composition Study, of whom 132 had T2D.
• Plasma F2-isoprostane levels were measured using baseline serum samples; bone turnover markers were also measured including procollagen type 1 N-terminal propeptide, osteocalcin, and C-terminal telopeptide of type 1 collagen.
• Incident clinical fractures were tracked over a follow-up period of up to 17.3 years, with fractures verified through radiology reports.

TAKEAWAY:

• Overall, 25.8% patients in the T2D group and 23.5% adults in the non-diabetes group reported an incident clinical fracture during a mean follow-up period of 6.2 and 8.0 years, respectively.
• In patients with T2D, the risk for incident clinical fracture increased by 93% for every standard deviation increase in the log F2-isoprostane serum levels (hazard ratio [HR], 1.93; 95% CI, 1.26-2.95; P = .002) independently of baseline bone density, medication use, and other risk factors, with no such association reported in individuals without T2D (HR, 0.98; 95% CI, 0.81-1.18; P = .79).
• In the T2D group, elevated plasma F2-isoprostane levels were also associated with a decrease in total hip bone mineral density over 4 years (r = −0.28; P = .008), but not in the non-diabetes group.
• No correlation was found between plasma F2-isoprostane levels and circulating advanced glycoxidation end-products, bone turnover markers, or A1c levels in either group.
•  

IN PRACTICE:

“Oxidative stress in T2D may play an important role in the decline of bone quality and not just bone quantity,” the authors wrote.

SOURCE:

This study was led by Bowen Wang, PhD, Rensselaer Polytechnic Institute, Troy, New York. It was published online in The Journal of Clinical Endocrinology & Metabolism.

LIMITATIONS:

This study was conducted in a well-functioning elderly population with only White and Black participants, which may limit the generalizability of the findings to other age groups or less healthy populations. Additionally, the study did not assess prevalent vertebral fracture risk due to the small sample size. 

DISCLOSURES:

This study was supported by the US National Institute on Aging and the Intramural Research Program of the US National Institutes of Health and the Dr and Ms Sands and Sands Family for Orthopaedic Research. 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:

Elevated levels of plasma F2-isoprostanes, a reliable marker of oxidative stress, are associated with an increased risk for fractures in older ambulatory patients with type 2 diabetes (T2D) independently of bone density.

METHODOLOGY:

• Patients with T2D face an increased risk for fractures at any given bone mineral density; oxidative stress levels (reflected in circulating F2-isoprostanes), which are elevated in T2D, are associated with other T2D complications, and may weaken bone integrity.
• Researchers analyzed data from an observational cohort study to investigate the association between the levels of circulating F2-isoprostanes and the risk for clinical fractures in older patients with T2D.
• The data included 703 older ambulatory adults (baseline age, 70-79 years; about half White individuals and half Black individuals ; about half men and half women) from the Health, Aging and Body Composition Study, of whom 132 had T2D.
• Plasma F2-isoprostane levels were measured using baseline serum samples; bone turnover markers were also measured including procollagen type 1 N-terminal propeptide, osteocalcin, and C-terminal telopeptide of type 1 collagen.
• Incident clinical fractures were tracked over a follow-up period of up to 17.3 years, with fractures verified through radiology reports.

TAKEAWAY:

• Overall, 25.8% patients in the T2D group and 23.5% adults in the non-diabetes group reported an incident clinical fracture during a mean follow-up period of 6.2 and 8.0 years, respectively.
• In patients with T2D, the risk for incident clinical fracture increased by 93% for every standard deviation increase in the log F2-isoprostane serum levels (hazard ratio [HR], 1.93; 95% CI, 1.26-2.95; P = .002) independently of baseline bone density, medication use, and other risk factors, with no such association reported in individuals without T2D (HR, 0.98; 95% CI, 0.81-1.18; P = .79).
• In the T2D group, elevated plasma F2-isoprostane levels were also associated with a decrease in total hip bone mineral density over 4 years (r = −0.28; P = .008), but not in the non-diabetes group.
• No correlation was found between plasma F2-isoprostane levels and circulating advanced glycoxidation end-products, bone turnover markers, or A1c levels in either group.
•  

IN PRACTICE:

“Oxidative stress in T2D may play an important role in the decline of bone quality and not just bone quantity,” the authors wrote.

SOURCE:

This study was led by Bowen Wang, PhD, Rensselaer Polytechnic Institute, Troy, New York. It was published online in The Journal of Clinical Endocrinology & Metabolism.

LIMITATIONS:

This study was conducted in a well-functioning elderly population with only White and Black participants, which may limit the generalizability of the findings to other age groups or less healthy populations. Additionally, the study did not assess prevalent vertebral fracture risk due to the small sample size. 

DISCLOSURES:

This study was supported by the US National Institute on Aging and the Intramural Research Program of the US National Institutes of Health and the Dr and Ms Sands and Sands Family for Orthopaedic Research. 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:

Elevated levels of plasma F2-isoprostanes, a reliable marker of oxidative stress, are associated with an increased risk for fractures in older ambulatory patients with type 2 diabetes (T2D) independently of bone density.

METHODOLOGY:

• Patients with T2D face an increased risk for fractures at any given bone mineral density; oxidative stress levels (reflected in circulating F2-isoprostanes), which are elevated in T2D, are associated with other T2D complications, and may weaken bone integrity.
• Researchers analyzed data from an observational cohort study to investigate the association between the levels of circulating F2-isoprostanes and the risk for clinical fractures in older patients with T2D.
• The data included 703 older ambulatory adults (baseline age, 70-79 years; about half White individuals and half Black individuals ; about half men and half women) from the Health, Aging and Body Composition Study, of whom 132 had T2D.
• Plasma F2-isoprostane levels were measured using baseline serum samples; bone turnover markers were also measured including procollagen type 1 N-terminal propeptide, osteocalcin, and C-terminal telopeptide of type 1 collagen.
• Incident clinical fractures were tracked over a follow-up period of up to 17.3 years, with fractures verified through radiology reports.

TAKEAWAY:

• Overall, 25.8% patients in the T2D group and 23.5% adults in the non-diabetes group reported an incident clinical fracture during a mean follow-up period of 6.2 and 8.0 years, respectively.
• In patients with T2D, the risk for incident clinical fracture increased by 93% for every standard deviation increase in the log F2-isoprostane serum levels (hazard ratio [HR], 1.93; 95% CI, 1.26-2.95; P = .002) independently of baseline bone density, medication use, and other risk factors, with no such association reported in individuals without T2D (HR, 0.98; 95% CI, 0.81-1.18; P = .79).
• In the T2D group, elevated plasma F2-isoprostane levels were also associated with a decrease in total hip bone mineral density over 4 years (r = −0.28; P = .008), but not in the non-diabetes group.
• No correlation was found between plasma F2-isoprostane levels and circulating advanced glycoxidation end-products, bone turnover markers, or A1c levels in either group.
•  

IN PRACTICE:

“Oxidative stress in T2D may play an important role in the decline of bone quality and not just bone quantity,” the authors wrote.

SOURCE:

This study was led by Bowen Wang, PhD, Rensselaer Polytechnic Institute, Troy, New York. It was published online in The Journal of Clinical Endocrinology & Metabolism.

LIMITATIONS:

This study was conducted in a well-functioning elderly population with only White and Black participants, which may limit the generalizability of the findings to other age groups or less healthy populations. Additionally, the study did not assess prevalent vertebral fracture risk due to the small sample size. 

DISCLOSURES:

This study was supported by the US National Institute on Aging and the Intramural Research Program of the US National Institutes of Health and the Dr and Ms Sands and Sands Family for Orthopaedic Research. 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.

VANCOUVER, BRITISH COLUMBIA — While polypharmacy is inevitable for patients with multiple chronic diseases, not all medications improve patient-oriented outcomes, members of the Patients, Experience, Evidence, Research (PEER) team, a group of Canadian primary care professionals who develop evidence-based guidelines, told attendees at the Family Medicine Forum (FMF) 2024.

In a thought-provoking presentation called “Axe the Rx: Deprescribing Chronic Medications with PEER,” the panelists gave examples of medications that may be safely stopped or tapered, particularly for older adults “whose pill bag is heavier than their lunch bag.”

 

Curbing Cardiovascular Drugs

The 2021 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular Disease in Adults call for reaching an LDL-C < 1.8 mmol/L in secondary cardiovascular prevention by potentially adding on medical therapies such as proprotein convertase subtilisin/kexin type 9 inhibitors or ezetimibe or both if that target is not reached with the maximal dosage of a statin.

But family physicians do not need to follow this guidance for their patients who have had a myocardial infarction, said Ontario family physician Jennifer Young, MD, a physician advisor in the Canadian College of Family Physicians’ Knowledge Experts and Tools Program.

Treating to below 1.8 mmol/L “means lab testing for the patients,” Young told this news organization. “It means increasing doses [of a statin] to try and get to that level.” If the patient is already on the highest dose of a statin, it means adding other medications that lower cholesterol.

“If that was translating into better outcomes like [preventing] death and another heart attack, then all of that extra effort would be worth it,” said Young. “But we don’t have evidence that it actually does have a benefit for outcomes like death and repeated heart attacks,” compared with putting them on a high dose of a potent statin.

 

Tapering Opioids

Before placing patients on an opioid taper, clinicians should first assess them for opioid use disorder (OUD), said Jessica Kirkwood, MD, assistant professor of family medicine at the University of Alberta in Edmonton, Canada. She suggested using the Prescription Opioid Misuse Index questionnaire to do so.

Clinicians should be much more careful in initiating a taper with patients with OUD, said Kirkwood. They must ensure that these patients are motivated to discontinue their opioids. “We’re losing 21 Canadians a day to the opioid crisis. We all know that cutting someone off their opioids and potentially having them seek opioids elsewhere through illicit means can be fatal.”

In addition, clinicians should spend more time counseling patients with OUD than those without, Kirkwood continued. They must explain to these patients how they are being tapered (eg, the intervals and doses) and highlight the benefits of a taper, such as reduced constipation. Opioid agonist therapy (such as methadone or buprenorphine) can be considered in these patients.

Some research has pointed to the importance of patient motivation as a factor in the success of opioid tapers, noted Kirkwood.

 

Deprescribing Benzodiazepines 

Benzodiazepine receptor agonists, too, often can be deprescribed. These drugs should not be prescribed to promote sleep on a long-term basis. Yet clinicians commonly encounter patients who have been taking them for more than a year, said pharmacist Betsy Thomas, assistant adjunct professor of family medicine at the University of Alberta.

The medications “are usually fairly effective for the first couple of weeks to about a month, and then the benefits start to decrease, and we start to see more harms,” she said.

Some of the harms that have been associated with continued use of benzodiazepine receptor agonists include delayed reaction time and impaired cognition, which can affect the ability to drive, the risk for falls, and the risk for hip fractures, she noted. Some research suggests that these drugs are not an option for treating insomnia in patients aged 65 years or older.

Clinicians should encourage tapering the use of benzodiazepine receptor agonists to minimize dependence and transition patients to nonpharmacologic approaches such as cognitive behavioral therapy to manage insomnia, she said. A recent study demonstrated the efficacy of the intervention, and Thomas suggested that family physicians visit the mysleepwell.ca website for more information.

Young, Kirkwood, and Thomas reported no relevant financial relationships.

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

VANCOUVER, BRITISH COLUMBIA — While polypharmacy is inevitable for patients with multiple chronic diseases, not all medications improve patient-oriented outcomes, members of the Patients, Experience, Evidence, Research (PEER) team, a group of Canadian primary care professionals who develop evidence-based guidelines, told attendees at the Family Medicine Forum (FMF) 2024.

In a thought-provoking presentation called “Axe the Rx: Deprescribing Chronic Medications with PEER,” the panelists gave examples of medications that may be safely stopped or tapered, particularly for older adults “whose pill bag is heavier than their lunch bag.”

 

Curbing Cardiovascular Drugs

The 2021 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular Disease in Adults call for reaching an LDL-C < 1.8 mmol/L in secondary cardiovascular prevention by potentially adding on medical therapies such as proprotein convertase subtilisin/kexin type 9 inhibitors or ezetimibe or both if that target is not reached with the maximal dosage of a statin.

But family physicians do not need to follow this guidance for their patients who have had a myocardial infarction, said Ontario family physician Jennifer Young, MD, a physician advisor in the Canadian College of Family Physicians’ Knowledge Experts and Tools Program.

Treating to below 1.8 mmol/L “means lab testing for the patients,” Young told this news organization. “It means increasing doses [of a statin] to try and get to that level.” If the patient is already on the highest dose of a statin, it means adding other medications that lower cholesterol.

“If that was translating into better outcomes like [preventing] death and another heart attack, then all of that extra effort would be worth it,” said Young. “But we don’t have evidence that it actually does have a benefit for outcomes like death and repeated heart attacks,” compared with putting them on a high dose of a potent statin.

 

Tapering Opioids

Before placing patients on an opioid taper, clinicians should first assess them for opioid use disorder (OUD), said Jessica Kirkwood, MD, assistant professor of family medicine at the University of Alberta in Edmonton, Canada. She suggested using the Prescription Opioid Misuse Index questionnaire to do so.

Clinicians should be much more careful in initiating a taper with patients with OUD, said Kirkwood. They must ensure that these patients are motivated to discontinue their opioids. “We’re losing 21 Canadians a day to the opioid crisis. We all know that cutting someone off their opioids and potentially having them seek opioids elsewhere through illicit means can be fatal.”

In addition, clinicians should spend more time counseling patients with OUD than those without, Kirkwood continued. They must explain to these patients how they are being tapered (eg, the intervals and doses) and highlight the benefits of a taper, such as reduced constipation. Opioid agonist therapy (such as methadone or buprenorphine) can be considered in these patients.

Some research has pointed to the importance of patient motivation as a factor in the success of opioid tapers, noted Kirkwood.

 

Deprescribing Benzodiazepines 

Benzodiazepine receptor agonists, too, often can be deprescribed. These drugs should not be prescribed to promote sleep on a long-term basis. Yet clinicians commonly encounter patients who have been taking them for more than a year, said pharmacist Betsy Thomas, assistant adjunct professor of family medicine at the University of Alberta.

The medications “are usually fairly effective for the first couple of weeks to about a month, and then the benefits start to decrease, and we start to see more harms,” she said.

Some of the harms that have been associated with continued use of benzodiazepine receptor agonists include delayed reaction time and impaired cognition, which can affect the ability to drive, the risk for falls, and the risk for hip fractures, she noted. Some research suggests that these drugs are not an option for treating insomnia in patients aged 65 years or older.

Clinicians should encourage tapering the use of benzodiazepine receptor agonists to minimize dependence and transition patients to nonpharmacologic approaches such as cognitive behavioral therapy to manage insomnia, she said. A recent study demonstrated the efficacy of the intervention, and Thomas suggested that family physicians visit the mysleepwell.ca website for more information.

Young, Kirkwood, and Thomas reported no relevant financial relationships.

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

VANCOUVER, BRITISH COLUMBIA — While polypharmacy is inevitable for patients with multiple chronic diseases, not all medications improve patient-oriented outcomes, members of the Patients, Experience, Evidence, Research (PEER) team, a group of Canadian primary care professionals who develop evidence-based guidelines, told attendees at the Family Medicine Forum (FMF) 2024.

In a thought-provoking presentation called “Axe the Rx: Deprescribing Chronic Medications with PEER,” the panelists gave examples of medications that may be safely stopped or tapered, particularly for older adults “whose pill bag is heavier than their lunch bag.”

 

Curbing Cardiovascular Drugs

The 2021 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular Disease in Adults call for reaching an LDL-C < 1.8 mmol/L in secondary cardiovascular prevention by potentially adding on medical therapies such as proprotein convertase subtilisin/kexin type 9 inhibitors or ezetimibe or both if that target is not reached with the maximal dosage of a statin.

But family physicians do not need to follow this guidance for their patients who have had a myocardial infarction, said Ontario family physician Jennifer Young, MD, a physician advisor in the Canadian College of Family Physicians’ Knowledge Experts and Tools Program.

Treating to below 1.8 mmol/L “means lab testing for the patients,” Young told this news organization. “It means increasing doses [of a statin] to try and get to that level.” If the patient is already on the highest dose of a statin, it means adding other medications that lower cholesterol.

“If that was translating into better outcomes like [preventing] death and another heart attack, then all of that extra effort would be worth it,” said Young. “But we don’t have evidence that it actually does have a benefit for outcomes like death and repeated heart attacks,” compared with putting them on a high dose of a potent statin.

 

Tapering Opioids

Before placing patients on an opioid taper, clinicians should first assess them for opioid use disorder (OUD), said Jessica Kirkwood, MD, assistant professor of family medicine at the University of Alberta in Edmonton, Canada. She suggested using the Prescription Opioid Misuse Index questionnaire to do so.

Clinicians should be much more careful in initiating a taper with patients with OUD, said Kirkwood. They must ensure that these patients are motivated to discontinue their opioids. “We’re losing 21 Canadians a day to the opioid crisis. We all know that cutting someone off their opioids and potentially having them seek opioids elsewhere through illicit means can be fatal.”

In addition, clinicians should spend more time counseling patients with OUD than those without, Kirkwood continued. They must explain to these patients how they are being tapered (eg, the intervals and doses) and highlight the benefits of a taper, such as reduced constipation. Opioid agonist therapy (such as methadone or buprenorphine) can be considered in these patients.

Some research has pointed to the importance of patient motivation as a factor in the success of opioid tapers, noted Kirkwood.

 

Deprescribing Benzodiazepines 

Benzodiazepine receptor agonists, too, often can be deprescribed. These drugs should not be prescribed to promote sleep on a long-term basis. Yet clinicians commonly encounter patients who have been taking them for more than a year, said pharmacist Betsy Thomas, assistant adjunct professor of family medicine at the University of Alberta.

The medications “are usually fairly effective for the first couple of weeks to about a month, and then the benefits start to decrease, and we start to see more harms,” she said.

Some of the harms that have been associated with continued use of benzodiazepine receptor agonists include delayed reaction time and impaired cognition, which can affect the ability to drive, the risk for falls, and the risk for hip fractures, she noted. Some research suggests that these drugs are not an option for treating insomnia in patients aged 65 years or older.

Clinicians should encourage tapering the use of benzodiazepine receptor agonists to minimize dependence and transition patients to nonpharmacologic approaches such as cognitive behavioral therapy to manage insomnia, she said. A recent study demonstrated the efficacy of the intervention, and Thomas suggested that family physicians visit the mysleepwell.ca website for more information.

Young, Kirkwood, and Thomas reported no relevant financial relationships.

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

TOPLINE:

Consumption of ultraprocessed foods (UPFs), such as carbonated drinks, processed meats, and sweet or savory packaged snacks, is associated with accelerated biological aging, as measured by 36 blood-based biomarkers, and factors other than poor nutritional content may be to blame.

METHODOLOGY:

• Previous studies have reported an association between high consumption of UPFs and some measures of early biological aging, such as shorter telomere length, cognitive decline, and frailty, but the relationship is largely unexplored so far, including exactly how UPFs may harm health.
• To examine the association between UPF consumption and biological aging, researchers conducted a cross-sectional analysis of 22,495 participants (mean chronological age, 55.6 years; 52% women) from the Moli-sani Study in Italy, who were recruited between 2005 and 2010.
• Food intake was assessed with a food frequency questionnaire that covered 188 different food items, each of which was categorized into one of four groups based on the extent of processing, ranging from minimally processed foods, such as fruits, vegetables, meat and fish, to UPFs.
• UPF intake was determined by weight, using the ratio of UPFs to the total weight of food and beverages (g/d), and participants were categorized into sex-specific fifths according to the proportion of UPFs in their total food intake. Diet quality was also evaluated using the Mediterranean Diet Score.
• Biological age was computed using a deep neural network approach based on 36 circulating blood biomarkers, and the mean difference between the mean biological and chronological ages was analyzed.

TAKEAWAY:

• The mean difference between biological and chronological ages of the participants was –0.70 years.
• Higher intake of UPFs was associated with accelerated biological aging compared with the lowest intake (regression coefficient, 0.34; 95% CI, 0.08-0.61), with a mean difference between the biological and chronological ages of −4.1 years and 1.6 years in those with the lowest and highest intakes, respectively.
• The association between UPF consumption and biological aging was nonlinear (P = .049 for nonlinearity). The association tended to be stronger in men than in women, but this was not statistically significant.
• Including the Mediterranean Diet Score in the model slightly attenuated the association by 9.1%, indicating that poor nutritional content was likely to explain a small part of the underlying mechanism.

IN PRACTICE:

“Our results showed that the UPFs–biological aging association was weakly explained by the poor nutritional composition of these highly processed foods, suggesting that biological aging could be mainly influenced by non-nutrient food characteristics, which include altered food matrix, contact materials and neo-formed compounds,” the authors wrote.

 

SOURCE:

The study was led by Simona Esposito, Research Unit of Epidemiology and Prevention, IRCCS Neuromed, Isernia, Italy. It was published online in The American Journal of Clinical Nutrition.

 

LIMITATIONS:

The cross-sectional design of the study limited the ability to determine the temporal directionality of the association, and the observational nature of the study limited the ability to establish the causality between UPF consumption and biological aging. The use of self-reported dietary data may have introduced recall bias. The study population was limited to adults from Central-Southern Italy, which may affect the generalizability of the findings.

 

DISCLOSURES:

The study was developed within the project funded by the Next Generation European Union “Age-It — Ageing well in an ageing society” project, National Recovery and Resilience Plan. The analyses were partially supported by the Italian Ministry of Health. The authors declared no 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 appeared on Medscape.com.

TOPLINE:

Consumption of ultraprocessed foods (UPFs), such as carbonated drinks, processed meats, and sweet or savory packaged snacks, is associated with accelerated biological aging, as measured by 36 blood-based biomarkers, and factors other than poor nutritional content may be to blame.

METHODOLOGY:

• Previous studies have reported an association between high consumption of UPFs and some measures of early biological aging, such as shorter telomere length, cognitive decline, and frailty, but the relationship is largely unexplored so far, including exactly how UPFs may harm health.
• To examine the association between UPF consumption and biological aging, researchers conducted a cross-sectional analysis of 22,495 participants (mean chronological age, 55.6 years; 52% women) from the Moli-sani Study in Italy, who were recruited between 2005 and 2010.
• Food intake was assessed with a food frequency questionnaire that covered 188 different food items, each of which was categorized into one of four groups based on the extent of processing, ranging from minimally processed foods, such as fruits, vegetables, meat and fish, to UPFs.
• UPF intake was determined by weight, using the ratio of UPFs to the total weight of food and beverages (g/d), and participants were categorized into sex-specific fifths according to the proportion of UPFs in their total food intake. Diet quality was also evaluated using the Mediterranean Diet Score.
• Biological age was computed using a deep neural network approach based on 36 circulating blood biomarkers, and the mean difference between the mean biological and chronological ages was analyzed.

TAKEAWAY:

• The mean difference between biological and chronological ages of the participants was –0.70 years.
• Higher intake of UPFs was associated with accelerated biological aging compared with the lowest intake (regression coefficient, 0.34; 95% CI, 0.08-0.61), with a mean difference between the biological and chronological ages of −4.1 years and 1.6 years in those with the lowest and highest intakes, respectively.
• The association between UPF consumption and biological aging was nonlinear (P = .049 for nonlinearity). The association tended to be stronger in men than in women, but this was not statistically significant.
• Including the Mediterranean Diet Score in the model slightly attenuated the association by 9.1%, indicating that poor nutritional content was likely to explain a small part of the underlying mechanism.

IN PRACTICE:

“Our results showed that the UPFs–biological aging association was weakly explained by the poor nutritional composition of these highly processed foods, suggesting that biological aging could be mainly influenced by non-nutrient food characteristics, which include altered food matrix, contact materials and neo-formed compounds,” the authors wrote.

 

SOURCE:

The study was led by Simona Esposito, Research Unit of Epidemiology and Prevention, IRCCS Neuromed, Isernia, Italy. It was published online in The American Journal of Clinical Nutrition.

 

LIMITATIONS:

The cross-sectional design of the study limited the ability to determine the temporal directionality of the association, and the observational nature of the study limited the ability to establish the causality between UPF consumption and biological aging. The use of self-reported dietary data may have introduced recall bias. The study population was limited to adults from Central-Southern Italy, which may affect the generalizability of the findings.

 

DISCLOSURES:

The study was developed within the project funded by the Next Generation European Union “Age-It — Ageing well in an ageing society” project, National Recovery and Resilience Plan. The analyses were partially supported by the Italian Ministry of Health. The authors declared no 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 appeared on Medscape.com.

TOPLINE:

Consumption of ultraprocessed foods (UPFs), such as carbonated drinks, processed meats, and sweet or savory packaged snacks, is associated with accelerated biological aging, as measured by 36 blood-based biomarkers, and factors other than poor nutritional content may be to blame.

METHODOLOGY:

• Previous studies have reported an association between high consumption of UPFs and some measures of early biological aging, such as shorter telomere length, cognitive decline, and frailty, but the relationship is largely unexplored so far, including exactly how UPFs may harm health.
• To examine the association between UPF consumption and biological aging, researchers conducted a cross-sectional analysis of 22,495 participants (mean chronological age, 55.6 years; 52% women) from the Moli-sani Study in Italy, who were recruited between 2005 and 2010.
• Food intake was assessed with a food frequency questionnaire that covered 188 different food items, each of which was categorized into one of four groups based on the extent of processing, ranging from minimally processed foods, such as fruits, vegetables, meat and fish, to UPFs.
• UPF intake was determined by weight, using the ratio of UPFs to the total weight of food and beverages (g/d), and participants were categorized into sex-specific fifths according to the proportion of UPFs in their total food intake. Diet quality was also evaluated using the Mediterranean Diet Score.
• Biological age was computed using a deep neural network approach based on 36 circulating blood biomarkers, and the mean difference between the mean biological and chronological ages was analyzed.

TAKEAWAY:

• The mean difference between biological and chronological ages of the participants was –0.70 years.
• Higher intake of UPFs was associated with accelerated biological aging compared with the lowest intake (regression coefficient, 0.34; 95% CI, 0.08-0.61), with a mean difference between the biological and chronological ages of −4.1 years and 1.6 years in those with the lowest and highest intakes, respectively.
• The association between UPF consumption and biological aging was nonlinear (P = .049 for nonlinearity). The association tended to be stronger in men than in women, but this was not statistically significant.
• Including the Mediterranean Diet Score in the model slightly attenuated the association by 9.1%, indicating that poor nutritional content was likely to explain a small part of the underlying mechanism.

IN PRACTICE:

“Our results showed that the UPFs–biological aging association was weakly explained by the poor nutritional composition of these highly processed foods, suggesting that biological aging could be mainly influenced by non-nutrient food characteristics, which include altered food matrix, contact materials and neo-formed compounds,” the authors wrote.

 

SOURCE:

The study was led by Simona Esposito, Research Unit of Epidemiology and Prevention, IRCCS Neuromed, Isernia, Italy. It was published online in The American Journal of Clinical Nutrition.

 

LIMITATIONS:

The cross-sectional design of the study limited the ability to determine the temporal directionality of the association, and the observational nature of the study limited the ability to establish the causality between UPF consumption and biological aging. The use of self-reported dietary data may have introduced recall bias. The study population was limited to adults from Central-Southern Italy, which may affect the generalizability of the findings.

 

DISCLOSURES:

The study was developed within the project funded by the Next Generation European Union “Age-It — Ageing well in an ageing society” project, National Recovery and Resilience Plan. The analyses were partially supported by the Italian Ministry of Health. The authors declared no 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 appeared on Medscape.com.

Adults with diabetes who participated in telehealth visits reported similar levels of care, trust in the healthcare system, and patient-centered communication compared to those who had in-person visits, a cross-sectional study suggested. 

The authors urged continued integration of telehealth into diabetes care beyond December 31, 2024, when the pandemic public health emergency ends, potentially limiting such services.

The study “provides population-level evidence that telehealth can deliver care quality comparable to in-person visits in diabetes management,” lead author Young-Rock Hong, PhD, MPH, an assistant professor in the University of Florida, Gainesville, told this news organization.

“Perhaps the most meaningful finding was the high utilization of telephone-only visits among older adults,” he said. “This has important policy implications, particularly as some insurers and healthcare systems have pushed to restrict telehealth coverage to video-only visits.”

“Maintaining telephone visit coverage is crucial for equitable access, especially for older adults who may be less comfortable with video technology; those with limited internet access; or patients facing other barriers to video visits,” he explained. 

The study was published online in BMJ Open.

 

Video-only, Voice-only, Both

The researchers did a secondary analysis of data from the 2022 Health Information National Trends Survey, a nationally representative survey that includes information on health communication and knowledge and perceptions about all health conditions among US adults aged ≥ 18 years.

Participants had a self-reported diagnosis of type 1 or type 2 diabetes. The mean age was 59.4 years; 50% were women; and 53% were non-Hispanic White individuals.

Primary and secondary outcomes were use of telehealth in the last 12-months; telehealth modality; overall perception of quality of care; perceived trust in the healthcare system; and patient-centered communication score.

In the analysis of 1116 participants representing 33.6 million individuals, 48.1% reported telehealth use in the past 12 months.

Telehealth users were more likely to be younger and women with higher household incomes and health insurance coverage; live in metropolitan areas; and have multiple chronic conditions, poorer perceived health status, and more frequent physician visits than nonusers.

After adjustment, adults aged ≥ 65 years had a significantly lower likelihood of telehealth use than those ages 18-49 years (odds ratio [OR], 0.43).

Higher income and more frequent healthcare visits were predictors of telehealth usage, with no significant differences across race, education, or location. 

Those with a household income between $35,000 and $74,999 had more than double the likelihood of telehealth use (OR, 2.14) than those with incomes below $35,000.

Among telehealth users, 39.3% reported having video-only; 35%, phone (voice)-only; and 25.7%, both modalities. Among those aged ≥ 65 years, 55.5% used phone calls only and 25.5% used video only. In contrast, those aged 18-49 years had higher rates of video-only use (36.1%) and combined video/phone use (31.2%).

Healthcare provider recommendation (68.1%) was the most common reason for telehealth use, followed by convenience (57.7%), avoiding potential COVID-19 exposure (48.1%), and obtaining advice about the need for in-person care (23.6%).

Nonusers said they preferred in-person visits and also cited privacy concerns and technology challenges.

Patient-reported quality-of-care outcomes were comparable between telehealth users and nonusers, with no significant differences by telehealth modality or area of residence (urban or rural).

Around 70% of individuals with diabetes in both groups rated their quality of care as “excellent” and “very good;” fewer than 10% rated their care as “fair” and “poor.” 

Similarly, trust in the healthcare system was comparable between users and nonusers: 41.3% of telehealth users 41% of nonusers reported trusting the healthcare system “very much.” Patient-centered communication scores were also similar between users and nonusers.

Telehealth appears to be a good option from the providers’ perspective as well, according to the authors. A previous study by the team found more than 80% of US physicians intended to continue telehealth beyond the pandemic.

“The recent unanimous bipartisan passage of the Telehealth Modernization Act by the House Energy & Commerce Committee signals strong political support for extending telehealth flexibilities through 2026,” Hong said. “The bill addresses key access issues by permanently removing geographic restrictions, expanding eligible providers, and maintaining audio-only coverage — provisions that align with our study’s findings about the importance of telephone visits, particularly for older adults and underserved populations.”

There is concern that extending telehealth services might increase Medicare spending by over $2 billion, he added. “While this may be a valid concern, there is a need for more robust evidence regarding the overall value of telehealth services — ie, the ‘benefits’ they provide relative to their costs and outcomes.”

 

Reassuring, but More Research Needed

COVID prompted “dramatic shifts” in care delivery from in-person to telehealth, Kevin Peterson, MD, MPH, American Diabetes Association vice president of primary care told this news organization. “The authors’ findings provide reassurance that these changes provided for additional convenience in care delivery without being associated with compromises in patient-reported care quality.”

However, he said, “the study does not necessarily capture representative samples of rural and underserved populations, making the impact of telehealth on health equity difficult to determine.” In addition, although patient-perceived care quality did not change with telehealth delivery, the study “does not address impacts on safety, clinical outcomes, equity, costs, or other important measures.”

Furthermore, he noted, “this is an association study that occurred during the dramatic changes brought about by COVID. It may not represent provider or patient preferences that characterize the role of telehealth under more normal circumstances.”

For now, clinicians should be aware that “initial evidence suggests that telehealth can be integrated into care without significantly compromising the patient’s perception of the quality of care,” he concluded.

No funding was declared. Hong and Peterson reported no conflicts of interest.

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

Adults with diabetes who participated in telehealth visits reported similar levels of care, trust in the healthcare system, and patient-centered communication compared to those who had in-person visits, a cross-sectional study suggested. 

The authors urged continued integration of telehealth into diabetes care beyond December 31, 2024, when the pandemic public health emergency ends, potentially limiting such services.

The study “provides population-level evidence that telehealth can deliver care quality comparable to in-person visits in diabetes management,” lead author Young-Rock Hong, PhD, MPH, an assistant professor in the University of Florida, Gainesville, told this news organization.

“Perhaps the most meaningful finding was the high utilization of telephone-only visits among older adults,” he said. “This has important policy implications, particularly as some insurers and healthcare systems have pushed to restrict telehealth coverage to video-only visits.”

“Maintaining telephone visit coverage is crucial for equitable access, especially for older adults who may be less comfortable with video technology; those with limited internet access; or patients facing other barriers to video visits,” he explained. 

The study was published online in BMJ Open.

 

Video-only, Voice-only, Both

The researchers did a secondary analysis of data from the 2022 Health Information National Trends Survey, a nationally representative survey that includes information on health communication and knowledge and perceptions about all health conditions among US adults aged ≥ 18 years.

Participants had a self-reported diagnosis of type 1 or type 2 diabetes. The mean age was 59.4 years; 50% were women; and 53% were non-Hispanic White individuals.

Primary and secondary outcomes were use of telehealth in the last 12-months; telehealth modality; overall perception of quality of care; perceived trust in the healthcare system; and patient-centered communication score.

In the analysis of 1116 participants representing 33.6 million individuals, 48.1% reported telehealth use in the past 12 months.

Telehealth users were more likely to be younger and women with higher household incomes and health insurance coverage; live in metropolitan areas; and have multiple chronic conditions, poorer perceived health status, and more frequent physician visits than nonusers.

After adjustment, adults aged ≥ 65 years had a significantly lower likelihood of telehealth use than those ages 18-49 years (odds ratio [OR], 0.43).

Higher income and more frequent healthcare visits were predictors of telehealth usage, with no significant differences across race, education, or location. 

Those with a household income between $35,000 and $74,999 had more than double the likelihood of telehealth use (OR, 2.14) than those with incomes below $35,000.

Among telehealth users, 39.3% reported having video-only; 35%, phone (voice)-only; and 25.7%, both modalities. Among those aged ≥ 65 years, 55.5% used phone calls only and 25.5% used video only. In contrast, those aged 18-49 years had higher rates of video-only use (36.1%) and combined video/phone use (31.2%).

Healthcare provider recommendation (68.1%) was the most common reason for telehealth use, followed by convenience (57.7%), avoiding potential COVID-19 exposure (48.1%), and obtaining advice about the need for in-person care (23.6%).

Nonusers said they preferred in-person visits and also cited privacy concerns and technology challenges.

Patient-reported quality-of-care outcomes were comparable between telehealth users and nonusers, with no significant differences by telehealth modality or area of residence (urban or rural).

Around 70% of individuals with diabetes in both groups rated their quality of care as “excellent” and “very good;” fewer than 10% rated their care as “fair” and “poor.” 

Similarly, trust in the healthcare system was comparable between users and nonusers: 41.3% of telehealth users 41% of nonusers reported trusting the healthcare system “very much.” Patient-centered communication scores were also similar between users and nonusers.

Telehealth appears to be a good option from the providers’ perspective as well, according to the authors. A previous study by the team found more than 80% of US physicians intended to continue telehealth beyond the pandemic.

“The recent unanimous bipartisan passage of the Telehealth Modernization Act by the House Energy & Commerce Committee signals strong political support for extending telehealth flexibilities through 2026,” Hong said. “The bill addresses key access issues by permanently removing geographic restrictions, expanding eligible providers, and maintaining audio-only coverage — provisions that align with our study’s findings about the importance of telephone visits, particularly for older adults and underserved populations.”

There is concern that extending telehealth services might increase Medicare spending by over $2 billion, he added. “While this may be a valid concern, there is a need for more robust evidence regarding the overall value of telehealth services — ie, the ‘benefits’ they provide relative to their costs and outcomes.”

 

Reassuring, but More Research Needed

COVID prompted “dramatic shifts” in care delivery from in-person to telehealth, Kevin Peterson, MD, MPH, American Diabetes Association vice president of primary care told this news organization. “The authors’ findings provide reassurance that these changes provided for additional convenience in care delivery without being associated with compromises in patient-reported care quality.”

However, he said, “the study does not necessarily capture representative samples of rural and underserved populations, making the impact of telehealth on health equity difficult to determine.” In addition, although patient-perceived care quality did not change with telehealth delivery, the study “does not address impacts on safety, clinical outcomes, equity, costs, or other important measures.”

Furthermore, he noted, “this is an association study that occurred during the dramatic changes brought about by COVID. It may not represent provider or patient preferences that characterize the role of telehealth under more normal circumstances.”

For now, clinicians should be aware that “initial evidence suggests that telehealth can be integrated into care without significantly compromising the patient’s perception of the quality of care,” he concluded.

No funding was declared. Hong and Peterson reported no conflicts of interest.

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

Adults with diabetes who participated in telehealth visits reported similar levels of care, trust in the healthcare system, and patient-centered communication compared to those who had in-person visits, a cross-sectional study suggested. 

The authors urged continued integration of telehealth into diabetes care beyond December 31, 2024, when the pandemic public health emergency ends, potentially limiting such services.

The study “provides population-level evidence that telehealth can deliver care quality comparable to in-person visits in diabetes management,” lead author Young-Rock Hong, PhD, MPH, an assistant professor in the University of Florida, Gainesville, told this news organization.

“Perhaps the most meaningful finding was the high utilization of telephone-only visits among older adults,” he said. “This has important policy implications, particularly as some insurers and healthcare systems have pushed to restrict telehealth coverage to video-only visits.”

“Maintaining telephone visit coverage is crucial for equitable access, especially for older adults who may be less comfortable with video technology; those with limited internet access; or patients facing other barriers to video visits,” he explained. 

The study was published online in BMJ Open.

 

Video-only, Voice-only, Both

The researchers did a secondary analysis of data from the 2022 Health Information National Trends Survey, a nationally representative survey that includes information on health communication and knowledge and perceptions about all health conditions among US adults aged ≥ 18 years.

Participants had a self-reported diagnosis of type 1 or type 2 diabetes. The mean age was 59.4 years; 50% were women; and 53% were non-Hispanic White individuals.

Primary and secondary outcomes were use of telehealth in the last 12-months; telehealth modality; overall perception of quality of care; perceived trust in the healthcare system; and patient-centered communication score.

In the analysis of 1116 participants representing 33.6 million individuals, 48.1% reported telehealth use in the past 12 months.

Telehealth users were more likely to be younger and women with higher household incomes and health insurance coverage; live in metropolitan areas; and have multiple chronic conditions, poorer perceived health status, and more frequent physician visits than nonusers.

After adjustment, adults aged ≥ 65 years had a significantly lower likelihood of telehealth use than those ages 18-49 years (odds ratio [OR], 0.43).

Higher income and more frequent healthcare visits were predictors of telehealth usage, with no significant differences across race, education, or location. 

Those with a household income between $35,000 and $74,999 had more than double the likelihood of telehealth use (OR, 2.14) than those with incomes below $35,000.

Among telehealth users, 39.3% reported having video-only; 35%, phone (voice)-only; and 25.7%, both modalities. Among those aged ≥ 65 years, 55.5% used phone calls only and 25.5% used video only. In contrast, those aged 18-49 years had higher rates of video-only use (36.1%) and combined video/phone use (31.2%).

Healthcare provider recommendation (68.1%) was the most common reason for telehealth use, followed by convenience (57.7%), avoiding potential COVID-19 exposure (48.1%), and obtaining advice about the need for in-person care (23.6%).

Nonusers said they preferred in-person visits and also cited privacy concerns and technology challenges.

Patient-reported quality-of-care outcomes were comparable between telehealth users and nonusers, with no significant differences by telehealth modality or area of residence (urban or rural).

Around 70% of individuals with diabetes in both groups rated their quality of care as “excellent” and “very good;” fewer than 10% rated their care as “fair” and “poor.” 

Similarly, trust in the healthcare system was comparable between users and nonusers: 41.3% of telehealth users 41% of nonusers reported trusting the healthcare system “very much.” Patient-centered communication scores were also similar between users and nonusers.

Telehealth appears to be a good option from the providers’ perspective as well, according to the authors. A previous study by the team found more than 80% of US physicians intended to continue telehealth beyond the pandemic.

“The recent unanimous bipartisan passage of the Telehealth Modernization Act by the House Energy & Commerce Committee signals strong political support for extending telehealth flexibilities through 2026,” Hong said. “The bill addresses key access issues by permanently removing geographic restrictions, expanding eligible providers, and maintaining audio-only coverage — provisions that align with our study’s findings about the importance of telephone visits, particularly for older adults and underserved populations.”

There is concern that extending telehealth services might increase Medicare spending by over $2 billion, he added. “While this may be a valid concern, there is a need for more robust evidence regarding the overall value of telehealth services — ie, the ‘benefits’ they provide relative to their costs and outcomes.”

 

Reassuring, but More Research Needed

COVID prompted “dramatic shifts” in care delivery from in-person to telehealth, Kevin Peterson, MD, MPH, American Diabetes Association vice president of primary care told this news organization. “The authors’ findings provide reassurance that these changes provided for additional convenience in care delivery without being associated with compromises in patient-reported care quality.”

However, he said, “the study does not necessarily capture representative samples of rural and underserved populations, making the impact of telehealth on health equity difficult to determine.” In addition, although patient-perceived care quality did not change with telehealth delivery, the study “does not address impacts on safety, clinical outcomes, equity, costs, or other important measures.”

Furthermore, he noted, “this is an association study that occurred during the dramatic changes brought about by COVID. It may not represent provider or patient preferences that characterize the role of telehealth under more normal circumstances.”

For now, clinicians should be aware that “initial evidence suggests that telehealth can be integrated into care without significantly compromising the patient’s perception of the quality of care,” he concluded.

No funding was declared. Hong and Peterson reported no conflicts of interest.

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

TOPLINE:

Light-intensity walking reduces postprandial glucose and diastolic blood pressure in young adults with obesity and can improve insulin levels, depending on the walking pattern.

METHODOLOGY:

• Researchers conducted a randomized crossover trial with 16 young adults aged 18-34 years with body mass index (BMI) ≥ 25 in Bangkok, Thailand, to examine the effects of different light-intensity walking patterns on postprandial cardiometabolic responses.
• Participants (mean age, 25; mean BMI, 29.8) engaged in four 7-hour experimental conditions, each involving a different activity: Uninterrupted sitting, 30-minutes of light-intensity walking, 3-minute light-intensity walking every 30 minutes, or a combination of both walking regimens. There was a 7- to 20-day washout period between each experiment period.
• Baseline and 6-hour postprandial concentrations of glucose, insulin, triglycerides, and blood pressure were measured.
• Incremental areas under the curve (iAUC) for each outcome and average blood pressure were compared between sitting and walking conditions.

TAKEAWAY:

• All the walking interventions reduced postprandial glucose concentrations and diastolic blood pressure compared with uninterrupted sitting.
• Continuous 30-minute light-intensity walking alone or combined with brief 3-minute bouts also attenuated postprandial insulin concentrations.
• No significant differences were found for triglycerides iAUC and systolic blood pressure between the four experiment conditions.

IN PRACTICE:

“These findings support the notion that engaging in light-intensity walking, regardless of the pattern, provides benefits to glycemic control. Moreover, the timing and patterns of light-intensity physical activity may be an important factor in reducing postprandial insulin concentrations,” the authors wrote.

SOURCE:

The study, led by Waris Wongpipit, PhD, Division of Health and Physical Education, Chulalongkorn University in Bangkok, Thailand, was published online in The Journal of Clinical Endocrinology & Metabolism.

LIMITATIONS:

The study’s small sample size of 16 participants may limit the generalizability of the findings. The short duration of the study (7-hour experimental conditions) may not reflect long-term effects. The prescribed activities and dietary profiles, along with the controlled laboratory setting, may not accurately represent real-world conditions. The lack of objective physical activity/sedentary behavior measurement to confirm compliance between conditions is a limitation.

DISCLOSURES:

This study was supported by grants from the Office of the Permanent Secretary, Ministry of Higher Education, Science, Research and Innovation, Thailand Science Research and Innovation, and Chulalongkorn University. Wongpipit received grant support from these organizations. Paddy C. Dempsey is supported by a National Health and Medical Research Council of Australia research fellowship. The other authors had no disclosures.

 

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 appeared on Medscape.com.

TOPLINE:

Light-intensity walking reduces postprandial glucose and diastolic blood pressure in young adults with obesity and can improve insulin levels, depending on the walking pattern.

METHODOLOGY:

• Researchers conducted a randomized crossover trial with 16 young adults aged 18-34 years with body mass index (BMI) ≥ 25 in Bangkok, Thailand, to examine the effects of different light-intensity walking patterns on postprandial cardiometabolic responses.
• Participants (mean age, 25; mean BMI, 29.8) engaged in four 7-hour experimental conditions, each involving a different activity: Uninterrupted sitting, 30-minutes of light-intensity walking, 3-minute light-intensity walking every 30 minutes, or a combination of both walking regimens. There was a 7- to 20-day washout period between each experiment period.
• Baseline and 6-hour postprandial concentrations of glucose, insulin, triglycerides, and blood pressure were measured.
• Incremental areas under the curve (iAUC) for each outcome and average blood pressure were compared between sitting and walking conditions.

TAKEAWAY:

• All the walking interventions reduced postprandial glucose concentrations and diastolic blood pressure compared with uninterrupted sitting.
• Continuous 30-minute light-intensity walking alone or combined with brief 3-minute bouts also attenuated postprandial insulin concentrations.
• No significant differences were found for triglycerides iAUC and systolic blood pressure between the four experiment conditions.

IN PRACTICE:

“These findings support the notion that engaging in light-intensity walking, regardless of the pattern, provides benefits to glycemic control. Moreover, the timing and patterns of light-intensity physical activity may be an important factor in reducing postprandial insulin concentrations,” the authors wrote.

SOURCE:

The study, led by Waris Wongpipit, PhD, Division of Health and Physical Education, Chulalongkorn University in Bangkok, Thailand, was published online in The Journal of Clinical Endocrinology & Metabolism.

LIMITATIONS:

The study’s small sample size of 16 participants may limit the generalizability of the findings. The short duration of the study (7-hour experimental conditions) may not reflect long-term effects. The prescribed activities and dietary profiles, along with the controlled laboratory setting, may not accurately represent real-world conditions. The lack of objective physical activity/sedentary behavior measurement to confirm compliance between conditions is a limitation.

DISCLOSURES:

This study was supported by grants from the Office of the Permanent Secretary, Ministry of Higher Education, Science, Research and Innovation, Thailand Science Research and Innovation, and Chulalongkorn University. Wongpipit received grant support from these organizations. Paddy C. Dempsey is supported by a National Health and Medical Research Council of Australia research fellowship. The other authors had no disclosures.

 

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 appeared on Medscape.com.

TOPLINE:

Light-intensity walking reduces postprandial glucose and diastolic blood pressure in young adults with obesity and can improve insulin levels, depending on the walking pattern.

METHODOLOGY:

• Researchers conducted a randomized crossover trial with 16 young adults aged 18-34 years with body mass index (BMI) ≥ 25 in Bangkok, Thailand, to examine the effects of different light-intensity walking patterns on postprandial cardiometabolic responses.
• Participants (mean age, 25; mean BMI, 29.8) engaged in four 7-hour experimental conditions, each involving a different activity: Uninterrupted sitting, 30-minutes of light-intensity walking, 3-minute light-intensity walking every 30 minutes, or a combination of both walking regimens. There was a 7- to 20-day washout period between each experiment period.
• Baseline and 6-hour postprandial concentrations of glucose, insulin, triglycerides, and blood pressure were measured.
• Incremental areas under the curve (iAUC) for each outcome and average blood pressure were compared between sitting and walking conditions.

TAKEAWAY:

• All the walking interventions reduced postprandial glucose concentrations and diastolic blood pressure compared with uninterrupted sitting.
• Continuous 30-minute light-intensity walking alone or combined with brief 3-minute bouts also attenuated postprandial insulin concentrations.
• No significant differences were found for triglycerides iAUC and systolic blood pressure between the four experiment conditions.

IN PRACTICE:

“These findings support the notion that engaging in light-intensity walking, regardless of the pattern, provides benefits to glycemic control. Moreover, the timing and patterns of light-intensity physical activity may be an important factor in reducing postprandial insulin concentrations,” the authors wrote.

SOURCE:

The study, led by Waris Wongpipit, PhD, Division of Health and Physical Education, Chulalongkorn University in Bangkok, Thailand, was published online in The Journal of Clinical Endocrinology & Metabolism.

LIMITATIONS:

The study’s small sample size of 16 participants may limit the generalizability of the findings. The short duration of the study (7-hour experimental conditions) may not reflect long-term effects. The prescribed activities and dietary profiles, along with the controlled laboratory setting, may not accurately represent real-world conditions. The lack of objective physical activity/sedentary behavior measurement to confirm compliance between conditions is a limitation.

DISCLOSURES:

This study was supported by grants from the Office of the Permanent Secretary, Ministry of Higher Education, Science, Research and Innovation, Thailand Science Research and Innovation, and Chulalongkorn University. Wongpipit received grant support from these organizations. Paddy C. Dempsey is supported by a National Health and Medical Research Council of Australia research fellowship. The other authors had no disclosures.

 

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 appeared on Medscape.com.

TOPLINE:

Replacing animal-based protein sources with plant-based alternatives in older adults reduced both the quality and quantity of protein intake only when all animal-based foods were eliminated for a vegan scenario, finds a simulation study that suggests a switch to 60% plant-based protein seems to be safe.

METHODOLOGY:

• For environmental and health reasons, the Dutch Health Council advises a switch to an animal-based to plant-based protein ratio of 40:60, but older adults also need adequate protein intake to prevent muscle loss and maintain health, and it’s uncertain if they can meet their protein requirements through a more sustainable diet.
• This simulation study evaluated the impact of more sustainable eating patterns on protein quantity and quality by using data of 607 community-dwelling older adults aged 65-79 years from the Dutch National Food Consumption Survey 2019-2021.
• Data on food consumption were collected via two 24-hour dietary recalls per participant on nonconsecutive days and calculated as three main meals and four in-between moments each day.
• In the simulation, certain food products in the original diet were replaced from a list of similar plant-based alternatives, using a random number generator, to create scenarios for two flexitarian diets (40% and 80% meat and fish were replaced), one pescetarian diet (meat was replaced, but not fish and other animal-based products), one vegetarian diet (meat and fish were replaced, but not other animal-based products), and one vegan diet (fish, meat, and animal-based products were replaced).
• Protein intake was calculated in three ways for each meal moment, including by total protein intake (quantity) and by the proportion of indispensable amino acids that must be eaten together within a limited timeframe (quality).

TAKEAWAY:

• In the reference diet, the total daily plant-based protein intake was 39.0% in men and 37.7% in women, while in the vegetarian scenario, it was 59.1% in men and 54.2% in women.
• In the flexitarian, pescetarian, and vegetarian scenarios, the usable protein intake was comparable; in the vegan scenario, both total protein intake and usable protein intake were lower, leading to nearly 50% less usable protein than in the original diet.
• In the original diet, 7.5% of men and 11.1% of women did not meet the estimated average requirements (EARs) for utilizable protein; in the vegan scenario, 83.3% of both sexes had a protein intake below the EAR.
• The loss in protein intake (quantity) in all scenarios was mainly observed at dinner; the loss in protein quality was greatest at breakfast and lunch, especially in lysine (found in beans or soy milk).

IN PRACTICE:

“Changing protein intake to 60% plant-based protein seems to be safe for older adults in terms of protein intake. In contrast, a vegan pattern was associated with a substantial decline in protein availability, leading to a majority of older adults not reaching the recommended protein levels,” the authors wrote.

SOURCE:

The study was led by Jos W. Borkent, HAN University of Applied Sciences, Nijmegen, the Netherlands. It was published online in The Journal of Nutrition, Health and Aging.

LIMITATIONS:

Study limitations included the use of a simulation model, which may not fully reflect real-life dietary practices. The strict timeframe for assessing protein quality (optimal combinations of indispensible amino acids) within one meal moment may have led to an underestimation of protein availability, especially in the vegan scenario. Additionally, the choice of processed meat replacements in the vegan scenario may not have represented protein sources of the highest quality available. Higher protein quality per meal in the vegan scenario is possible when smart combinations are made in multiple meal components.

DISCLOSURES:

The study was partly funded by a grant from the Taskforce for Applied Research SIA, which is part of the Netherlands Organisation for Scientific Research and financed by the Dutch Ministry of Education, Culture and Science and by a fund of the Dutch Dairy Association. The authors declared that they had no 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 appeared on Medscape.com.

TOPLINE:

Replacing animal-based protein sources with plant-based alternatives in older adults reduced both the quality and quantity of protein intake only when all animal-based foods were eliminated for a vegan scenario, finds a simulation study that suggests a switch to 60% plant-based protein seems to be safe.

METHODOLOGY:

• For environmental and health reasons, the Dutch Health Council advises a switch to an animal-based to plant-based protein ratio of 40:60, but older adults also need adequate protein intake to prevent muscle loss and maintain health, and it’s uncertain if they can meet their protein requirements through a more sustainable diet.
• This simulation study evaluated the impact of more sustainable eating patterns on protein quantity and quality by using data of 607 community-dwelling older adults aged 65-79 years from the Dutch National Food Consumption Survey 2019-2021.
• Data on food consumption were collected via two 24-hour dietary recalls per participant on nonconsecutive days and calculated as three main meals and four in-between moments each day.
• In the simulation, certain food products in the original diet were replaced from a list of similar plant-based alternatives, using a random number generator, to create scenarios for two flexitarian diets (40% and 80% meat and fish were replaced), one pescetarian diet (meat was replaced, but not fish and other animal-based products), one vegetarian diet (meat and fish were replaced, but not other animal-based products), and one vegan diet (fish, meat, and animal-based products were replaced).
• Protein intake was calculated in three ways for each meal moment, including by total protein intake (quantity) and by the proportion of indispensable amino acids that must be eaten together within a limited timeframe (quality).

TAKEAWAY:

• In the reference diet, the total daily plant-based protein intake was 39.0% in men and 37.7% in women, while in the vegetarian scenario, it was 59.1% in men and 54.2% in women.
• In the flexitarian, pescetarian, and vegetarian scenarios, the usable protein intake was comparable; in the vegan scenario, both total protein intake and usable protein intake were lower, leading to nearly 50% less usable protein than in the original diet.
• In the original diet, 7.5% of men and 11.1% of women did not meet the estimated average requirements (EARs) for utilizable protein; in the vegan scenario, 83.3% of both sexes had a protein intake below the EAR.
• The loss in protein intake (quantity) in all scenarios was mainly observed at dinner; the loss in protein quality was greatest at breakfast and lunch, especially in lysine (found in beans or soy milk).

IN PRACTICE:

“Changing protein intake to 60% plant-based protein seems to be safe for older adults in terms of protein intake. In contrast, a vegan pattern was associated with a substantial decline in protein availability, leading to a majority of older adults not reaching the recommended protein levels,” the authors wrote.

SOURCE:

The study was led by Jos W. Borkent, HAN University of Applied Sciences, Nijmegen, the Netherlands. It was published online in The Journal of Nutrition, Health and Aging.

LIMITATIONS:

Study limitations included the use of a simulation model, which may not fully reflect real-life dietary practices. The strict timeframe for assessing protein quality (optimal combinations of indispensible amino acids) within one meal moment may have led to an underestimation of protein availability, especially in the vegan scenario. Additionally, the choice of processed meat replacements in the vegan scenario may not have represented protein sources of the highest quality available. Higher protein quality per meal in the vegan scenario is possible when smart combinations are made in multiple meal components.

DISCLOSURES:

The study was partly funded by a grant from the Taskforce for Applied Research SIA, which is part of the Netherlands Organisation for Scientific Research and financed by the Dutch Ministry of Education, Culture and Science and by a fund of the Dutch Dairy Association. The authors declared that they had no 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 appeared on Medscape.com.

TOPLINE:

Replacing animal-based protein sources with plant-based alternatives in older adults reduced both the quality and quantity of protein intake only when all animal-based foods were eliminated for a vegan scenario, finds a simulation study that suggests a switch to 60% plant-based protein seems to be safe.

METHODOLOGY:

• For environmental and health reasons, the Dutch Health Council advises a switch to an animal-based to plant-based protein ratio of 40:60, but older adults also need adequate protein intake to prevent muscle loss and maintain health, and it’s uncertain if they can meet their protein requirements through a more sustainable diet.
• This simulation study evaluated the impact of more sustainable eating patterns on protein quantity and quality by using data of 607 community-dwelling older adults aged 65-79 years from the Dutch National Food Consumption Survey 2019-2021.
• Data on food consumption were collected via two 24-hour dietary recalls per participant on nonconsecutive days and calculated as three main meals and four in-between moments each day.
• In the simulation, certain food products in the original diet were replaced from a list of similar plant-based alternatives, using a random number generator, to create scenarios for two flexitarian diets (40% and 80% meat and fish were replaced), one pescetarian diet (meat was replaced, but not fish and other animal-based products), one vegetarian diet (meat and fish were replaced, but not other animal-based products), and one vegan diet (fish, meat, and animal-based products were replaced).
• Protein intake was calculated in three ways for each meal moment, including by total protein intake (quantity) and by the proportion of indispensable amino acids that must be eaten together within a limited timeframe (quality).

TAKEAWAY:

• In the reference diet, the total daily plant-based protein intake was 39.0% in men and 37.7% in women, while in the vegetarian scenario, it was 59.1% in men and 54.2% in women.
• In the flexitarian, pescetarian, and vegetarian scenarios, the usable protein intake was comparable; in the vegan scenario, both total protein intake and usable protein intake were lower, leading to nearly 50% less usable protein than in the original diet.
• In the original diet, 7.5% of men and 11.1% of women did not meet the estimated average requirements (EARs) for utilizable protein; in the vegan scenario, 83.3% of both sexes had a protein intake below the EAR.
• The loss in protein intake (quantity) in all scenarios was mainly observed at dinner; the loss in protein quality was greatest at breakfast and lunch, especially in lysine (found in beans or soy milk).

IN PRACTICE:

“Changing protein intake to 60% plant-based protein seems to be safe for older adults in terms of protein intake. In contrast, a vegan pattern was associated with a substantial decline in protein availability, leading to a majority of older adults not reaching the recommended protein levels,” the authors wrote.

SOURCE:

The study was led by Jos W. Borkent, HAN University of Applied Sciences, Nijmegen, the Netherlands. It was published online in The Journal of Nutrition, Health and Aging.

LIMITATIONS:

Study limitations included the use of a simulation model, which may not fully reflect real-life dietary practices. The strict timeframe for assessing protein quality (optimal combinations of indispensible amino acids) within one meal moment may have led to an underestimation of protein availability, especially in the vegan scenario. Additionally, the choice of processed meat replacements in the vegan scenario may not have represented protein sources of the highest quality available. Higher protein quality per meal in the vegan scenario is possible when smart combinations are made in multiple meal components.

DISCLOSURES:

The study was partly funded by a grant from the Taskforce for Applied Research SIA, which is part of the Netherlands Organisation for Scientific Research and financed by the Dutch Ministry of Education, Culture and Science and by a fund of the Dutch Dairy Association. The authors declared that they had no 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 appeared on Medscape.com.

VANCOUVER, BRITISH COLUMBIA — Conditions like diabetes and dementia are common in patients who are admitted to long-term care facilities, but aggressive management of these conditions in long-term care residents is not recommended, according to a presentation given at the Family Medicine Forum (FMF) 2024.

Hospitalizations for hypoglycemia are risky for patients with diabetes who are residents of long-term care facilities, particularly those aged 75 years or older, said Adam Gurau, MD, a family physician in Toronto. Gurau completed a fellowship in care of the elderly at the University of Toronto, in Ontario, Canada.

“A lot of studies have shown diabetes-related hospitalizations,” said Gurau. He cited a 2014 study that found that hypoglycemia hospitalization rates were twice as high in older patients (age, 75 years or older) as in younger patients (age, 65-74 years).

“It is important to keep in mind that our residents in long-term care are at increasing risk for hypoglycemia, and we really should try to reduce [this risk] and not use dangerous medications or potentially dangerous [means of] diabetes management,” said Gurau.

A Canadian study that examined the composite risk for emergency department visits, hospitalizations, or death within 30 days of reaching intensive glycemic control with high-risk agents (such as insulin or sulfonylureas) suggested little benefit and possible harm in using these agents in adults aged 75 years or older.

In addition, current guidelines on diabetes management encourage a different approach. “Looking at some of the more recent North American guidelines, many of them actually now recommend relaxing glycemic targets to reduce overtreatment and prevent hypoglycemia,” said Gurau.

 

Deprescribing Medications

Medication reviews present opportunities for taking a global view of a patient’s treatments and determining whether any drug can be removed from the list. “What we want to do is optimize medications,” said Gurau. “We’re not talking about adding medications. We’re talking about removing medications, which is, I think, what we should be doing.”

Some research suggests that patients are open to deprescribing. One survey examined older adults (mean age, 79.1 years) with three or more chronic conditions who had been prescribed at least five medications. The researchers found that most participants (77%) were willing to deprescribe one or more medicines if a doctor advised that it was possible. “General practitioners may be able to increase deprescribing by building trust with their patients and communicating evidence about the risks of medication use,” the researchers wrote.

About 62% of seniors living in a residential care home have a diagnosis of Alzheimer’s disease or another dementia, according to the Alzheimer Society of Canada. Evidence suggests that nonpharmacologic approaches, such as massage and touch therapy and music, can manage neuropsychiatric symptoms, such as aggression and agitation, that are associated with dementia in older adults, noted Gurau.

“We want to focus on nonpharmacologic approaches for many of these [long-term care] residents,” said Gurau. “We have to do as much as we can to exhaust all the nonpharmacologic approaches.”

 

Preventing Hospitalizations

Another challenge to tackle in long-term care is the unnecessary transfer of residents to hospital emergency departments, according to Gurau. “In many situations, it’s worth trying as hard as we can to treat them in the nursing home, as opposed to having them go to hospital.”

Researchers estimated that 25% of the transfers from long-term care facilities in Canada to hospital emergency departments in 2014 were potentially preventable.

Urinary tract infections accounted for 30% of hospital emergency department visits for potentially preventable conditions by older patients who are residents in long-term care, according to 2013-2014 data from the Canadian Institute for Health Information.

“There are lots of downsides to going to the hospital [from long-term care],” Gurau told this news organization. “There are risks for infections, risks for increasing delirium and agitation [in patients with dementia], and risks for other behavior that can really impact somebody’s life.”

Gurau reported having no relevant financial relationships.

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

VANCOUVER, BRITISH COLUMBIA — Conditions like diabetes and dementia are common in patients who are admitted to long-term care facilities, but aggressive management of these conditions in long-term care residents is not recommended, according to a presentation given at the Family Medicine Forum (FMF) 2024.

Hospitalizations for hypoglycemia are risky for patients with diabetes who are residents of long-term care facilities, particularly those aged 75 years or older, said Adam Gurau, MD, a family physician in Toronto. Gurau completed a fellowship in care of the elderly at the University of Toronto, in Ontario, Canada.

“A lot of studies have shown diabetes-related hospitalizations,” said Gurau. He cited a 2014 study that found that hypoglycemia hospitalization rates were twice as high in older patients (age, 75 years or older) as in younger patients (age, 65-74 years).

“It is important to keep in mind that our residents in long-term care are at increasing risk for hypoglycemia, and we really should try to reduce [this risk] and not use dangerous medications or potentially dangerous [means of] diabetes management,” said Gurau.

A Canadian study that examined the composite risk for emergency department visits, hospitalizations, or death within 30 days of reaching intensive glycemic control with high-risk agents (such as insulin or sulfonylureas) suggested little benefit and possible harm in using these agents in adults aged 75 years or older.

In addition, current guidelines on diabetes management encourage a different approach. “Looking at some of the more recent North American guidelines, many of them actually now recommend relaxing glycemic targets to reduce overtreatment and prevent hypoglycemia,” said Gurau.

 

Deprescribing Medications

Medication reviews present opportunities for taking a global view of a patient’s treatments and determining whether any drug can be removed from the list. “What we want to do is optimize medications,” said Gurau. “We’re not talking about adding medications. We’re talking about removing medications, which is, I think, what we should be doing.”

Some research suggests that patients are open to deprescribing. One survey examined older adults (mean age, 79.1 years) with three or more chronic conditions who had been prescribed at least five medications. The researchers found that most participants (77%) were willing to deprescribe one or more medicines if a doctor advised that it was possible. “General practitioners may be able to increase deprescribing by building trust with their patients and communicating evidence about the risks of medication use,” the researchers wrote.

About 62% of seniors living in a residential care home have a diagnosis of Alzheimer’s disease or another dementia, according to the Alzheimer Society of Canada. Evidence suggests that nonpharmacologic approaches, such as massage and touch therapy and music, can manage neuropsychiatric symptoms, such as aggression and agitation, that are associated with dementia in older adults, noted Gurau.

“We want to focus on nonpharmacologic approaches for many of these [long-term care] residents,” said Gurau. “We have to do as much as we can to exhaust all the nonpharmacologic approaches.”

 

Preventing Hospitalizations

Another challenge to tackle in long-term care is the unnecessary transfer of residents to hospital emergency departments, according to Gurau. “In many situations, it’s worth trying as hard as we can to treat them in the nursing home, as opposed to having them go to hospital.”

Researchers estimated that 25% of the transfers from long-term care facilities in Canada to hospital emergency departments in 2014 were potentially preventable.

Urinary tract infections accounted for 30% of hospital emergency department visits for potentially preventable conditions by older patients who are residents in long-term care, according to 2013-2014 data from the Canadian Institute for Health Information.

“There are lots of downsides to going to the hospital [from long-term care],” Gurau told this news organization. “There are risks for infections, risks for increasing delirium and agitation [in patients with dementia], and risks for other behavior that can really impact somebody’s life.”

Gurau reported having no relevant financial relationships.

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

VANCOUVER, BRITISH COLUMBIA — Conditions like diabetes and dementia are common in patients who are admitted to long-term care facilities, but aggressive management of these conditions in long-term care residents is not recommended, according to a presentation given at the Family Medicine Forum (FMF) 2024.

Hospitalizations for hypoglycemia are risky for patients with diabetes who are residents of long-term care facilities, particularly those aged 75 years or older, said Adam Gurau, MD, a family physician in Toronto. Gurau completed a fellowship in care of the elderly at the University of Toronto, in Ontario, Canada.

“A lot of studies have shown diabetes-related hospitalizations,” said Gurau. He cited a 2014 study that found that hypoglycemia hospitalization rates were twice as high in older patients (age, 75 years or older) as in younger patients (age, 65-74 years).

“It is important to keep in mind that our residents in long-term care are at increasing risk for hypoglycemia, and we really should try to reduce [this risk] and not use dangerous medications or potentially dangerous [means of] diabetes management,” said Gurau.

A Canadian study that examined the composite risk for emergency department visits, hospitalizations, or death within 30 days of reaching intensive glycemic control with high-risk agents (such as insulin or sulfonylureas) suggested little benefit and possible harm in using these agents in adults aged 75 years or older.

In addition, current guidelines on diabetes management encourage a different approach. “Looking at some of the more recent North American guidelines, many of them actually now recommend relaxing glycemic targets to reduce overtreatment and prevent hypoglycemia,” said Gurau.

 

Deprescribing Medications

Medication reviews present opportunities for taking a global view of a patient’s treatments and determining whether any drug can be removed from the list. “What we want to do is optimize medications,” said Gurau. “We’re not talking about adding medications. We’re talking about removing medications, which is, I think, what we should be doing.”

Some research suggests that patients are open to deprescribing. One survey examined older adults (mean age, 79.1 years) with three or more chronic conditions who had been prescribed at least five medications. The researchers found that most participants (77%) were willing to deprescribe one or more medicines if a doctor advised that it was possible. “General practitioners may be able to increase deprescribing by building trust with their patients and communicating evidence about the risks of medication use,” the researchers wrote.

About 62% of seniors living in a residential care home have a diagnosis of Alzheimer’s disease or another dementia, according to the Alzheimer Society of Canada. Evidence suggests that nonpharmacologic approaches, such as massage and touch therapy and music, can manage neuropsychiatric symptoms, such as aggression and agitation, that are associated with dementia in older adults, noted Gurau.

“We want to focus on nonpharmacologic approaches for many of these [long-term care] residents,” said Gurau. “We have to do as much as we can to exhaust all the nonpharmacologic approaches.”

 

Preventing Hospitalizations

Another challenge to tackle in long-term care is the unnecessary transfer of residents to hospital emergency departments, according to Gurau. “In many situations, it’s worth trying as hard as we can to treat them in the nursing home, as opposed to having them go to hospital.”

Researchers estimated that 25% of the transfers from long-term care facilities in Canada to hospital emergency departments in 2014 were potentially preventable.

Urinary tract infections accounted for 30% of hospital emergency department visits for potentially preventable conditions by older patients who are residents in long-term care, according to 2013-2014 data from the Canadian Institute for Health Information.

“There are lots of downsides to going to the hospital [from long-term care],” Gurau told this news organization. “There are risks for infections, risks for increasing delirium and agitation [in patients with dementia], and risks for other behavior that can really impact somebody’s life.”

Gurau reported having no relevant financial relationships.

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

Signs of frailty may signal future dementia more than a decade before cognitive symptoms occur, in new findings that may provide a potential opportunity to identify high-risk populations for targeted enrollment in clinical trials of dementia prevention and treatment.

Results of an international study assessing frailty trajectories showed frailty levels notably increased in the 4-9 years before dementia diagnosis. Even among study participants whose baseline frailty measurement was taken prior to that acceleration period, frailty was still positively associated with dementia risk, the investigators noted.

“We found that with every four to five additional health problems, there is on average a 40% higher risk of developing dementia, while the risk is lower for people who are more physically fit,” said study investigator David Ward, PhD, of the Centre for Health Services Research, The University of Queensland, Brisbane, Australia.

The findings were published online in JAMA Neurology.

 

A Promising Biomarker

An accessible biomarker for both biologic age and dementia risk is essential for advancing dementia prevention and treatment strategies, the investigators noted, adding that growing evidence suggests frailty may be a promising candidate for this role.

To learn more about the association between frailty and dementia, Ward and his team analyzed data on 29,849 participants aged 60 years or above (mean age, 71.6 years; 62% women) who participated in four cohort studies: the English Longitudinal Study of Ageing (ELSA; n = 6771), the Health and Retirement Study (HRS; n = 9045), the Rush Memory and Aging Project (MAP; n = 1451), and the National Alzheimer’s Coordinating Center (NACC; n = 12,582).

The primary outcome was all-cause dementia. Depending on the cohort, dementia diagnoses were determined through cognitive testing, self- or family report of physician diagnosis, or a diagnosis by the study physician. Participants were excluded if they had cognitive impairment at baseline.

Investigators retrospectively determined frailty index scores by gathering information on health and functional outcomes for participants from each cohort. Only participants with frailty data on at least 30 deficits were included.

Commonly included deficits included high blood pressure, cancer, and chronic pain, as well as functional problems such as hearing impairment, difficulty with mobility, and challenges managing finances.

Investigators conducted follow-up visits with participants until they developed dementia or until the study ended, with follow-up periods varying across cohorts.

After adjustment for potential confounders, frailty scores were modeled using backward time scales.

Among participants who developed incident dementia (n = 3154), covariate-adjusted expected frailty index scores were, on average, higher in women than in men by 18.5% in ELSA, 20.9% in HRS, and 16.2% in MAP. There were no differences in frailty scores between sexes in the NACC cohort.

When measured on a timeline, as compared with those who didn’t develop dementia, frailty scores were significantly and consistently higher in the dementia groups 8-20 before dementia onset (20 years in HRS; 13 in MAP; 12 in ELSA; 8 in NACC).

Increases in the rates of frailty index scores began accelerating 4-9 years before dementia onset for the various cohorts, investigators noted.

In all four cohorts, each 0.1 increase in frailty scores was positively associated with increased dementia risk.

Adjusted hazard ratios [aHRs] ranged from 1.18 in the HRS cohort to 1.73 in the NACC cohort, which showed the strongest association.

In participants whose baseline frailty measurement was conducted before the predementia acceleration period began, the association of frailty scores and dementia risk was positive. These aHRs ranged from 1.18 in the HRS cohort to 1.43 in the NACC cohort.

 

The ‘Four Pillars’ of Prevention

The good news, investigators said, is that the long trajectory of frailty symptoms preceding dementia onset provides plenty of opportunity for intervention.

To slow the development of frailty, Ward suggested adhering to the “four pillars of frailty prevention and management,” which include good nutrition with plenty of protein, exercise, optimizing medications for chronic conditions, and maintaining a strong social network.

Ward suggested neurologists track frailty in their patients and pointed to a recent article focused on helping neurologists use frailty measures to influence care planning.

Study limitations include the possibility of reverse causality and the fact that investigators could not adjust for genetic risk for dementia.

 

Unclear Pathway

Commenting on the findings, Lycia Neumann, PhD, senior director of Health Services Research at the Alzheimer’s Association, noted that many studies over the years have shown a link between frailty and dementia. However, she cautioned that a link does not imply causation.

The pathway from frailty to dementia is not 100% clear, and both are complex conditions, said Neumann, who was not part of the study.

“Adopting healthy lifestyle behaviors early and consistently can help decrease the risk of — or postpone the onset of — both frailty and cognitive decline,” she said. Neumann added that physical activity, a healthy diet, social engagement, and controlling diabetes and blood pressure can also reduce the risk for dementia as well as cardiovascular disease.

The study was funded in part by the Deep Dementia Phenotyping Network through the Frailty and Dementia Special Interest Group. Ward and Neumann reported no relevant financial relationships.

 

A version of this article appeared on Medscape.com.

Signs of frailty may signal future dementia more than a decade before cognitive symptoms occur, in new findings that may provide a potential opportunity to identify high-risk populations for targeted enrollment in clinical trials of dementia prevention and treatment.

Results of an international study assessing frailty trajectories showed frailty levels notably increased in the 4-9 years before dementia diagnosis. Even among study participants whose baseline frailty measurement was taken prior to that acceleration period, frailty was still positively associated with dementia risk, the investigators noted.

“We found that with every four to five additional health problems, there is on average a 40% higher risk of developing dementia, while the risk is lower for people who are more physically fit,” said study investigator David Ward, PhD, of the Centre for Health Services Research, The University of Queensland, Brisbane, Australia.

The findings were published online in JAMA Neurology.

 

A Promising Biomarker

An accessible biomarker for both biologic age and dementia risk is essential for advancing dementia prevention and treatment strategies, the investigators noted, adding that growing evidence suggests frailty may be a promising candidate for this role.

To learn more about the association between frailty and dementia, Ward and his team analyzed data on 29,849 participants aged 60 years or above (mean age, 71.6 years; 62% women) who participated in four cohort studies: the English Longitudinal Study of Ageing (ELSA; n = 6771), the Health and Retirement Study (HRS; n = 9045), the Rush Memory and Aging Project (MAP; n = 1451), and the National Alzheimer’s Coordinating Center (NACC; n = 12,582).

The primary outcome was all-cause dementia. Depending on the cohort, dementia diagnoses were determined through cognitive testing, self- or family report of physician diagnosis, or a diagnosis by the study physician. Participants were excluded if they had cognitive impairment at baseline.

Investigators retrospectively determined frailty index scores by gathering information on health and functional outcomes for participants from each cohort. Only participants with frailty data on at least 30 deficits were included.

Commonly included deficits included high blood pressure, cancer, and chronic pain, as well as functional problems such as hearing impairment, difficulty with mobility, and challenges managing finances.

Investigators conducted follow-up visits with participants until they developed dementia or until the study ended, with follow-up periods varying across cohorts.

After adjustment for potential confounders, frailty scores were modeled using backward time scales.

Among participants who developed incident dementia (n = 3154), covariate-adjusted expected frailty index scores were, on average, higher in women than in men by 18.5% in ELSA, 20.9% in HRS, and 16.2% in MAP. There were no differences in frailty scores between sexes in the NACC cohort.

When measured on a timeline, as compared with those who didn’t develop dementia, frailty scores were significantly and consistently higher in the dementia groups 8-20 before dementia onset (20 years in HRS; 13 in MAP; 12 in ELSA; 8 in NACC).

Increases in the rates of frailty index scores began accelerating 4-9 years before dementia onset for the various cohorts, investigators noted.

In all four cohorts, each 0.1 increase in frailty scores was positively associated with increased dementia risk.

Adjusted hazard ratios [aHRs] ranged from 1.18 in the HRS cohort to 1.73 in the NACC cohort, which showed the strongest association.

In participants whose baseline frailty measurement was conducted before the predementia acceleration period began, the association of frailty scores and dementia risk was positive. These aHRs ranged from 1.18 in the HRS cohort to 1.43 in the NACC cohort.

 

The ‘Four Pillars’ of Prevention

The good news, investigators said, is that the long trajectory of frailty symptoms preceding dementia onset provides plenty of opportunity for intervention.

To slow the development of frailty, Ward suggested adhering to the “four pillars of frailty prevention and management,” which include good nutrition with plenty of protein, exercise, optimizing medications for chronic conditions, and maintaining a strong social network.

Ward suggested neurologists track frailty in their patients and pointed to a recent article focused on helping neurologists use frailty measures to influence care planning.

Study limitations include the possibility of reverse causality and the fact that investigators could not adjust for genetic risk for dementia.

 

Unclear Pathway

Commenting on the findings, Lycia Neumann, PhD, senior director of Health Services Research at the Alzheimer’s Association, noted that many studies over the years have shown a link between frailty and dementia. However, she cautioned that a link does not imply causation.

The pathway from frailty to dementia is not 100% clear, and both are complex conditions, said Neumann, who was not part of the study.

“Adopting healthy lifestyle behaviors early and consistently can help decrease the risk of — or postpone the onset of — both frailty and cognitive decline,” she said. Neumann added that physical activity, a healthy diet, social engagement, and controlling diabetes and blood pressure can also reduce the risk for dementia as well as cardiovascular disease.

The study was funded in part by the Deep Dementia Phenotyping Network through the Frailty and Dementia Special Interest Group. Ward and Neumann reported no relevant financial relationships.

 

A version of this article appeared on Medscape.com.

Signs of frailty may signal future dementia more than a decade before cognitive symptoms occur, in new findings that may provide a potential opportunity to identify high-risk populations for targeted enrollment in clinical trials of dementia prevention and treatment.

Results of an international study assessing frailty trajectories showed frailty levels notably increased in the 4-9 years before dementia diagnosis. Even among study participants whose baseline frailty measurement was taken prior to that acceleration period, frailty was still positively associated with dementia risk, the investigators noted.

“We found that with every four to five additional health problems, there is on average a 40% higher risk of developing dementia, while the risk is lower for people who are more physically fit,” said study investigator David Ward, PhD, of the Centre for Health Services Research, The University of Queensland, Brisbane, Australia.

The findings were published online in JAMA Neurology.

 

A Promising Biomarker

An accessible biomarker for both biologic age and dementia risk is essential for advancing dementia prevention and treatment strategies, the investigators noted, adding that growing evidence suggests frailty may be a promising candidate for this role.

To learn more about the association between frailty and dementia, Ward and his team analyzed data on 29,849 participants aged 60 years or above (mean age, 71.6 years; 62% women) who participated in four cohort studies: the English Longitudinal Study of Ageing (ELSA; n = 6771), the Health and Retirement Study (HRS; n = 9045), the Rush Memory and Aging Project (MAP; n = 1451), and the National Alzheimer’s Coordinating Center (NACC; n = 12,582).

The primary outcome was all-cause dementia. Depending on the cohort, dementia diagnoses were determined through cognitive testing, self- or family report of physician diagnosis, or a diagnosis by the study physician. Participants were excluded if they had cognitive impairment at baseline.

Investigators retrospectively determined frailty index scores by gathering information on health and functional outcomes for participants from each cohort. Only participants with frailty data on at least 30 deficits were included.

Commonly included deficits included high blood pressure, cancer, and chronic pain, as well as functional problems such as hearing impairment, difficulty with mobility, and challenges managing finances.

Investigators conducted follow-up visits with participants until they developed dementia or until the study ended, with follow-up periods varying across cohorts.

After adjustment for potential confounders, frailty scores were modeled using backward time scales.

Among participants who developed incident dementia (n = 3154), covariate-adjusted expected frailty index scores were, on average, higher in women than in men by 18.5% in ELSA, 20.9% in HRS, and 16.2% in MAP. There were no differences in frailty scores between sexes in the NACC cohort.

When measured on a timeline, as compared with those who didn’t develop dementia, frailty scores were significantly and consistently higher in the dementia groups 8-20 before dementia onset (20 years in HRS; 13 in MAP; 12 in ELSA; 8 in NACC).

Increases in the rates of frailty index scores began accelerating 4-9 years before dementia onset for the various cohorts, investigators noted.

In all four cohorts, each 0.1 increase in frailty scores was positively associated with increased dementia risk.

Adjusted hazard ratios [aHRs] ranged from 1.18 in the HRS cohort to 1.73 in the NACC cohort, which showed the strongest association.

In participants whose baseline frailty measurement was conducted before the predementia acceleration period began, the association of frailty scores and dementia risk was positive. These aHRs ranged from 1.18 in the HRS cohort to 1.43 in the NACC cohort.

 

The ‘Four Pillars’ of Prevention

The good news, investigators said, is that the long trajectory of frailty symptoms preceding dementia onset provides plenty of opportunity for intervention.

To slow the development of frailty, Ward suggested adhering to the “four pillars of frailty prevention and management,” which include good nutrition with plenty of protein, exercise, optimizing medications for chronic conditions, and maintaining a strong social network.

Ward suggested neurologists track frailty in their patients and pointed to a recent article focused on helping neurologists use frailty measures to influence care planning.

Study limitations include the possibility of reverse causality and the fact that investigators could not adjust for genetic risk for dementia.

 

Unclear Pathway

Commenting on the findings, Lycia Neumann, PhD, senior director of Health Services Research at the Alzheimer’s Association, noted that many studies over the years have shown a link between frailty and dementia. However, she cautioned that a link does not imply causation.

The pathway from frailty to dementia is not 100% clear, and both are complex conditions, said Neumann, who was not part of the study.

“Adopting healthy lifestyle behaviors early and consistently can help decrease the risk of — or postpone the onset of — both frailty and cognitive decline,” she said. Neumann added that physical activity, a healthy diet, social engagement, and controlling diabetes and blood pressure can also reduce the risk for dementia as well as cardiovascular disease.

The study was funded in part by the Deep Dementia Phenotyping Network through the Frailty and Dementia Special Interest Group. Ward and Neumann reported no relevant financial relationships.

 

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity. 

Matthew F. Watto, MD: Welcome back to The Curbsiders. I’m Dr. Matthew Frank Watto, here with my great friend and America’s primary care physician, Dr. Paul Nelson Williams. Paul, what is MASLD?

Paul N. Williams, MD: MASLD is metabolic dysfunction–associated steatotic liver disease. 

Watto: We talked about a really stripped-down way of testing people for MASLD. If we see mildly elevated liver enzymes, what should we be testing, and how does alcohol factor in?

Williams: Before you can make a definitive diagnosis of MASLD, you need to rule out other causes of liver inflammation — things that would cause a patient’s transaminases to increase. Alcohol is synergistic with everything that can harm the liver.

A great place to start is to gauge someone’s alcohol intake to make sure it isn’t causing hepatic inflammation. The phosphatidyl ethanol level is a serologic test to determine chronic, heavy alcohol use. It’s a new kid on the block. I’ve seen it mostly ordered by hepatologists. It is a way of determining whether someone has had fairly consistent alcohol use up to 4 weeks after the fact. The cutoff for a positive test is 20 ng/mL.

Dr Tapper frames the test this way. He isn’t using the test to catch someone in a lie about their alcohol use. He tells patients that he orders this test for all patients with liver inflammation, because alcohol is a common cause. The test helps him better understand the factors that might be affecting the patient’s liver function. 

If the test comes back positive, you can have a conversation about that, and if it’s not positive, you move on to the next possible cause. Other fairly common causes of liver inflammation are relatively easy to address. 

Watto: Instead of ordering ceruloplasmin or alpha-1 antitrypsin tests, for example, the first thing Dr Tapper recommends is checking for hepatitis B and C. We can cure hepatitis C. We can’t cure hepatitis B, but it’s important to know if the patient has it. Primary care physicians should be comfortable ordering these tests. 

Really high ALT levels (eg, in the 200s) don’t usually happen from steatotic liver disease. In those cases, we would send an expanded panel that might include tests for autoimmune hepatitis-ANA, anti–smooth muscle antibody, and IgG levels. Otherwise, most of these patients don’t need much more testing.

What is a FIB4 score and how does that factor in?

Williams: The FIB4 score estimates the degree of fibrosis based on the ALT and AST levels, platelet count, and the patient’s age. These data are plugged into a formula. If the FIB4 score is low (meaning not much fibrosis is present), you can stop there and do your counseling about lifestyle changes and address the reversible factors.

If the FIB4 score is above a certain threshold (1.3 in young adults and 2.0 in older adults), you need to find a more concrete way to determine the degree of fibrosis, typically through imaging. 

Elastography can be done either with ultrasound or MRI. Ultrasound is typically ordered, but Dr Tapper recommends doing MRI on patients with a BMI > 40. Those patients are probably better served by doing MRI to determine the degree of liver fibrosis.

Watto: Patients with low FIB4 scores probably don’t need elastography but those with high FIB4 scores do. For the interpretation of ultrasound-based elastography results, Dr Tapper gave us the “rule of 5s”.

Elastography results are reported in kilopascal (kPa) units. A finding of 5 kPa or less is normal. Forty percent of those with a result of 10 kPa might have advanced liver disease. Above 15 kPa, the likelihood of cirrhosis is high, becoming very likely at 25 kPa. Finally, with a result of > 25 kPa, portal hypertension is likely, and you might need to have a conversation about starting the patient on medicine to prevent variceal bleeding.

We are moving toward more noninvasive testing and avoiding biopsies. We have cutoff values for MRI-based elastography as well. Both of these tests can help stage the liver. 

What can we tell people about diet? 

Williams: Weight loss is helpful. You can reverse fibrosis with weight loss. You can truly help your liver and bring it closer to its healthy baseline with weight loss. A loss of 7.5% body weight can reduce steatohepatitis, and with around 10% of body weight loss, you can actually resolve fibrosis, which is remarkable.

We all know that weight loss can be very therapeutic for many conditions. It’s just very hard to achieve. As primary care doctors, we should use what we have in our armamentarium to achieve that goal. Often, that will include certain medications.

Watto: I like giving patients the 10% number because if they weigh 220 pounds, they need to lose 22 pounds. If they weigh 300 pounds, it’s 30 pounds. Most people who weigh 300 pounds think they need to lose 100 pounds to have any sort of health benefit, but it’s much less than that. So, I do find that helpful.

But now a new drug has been approved. It’s a thyroid memetic called resmetirom. It was from the MAESTRO-NASH trial. Without weight loss, it helped to reverse fibrosis.

This is going to be used more and more in the future. It’s still being worked out exactly where the place is for that drug, so much so that Dr Tapper, as a liver expert, hadn’t even had the chance to prescribe it yet. Of course, it was very recently approved. 

Dr. Tapper is one of our most celebrated guests, so check out the full podcast here.

A version of this article appeared on Medscape.com. 

This transcript has been edited for clarity. 

Matthew F. Watto, MD: Welcome back to The Curbsiders. I’m Dr. Matthew Frank Watto, here with my great friend and America’s primary care physician, Dr. Paul Nelson Williams. Paul, what is MASLD?

Paul N. Williams, MD: MASLD is metabolic dysfunction–associated steatotic liver disease. 

Watto: We talked about a really stripped-down way of testing people for MASLD. If we see mildly elevated liver enzymes, what should we be testing, and how does alcohol factor in?

Williams: Before you can make a definitive diagnosis of MASLD, you need to rule out other causes of liver inflammation — things that would cause a patient’s transaminases to increase. Alcohol is synergistic with everything that can harm the liver.

A great place to start is to gauge someone’s alcohol intake to make sure it isn’t causing hepatic inflammation. The phosphatidyl ethanol level is a serologic test to determine chronic, heavy alcohol use. It’s a new kid on the block. I’ve seen it mostly ordered by hepatologists. It is a way of determining whether someone has had fairly consistent alcohol use up to 4 weeks after the fact. The cutoff for a positive test is 20 ng/mL.

Dr Tapper frames the test this way. He isn’t using the test to catch someone in a lie about their alcohol use. He tells patients that he orders this test for all patients with liver inflammation, because alcohol is a common cause. The test helps him better understand the factors that might be affecting the patient’s liver function. 

If the test comes back positive, you can have a conversation about that, and if it’s not positive, you move on to the next possible cause. Other fairly common causes of liver inflammation are relatively easy to address. 

Watto: Instead of ordering ceruloplasmin or alpha-1 antitrypsin tests, for example, the first thing Dr Tapper recommends is checking for hepatitis B and C. We can cure hepatitis C. We can’t cure hepatitis B, but it’s important to know if the patient has it. Primary care physicians should be comfortable ordering these tests. 

Really high ALT levels (eg, in the 200s) don’t usually happen from steatotic liver disease. In those cases, we would send an expanded panel that might include tests for autoimmune hepatitis-ANA, anti–smooth muscle antibody, and IgG levels. Otherwise, most of these patients don’t need much more testing.

What is a FIB4 score and how does that factor in?

Williams: The FIB4 score estimates the degree of fibrosis based on the ALT and AST levels, platelet count, and the patient’s age. These data are plugged into a formula. If the FIB4 score is low (meaning not much fibrosis is present), you can stop there and do your counseling about lifestyle changes and address the reversible factors.

If the FIB4 score is above a certain threshold (1.3 in young adults and 2.0 in older adults), you need to find a more concrete way to determine the degree of fibrosis, typically through imaging. 

Elastography can be done either with ultrasound or MRI. Ultrasound is typically ordered, but Dr Tapper recommends doing MRI on patients with a BMI > 40. Those patients are probably better served by doing MRI to determine the degree of liver fibrosis.

Watto: Patients with low FIB4 scores probably don’t need elastography but those with high FIB4 scores do. For the interpretation of ultrasound-based elastography results, Dr Tapper gave us the “rule of 5s”.

Elastography results are reported in kilopascal (kPa) units. A finding of 5 kPa or less is normal. Forty percent of those with a result of 10 kPa might have advanced liver disease. Above 15 kPa, the likelihood of cirrhosis is high, becoming very likely at 25 kPa. Finally, with a result of > 25 kPa, portal hypertension is likely, and you might need to have a conversation about starting the patient on medicine to prevent variceal bleeding.

We are moving toward more noninvasive testing and avoiding biopsies. We have cutoff values for MRI-based elastography as well. Both of these tests can help stage the liver. 

What can we tell people about diet? 

Williams: Weight loss is helpful. You can reverse fibrosis with weight loss. You can truly help your liver and bring it closer to its healthy baseline with weight loss. A loss of 7.5% body weight can reduce steatohepatitis, and with around 10% of body weight loss, you can actually resolve fibrosis, which is remarkable.

We all know that weight loss can be very therapeutic for many conditions. It’s just very hard to achieve. As primary care doctors, we should use what we have in our armamentarium to achieve that goal. Often, that will include certain medications.

Watto: I like giving patients the 10% number because if they weigh 220 pounds, they need to lose 22 pounds. If they weigh 300 pounds, it’s 30 pounds. Most people who weigh 300 pounds think they need to lose 100 pounds to have any sort of health benefit, but it’s much less than that. So, I do find that helpful.

But now a new drug has been approved. It’s a thyroid memetic called resmetirom. It was from the MAESTRO-NASH trial. Without weight loss, it helped to reverse fibrosis.

This is going to be used more and more in the future. It’s still being worked out exactly where the place is for that drug, so much so that Dr Tapper, as a liver expert, hadn’t even had the chance to prescribe it yet. Of course, it was very recently approved. 

Dr. Tapper is one of our most celebrated guests, so check out the full podcast here.

A version of this article appeared on Medscape.com. 

This transcript has been edited for clarity. 

Matthew F. Watto, MD: Welcome back to The Curbsiders. I’m Dr. Matthew Frank Watto, here with my great friend and America’s primary care physician, Dr. Paul Nelson Williams. Paul, what is MASLD?

Paul N. Williams, MD: MASLD is metabolic dysfunction–associated steatotic liver disease. 

Watto: We talked about a really stripped-down way of testing people for MASLD. If we see mildly elevated liver enzymes, what should we be testing, and how does alcohol factor in?

Williams: Before you can make a definitive diagnosis of MASLD, you need to rule out other causes of liver inflammation — things that would cause a patient’s transaminases to increase. Alcohol is synergistic with everything that can harm the liver.

A great place to start is to gauge someone’s alcohol intake to make sure it isn’t causing hepatic inflammation. The phosphatidyl ethanol level is a serologic test to determine chronic, heavy alcohol use. It’s a new kid on the block. I’ve seen it mostly ordered by hepatologists. It is a way of determining whether someone has had fairly consistent alcohol use up to 4 weeks after the fact. The cutoff for a positive test is 20 ng/mL.

Dr Tapper frames the test this way. He isn’t using the test to catch someone in a lie about their alcohol use. He tells patients that he orders this test for all patients with liver inflammation, because alcohol is a common cause. The test helps him better understand the factors that might be affecting the patient’s liver function. 

If the test comes back positive, you can have a conversation about that, and if it’s not positive, you move on to the next possible cause. Other fairly common causes of liver inflammation are relatively easy to address. 

Watto: Instead of ordering ceruloplasmin or alpha-1 antitrypsin tests, for example, the first thing Dr Tapper recommends is checking for hepatitis B and C. We can cure hepatitis C. We can’t cure hepatitis B, but it’s important to know if the patient has it. Primary care physicians should be comfortable ordering these tests. 

Really high ALT levels (eg, in the 200s) don’t usually happen from steatotic liver disease. In those cases, we would send an expanded panel that might include tests for autoimmune hepatitis-ANA, anti–smooth muscle antibody, and IgG levels. Otherwise, most of these patients don’t need much more testing.

What is a FIB4 score and how does that factor in?

Williams: The FIB4 score estimates the degree of fibrosis based on the ALT and AST levels, platelet count, and the patient’s age. These data are plugged into a formula. If the FIB4 score is low (meaning not much fibrosis is present), you can stop there and do your counseling about lifestyle changes and address the reversible factors.

If the FIB4 score is above a certain threshold (1.3 in young adults and 2.0 in older adults), you need to find a more concrete way to determine the degree of fibrosis, typically through imaging. 

Elastography can be done either with ultrasound or MRI. Ultrasound is typically ordered, but Dr Tapper recommends doing MRI on patients with a BMI > 40. Those patients are probably better served by doing MRI to determine the degree of liver fibrosis.

Watto: Patients with low FIB4 scores probably don’t need elastography but those with high FIB4 scores do. For the interpretation of ultrasound-based elastography results, Dr Tapper gave us the “rule of 5s”.

Elastography results are reported in kilopascal (kPa) units. A finding of 5 kPa or less is normal. Forty percent of those with a result of 10 kPa might have advanced liver disease. Above 15 kPa, the likelihood of cirrhosis is high, becoming very likely at 25 kPa. Finally, with a result of > 25 kPa, portal hypertension is likely, and you might need to have a conversation about starting the patient on medicine to prevent variceal bleeding.

We are moving toward more noninvasive testing and avoiding biopsies. We have cutoff values for MRI-based elastography as well. Both of these tests can help stage the liver. 

What can we tell people about diet? 

Williams: Weight loss is helpful. You can reverse fibrosis with weight loss. You can truly help your liver and bring it closer to its healthy baseline with weight loss. A loss of 7.5% body weight can reduce steatohepatitis, and with around 10% of body weight loss, you can actually resolve fibrosis, which is remarkable.

We all know that weight loss can be very therapeutic for many conditions. It’s just very hard to achieve. As primary care doctors, we should use what we have in our armamentarium to achieve that goal. Often, that will include certain medications.

Watto: I like giving patients the 10% number because if they weigh 220 pounds, they need to lose 22 pounds. If they weigh 300 pounds, it’s 30 pounds. Most people who weigh 300 pounds think they need to lose 100 pounds to have any sort of health benefit, but it’s much less than that. So, I do find that helpful.

But now a new drug has been approved. It’s a thyroid memetic called resmetirom. It was from the MAESTRO-NASH trial. Without weight loss, it helped to reverse fibrosis.

This is going to be used more and more in the future. It’s still being worked out exactly where the place is for that drug, so much so that Dr Tapper, as a liver expert, hadn’t even had the chance to prescribe it yet. Of course, it was very recently approved. 

Dr. Tapper is one of our most celebrated guests, so check out the full podcast here.

A version of this article appeared on Medscape.com.