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Lorcaserin shows CV safety in CAMELLIA-TIMI 61
MUNICH – Lorcaserin is the first weight-loss drug proven to have cardiovascular safety, Erin A. Bohula, MD, DPhil, told Mitchel L. Zoler in an interview.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Dr. Bohula reported on the results of the CAMELLIA-TIMI 61 trial, which was designed to evaluate the cardiovascular safety of the weight-loss drug lorcaserin in more than 10,000 patients. She presented the data at the annual congress of the European Society of Cardiology.
In CAMELLIA-TIMI 61, the primary safety endpoint, a composite of cardiovascular death, MI, or stroke, was nearly identical between patients on lorcaserin and those given placebo, 2% and 2.1% per year, at P less than .001 for noninferiority. Similarly, the primary efficacy outcome comprising heart failure, hospitalization for unstable angina, and coronary revascularization, was very close between the treated and placebo patients, occurring in 4.1% and 4.2% per year, respectively.
In addition, “there was a sustained weight loss, more than with lifestyle alone or lifestyle plus placebo, which at its peak was about 3 kg. With that there were small, but significant, reductions in heart rate, blood pressure, triglycerides, and hemoglobin A1c, and there was a significant reduction in new-onset diabetes.”
“Overall, there’s not a lot of use of pharmacologic agents for weight loss in the United States, and a lot of that is based on fear of the historical experience, which is that they were not safe. I suspect that having a drug that is proven safe will now lead people to reach for a pharmacologic agent like lorcaserin,” said Dr. Bohula, a cardiologist at of Brigham and Women’s Hospital and an investigator at the TIMI study group.
MUNICH – Lorcaserin is the first weight-loss drug proven to have cardiovascular safety, Erin A. Bohula, MD, DPhil, told Mitchel L. Zoler in an interview.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Dr. Bohula reported on the results of the CAMELLIA-TIMI 61 trial, which was designed to evaluate the cardiovascular safety of the weight-loss drug lorcaserin in more than 10,000 patients. She presented the data at the annual congress of the European Society of Cardiology.
In CAMELLIA-TIMI 61, the primary safety endpoint, a composite of cardiovascular death, MI, or stroke, was nearly identical between patients on lorcaserin and those given placebo, 2% and 2.1% per year, at P less than .001 for noninferiority. Similarly, the primary efficacy outcome comprising heart failure, hospitalization for unstable angina, and coronary revascularization, was very close between the treated and placebo patients, occurring in 4.1% and 4.2% per year, respectively.
In addition, “there was a sustained weight loss, more than with lifestyle alone or lifestyle plus placebo, which at its peak was about 3 kg. With that there were small, but significant, reductions in heart rate, blood pressure, triglycerides, and hemoglobin A1c, and there was a significant reduction in new-onset diabetes.”
“Overall, there’s not a lot of use of pharmacologic agents for weight loss in the United States, and a lot of that is based on fear of the historical experience, which is that they were not safe. I suspect that having a drug that is proven safe will now lead people to reach for a pharmacologic agent like lorcaserin,” said Dr. Bohula, a cardiologist at of Brigham and Women’s Hospital and an investigator at the TIMI study group.
MUNICH – Lorcaserin is the first weight-loss drug proven to have cardiovascular safety, Erin A. Bohula, MD, DPhil, told Mitchel L. Zoler in an interview.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Dr. Bohula reported on the results of the CAMELLIA-TIMI 61 trial, which was designed to evaluate the cardiovascular safety of the weight-loss drug lorcaserin in more than 10,000 patients. She presented the data at the annual congress of the European Society of Cardiology.
In CAMELLIA-TIMI 61, the primary safety endpoint, a composite of cardiovascular death, MI, or stroke, was nearly identical between patients on lorcaserin and those given placebo, 2% and 2.1% per year, at P less than .001 for noninferiority. Similarly, the primary efficacy outcome comprising heart failure, hospitalization for unstable angina, and coronary revascularization, was very close between the treated and placebo patients, occurring in 4.1% and 4.2% per year, respectively.
In addition, “there was a sustained weight loss, more than with lifestyle alone or lifestyle plus placebo, which at its peak was about 3 kg. With that there were small, but significant, reductions in heart rate, blood pressure, triglycerides, and hemoglobin A1c, and there was a significant reduction in new-onset diabetes.”
“Overall, there’s not a lot of use of pharmacologic agents for weight loss in the United States, and a lot of that is based on fear of the historical experience, which is that they were not safe. I suspect that having a drug that is proven safe will now lead people to reach for a pharmacologic agent like lorcaserin,” said Dr. Bohula, a cardiologist at of Brigham and Women’s Hospital and an investigator at the TIMI study group.
Lorcaserin shows CV safety in CAMELLIA-TIMI 61
Erin A. Bohula, MD, DPhil, told Mitchel L. Zoler in an interview.
Dr. Bohula reported on the results of the CAMELLIA-TIMI 61 trial, which was designed to evaluate the cardiovascular safety of the weight-loss drug lorcaserin in more than 10,000 patients. She presented the data at the annual congress of the European Society of Cardiology.
In CAMELLIA-TIMI 61, the primary safety endpoint, a composite of cardiovascular death, MI, or stroke, was nearly identical between patients on lorcaserin and those given placebo, 2% and 2.1% per year, at P less than .001 for noninferiority. Similarly, the primary efficacy outcome comprising heart failure, hospitalization for unstable angina, and coronary revascularization, was very close between the treated and placebo patients, occurring in 4.1% and 4.2% per year, respectively.
In addition, “there was a sustained weight loss, more than with lifestyle alone or lifestyle plus placebo, which at its peak was about 3 kg. With that there were small, but significant, reductions in heart rate, blood pressure, triglycerides, and hemoglobin A1c, and there was a significant reduction in new-onset diabetes.”
“Overall, there’s not a lot of use of pharmacologic agents for weight loss in the United States, and a lot of that is based on fear of the historical experience, which is that they were not safe. I suspect that having a drug that is proven safe will now lead people to reach for a pharmacologic agent like lorcaserin,” said Dr. Bohula, a cardiologist at of Brigham and Women’s Hospital and an investigator at the TIMI study group.
The AGA Obesity Practice Guide provides physicians with a comprehensive, multi-disciplinary process to guide and personalize innovative obesity care for safe and effective weight management. Learn more at https://www.gastro.org/practice-guidance/practice-updates/obesity-practice-guide.
Erin A. Bohula, MD, DPhil, told Mitchel L. Zoler in an interview.
Dr. Bohula reported on the results of the CAMELLIA-TIMI 61 trial, which was designed to evaluate the cardiovascular safety of the weight-loss drug lorcaserin in more than 10,000 patients. She presented the data at the annual congress of the European Society of Cardiology.
In CAMELLIA-TIMI 61, the primary safety endpoint, a composite of cardiovascular death, MI, or stroke, was nearly identical between patients on lorcaserin and those given placebo, 2% and 2.1% per year, at P less than .001 for noninferiority. Similarly, the primary efficacy outcome comprising heart failure, hospitalization for unstable angina, and coronary revascularization, was very close between the treated and placebo patients, occurring in 4.1% and 4.2% per year, respectively.
In addition, “there was a sustained weight loss, more than with lifestyle alone or lifestyle plus placebo, which at its peak was about 3 kg. With that there were small, but significant, reductions in heart rate, blood pressure, triglycerides, and hemoglobin A1c, and there was a significant reduction in new-onset diabetes.”
“Overall, there’s not a lot of use of pharmacologic agents for weight loss in the United States, and a lot of that is based on fear of the historical experience, which is that they were not safe. I suspect that having a drug that is proven safe will now lead people to reach for a pharmacologic agent like lorcaserin,” said Dr. Bohula, a cardiologist at of Brigham and Women’s Hospital and an investigator at the TIMI study group.
The AGA Obesity Practice Guide provides physicians with a comprehensive, multi-disciplinary process to guide and personalize innovative obesity care for safe and effective weight management. Learn more at https://www.gastro.org/practice-guidance/practice-updates/obesity-practice-guide.
Erin A. Bohula, MD, DPhil, told Mitchel L. Zoler in an interview.
Dr. Bohula reported on the results of the CAMELLIA-TIMI 61 trial, which was designed to evaluate the cardiovascular safety of the weight-loss drug lorcaserin in more than 10,000 patients. She presented the data at the annual congress of the European Society of Cardiology.
In CAMELLIA-TIMI 61, the primary safety endpoint, a composite of cardiovascular death, MI, or stroke, was nearly identical between patients on lorcaserin and those given placebo, 2% and 2.1% per year, at P less than .001 for noninferiority. Similarly, the primary efficacy outcome comprising heart failure, hospitalization for unstable angina, and coronary revascularization, was very close between the treated and placebo patients, occurring in 4.1% and 4.2% per year, respectively.
In addition, “there was a sustained weight loss, more than with lifestyle alone or lifestyle plus placebo, which at its peak was about 3 kg. With that there were small, but significant, reductions in heart rate, blood pressure, triglycerides, and hemoglobin A1c, and there was a significant reduction in new-onset diabetes.”
“Overall, there’s not a lot of use of pharmacologic agents for weight loss in the United States, and a lot of that is based on fear of the historical experience, which is that they were not safe. I suspect that having a drug that is proven safe will now lead people to reach for a pharmacologic agent like lorcaserin,” said Dr. Bohula, a cardiologist at of Brigham and Women’s Hospital and an investigator at the TIMI study group.
The AGA Obesity Practice Guide provides physicians with a comprehensive, multi-disciplinary process to guide and personalize innovative obesity care for safe and effective weight management. Learn more at https://www.gastro.org/practice-guidance/practice-updates/obesity-practice-guide.
REPORTING FROM THE ESC CONGRESS 2018
Prepare for ‘the coming tsunami’ of NAFLD
NEW ORLEANS – Zobair M. Younossi, MD, declared at the annual meeting of the American College of Physicians.
The massive growth in nonalcoholic fatty liver disease (NAFLD) is being fueled to a great extent by the related epidemics of obesity and type 2 diabetes mellitus. While the overall prevalence of NAFLD worldwide is 24%, almost three-quarters of patients with NAFLD are obese. And the prevalence of NAFLD in individuals with T2DM was 58% in a recent meta-analysis of studies from 20 countries conducted by Dr. Younossi and his coinvestigators.
“The prevalence of NAFLD in U.S. kids is about 10%. This is of course part of the coming tsunami because our kids are getting obese, diabetic, and they’re going to have problems with NASH [nonalcoholic steatohepatitis],” said Dr. Younossi, a gastroenterologist who is professor and chairman of the department of medicine at the Inova Fairfax (Va.) campus of Virginia Commonwealth University.
NASH is the form of NAFLD that has the strongest prognostic implications. It can progress to cirrhosis, liver failure, or hepatocellular carcinoma. As Dr. Younossi and his coworkers have shown (Hepat Commun. 2017 Jun 6;1[5]:421-8), it is associated with a significantly greater risk of both liver-related and all-cause mortality than that of non-NASH NAFLD, although NAFLD also carries an increased risk of cardiovascular disease, the leading cause of death in that population.
In addition to highlighting the enormous clinical, economic, and quality-of-life implications of the NAFLD epidemic, Dr. Younossi offered practical tips on how busy primary care physicians can identify patients in their practice who have high-risk NAFLD. They have not done a very good job of this to date. That’s possibly due to lack of incentive, since in 2018 there is no approved drug for the treatment of NASH. He cited one representative retrospective study in which only about 15% of patients identified as having NAFLD received a recommendation for lifestyle modification involving diet and exercise, which is the standard evidence-based treatment, albeit admittedly difficult to sustain. And only 3% of patients with advanced liver fibrosis were referred to a specialist for management.
“So NAFLD is common, but its recognition and doing something about it is quite a challenge,” Dr. Younossi observed.
He argued that patients who have NASH deserve to know it because of its prognostic implications and also so they can have the chance to participate in one of the roughly two dozen ongoing clinical trials of potential therapies, some of which look quite promising. All of the trials required a liver biopsy as a condition for enrollment. Plus, once a patient is known to have stage 3 fibrosis, it’s time to start screening for hepatocellular carcinoma and esophageal varices.
The scope of the epidemic
NASH is the most rapidly growing indication for liver transplantation in the United States, with most of the increase coming from the baby boomer population. NASH is now the second most common indication for placement on the wait list. Meanwhile, liver transplantation due to the consequences of hepatitis C, the No. 1 indication, is declining as a result of the spectacular advances in medical treatment introduced a few years ago. It’s likely that in coming years NASH will take over the top spot, according to Dr. Younossi.
He was coauthor of a recent study that modeled the estimated trends for the NAFLD epidemic in the United States through 2030. The forecast is that the prevalence of NAFLD among adults will climb to 33.5% and the proportion of NAFLD categorized as NASH will increase from 20% at present to 27%. Moreover, this will result in a 168% jump in the incidence of decompensated cirrhosis, a 137% increase in the incidence of hepatocellular carcinoma, and a 178% increase in liver-related mortality, which will account for an estimated 78,300 deaths in 2030 (Hepatology. 2018 Jan;67[1]:123-33).
Practical ways to identify high-risk patients
The best noninvasive means of detecting NAFLD is by ultrasound showing a fatty liver. Often the condition is detected as an incidental finding on abdominal ultrasound ordered for another reason. Elevated liver enzymes can be a tipoff as well. Of course, alcoholic liver disease and other causes must be excluded.
But what’s most important is to identify patients with NASH. It’s a diagnosis made by biopsy. However, it is unthinkable to perform liver biopsies in the entire vast population with NAFLD, so there is a great deal of interest in developing noninvasive diagnostic modalities that can help zero in on the subset of high-risk NAFLD patients who should be considered for referral for liver biopsy.
One useful clue is the presence of comorbid metabolic syndrome in patients with NAFLD. It confers a substantially higher mortality risk – especially cardiovascular mortality – than does NAFLD without metabolic syndrome. Dr. Younossi and his coinvestigators have shown in a study of 3,613 NAFLD patients followed long-term that those with one component of the metabolic syndrome – either hypertension, central obesity, increased fasting plasma glucose, or hyperlipidemia – had 8- and 16-year all-cause mortality rates of 4.7% and 11.9%, nearly double the 2.6% and 6% rates in NAFLD patients with no elements of the metabolic syndrome.
Moreover, the magnitude of risk increased with each additional metabolic syndrome condition: a 3.57-fold increased mortality risk in NAFLD patients with two components of metabolic syndrome, a 5.87-fold increase in those with three, and a 13.09-fold increase in NAFLD patients with all four elements of metabolic syndrome (Medicine [Baltimore]. 2018 Mar;97[13]:e0214. doi: 10.1097/MD.0000000000010214).
Dr. Younossi was a member of the American Association for the Study of Liver Disease expert panel that developed the latest practice guidance regarding the diagnosis and management of NAFLD (Hepatology. 2018 Jan;67[1]:328-57). He said that probably the best simple noninvasive scoring system for the detection of NASH with advanced fibrosis is the NAFLD fibrosis score, which is easily calculated using laboratory values and clinical parameters already in a patient’s chart.
A more sophisticated serum biomarker test known as ELF, or the Enhanced Liver Fibrosis test, combines serum levels of hyaluronic acid, tissue inhibitor of metalloproteinase I, and procollagen amino terminal peptide.
“ELF is a very, very good test. It’s approved in Europe and I suspect it will be in the U.S. within the next year or so,” said Dr. Younossi.
The most exciting noninvasive tests, however, involve imaging that measures liver stiffness, which provides a fairly accurate indication of the degree of scarring in the organ. There are two methods available: vibration wave transient elastography and magnetic resonance elastography.
Transient elastography using the FibroScan device is commercially available in the United States. “It’s a good test, very easy to do, noninvasive. I have a couple of these machines, and we use them all the time,” the gastroenterologist said.
MR elastography provides superior accuracy, but access is an issue.
“At our institution you sometimes have to wait for weeks to get an outpatient MRI, so if you have hundreds of patients with fatty liver disease it makes things difficult. So in our practice we use transient elastography,” he explained.
Both imaging modalities also measure the amount of fat in the liver.
Dr. Younossi uses transient elastography in patients who don’t have type 2 diabetes or frank insulin resistance. If the FibroScan score is 7 kiloPascals or more, he considers liver biopsy, since that’s the threshold for detection of earlier, potentially reversible stage 2 fibrosis. If, however, a patient has diabetes or insulin resistance along with a NAFLD fibrosis score suggesting a high possibility of fibrosis, he sends that patient for liver biopsy, since those endocrinologic disorders are known to be independent risk factors for mortality in the setting of NAFLD.
Dr. Younossi reported having no financial conflicts of interest regarding his presentation.
NEW ORLEANS – Zobair M. Younossi, MD, declared at the annual meeting of the American College of Physicians.
The massive growth in nonalcoholic fatty liver disease (NAFLD) is being fueled to a great extent by the related epidemics of obesity and type 2 diabetes mellitus. While the overall prevalence of NAFLD worldwide is 24%, almost three-quarters of patients with NAFLD are obese. And the prevalence of NAFLD in individuals with T2DM was 58% in a recent meta-analysis of studies from 20 countries conducted by Dr. Younossi and his coinvestigators.
“The prevalence of NAFLD in U.S. kids is about 10%. This is of course part of the coming tsunami because our kids are getting obese, diabetic, and they’re going to have problems with NASH [nonalcoholic steatohepatitis],” said Dr. Younossi, a gastroenterologist who is professor and chairman of the department of medicine at the Inova Fairfax (Va.) campus of Virginia Commonwealth University.
NASH is the form of NAFLD that has the strongest prognostic implications. It can progress to cirrhosis, liver failure, or hepatocellular carcinoma. As Dr. Younossi and his coworkers have shown (Hepat Commun. 2017 Jun 6;1[5]:421-8), it is associated with a significantly greater risk of both liver-related and all-cause mortality than that of non-NASH NAFLD, although NAFLD also carries an increased risk of cardiovascular disease, the leading cause of death in that population.
In addition to highlighting the enormous clinical, economic, and quality-of-life implications of the NAFLD epidemic, Dr. Younossi offered practical tips on how busy primary care physicians can identify patients in their practice who have high-risk NAFLD. They have not done a very good job of this to date. That’s possibly due to lack of incentive, since in 2018 there is no approved drug for the treatment of NASH. He cited one representative retrospective study in which only about 15% of patients identified as having NAFLD received a recommendation for lifestyle modification involving diet and exercise, which is the standard evidence-based treatment, albeit admittedly difficult to sustain. And only 3% of patients with advanced liver fibrosis were referred to a specialist for management.
“So NAFLD is common, but its recognition and doing something about it is quite a challenge,” Dr. Younossi observed.
He argued that patients who have NASH deserve to know it because of its prognostic implications and also so they can have the chance to participate in one of the roughly two dozen ongoing clinical trials of potential therapies, some of which look quite promising. All of the trials required a liver biopsy as a condition for enrollment. Plus, once a patient is known to have stage 3 fibrosis, it’s time to start screening for hepatocellular carcinoma and esophageal varices.
The scope of the epidemic
NASH is the most rapidly growing indication for liver transplantation in the United States, with most of the increase coming from the baby boomer population. NASH is now the second most common indication for placement on the wait list. Meanwhile, liver transplantation due to the consequences of hepatitis C, the No. 1 indication, is declining as a result of the spectacular advances in medical treatment introduced a few years ago. It’s likely that in coming years NASH will take over the top spot, according to Dr. Younossi.
He was coauthor of a recent study that modeled the estimated trends for the NAFLD epidemic in the United States through 2030. The forecast is that the prevalence of NAFLD among adults will climb to 33.5% and the proportion of NAFLD categorized as NASH will increase from 20% at present to 27%. Moreover, this will result in a 168% jump in the incidence of decompensated cirrhosis, a 137% increase in the incidence of hepatocellular carcinoma, and a 178% increase in liver-related mortality, which will account for an estimated 78,300 deaths in 2030 (Hepatology. 2018 Jan;67[1]:123-33).
Practical ways to identify high-risk patients
The best noninvasive means of detecting NAFLD is by ultrasound showing a fatty liver. Often the condition is detected as an incidental finding on abdominal ultrasound ordered for another reason. Elevated liver enzymes can be a tipoff as well. Of course, alcoholic liver disease and other causes must be excluded.
But what’s most important is to identify patients with NASH. It’s a diagnosis made by biopsy. However, it is unthinkable to perform liver biopsies in the entire vast population with NAFLD, so there is a great deal of interest in developing noninvasive diagnostic modalities that can help zero in on the subset of high-risk NAFLD patients who should be considered for referral for liver biopsy.
One useful clue is the presence of comorbid metabolic syndrome in patients with NAFLD. It confers a substantially higher mortality risk – especially cardiovascular mortality – than does NAFLD without metabolic syndrome. Dr. Younossi and his coinvestigators have shown in a study of 3,613 NAFLD patients followed long-term that those with one component of the metabolic syndrome – either hypertension, central obesity, increased fasting plasma glucose, or hyperlipidemia – had 8- and 16-year all-cause mortality rates of 4.7% and 11.9%, nearly double the 2.6% and 6% rates in NAFLD patients with no elements of the metabolic syndrome.
Moreover, the magnitude of risk increased with each additional metabolic syndrome condition: a 3.57-fold increased mortality risk in NAFLD patients with two components of metabolic syndrome, a 5.87-fold increase in those with three, and a 13.09-fold increase in NAFLD patients with all four elements of metabolic syndrome (Medicine [Baltimore]. 2018 Mar;97[13]:e0214. doi: 10.1097/MD.0000000000010214).
Dr. Younossi was a member of the American Association for the Study of Liver Disease expert panel that developed the latest practice guidance regarding the diagnosis and management of NAFLD (Hepatology. 2018 Jan;67[1]:328-57). He said that probably the best simple noninvasive scoring system for the detection of NASH with advanced fibrosis is the NAFLD fibrosis score, which is easily calculated using laboratory values and clinical parameters already in a patient’s chart.
A more sophisticated serum biomarker test known as ELF, or the Enhanced Liver Fibrosis test, combines serum levels of hyaluronic acid, tissue inhibitor of metalloproteinase I, and procollagen amino terminal peptide.
“ELF is a very, very good test. It’s approved in Europe and I suspect it will be in the U.S. within the next year or so,” said Dr. Younossi.
The most exciting noninvasive tests, however, involve imaging that measures liver stiffness, which provides a fairly accurate indication of the degree of scarring in the organ. There are two methods available: vibration wave transient elastography and magnetic resonance elastography.
Transient elastography using the FibroScan device is commercially available in the United States. “It’s a good test, very easy to do, noninvasive. I have a couple of these machines, and we use them all the time,” the gastroenterologist said.
MR elastography provides superior accuracy, but access is an issue.
“At our institution you sometimes have to wait for weeks to get an outpatient MRI, so if you have hundreds of patients with fatty liver disease it makes things difficult. So in our practice we use transient elastography,” he explained.
Both imaging modalities also measure the amount of fat in the liver.
Dr. Younossi uses transient elastography in patients who don’t have type 2 diabetes or frank insulin resistance. If the FibroScan score is 7 kiloPascals or more, he considers liver biopsy, since that’s the threshold for detection of earlier, potentially reversible stage 2 fibrosis. If, however, a patient has diabetes or insulin resistance along with a NAFLD fibrosis score suggesting a high possibility of fibrosis, he sends that patient for liver biopsy, since those endocrinologic disorders are known to be independent risk factors for mortality in the setting of NAFLD.
Dr. Younossi reported having no financial conflicts of interest regarding his presentation.
NEW ORLEANS – Zobair M. Younossi, MD, declared at the annual meeting of the American College of Physicians.
The massive growth in nonalcoholic fatty liver disease (NAFLD) is being fueled to a great extent by the related epidemics of obesity and type 2 diabetes mellitus. While the overall prevalence of NAFLD worldwide is 24%, almost three-quarters of patients with NAFLD are obese. And the prevalence of NAFLD in individuals with T2DM was 58% in a recent meta-analysis of studies from 20 countries conducted by Dr. Younossi and his coinvestigators.
“The prevalence of NAFLD in U.S. kids is about 10%. This is of course part of the coming tsunami because our kids are getting obese, diabetic, and they’re going to have problems with NASH [nonalcoholic steatohepatitis],” said Dr. Younossi, a gastroenterologist who is professor and chairman of the department of medicine at the Inova Fairfax (Va.) campus of Virginia Commonwealth University.
NASH is the form of NAFLD that has the strongest prognostic implications. It can progress to cirrhosis, liver failure, or hepatocellular carcinoma. As Dr. Younossi and his coworkers have shown (Hepat Commun. 2017 Jun 6;1[5]:421-8), it is associated with a significantly greater risk of both liver-related and all-cause mortality than that of non-NASH NAFLD, although NAFLD also carries an increased risk of cardiovascular disease, the leading cause of death in that population.
In addition to highlighting the enormous clinical, economic, and quality-of-life implications of the NAFLD epidemic, Dr. Younossi offered practical tips on how busy primary care physicians can identify patients in their practice who have high-risk NAFLD. They have not done a very good job of this to date. That’s possibly due to lack of incentive, since in 2018 there is no approved drug for the treatment of NASH. He cited one representative retrospective study in which only about 15% of patients identified as having NAFLD received a recommendation for lifestyle modification involving diet and exercise, which is the standard evidence-based treatment, albeit admittedly difficult to sustain. And only 3% of patients with advanced liver fibrosis were referred to a specialist for management.
“So NAFLD is common, but its recognition and doing something about it is quite a challenge,” Dr. Younossi observed.
He argued that patients who have NASH deserve to know it because of its prognostic implications and also so they can have the chance to participate in one of the roughly two dozen ongoing clinical trials of potential therapies, some of which look quite promising. All of the trials required a liver biopsy as a condition for enrollment. Plus, once a patient is known to have stage 3 fibrosis, it’s time to start screening for hepatocellular carcinoma and esophageal varices.
The scope of the epidemic
NASH is the most rapidly growing indication for liver transplantation in the United States, with most of the increase coming from the baby boomer population. NASH is now the second most common indication for placement on the wait list. Meanwhile, liver transplantation due to the consequences of hepatitis C, the No. 1 indication, is declining as a result of the spectacular advances in medical treatment introduced a few years ago. It’s likely that in coming years NASH will take over the top spot, according to Dr. Younossi.
He was coauthor of a recent study that modeled the estimated trends for the NAFLD epidemic in the United States through 2030. The forecast is that the prevalence of NAFLD among adults will climb to 33.5% and the proportion of NAFLD categorized as NASH will increase from 20% at present to 27%. Moreover, this will result in a 168% jump in the incidence of decompensated cirrhosis, a 137% increase in the incidence of hepatocellular carcinoma, and a 178% increase in liver-related mortality, which will account for an estimated 78,300 deaths in 2030 (Hepatology. 2018 Jan;67[1]:123-33).
Practical ways to identify high-risk patients
The best noninvasive means of detecting NAFLD is by ultrasound showing a fatty liver. Often the condition is detected as an incidental finding on abdominal ultrasound ordered for another reason. Elevated liver enzymes can be a tipoff as well. Of course, alcoholic liver disease and other causes must be excluded.
But what’s most important is to identify patients with NASH. It’s a diagnosis made by biopsy. However, it is unthinkable to perform liver biopsies in the entire vast population with NAFLD, so there is a great deal of interest in developing noninvasive diagnostic modalities that can help zero in on the subset of high-risk NAFLD patients who should be considered for referral for liver biopsy.
One useful clue is the presence of comorbid metabolic syndrome in patients with NAFLD. It confers a substantially higher mortality risk – especially cardiovascular mortality – than does NAFLD without metabolic syndrome. Dr. Younossi and his coinvestigators have shown in a study of 3,613 NAFLD patients followed long-term that those with one component of the metabolic syndrome – either hypertension, central obesity, increased fasting plasma glucose, or hyperlipidemia – had 8- and 16-year all-cause mortality rates of 4.7% and 11.9%, nearly double the 2.6% and 6% rates in NAFLD patients with no elements of the metabolic syndrome.
Moreover, the magnitude of risk increased with each additional metabolic syndrome condition: a 3.57-fold increased mortality risk in NAFLD patients with two components of metabolic syndrome, a 5.87-fold increase in those with three, and a 13.09-fold increase in NAFLD patients with all four elements of metabolic syndrome (Medicine [Baltimore]. 2018 Mar;97[13]:e0214. doi: 10.1097/MD.0000000000010214).
Dr. Younossi was a member of the American Association for the Study of Liver Disease expert panel that developed the latest practice guidance regarding the diagnosis and management of NAFLD (Hepatology. 2018 Jan;67[1]:328-57). He said that probably the best simple noninvasive scoring system for the detection of NASH with advanced fibrosis is the NAFLD fibrosis score, which is easily calculated using laboratory values and clinical parameters already in a patient’s chart.
A more sophisticated serum biomarker test known as ELF, or the Enhanced Liver Fibrosis test, combines serum levels of hyaluronic acid, tissue inhibitor of metalloproteinase I, and procollagen amino terminal peptide.
“ELF is a very, very good test. It’s approved in Europe and I suspect it will be in the U.S. within the next year or so,” said Dr. Younossi.
The most exciting noninvasive tests, however, involve imaging that measures liver stiffness, which provides a fairly accurate indication of the degree of scarring in the organ. There are two methods available: vibration wave transient elastography and magnetic resonance elastography.
Transient elastography using the FibroScan device is commercially available in the United States. “It’s a good test, very easy to do, noninvasive. I have a couple of these machines, and we use them all the time,” the gastroenterologist said.
MR elastography provides superior accuracy, but access is an issue.
“At our institution you sometimes have to wait for weeks to get an outpatient MRI, so if you have hundreds of patients with fatty liver disease it makes things difficult. So in our practice we use transient elastography,” he explained.
Both imaging modalities also measure the amount of fat in the liver.
Dr. Younossi uses transient elastography in patients who don’t have type 2 diabetes or frank insulin resistance. If the FibroScan score is 7 kiloPascals or more, he considers liver biopsy, since that’s the threshold for detection of earlier, potentially reversible stage 2 fibrosis. If, however, a patient has diabetes or insulin resistance along with a NAFLD fibrosis score suggesting a high possibility of fibrosis, he sends that patient for liver biopsy, since those endocrinologic disorders are known to be independent risk factors for mortality in the setting of NAFLD.
Dr. Younossi reported having no financial conflicts of interest regarding his presentation.
REPORTING FROM ACP INTERNAL MEDICINE
Address physical health risks of people with SMI
ROCKVILLE, MD. – The problem of medical comorbidities in people with serious mental illness (SMI) persists and must be addressed, researchers said at a National Institute on Mental Health conference on mental health services research. Part of that effort, they said, is a more careful consideration of risks tied to the off-label use of second-generation antipsychotics.
The researchers discussed strategies aimed at combating obesity and diabetes, as well as behaviors such as smoking and sedentary lifestyle.
“One of the things that jumps out is the tremendous need for evidence-based strategies to address these physical health problems that are common in general population but even more of a burden for people with serious mental illness,” said Susan T. Azrin, PhD, of the NIMH, in an interview.
A study published in 2015, estimated that people with schizophrenia, for example, might lose almost 30 years of life because of premature death. Individuals with serious mental illness also experience elevated morbidity from cardiovascular disease and cancer. The NIMH and other federal agencies have in recent years looked for ways to help people with SMI quit smoking, and better control their weight and cholesterol.
But approaches that sound promising for boosting physical fitness in this group of patients have not always proven successful. Joshua Breslau, PhD, ScD, of the Rand Corp. discussed findings from a 2014 paper where he and his colleagues reported somewhat disappointing results from a study of federal Primary and Behavioral Health Care Integration grants.
The researchers matched clinics receiving this funding with similar ones that did not. They found that people with mental illness treated at the clinics receiving the grants showed improvements in some indicators of physical health (diastolic blood pressure, total cholesterol, LDL cholesterol, and fasting plasma glucose) but not in others (systolic blood pressure, body mass index, HDL cholesterol, hemoglobin A1c, triglycerides, self-reported smoking). Dr. Breslau said he and his colleagues also found only limited benefits in quality of care for physical health conditions associated with the grant program. Still, he remains hopeful.
“There is some potential here,” Dr. Breslau said. “Sometimes, we are seeing positive effects, but it’s certainly not a slam-dunk.”
He noted that opening a new setting for primary care services could strain a workforce that’s already in short supply. In addition, he said, attempts to fold primary care services into mental health programs could, in some cases, result in replication of care of chronic conditions for certain patients with SMI.
We “may still not reach that portion of the target population that has the greatest need,” Dr. Breslau said in an interview. “The new services may turn out to be duplicative rather than filling a gap.”
In another session, Gail L. Daumit, MD, MHS, of Johns Hopkins University, Baltimore, discussed her plan to build on a past success in helping people with SMI lose weight.
In the ACHIEVE (Achieving Healthy Lifestyles In Psych Rehabilitation) trial, Dr. Daumit and her colleagues found that people enrolled in an intervention group lost an average of 3.2 kg more than did a control group after 18 months (N Engl J Med. 2013;368:1594-602). The intervention steps included alternating group and individual weight management sessions, on-site group physical activity three times weekly, and weigh-ins. The study had 291 patients who were randomized between the control and intervention groups.
that can be used more broadly. She’s seeking to scale up effective interventions to address cardiovascular risk factors in people with SMI.
“Our goal is not just to get process-of-care measures like ‘counseling was delivered,’ ‘a medicine was started,’ but to actually show impact on health outcomes,” Dr. Daumit said.
Risks tied to antipsychotics
People with SMI face cardiovascular risks not only from unhealthy behaviors but also from the medications used to treat their psychiatric conditions. The American Diabetes Association and American Psychiatric Association in 2004 released a consensus statement on the impact of antipsychotics such as clozapine, olanzapine, and risperidone on obesity and diabetes. It included guidelines for monitoring the metabolic status of patients both at baseline and after initiating treatment, including checking body mass index, waist circumference, blood pressure, fasting glucose, and fasting lipids.
Yet, substantial evidence suggests that the medical community still has not paid enough attention to the health risks of those medications, said Alisa Busch, MD, of Harvard Medical School, Boston.
“A slew of research has shown since then that we have done a very poor job in adhering to those monitoring guidelines,” Dr. Busch said.
A fellow panelist, Marcela Horvitz-Lennon, MD, MPH, of the Rand Corp., presented results from her study showing continued common use of second-generation antipsychotics for off-label use for treatment of anxiety, posttraumatic stress disorder, and dementia in people of all ages.
Consistent with previous research, Dr. Horvitz-Lennon and her colleagues found that off-label use of second-generation antipsychotics was common during 2008-2012 in the four states they studied. They looked at available data from fee-for-service Medicare, Medicaid, and dually (Medicaid-Medicare) covered adult beneficiaries in California, Georgia, Mississippi, and Oklahoma.
Throughout the study period, California had the highest rate of fee-for-service beneficiaries whose SGA use was consistently off label (44.6%). Georgia had the lowest rate of always off-label use (35.1%), while Mississippi (42%) and Oklahoma (36.3%) fell somewhere in the middle.
When second-generation antipsychotics have approved uses such as schizophrenia, the known profile of a medication gives some assurance that the benefit of the medications will exceed the risk for that patient, she said. “When the medication is used off label, the implication is that there is no good evidence that the benefits are there,” Dr. Horvitz-Lennon said. “Hence, the potential for harm is most likely exceeding that likely or unlikely benefit.”
Dr. Daumit, Dr. Breslau, and Dr. Horvitz-Lennon said they had no financial disclosures.
ROCKVILLE, MD. – The problem of medical comorbidities in people with serious mental illness (SMI) persists and must be addressed, researchers said at a National Institute on Mental Health conference on mental health services research. Part of that effort, they said, is a more careful consideration of risks tied to the off-label use of second-generation antipsychotics.
The researchers discussed strategies aimed at combating obesity and diabetes, as well as behaviors such as smoking and sedentary lifestyle.
“One of the things that jumps out is the tremendous need for evidence-based strategies to address these physical health problems that are common in general population but even more of a burden for people with serious mental illness,” said Susan T. Azrin, PhD, of the NIMH, in an interview.
A study published in 2015, estimated that people with schizophrenia, for example, might lose almost 30 years of life because of premature death. Individuals with serious mental illness also experience elevated morbidity from cardiovascular disease and cancer. The NIMH and other federal agencies have in recent years looked for ways to help people with SMI quit smoking, and better control their weight and cholesterol.
But approaches that sound promising for boosting physical fitness in this group of patients have not always proven successful. Joshua Breslau, PhD, ScD, of the Rand Corp. discussed findings from a 2014 paper where he and his colleagues reported somewhat disappointing results from a study of federal Primary and Behavioral Health Care Integration grants.
The researchers matched clinics receiving this funding with similar ones that did not. They found that people with mental illness treated at the clinics receiving the grants showed improvements in some indicators of physical health (diastolic blood pressure, total cholesterol, LDL cholesterol, and fasting plasma glucose) but not in others (systolic blood pressure, body mass index, HDL cholesterol, hemoglobin A1c, triglycerides, self-reported smoking). Dr. Breslau said he and his colleagues also found only limited benefits in quality of care for physical health conditions associated with the grant program. Still, he remains hopeful.
“There is some potential here,” Dr. Breslau said. “Sometimes, we are seeing positive effects, but it’s certainly not a slam-dunk.”
He noted that opening a new setting for primary care services could strain a workforce that’s already in short supply. In addition, he said, attempts to fold primary care services into mental health programs could, in some cases, result in replication of care of chronic conditions for certain patients with SMI.
We “may still not reach that portion of the target population that has the greatest need,” Dr. Breslau said in an interview. “The new services may turn out to be duplicative rather than filling a gap.”
In another session, Gail L. Daumit, MD, MHS, of Johns Hopkins University, Baltimore, discussed her plan to build on a past success in helping people with SMI lose weight.
In the ACHIEVE (Achieving Healthy Lifestyles In Psych Rehabilitation) trial, Dr. Daumit and her colleagues found that people enrolled in an intervention group lost an average of 3.2 kg more than did a control group after 18 months (N Engl J Med. 2013;368:1594-602). The intervention steps included alternating group and individual weight management sessions, on-site group physical activity three times weekly, and weigh-ins. The study had 291 patients who were randomized between the control and intervention groups.
that can be used more broadly. She’s seeking to scale up effective interventions to address cardiovascular risk factors in people with SMI.
“Our goal is not just to get process-of-care measures like ‘counseling was delivered,’ ‘a medicine was started,’ but to actually show impact on health outcomes,” Dr. Daumit said.
Risks tied to antipsychotics
People with SMI face cardiovascular risks not only from unhealthy behaviors but also from the medications used to treat their psychiatric conditions. The American Diabetes Association and American Psychiatric Association in 2004 released a consensus statement on the impact of antipsychotics such as clozapine, olanzapine, and risperidone on obesity and diabetes. It included guidelines for monitoring the metabolic status of patients both at baseline and after initiating treatment, including checking body mass index, waist circumference, blood pressure, fasting glucose, and fasting lipids.
Yet, substantial evidence suggests that the medical community still has not paid enough attention to the health risks of those medications, said Alisa Busch, MD, of Harvard Medical School, Boston.
“A slew of research has shown since then that we have done a very poor job in adhering to those monitoring guidelines,” Dr. Busch said.
A fellow panelist, Marcela Horvitz-Lennon, MD, MPH, of the Rand Corp., presented results from her study showing continued common use of second-generation antipsychotics for off-label use for treatment of anxiety, posttraumatic stress disorder, and dementia in people of all ages.
Consistent with previous research, Dr. Horvitz-Lennon and her colleagues found that off-label use of second-generation antipsychotics was common during 2008-2012 in the four states they studied. They looked at available data from fee-for-service Medicare, Medicaid, and dually (Medicaid-Medicare) covered adult beneficiaries in California, Georgia, Mississippi, and Oklahoma.
Throughout the study period, California had the highest rate of fee-for-service beneficiaries whose SGA use was consistently off label (44.6%). Georgia had the lowest rate of always off-label use (35.1%), while Mississippi (42%) and Oklahoma (36.3%) fell somewhere in the middle.
When second-generation antipsychotics have approved uses such as schizophrenia, the known profile of a medication gives some assurance that the benefit of the medications will exceed the risk for that patient, she said. “When the medication is used off label, the implication is that there is no good evidence that the benefits are there,” Dr. Horvitz-Lennon said. “Hence, the potential for harm is most likely exceeding that likely or unlikely benefit.”
Dr. Daumit, Dr. Breslau, and Dr. Horvitz-Lennon said they had no financial disclosures.
ROCKVILLE, MD. – The problem of medical comorbidities in people with serious mental illness (SMI) persists and must be addressed, researchers said at a National Institute on Mental Health conference on mental health services research. Part of that effort, they said, is a more careful consideration of risks tied to the off-label use of second-generation antipsychotics.
The researchers discussed strategies aimed at combating obesity and diabetes, as well as behaviors such as smoking and sedentary lifestyle.
“One of the things that jumps out is the tremendous need for evidence-based strategies to address these physical health problems that are common in general population but even more of a burden for people with serious mental illness,” said Susan T. Azrin, PhD, of the NIMH, in an interview.
A study published in 2015, estimated that people with schizophrenia, for example, might lose almost 30 years of life because of premature death. Individuals with serious mental illness also experience elevated morbidity from cardiovascular disease and cancer. The NIMH and other federal agencies have in recent years looked for ways to help people with SMI quit smoking, and better control their weight and cholesterol.
But approaches that sound promising for boosting physical fitness in this group of patients have not always proven successful. Joshua Breslau, PhD, ScD, of the Rand Corp. discussed findings from a 2014 paper where he and his colleagues reported somewhat disappointing results from a study of federal Primary and Behavioral Health Care Integration grants.
The researchers matched clinics receiving this funding with similar ones that did not. They found that people with mental illness treated at the clinics receiving the grants showed improvements in some indicators of physical health (diastolic blood pressure, total cholesterol, LDL cholesterol, and fasting plasma glucose) but not in others (systolic blood pressure, body mass index, HDL cholesterol, hemoglobin A1c, triglycerides, self-reported smoking). Dr. Breslau said he and his colleagues also found only limited benefits in quality of care for physical health conditions associated with the grant program. Still, he remains hopeful.
“There is some potential here,” Dr. Breslau said. “Sometimes, we are seeing positive effects, but it’s certainly not a slam-dunk.”
He noted that opening a new setting for primary care services could strain a workforce that’s already in short supply. In addition, he said, attempts to fold primary care services into mental health programs could, in some cases, result in replication of care of chronic conditions for certain patients with SMI.
We “may still not reach that portion of the target population that has the greatest need,” Dr. Breslau said in an interview. “The new services may turn out to be duplicative rather than filling a gap.”
In another session, Gail L. Daumit, MD, MHS, of Johns Hopkins University, Baltimore, discussed her plan to build on a past success in helping people with SMI lose weight.
In the ACHIEVE (Achieving Healthy Lifestyles In Psych Rehabilitation) trial, Dr. Daumit and her colleagues found that people enrolled in an intervention group lost an average of 3.2 kg more than did a control group after 18 months (N Engl J Med. 2013;368:1594-602). The intervention steps included alternating group and individual weight management sessions, on-site group physical activity three times weekly, and weigh-ins. The study had 291 patients who were randomized between the control and intervention groups.
that can be used more broadly. She’s seeking to scale up effective interventions to address cardiovascular risk factors in people with SMI.
“Our goal is not just to get process-of-care measures like ‘counseling was delivered,’ ‘a medicine was started,’ but to actually show impact on health outcomes,” Dr. Daumit said.
Risks tied to antipsychotics
People with SMI face cardiovascular risks not only from unhealthy behaviors but also from the medications used to treat their psychiatric conditions. The American Diabetes Association and American Psychiatric Association in 2004 released a consensus statement on the impact of antipsychotics such as clozapine, olanzapine, and risperidone on obesity and diabetes. It included guidelines for monitoring the metabolic status of patients both at baseline and after initiating treatment, including checking body mass index, waist circumference, blood pressure, fasting glucose, and fasting lipids.
Yet, substantial evidence suggests that the medical community still has not paid enough attention to the health risks of those medications, said Alisa Busch, MD, of Harvard Medical School, Boston.
“A slew of research has shown since then that we have done a very poor job in adhering to those monitoring guidelines,” Dr. Busch said.
A fellow panelist, Marcela Horvitz-Lennon, MD, MPH, of the Rand Corp., presented results from her study showing continued common use of second-generation antipsychotics for off-label use for treatment of anxiety, posttraumatic stress disorder, and dementia in people of all ages.
Consistent with previous research, Dr. Horvitz-Lennon and her colleagues found that off-label use of second-generation antipsychotics was common during 2008-2012 in the four states they studied. They looked at available data from fee-for-service Medicare, Medicaid, and dually (Medicaid-Medicare) covered adult beneficiaries in California, Georgia, Mississippi, and Oklahoma.
Throughout the study period, California had the highest rate of fee-for-service beneficiaries whose SGA use was consistently off label (44.6%). Georgia had the lowest rate of always off-label use (35.1%), while Mississippi (42%) and Oklahoma (36.3%) fell somewhere in the middle.
When second-generation antipsychotics have approved uses such as schizophrenia, the known profile of a medication gives some assurance that the benefit of the medications will exceed the risk for that patient, she said. “When the medication is used off label, the implication is that there is no good evidence that the benefits are there,” Dr. Horvitz-Lennon said. “Hence, the potential for harm is most likely exceeding that likely or unlikely benefit.”
Dr. Daumit, Dr. Breslau, and Dr. Horvitz-Lennon said they had no financial disclosures.
REPORTING FROM AN NIMH CONFERENCE
Childhood obesity linked to severe dental infections
ATLANTA – Childhood obesity increases the risk of severe dental infections, according to a review presented at the Pediatric Hospital Medicine meeting.
Among 171 children admitted to Rady Children’s Hospital, San Diego, for infected cavities, obese children were almost four times more likely than others to require surgery, and five times more likely to have a tooth pulled.
The average cost for obese children was $13,000/day, versus $10,000/day for nonobese children, probably because of the greater need for surgery. Average length of stay was the same between the two groups, just under 2 days. The findings were statistically significant.
Obesity turns out to be “an important risk factor for invasive interventions for pediatric dental infections,” concluded study leader Michelle Edmunds, MD, a pediatric hospital medicine fellow at Rady.
Childhood obesity has been associated with cavities before, but it’s new information that it increases the severity of dental infections. The finding is something for pediatricians to be aware of and to use to encourage regular dental care. “Even if you are obese, if you are getting routine care, you should be able to have cavities fixed” before they get out of hand. “Unfortunately, a lot of the kids we see don’t get routine care,” Dr. Edmunds said.
The investigators couldn’t assess the role of diet because there wasn’t enough information about it in the medical records. It certainly must play a role, because soda and other junk foods increase the risk of both obesity and cavities.
Other factors also are likely at play. Obesity might affect the oral flora, and perhaps the balance of pathogens. It also seems to reduce healing and infection-fighting ability, so “there might be some immunocompromise that’s playing a role here,” Dr. Edmunds said.
The team compared 25 children up to 18 years old who were at or above the 95th percentile for body mass index – the study definition of obesity – to 146 children who were below that mark. They had all been admitted through the ED between July 2011 and June 2016 with dental abscesses, facial cellulitis, or other dental-associated infections. Eighty percent of the children were on Medicaid, which has, itself, been associated with less frequent visits to the dentist.
About 50% of the children were discharged home without a dental procedure. Among the rest, a quarter had incision and drainage, and a quarter had tooth extractions. Overall 72% (18) of obese children had surgery, usually extractions, versus 43% (62) of nonobese children.
There’s perhaps around 200,000 pediatric ED visits a year in the United States for dental problems. “We’ve had toddlers and kids who have never seen a dentist before; all of their teeth were rotten and had to be pulled out, every single tooth,” Dr. Edmunds said at the meeting sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
The mean age in the study was about 8 years. Nearly 60% of the subjects were boys, and a bit over 60% Hispanic. There were no statistical difference in demographics, prior antibiotic use, or cavity history between obese and nonobese children. Obese children were more likely to be on Medicaid, but not significantly so.
There was no industry funding for the work, and Dr. Edmunds didn’t have any disclosures.
ATLANTA – Childhood obesity increases the risk of severe dental infections, according to a review presented at the Pediatric Hospital Medicine meeting.
Among 171 children admitted to Rady Children’s Hospital, San Diego, for infected cavities, obese children were almost four times more likely than others to require surgery, and five times more likely to have a tooth pulled.
The average cost for obese children was $13,000/day, versus $10,000/day for nonobese children, probably because of the greater need for surgery. Average length of stay was the same between the two groups, just under 2 days. The findings were statistically significant.
Obesity turns out to be “an important risk factor for invasive interventions for pediatric dental infections,” concluded study leader Michelle Edmunds, MD, a pediatric hospital medicine fellow at Rady.
Childhood obesity has been associated with cavities before, but it’s new information that it increases the severity of dental infections. The finding is something for pediatricians to be aware of and to use to encourage regular dental care. “Even if you are obese, if you are getting routine care, you should be able to have cavities fixed” before they get out of hand. “Unfortunately, a lot of the kids we see don’t get routine care,” Dr. Edmunds said.
The investigators couldn’t assess the role of diet because there wasn’t enough information about it in the medical records. It certainly must play a role, because soda and other junk foods increase the risk of both obesity and cavities.
Other factors also are likely at play. Obesity might affect the oral flora, and perhaps the balance of pathogens. It also seems to reduce healing and infection-fighting ability, so “there might be some immunocompromise that’s playing a role here,” Dr. Edmunds said.
The team compared 25 children up to 18 years old who were at or above the 95th percentile for body mass index – the study definition of obesity – to 146 children who were below that mark. They had all been admitted through the ED between July 2011 and June 2016 with dental abscesses, facial cellulitis, or other dental-associated infections. Eighty percent of the children were on Medicaid, which has, itself, been associated with less frequent visits to the dentist.
About 50% of the children were discharged home without a dental procedure. Among the rest, a quarter had incision and drainage, and a quarter had tooth extractions. Overall 72% (18) of obese children had surgery, usually extractions, versus 43% (62) of nonobese children.
There’s perhaps around 200,000 pediatric ED visits a year in the United States for dental problems. “We’ve had toddlers and kids who have never seen a dentist before; all of their teeth were rotten and had to be pulled out, every single tooth,” Dr. Edmunds said at the meeting sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
The mean age in the study was about 8 years. Nearly 60% of the subjects were boys, and a bit over 60% Hispanic. There were no statistical difference in demographics, prior antibiotic use, or cavity history between obese and nonobese children. Obese children were more likely to be on Medicaid, but not significantly so.
There was no industry funding for the work, and Dr. Edmunds didn’t have any disclosures.
ATLANTA – Childhood obesity increases the risk of severe dental infections, according to a review presented at the Pediatric Hospital Medicine meeting.
Among 171 children admitted to Rady Children’s Hospital, San Diego, for infected cavities, obese children were almost four times more likely than others to require surgery, and five times more likely to have a tooth pulled.
The average cost for obese children was $13,000/day, versus $10,000/day for nonobese children, probably because of the greater need for surgery. Average length of stay was the same between the two groups, just under 2 days. The findings were statistically significant.
Obesity turns out to be “an important risk factor for invasive interventions for pediatric dental infections,” concluded study leader Michelle Edmunds, MD, a pediatric hospital medicine fellow at Rady.
Childhood obesity has been associated with cavities before, but it’s new information that it increases the severity of dental infections. The finding is something for pediatricians to be aware of and to use to encourage regular dental care. “Even if you are obese, if you are getting routine care, you should be able to have cavities fixed” before they get out of hand. “Unfortunately, a lot of the kids we see don’t get routine care,” Dr. Edmunds said.
The investigators couldn’t assess the role of diet because there wasn’t enough information about it in the medical records. It certainly must play a role, because soda and other junk foods increase the risk of both obesity and cavities.
Other factors also are likely at play. Obesity might affect the oral flora, and perhaps the balance of pathogens. It also seems to reduce healing and infection-fighting ability, so “there might be some immunocompromise that’s playing a role here,” Dr. Edmunds said.
The team compared 25 children up to 18 years old who were at or above the 95th percentile for body mass index – the study definition of obesity – to 146 children who were below that mark. They had all been admitted through the ED between July 2011 and June 2016 with dental abscesses, facial cellulitis, or other dental-associated infections. Eighty percent of the children were on Medicaid, which has, itself, been associated with less frequent visits to the dentist.
About 50% of the children were discharged home without a dental procedure. Among the rest, a quarter had incision and drainage, and a quarter had tooth extractions. Overall 72% (18) of obese children had surgery, usually extractions, versus 43% (62) of nonobese children.
There’s perhaps around 200,000 pediatric ED visits a year in the United States for dental problems. “We’ve had toddlers and kids who have never seen a dentist before; all of their teeth were rotten and had to be pulled out, every single tooth,” Dr. Edmunds said at the meeting sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
The mean age in the study was about 8 years. Nearly 60% of the subjects were boys, and a bit over 60% Hispanic. There were no statistical difference in demographics, prior antibiotic use, or cavity history between obese and nonobese children. Obese children were more likely to be on Medicaid, but not significantly so.
There was no industry funding for the work, and Dr. Edmunds didn’t have any disclosures.
REPORTING FROM PHM 2018
Key clinical point: Childhood obesity increases the risk of severe dental infections.
Major finding:
Study details: Review of 171 children admitted to Rady Children’s Hospital, San Diego, for infected cavities
Disclosures: There was no industry funding, and the presenter had no disclosures.
Varied diet not necessarily a high-quality one
A diverse diet is not necessarily a healthy one, according to an advisory issued by the American Heart Association that has instead emphasized the importance of a healthy eating pattern.
Published in the Aug. 9 online edition of Circulation, the science advisory was prompted by emerging evidence that greater dietary diversity may actually be associated with eating more poor quality foods and higher energy intake, especially among middle-aged adults.
Researchers conducted a literature search across 2000-2017 for studies of dietary diversity – defined as the number of different foods or food groups eaten over a given period of time – and dietary quality.
However, they also noted that many studies had significant limitations that contributed to high levels of inconsistency across all studies.
For example, one study in overweight and obese individuals found increasing dietary diversity was associated with a decrease in body mass index but with respect to intakes of only low–energy dense foods. Another study in Chinese adults saw an increase in diversity in the intake of snacks but not grains, vegetables, fruits, meats, or beverages, and this was associated with a 45% greater odds of being overweight, compared with individuals with a lower diversity of snack consumption.
Similarly, an observational study in 2,505 U.S. adults found individuals in the highest quintile of dietary diversity had a 120% greater gain in waist circumference, compared with those in the lowest quintile.
“Associations with dissimilarity scores are consistent with evidence from feeding studies showing that exposure to foods with different characteristics led to increased energy intake, which may partially explain gain in waist circumference over time,” wrote Marcia C. de Oliveira Otto, PhD, from the University of Texas Health Science Centre at Houston and coauthors.
The same was seen in short-term interventional studies, where most showed that having access to a wider variety of foods actually led to an increase in intake, compared with being served only a single food.
For example, one study showed adults offered a second course of sandwiches with different fillings to the first course actually ate 30% more than those served the same option for both courses.
Another study randomized overweight and obese adults to an unlimited number of snack options consumed less than once a day, or any amount of one favored snack option, with all snacks being within a daily caloric goal. This study found that, over the course of 8 weeks, participants offered a variety of snacks ate 25% more servings than those with the one snack type.
The authors suggested that variety amplifies sensory stimulation and decreases satiety.
“Although calorie restriction goals were achieved in both groups, a significant increase in sensory-specific satiety and monotony ratings over time was observed in participants assigned to the one-snack option but not in participants assigned to a variety of snacks,” they wrote.
The relationship between dietary diversity and dietary quality is also complex. Investigators for a cross-sectional study in China found less-than-optimal consumption of the nine food groups in the Chinese dietary guidelines – in particular, fruits, vegetables, fish, and dairy – in diets with higher diversity scores.
“Overall, limited evidence shows no benefit to diet quality or diet healthfulness associated with increased food count or with a more even distribution of energy across foods, whereas findings from one observational study suggest that greater dissimilarity in foods consumed may be inversely associated with a healthy eating pattern.”
In conclusion, the advisory committee said that it was more appropriate to promote a healthy eating pattern, emphasizing intake of plant foods, protein sources, low-fat dairy, vegetable oils, and nuts.
One author declared research funding from the Hass Avocado Board. No other relevant conflicts of interest were declared.
SOURCE: de Oliveira Otto MC et al. Circulation. 2018 Aug. 9. doi: 10.1161/CIR.0000000000000595.
A diverse diet is not necessarily a healthy one, according to an advisory issued by the American Heart Association that has instead emphasized the importance of a healthy eating pattern.
Published in the Aug. 9 online edition of Circulation, the science advisory was prompted by emerging evidence that greater dietary diversity may actually be associated with eating more poor quality foods and higher energy intake, especially among middle-aged adults.
Researchers conducted a literature search across 2000-2017 for studies of dietary diversity – defined as the number of different foods or food groups eaten over a given period of time – and dietary quality.
However, they also noted that many studies had significant limitations that contributed to high levels of inconsistency across all studies.
For example, one study in overweight and obese individuals found increasing dietary diversity was associated with a decrease in body mass index but with respect to intakes of only low–energy dense foods. Another study in Chinese adults saw an increase in diversity in the intake of snacks but not grains, vegetables, fruits, meats, or beverages, and this was associated with a 45% greater odds of being overweight, compared with individuals with a lower diversity of snack consumption.
Similarly, an observational study in 2,505 U.S. adults found individuals in the highest quintile of dietary diversity had a 120% greater gain in waist circumference, compared with those in the lowest quintile.
“Associations with dissimilarity scores are consistent with evidence from feeding studies showing that exposure to foods with different characteristics led to increased energy intake, which may partially explain gain in waist circumference over time,” wrote Marcia C. de Oliveira Otto, PhD, from the University of Texas Health Science Centre at Houston and coauthors.
The same was seen in short-term interventional studies, where most showed that having access to a wider variety of foods actually led to an increase in intake, compared with being served only a single food.
For example, one study showed adults offered a second course of sandwiches with different fillings to the first course actually ate 30% more than those served the same option for both courses.
Another study randomized overweight and obese adults to an unlimited number of snack options consumed less than once a day, or any amount of one favored snack option, with all snacks being within a daily caloric goal. This study found that, over the course of 8 weeks, participants offered a variety of snacks ate 25% more servings than those with the one snack type.
The authors suggested that variety amplifies sensory stimulation and decreases satiety.
“Although calorie restriction goals were achieved in both groups, a significant increase in sensory-specific satiety and monotony ratings over time was observed in participants assigned to the one-snack option but not in participants assigned to a variety of snacks,” they wrote.
The relationship between dietary diversity and dietary quality is also complex. Investigators for a cross-sectional study in China found less-than-optimal consumption of the nine food groups in the Chinese dietary guidelines – in particular, fruits, vegetables, fish, and dairy – in diets with higher diversity scores.
“Overall, limited evidence shows no benefit to diet quality or diet healthfulness associated with increased food count or with a more even distribution of energy across foods, whereas findings from one observational study suggest that greater dissimilarity in foods consumed may be inversely associated with a healthy eating pattern.”
In conclusion, the advisory committee said that it was more appropriate to promote a healthy eating pattern, emphasizing intake of plant foods, protein sources, low-fat dairy, vegetable oils, and nuts.
One author declared research funding from the Hass Avocado Board. No other relevant conflicts of interest were declared.
SOURCE: de Oliveira Otto MC et al. Circulation. 2018 Aug. 9. doi: 10.1161/CIR.0000000000000595.
A diverse diet is not necessarily a healthy one, according to an advisory issued by the American Heart Association that has instead emphasized the importance of a healthy eating pattern.
Published in the Aug. 9 online edition of Circulation, the science advisory was prompted by emerging evidence that greater dietary diversity may actually be associated with eating more poor quality foods and higher energy intake, especially among middle-aged adults.
Researchers conducted a literature search across 2000-2017 for studies of dietary diversity – defined as the number of different foods or food groups eaten over a given period of time – and dietary quality.
However, they also noted that many studies had significant limitations that contributed to high levels of inconsistency across all studies.
For example, one study in overweight and obese individuals found increasing dietary diversity was associated with a decrease in body mass index but with respect to intakes of only low–energy dense foods. Another study in Chinese adults saw an increase in diversity in the intake of snacks but not grains, vegetables, fruits, meats, or beverages, and this was associated with a 45% greater odds of being overweight, compared with individuals with a lower diversity of snack consumption.
Similarly, an observational study in 2,505 U.S. adults found individuals in the highest quintile of dietary diversity had a 120% greater gain in waist circumference, compared with those in the lowest quintile.
“Associations with dissimilarity scores are consistent with evidence from feeding studies showing that exposure to foods with different characteristics led to increased energy intake, which may partially explain gain in waist circumference over time,” wrote Marcia C. de Oliveira Otto, PhD, from the University of Texas Health Science Centre at Houston and coauthors.
The same was seen in short-term interventional studies, where most showed that having access to a wider variety of foods actually led to an increase in intake, compared with being served only a single food.
For example, one study showed adults offered a second course of sandwiches with different fillings to the first course actually ate 30% more than those served the same option for both courses.
Another study randomized overweight and obese adults to an unlimited number of snack options consumed less than once a day, or any amount of one favored snack option, with all snacks being within a daily caloric goal. This study found that, over the course of 8 weeks, participants offered a variety of snacks ate 25% more servings than those with the one snack type.
The authors suggested that variety amplifies sensory stimulation and decreases satiety.
“Although calorie restriction goals were achieved in both groups, a significant increase in sensory-specific satiety and monotony ratings over time was observed in participants assigned to the one-snack option but not in participants assigned to a variety of snacks,” they wrote.
The relationship between dietary diversity and dietary quality is also complex. Investigators for a cross-sectional study in China found less-than-optimal consumption of the nine food groups in the Chinese dietary guidelines – in particular, fruits, vegetables, fish, and dairy – in diets with higher diversity scores.
“Overall, limited evidence shows no benefit to diet quality or diet healthfulness associated with increased food count or with a more even distribution of energy across foods, whereas findings from one observational study suggest that greater dissimilarity in foods consumed may be inversely associated with a healthy eating pattern.”
In conclusion, the advisory committee said that it was more appropriate to promote a healthy eating pattern, emphasizing intake of plant foods, protein sources, low-fat dairy, vegetable oils, and nuts.
One author declared research funding from the Hass Avocado Board. No other relevant conflicts of interest were declared.
SOURCE: de Oliveira Otto MC et al. Circulation. 2018 Aug. 9. doi: 10.1161/CIR.0000000000000595.
FROM CIRCULATION
Key clinical point: Dietary variety may not reflect healthiness or dietary quality.
Major finding: A varied diet is associated with higher intake and poorer quality.
Study details: Literature review and science advisory from the American Heart Association.
Disclosures: One author declared research funding from the Hass Avocado Board. No other relevant conflicts of interest were declared.
Source: de Oliveira Otto MC et al. Circulation. 2018 Aug. 9. doi: 10.1161/CIR.0000000000000595.
Colorectal cancer: New observations, new implications
The incidence and mortality of colorectal cancer (CRC) have declined by 3% per year over the past 10-15 years – a remarkable achievement. The decline in incidence has been dramatic for individuals over age 50 years, who are targeted by screening. However, the reduction in CRC risk does not apply to all populations in the United States. New epidemiologic trends and observations point to patient demographics and regional variation as potential risk factors. While such observations provide what I call “blurry snapshots,” they may well have important implications for our approach to screening and prevention.
What are the reasons? There are several personal and environmental factors that could be contributing. Obesity and metabolic syndrome are risk factors for CRC and have been more commonly developing in childhood over the past 40 years. Alteration of the microbiome could also potentially predispose one to developing CRC. The use of antibiotics in childhood was more common for some of these younger generations than it was for the preceding generations, and antibiotics have been introduced into the food industry to fatten animals. The introduction of food chemicals could also either alter the microbiome and/or promote inflammation, which could lead to neoplasia. Exposure to more ambient radiation may be another risk factor.
These hypotheses are biologically plausible – but untested. Nevertheless, this observational trend does have implications for clinicians. First, studies have shown that up to 20% of CRCs before age 50 years are associated with germline mutations, while others are associated with a family history of CRC. Therefore, it is important to capture and update family history. In addition, there is evidence that individuals aged 40-49 years with rectal bleeding have a higher risk of advanced adenomas, so our threshold for performing diagnostic colonoscopy should be lowered. African Americans also have a higher risk of CRC at a younger age than do other racial groups and might benefit from early screening at age 45 years. Notably, recent recommendations from the American Cancer Society call for consideration of screening everyone at age 45 years.
There is substantial state-to-state and county-to-county variation in the incidence and mortality of CRC. While some of this variation can be explained by racial variation, smoking, obesity, and social determinants of health, there are “hot-spots” that may defy easy explanation. There has been very little research about environmental factors (air, water, and ambient radiation). Two regions at particularly high risk are the Mississippi Delta region and Appalachia – areas where water pollution could be a factor. The substantial county-to-county variation within these high-risk areas points to a potential environmental culprit, but further research is needed.
For the GI community, there are several implications to be found in these changing demographics and risks. For one, we may need to consider expanding our risk concepts to include not only genetic and personal risk factors but also environmental factors. To mitigate risk, providers and public health officials may need to then target these high-risk areas for more intensive screening efforts.
Dr. Lieberman is a professor of medicine and chief of gastroenterology and hepatology at Oregon Health and Science University in Portland. He has no conflicts of interest. Dr. Lieberman made his comments during the AGA Institute Presidential Plenary at the Annual Digestive Disease Week.
The incidence and mortality of colorectal cancer (CRC) have declined by 3% per year over the past 10-15 years – a remarkable achievement. The decline in incidence has been dramatic for individuals over age 50 years, who are targeted by screening. However, the reduction in CRC risk does not apply to all populations in the United States. New epidemiologic trends and observations point to patient demographics and regional variation as potential risk factors. While such observations provide what I call “blurry snapshots,” they may well have important implications for our approach to screening and prevention.
What are the reasons? There are several personal and environmental factors that could be contributing. Obesity and metabolic syndrome are risk factors for CRC and have been more commonly developing in childhood over the past 40 years. Alteration of the microbiome could also potentially predispose one to developing CRC. The use of antibiotics in childhood was more common for some of these younger generations than it was for the preceding generations, and antibiotics have been introduced into the food industry to fatten animals. The introduction of food chemicals could also either alter the microbiome and/or promote inflammation, which could lead to neoplasia. Exposure to more ambient radiation may be another risk factor.
These hypotheses are biologically plausible – but untested. Nevertheless, this observational trend does have implications for clinicians. First, studies have shown that up to 20% of CRCs before age 50 years are associated with germline mutations, while others are associated with a family history of CRC. Therefore, it is important to capture and update family history. In addition, there is evidence that individuals aged 40-49 years with rectal bleeding have a higher risk of advanced adenomas, so our threshold for performing diagnostic colonoscopy should be lowered. African Americans also have a higher risk of CRC at a younger age than do other racial groups and might benefit from early screening at age 45 years. Notably, recent recommendations from the American Cancer Society call for consideration of screening everyone at age 45 years.
There is substantial state-to-state and county-to-county variation in the incidence and mortality of CRC. While some of this variation can be explained by racial variation, smoking, obesity, and social determinants of health, there are “hot-spots” that may defy easy explanation. There has been very little research about environmental factors (air, water, and ambient radiation). Two regions at particularly high risk are the Mississippi Delta region and Appalachia – areas where water pollution could be a factor. The substantial county-to-county variation within these high-risk areas points to a potential environmental culprit, but further research is needed.
For the GI community, there are several implications to be found in these changing demographics and risks. For one, we may need to consider expanding our risk concepts to include not only genetic and personal risk factors but also environmental factors. To mitigate risk, providers and public health officials may need to then target these high-risk areas for more intensive screening efforts.
Dr. Lieberman is a professor of medicine and chief of gastroenterology and hepatology at Oregon Health and Science University in Portland. He has no conflicts of interest. Dr. Lieberman made his comments during the AGA Institute Presidential Plenary at the Annual Digestive Disease Week.
The incidence and mortality of colorectal cancer (CRC) have declined by 3% per year over the past 10-15 years – a remarkable achievement. The decline in incidence has been dramatic for individuals over age 50 years, who are targeted by screening. However, the reduction in CRC risk does not apply to all populations in the United States. New epidemiologic trends and observations point to patient demographics and regional variation as potential risk factors. While such observations provide what I call “blurry snapshots,” they may well have important implications for our approach to screening and prevention.
What are the reasons? There are several personal and environmental factors that could be contributing. Obesity and metabolic syndrome are risk factors for CRC and have been more commonly developing in childhood over the past 40 years. Alteration of the microbiome could also potentially predispose one to developing CRC. The use of antibiotics in childhood was more common for some of these younger generations than it was for the preceding generations, and antibiotics have been introduced into the food industry to fatten animals. The introduction of food chemicals could also either alter the microbiome and/or promote inflammation, which could lead to neoplasia. Exposure to more ambient radiation may be another risk factor.
These hypotheses are biologically plausible – but untested. Nevertheless, this observational trend does have implications for clinicians. First, studies have shown that up to 20% of CRCs before age 50 years are associated with germline mutations, while others are associated with a family history of CRC. Therefore, it is important to capture and update family history. In addition, there is evidence that individuals aged 40-49 years with rectal bleeding have a higher risk of advanced adenomas, so our threshold for performing diagnostic colonoscopy should be lowered. African Americans also have a higher risk of CRC at a younger age than do other racial groups and might benefit from early screening at age 45 years. Notably, recent recommendations from the American Cancer Society call for consideration of screening everyone at age 45 years.
There is substantial state-to-state and county-to-county variation in the incidence and mortality of CRC. While some of this variation can be explained by racial variation, smoking, obesity, and social determinants of health, there are “hot-spots” that may defy easy explanation. There has been very little research about environmental factors (air, water, and ambient radiation). Two regions at particularly high risk are the Mississippi Delta region and Appalachia – areas where water pollution could be a factor. The substantial county-to-county variation within these high-risk areas points to a potential environmental culprit, but further research is needed.
For the GI community, there are several implications to be found in these changing demographics and risks. For one, we may need to consider expanding our risk concepts to include not only genetic and personal risk factors but also environmental factors. To mitigate risk, providers and public health officials may need to then target these high-risk areas for more intensive screening efforts.
Dr. Lieberman is a professor of medicine and chief of gastroenterology and hepatology at Oregon Health and Science University in Portland. He has no conflicts of interest. Dr. Lieberman made his comments during the AGA Institute Presidential Plenary at the Annual Digestive Disease Week.
Pseudotumor cerebri pediatric rates are rising
Pseudotumor cerebri, benign intracranial hypertension, and idiopathic intracranial hypertension are all terms to describe a syndrome of increased intracranial pressure, headaches, vision loss, or changes without an associated mass lesion.1 The condition was considered relatively rare, presenting most commonly in obese women in childbearing years. Surprisingly, 2
Obesity is the fastest growing morbidity among adolescents. The Centers for Disease Control and Prevention reported 32% of children 2-19 years were obese.1 This reality is impacting many areas of an adolescent’s health, but it also is changing the landscape of diseases that present in this age group. Although pediatric and adult pseudotumor cerebri always have had slightly varied features, many features were similar such as the papilledema, vision loss, headaches, and sixth nerve palsy. Obesity and female predominance tended to present more in the adult population, as many pediatric patients were not obese,2 and had fewer associated symptoms at the time of diagnosis, and the cause was thought to idiopathic.
Now, with the increase in obesity, more adolescents and more male patients are presenting with pseudotumor cerebri as a cause for their headache, and 57%-100% are obese, making it a compounding factor.3
Pediatric populations also are at risk of secondary pseudotumor cerebri, which is an increase in intracranial pressure from the use of medication, or other disease states such as anemia, kidney disease, or Down syndrome. Minocycline use is the most common medication cause and usually presents 1-2 months after normal use.4 Discontinuing the drug does lead to resolution. Retinoids, vitamin A products, growth hormone, and steroids also have been implicated. Given that acne is a common complaint amongst teens, knowledge of these side effects is important.4
In 2013, the criteria for diagnosis of pseudotumor cerebri was revised. Currently, the presence of papilledema, normal neurologic exam except for abnormal sixth cranial nerve, normal cerebral spinal fluid, elevated lumbar opening pressure, and normal imaging are needed for a definitive diagnosis. A probable diagnosis can be made if papilledema is not present but there abducens nerve palsy.2
In a routine physical exam, when I questioned a patient on any medication that was used daily, she replied she took ibuprofen daily for headaches and that she had been doing this for several months. Headaches were not in her chief complaints as she had learned to live with and ignore this symptom. Upon further evaluation, she was slightly overweight and has a questionable fundoscopic exam. After further evaluation by an ophthalmologist and a neurologist, pseudotumor cerebri was diagnosed.
Index of suspicion is key in correctly diagnosing patients, and understanding the changing landscape of medicine will lead to more thoughtful questioning during routine health exams and better outcomes for your patients.
Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.
References
1. Am J Ophthalmol. 2015 Feb;159(2):344-52.e1.
2. Horm Res Paediatr. 2014;81(4):217-25.
3. Clin Imaging. 2018 May 24. doi: 10.1016/j.clinimag.2018.05.020.
4. Am J Ophthalmol. 1998 Jul;126(1):116-21.
5. Glob Pediatr Health. 2018. doi:10.1177/2333794X18785550.
Pseudotumor cerebri, benign intracranial hypertension, and idiopathic intracranial hypertension are all terms to describe a syndrome of increased intracranial pressure, headaches, vision loss, or changes without an associated mass lesion.1 The condition was considered relatively rare, presenting most commonly in obese women in childbearing years. Surprisingly, 2
Obesity is the fastest growing morbidity among adolescents. The Centers for Disease Control and Prevention reported 32% of children 2-19 years were obese.1 This reality is impacting many areas of an adolescent’s health, but it also is changing the landscape of diseases that present in this age group. Although pediatric and adult pseudotumor cerebri always have had slightly varied features, many features were similar such as the papilledema, vision loss, headaches, and sixth nerve palsy. Obesity and female predominance tended to present more in the adult population, as many pediatric patients were not obese,2 and had fewer associated symptoms at the time of diagnosis, and the cause was thought to idiopathic.
Now, with the increase in obesity, more adolescents and more male patients are presenting with pseudotumor cerebri as a cause for their headache, and 57%-100% are obese, making it a compounding factor.3
Pediatric populations also are at risk of secondary pseudotumor cerebri, which is an increase in intracranial pressure from the use of medication, or other disease states such as anemia, kidney disease, or Down syndrome. Minocycline use is the most common medication cause and usually presents 1-2 months after normal use.4 Discontinuing the drug does lead to resolution. Retinoids, vitamin A products, growth hormone, and steroids also have been implicated. Given that acne is a common complaint amongst teens, knowledge of these side effects is important.4
In 2013, the criteria for diagnosis of pseudotumor cerebri was revised. Currently, the presence of papilledema, normal neurologic exam except for abnormal sixth cranial nerve, normal cerebral spinal fluid, elevated lumbar opening pressure, and normal imaging are needed for a definitive diagnosis. A probable diagnosis can be made if papilledema is not present but there abducens nerve palsy.2
In a routine physical exam, when I questioned a patient on any medication that was used daily, she replied she took ibuprofen daily for headaches and that she had been doing this for several months. Headaches were not in her chief complaints as she had learned to live with and ignore this symptom. Upon further evaluation, she was slightly overweight and has a questionable fundoscopic exam. After further evaluation by an ophthalmologist and a neurologist, pseudotumor cerebri was diagnosed.
Index of suspicion is key in correctly diagnosing patients, and understanding the changing landscape of medicine will lead to more thoughtful questioning during routine health exams and better outcomes for your patients.
Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.
References
1. Am J Ophthalmol. 2015 Feb;159(2):344-52.e1.
2. Horm Res Paediatr. 2014;81(4):217-25.
3. Clin Imaging. 2018 May 24. doi: 10.1016/j.clinimag.2018.05.020.
4. Am J Ophthalmol. 1998 Jul;126(1):116-21.
5. Glob Pediatr Health. 2018. doi:10.1177/2333794X18785550.
Pseudotumor cerebri, benign intracranial hypertension, and idiopathic intracranial hypertension are all terms to describe a syndrome of increased intracranial pressure, headaches, vision loss, or changes without an associated mass lesion.1 The condition was considered relatively rare, presenting most commonly in obese women in childbearing years. Surprisingly, 2
Obesity is the fastest growing morbidity among adolescents. The Centers for Disease Control and Prevention reported 32% of children 2-19 years were obese.1 This reality is impacting many areas of an adolescent’s health, but it also is changing the landscape of diseases that present in this age group. Although pediatric and adult pseudotumor cerebri always have had slightly varied features, many features were similar such as the papilledema, vision loss, headaches, and sixth nerve palsy. Obesity and female predominance tended to present more in the adult population, as many pediatric patients were not obese,2 and had fewer associated symptoms at the time of diagnosis, and the cause was thought to idiopathic.
Now, with the increase in obesity, more adolescents and more male patients are presenting with pseudotumor cerebri as a cause for their headache, and 57%-100% are obese, making it a compounding factor.3
Pediatric populations also are at risk of secondary pseudotumor cerebri, which is an increase in intracranial pressure from the use of medication, or other disease states such as anemia, kidney disease, or Down syndrome. Minocycline use is the most common medication cause and usually presents 1-2 months after normal use.4 Discontinuing the drug does lead to resolution. Retinoids, vitamin A products, growth hormone, and steroids also have been implicated. Given that acne is a common complaint amongst teens, knowledge of these side effects is important.4
In 2013, the criteria for diagnosis of pseudotumor cerebri was revised. Currently, the presence of papilledema, normal neurologic exam except for abnormal sixth cranial nerve, normal cerebral spinal fluid, elevated lumbar opening pressure, and normal imaging are needed for a definitive diagnosis. A probable diagnosis can be made if papilledema is not present but there abducens nerve palsy.2
In a routine physical exam, when I questioned a patient on any medication that was used daily, she replied she took ibuprofen daily for headaches and that she had been doing this for several months. Headaches were not in her chief complaints as she had learned to live with and ignore this symptom. Upon further evaluation, she was slightly overweight and has a questionable fundoscopic exam. After further evaluation by an ophthalmologist and a neurologist, pseudotumor cerebri was diagnosed.
Index of suspicion is key in correctly diagnosing patients, and understanding the changing landscape of medicine will lead to more thoughtful questioning during routine health exams and better outcomes for your patients.
Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.
References
1. Am J Ophthalmol. 2015 Feb;159(2):344-52.e1.
2. Horm Res Paediatr. 2014;81(4):217-25.
3. Clin Imaging. 2018 May 24. doi: 10.1016/j.clinimag.2018.05.020.
4. Am J Ophthalmol. 1998 Jul;126(1):116-21.
5. Glob Pediatr Health. 2018. doi:10.1177/2333794X18785550.
Enhanced recovery initiative improved bariatric length of stay
ORLANDO – Adopting a 28-point significantly reduced length of stay without significant effects on complications or readmissions, according to interim results of a large, nationwide surgical quality initiative. 
Thirty-six centers participated in this pilot initiative, making it one of the largest national projects focused on enhanced recovery to date, according to Stacy A. Brethauer, MD, FACS, cochair of the Quality and Data Committee of the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP).
The initiative, known as Employing New Enhanced Recovery Goals for Bariatric Surgery (ENERGY), was developed in light of “huge gaps in literature and knowledge” about what best practices of enhanced recovery should look like for bariatric surgery, Dr. Brethauer said in a podium presentation at the American College of Surgeons Quality and Safety Conference.
“Bariatric surgery is very pathway driven, but the pathway can be very cumbersome and very antiquated if you don’t keep it up to date and evidence based,” said Dr. Brethauer, associate professor of surgery at the Cleveland Clinic.
Invitations to join in the ENERGY pilot were targeted to the 80 or so MBSAQIP-accredited centers in the top decile of programs for length of stay. “That’s the needle that we want to move,” Dr. Brethauer said.
ENERGY includes interventions in the preoperative, perioperative, and postoperative setting for each patient who undergoes a primary band, lap sleeve, or lap bypass procedure.
The 36 participating centers were asked to document 28 discrete process measures, starting with “did the patient stop smoking before surgery?” and ending with “did the patient have a follow-up clinic appointment scheduled?” Each one was entered by a trained clinical reviewer. The program included monthly audits for each participating center.
Data collection started on July 1, 2017, and continued to June 30, 2018, following a 6-month run-up period to allow centers to incorporate the measures.
The interim analysis presented included 4,700 patients who underwent procedures in the first 6 months of the data collection period. Nearly 60% (2,790 patients) had a laparoscopic sleeve gastrectomy, while about 40% (1,896 patients) underwent laparoscopic gastric bypass, and 0.1% (6 patients) had a band procedure.
Average length of stay was 1.76 days in the first 6 months of the pilot, down from 2.24 days in 2016 for those same participating centers (P less than .001), Dr. Brethauer reported.
Similarly, the rate of extended length of stay was 4.4% in the first 6 months of the pilot, down from 8.2% in 2016. Extended length of stay decreased with increasing adherence to the protocol, Dr. Brethauer and his colleagues found in their analysis.
Those length-of-stay reductions were accomplished with no increase in bleeding rates, all-cause reoperation rates, or readmissions. “We’re not doing this at the expense of other complications,” Dr. Brethauer said in a comment on the results.
Adherence to the 28 ENERGY measures increased from 26% in the first month of the pilot to 80.2% in March 2017, the latest month included in the interim analysis.
Opioid-sparing pain management strategies are incorporated into ENERGY. Over the first six months of the pilot, the average proportion of patients receiving no opioids postoperatively was 26.8%.
The ultimate goal of ENERGY is a large-scale rollout of enhanced recovery strategies, according to Dr. Brethauer.
ENERGY is the second national quality improvement project of the MBSAQIP. In the first, known as Decreasing Readmissions through Opportunities Provided (DROP), 128 U.S. hospitals implemented a set of standard processes organized into preoperative, inpatient, and postoperative care bundles. Results of a yearlong study of the DROP intervention demonstrated a significant reduction in 30-day all-cause hospital readmissions following sleeve gastrectomy.
“If you look at what’s happened in our specialty, and all the changes and all the work that’s been done, it’s really quite impressive,” Dr. Brethauer told attendees at the meeting. “It’s something that we’re very proud of. “
Dr. Brethauer reported disclosures related to Medtronic and Ethicon outside of the scope of this presentation.
ORLANDO – Adopting a 28-point significantly reduced length of stay without significant effects on complications or readmissions, according to interim results of a large, nationwide surgical quality initiative.
Thirty-six centers participated in this pilot initiative, making it one of the largest national projects focused on enhanced recovery to date, according to Stacy A. Brethauer, MD, FACS, cochair of the Quality and Data Committee of the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP).
The initiative, known as Employing New Enhanced Recovery Goals for Bariatric Surgery (ENERGY), was developed in light of “huge gaps in literature and knowledge” about what best practices of enhanced recovery should look like for bariatric surgery, Dr. Brethauer said in a podium presentation at the American College of Surgeons Quality and Safety Conference.
“Bariatric surgery is very pathway driven, but the pathway can be very cumbersome and very antiquated if you don’t keep it up to date and evidence based,” said Dr. Brethauer, associate professor of surgery at the Cleveland Clinic.
Invitations to join in the ENERGY pilot were targeted to the 80 or so MBSAQIP-accredited centers in the top decile of programs for length of stay. “That’s the needle that we want to move,” Dr. Brethauer said.
ENERGY includes interventions in the preoperative, perioperative, and postoperative setting for each patient who undergoes a primary band, lap sleeve, or lap bypass procedure.
The 36 participating centers were asked to document 28 discrete process measures, starting with “did the patient stop smoking before surgery?” and ending with “did the patient have a follow-up clinic appointment scheduled?” Each one was entered by a trained clinical reviewer. The program included monthly audits for each participating center.
Data collection started on July 1, 2017, and continued to June 30, 2018, following a 6-month run-up period to allow centers to incorporate the measures.
The interim analysis presented included 4,700 patients who underwent procedures in the first 6 months of the data collection period. Nearly 60% (2,790 patients) had a laparoscopic sleeve gastrectomy, while about 40% (1,896 patients) underwent laparoscopic gastric bypass, and 0.1% (6 patients) had a band procedure.
Average length of stay was 1.76 days in the first 6 months of the pilot, down from 2.24 days in 2016 for those same participating centers (P less than .001), Dr. Brethauer reported.
Similarly, the rate of extended length of stay was 4.4% in the first 6 months of the pilot, down from 8.2% in 2016. Extended length of stay decreased with increasing adherence to the protocol, Dr. Brethauer and his colleagues found in their analysis.
Those length-of-stay reductions were accomplished with no increase in bleeding rates, all-cause reoperation rates, or readmissions. “We’re not doing this at the expense of other complications,” Dr. Brethauer said in a comment on the results.
Adherence to the 28 ENERGY measures increased from 26% in the first month of the pilot to 80.2% in March 2017, the latest month included in the interim analysis.
Opioid-sparing pain management strategies are incorporated into ENERGY. Over the first six months of the pilot, the average proportion of patients receiving no opioids postoperatively was 26.8%.
The ultimate goal of ENERGY is a large-scale rollout of enhanced recovery strategies, according to Dr. Brethauer.
ENERGY is the second national quality improvement project of the MBSAQIP. In the first, known as Decreasing Readmissions through Opportunities Provided (DROP), 128 U.S. hospitals implemented a set of standard processes organized into preoperative, inpatient, and postoperative care bundles. Results of a yearlong study of the DROP intervention demonstrated a significant reduction in 30-day all-cause hospital readmissions following sleeve gastrectomy.
“If you look at what’s happened in our specialty, and all the changes and all the work that’s been done, it’s really quite impressive,” Dr. Brethauer told attendees at the meeting. “It’s something that we’re very proud of. “
Dr. Brethauer reported disclosures related to Medtronic and Ethicon outside of the scope of this presentation.
ORLANDO – Adopting a 28-point significantly reduced length of stay without significant effects on complications or readmissions, according to interim results of a large, nationwide surgical quality initiative.
Thirty-six centers participated in this pilot initiative, making it one of the largest national projects focused on enhanced recovery to date, according to Stacy A. Brethauer, MD, FACS, cochair of the Quality and Data Committee of the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP).
The initiative, known as Employing New Enhanced Recovery Goals for Bariatric Surgery (ENERGY), was developed in light of “huge gaps in literature and knowledge” about what best practices of enhanced recovery should look like for bariatric surgery, Dr. Brethauer said in a podium presentation at the American College of Surgeons Quality and Safety Conference.
“Bariatric surgery is very pathway driven, but the pathway can be very cumbersome and very antiquated if you don’t keep it up to date and evidence based,” said Dr. Brethauer, associate professor of surgery at the Cleveland Clinic.
Invitations to join in the ENERGY pilot were targeted to the 80 or so MBSAQIP-accredited centers in the top decile of programs for length of stay. “That’s the needle that we want to move,” Dr. Brethauer said.
ENERGY includes interventions in the preoperative, perioperative, and postoperative setting for each patient who undergoes a primary band, lap sleeve, or lap bypass procedure.
The 36 participating centers were asked to document 28 discrete process measures, starting with “did the patient stop smoking before surgery?” and ending with “did the patient have a follow-up clinic appointment scheduled?” Each one was entered by a trained clinical reviewer. The program included monthly audits for each participating center.
Data collection started on July 1, 2017, and continued to June 30, 2018, following a 6-month run-up period to allow centers to incorporate the measures.
The interim analysis presented included 4,700 patients who underwent procedures in the first 6 months of the data collection period. Nearly 60% (2,790 patients) had a laparoscopic sleeve gastrectomy, while about 40% (1,896 patients) underwent laparoscopic gastric bypass, and 0.1% (6 patients) had a band procedure.
Average length of stay was 1.76 days in the first 6 months of the pilot, down from 2.24 days in 2016 for those same participating centers (P less than .001), Dr. Brethauer reported.
Similarly, the rate of extended length of stay was 4.4% in the first 6 months of the pilot, down from 8.2% in 2016. Extended length of stay decreased with increasing adherence to the protocol, Dr. Brethauer and his colleagues found in their analysis.
Those length-of-stay reductions were accomplished with no increase in bleeding rates, all-cause reoperation rates, or readmissions. “We’re not doing this at the expense of other complications,” Dr. Brethauer said in a comment on the results.
Adherence to the 28 ENERGY measures increased from 26% in the first month of the pilot to 80.2% in March 2017, the latest month included in the interim analysis.
Opioid-sparing pain management strategies are incorporated into ENERGY. Over the first six months of the pilot, the average proportion of patients receiving no opioids postoperatively was 26.8%.
The ultimate goal of ENERGY is a large-scale rollout of enhanced recovery strategies, according to Dr. Brethauer.
ENERGY is the second national quality improvement project of the MBSAQIP. In the first, known as Decreasing Readmissions through Opportunities Provided (DROP), 128 U.S. hospitals implemented a set of standard processes organized into preoperative, inpatient, and postoperative care bundles. Results of a yearlong study of the DROP intervention demonstrated a significant reduction in 30-day all-cause hospital readmissions following sleeve gastrectomy.
“If you look at what’s happened in our specialty, and all the changes and all the work that’s been done, it’s really quite impressive,” Dr. Brethauer told attendees at the meeting. “It’s something that we’re very proud of. “
Dr. Brethauer reported disclosures related to Medtronic and Ethicon outside of the scope of this presentation.
REPORTING FROM ACSQSC 2018
Key clinical point: An evidence-based enhanced recovery protocol reduced length of stay for bariatric surgery patients.
Major finding: Average length of stay was 1.76 days in the first 6 months of the pilot, down from 2.24 days in 2016 for those same participating centers.
Study details: Data on 36 bariatric surgery centers and 4,700 patients who underwent procedures in the first 6 months of the data collection period.
Disclosures: Dr. Brethauer reported disclosures related to Medtronic and Ethicon outside of the scope of this presentation.
Endoscopic weight loss interventions need lifestyle component
WASHINGTON – and used in the context of a multidimensional lifestyle intervention, Shelby Sullivan, MD, said at the annual Digestive Disease Week.®
Regardless of which endoscopic intervention a clinician uses, the chances for successful and complication-free weight loss highly depends on enlisting adjunctive care by specialists, including a dietitian, behavior coach, psychologist, exercise specialist, and an endocrine or obesity-specialist physician, said Dr. Sullivan, director of the gastroenterology metabolic and bariatric program at the University of Colorado, Aurora. Often it’s more cost effective to arrange for collaboration with these adjunctive specialists as consultants rather than having them on staff, she noted.
A weight loss program that provides at least 14 interventions with the patient over a 6-month period has led to a 5% greater increase in weight loss compared with a moderate-intensity program that includes 6-13 encounters with members of the weight-loss team, Dr. Sullivan said. These intervention episodes need not all be individual or one on one, but can include group sessions, telephone consults, and even online coaching sessions, according to 2013 recommendations from The Obesity Society, the American College of Cardiology, and the American Heart Association (Obesity. 2014 Jun 24;22[S2]:S5-S39). “Patient contact is the key to success with weight loss,” Dr. Sullivan said. She also strongly suggested that clinicians who wish to offer an obesity intervention “get training in delivering basic obesity education.”
Another tip for providers is to have protocols in place to both prevent and, when necessary, manage potential complications. This can involve administration of additional antibiotics beyond what’s used for prophylaxis, treatment with additional IV fluid, and imaging. Complication prevention and management of complications when they occur are two of the most important steps to take to make sure that an elective obesity intervention practice runs smoothly, Dr. Sullivan said. “Make sure you can manage these patients safely,” she admonished. Also, be sure to arrange in advance for institutional approval for using whatever devices the procedure requires, and make sure you have malpractice coverage for any novel devices or procedures. Approval for use of a novel device often requires documentation of specialized training or certification.
Endoscopic weight loss procedures often are not fully or even partially covered by health insurance, which means that patients will pay most or all of the costs out of pocket and, hence, the clinician should look on this practice as a “concierge service.” Therefore, the clinician should be especially attuned to ensuring that the staff is uniformly courteous, and be alert for any overt or covert obesity bias the staff may have that could mar a patient’s experience. You need a “reliable and compassionate” staff, Dr. Sullivan advised, and the staff should schedule patient appointments that minimize wait times.
Marketing and procedure pricing are other concerns for the physician who is contemplating an obestiy-intervention practice. A great marketing tool is delivering seminars to patients, either in person or on the Internet. The general format for such a seminar addresses the health risks of obesity, the range of intervention options in addition to what you are offering, and the objective risks and benefits for each of the intervention options. Prospective patients who respond to your presentation and contact you should receive very prompt callbacks. Regarding pricing, Dr. Sullivan recommended making sure that the price you charge will fully cover all costs, including the potential cost of complications.
WASHINGTON – and used in the context of a multidimensional lifestyle intervention, Shelby Sullivan, MD, said at the annual Digestive Disease Week.®
Regardless of which endoscopic intervention a clinician uses, the chances for successful and complication-free weight loss highly depends on enlisting adjunctive care by specialists, including a dietitian, behavior coach, psychologist, exercise specialist, and an endocrine or obesity-specialist physician, said Dr. Sullivan, director of the gastroenterology metabolic and bariatric program at the University of Colorado, Aurora. Often it’s more cost effective to arrange for collaboration with these adjunctive specialists as consultants rather than having them on staff, she noted.
A weight loss program that provides at least 14 interventions with the patient over a 6-month period has led to a 5% greater increase in weight loss compared with a moderate-intensity program that includes 6-13 encounters with members of the weight-loss team, Dr. Sullivan said. These intervention episodes need not all be individual or one on one, but can include group sessions, telephone consults, and even online coaching sessions, according to 2013 recommendations from The Obesity Society, the American College of Cardiology, and the American Heart Association (Obesity. 2014 Jun 24;22[S2]:S5-S39). “Patient contact is the key to success with weight loss,” Dr. Sullivan said. She also strongly suggested that clinicians who wish to offer an obesity intervention “get training in delivering basic obesity education.”
Another tip for providers is to have protocols in place to both prevent and, when necessary, manage potential complications. This can involve administration of additional antibiotics beyond what’s used for prophylaxis, treatment with additional IV fluid, and imaging. Complication prevention and management of complications when they occur are two of the most important steps to take to make sure that an elective obesity intervention practice runs smoothly, Dr. Sullivan said. “Make sure you can manage these patients safely,” she admonished. Also, be sure to arrange in advance for institutional approval for using whatever devices the procedure requires, and make sure you have malpractice coverage for any novel devices or procedures. Approval for use of a novel device often requires documentation of specialized training or certification.
Endoscopic weight loss procedures often are not fully or even partially covered by health insurance, which means that patients will pay most or all of the costs out of pocket and, hence, the clinician should look on this practice as a “concierge service.” Therefore, the clinician should be especially attuned to ensuring that the staff is uniformly courteous, and be alert for any overt or covert obesity bias the staff may have that could mar a patient’s experience. You need a “reliable and compassionate” staff, Dr. Sullivan advised, and the staff should schedule patient appointments that minimize wait times.
Marketing and procedure pricing are other concerns for the physician who is contemplating an obestiy-intervention practice. A great marketing tool is delivering seminars to patients, either in person or on the Internet. The general format for such a seminar addresses the health risks of obesity, the range of intervention options in addition to what you are offering, and the objective risks and benefits for each of the intervention options. Prospective patients who respond to your presentation and contact you should receive very prompt callbacks. Regarding pricing, Dr. Sullivan recommended making sure that the price you charge will fully cover all costs, including the potential cost of complications.
WASHINGTON – and used in the context of a multidimensional lifestyle intervention, Shelby Sullivan, MD, said at the annual Digestive Disease Week.®
Regardless of which endoscopic intervention a clinician uses, the chances for successful and complication-free weight loss highly depends on enlisting adjunctive care by specialists, including a dietitian, behavior coach, psychologist, exercise specialist, and an endocrine or obesity-specialist physician, said Dr. Sullivan, director of the gastroenterology metabolic and bariatric program at the University of Colorado, Aurora. Often it’s more cost effective to arrange for collaboration with these adjunctive specialists as consultants rather than having them on staff, she noted.
A weight loss program that provides at least 14 interventions with the patient over a 6-month period has led to a 5% greater increase in weight loss compared with a moderate-intensity program that includes 6-13 encounters with members of the weight-loss team, Dr. Sullivan said. These intervention episodes need not all be individual or one on one, but can include group sessions, telephone consults, and even online coaching sessions, according to 2013 recommendations from The Obesity Society, the American College of Cardiology, and the American Heart Association (Obesity. 2014 Jun 24;22[S2]:S5-S39). “Patient contact is the key to success with weight loss,” Dr. Sullivan said. She also strongly suggested that clinicians who wish to offer an obesity intervention “get training in delivering basic obesity education.”
Another tip for providers is to have protocols in place to both prevent and, when necessary, manage potential complications. This can involve administration of additional antibiotics beyond what’s used for prophylaxis, treatment with additional IV fluid, and imaging. Complication prevention and management of complications when they occur are two of the most important steps to take to make sure that an elective obesity intervention practice runs smoothly, Dr. Sullivan said. “Make sure you can manage these patients safely,” she admonished. Also, be sure to arrange in advance for institutional approval for using whatever devices the procedure requires, and make sure you have malpractice coverage for any novel devices or procedures. Approval for use of a novel device often requires documentation of specialized training or certification.
Endoscopic weight loss procedures often are not fully or even partially covered by health insurance, which means that patients will pay most or all of the costs out of pocket and, hence, the clinician should look on this practice as a “concierge service.” Therefore, the clinician should be especially attuned to ensuring that the staff is uniformly courteous, and be alert for any overt or covert obesity bias the staff may have that could mar a patient’s experience. You need a “reliable and compassionate” staff, Dr. Sullivan advised, and the staff should schedule patient appointments that minimize wait times.
Marketing and procedure pricing are other concerns for the physician who is contemplating an obestiy-intervention practice. A great marketing tool is delivering seminars to patients, either in person or on the Internet. The general format for such a seminar addresses the health risks of obesity, the range of intervention options in addition to what you are offering, and the objective risks and benefits for each of the intervention options. Prospective patients who respond to your presentation and contact you should receive very prompt callbacks. Regarding pricing, Dr. Sullivan recommended making sure that the price you charge will fully cover all costs, including the potential cost of complications.
EXPERT ANALYSIS FROM DDW 2018