Tuesday, January 10, 2017

What's in a name? Obesity, ABCD, and prediabetes

- Kenny Lin, MD, MPH

A recent position statement from the American Association of Clinical Endocrinologists and the American College of Endocrinology proposed replacing obesity with the term "adiposity-based chronic disease," or ABCD for short. The authors argued that this new term emphasizes that most persons with obesity will struggle with weight gain for their entire lives; encourages a complications-centric as opposed to body mass index-based management approach; and "avoids the stigmata [sic] and confusion" associated with obesity in popular culture. They also asserted that ABCD is more amenable to interventions based on the Chronic Care Model, which explicitly recognizes that screening and office-based management need to be adapted to the patient's unique environment.

None of these concepts should surprise family physicians, though, and after reading through the AACE/ACE statement, I was not sold on the benefits of the new term. Some patients with body mass indexes above 30 don't like the obesity label, but would they respond any more positively to the disease acronym ABCD? There are potential harms to consider, too. One of my AFP physician colleagues felt that the new term was "intimidating" and "not at all patient centered," while another thought that it "only hides the issue [of obesity] instead of confronting it."

This discussion brought to mind another medical term often associated with overweight and obese patients: prediabetes. On one hand, being classified as "prediabetic" or at risk for this exceptionally common diagnosis may motivate obese patients to lose weight through improved diet and physical activity. On the other, the term prediabetes is misleading: many of these patients will not develop diabetes, and the diagnostic accuracy of the most common screening tests (hemoglobin A1c and fasting glucose levels) is poor, according to a systematic review published in the BMJ. Due to the tests' low sensitivity and specificity, some persons are incorrectly diagnosed with prediabetes, and others who might actually benefit from interventions to prevent diabetes are falsely reassured. Therefore, the review authors concluded, "'screen and treat' policies alone are unlikely to have substantial impact on the worsening epidemic of type 2 diabetes."

For all its limitations, obesity is a diagnosis with well-established clinical utility. It is less clear how many patients have been helped (or harmed) by being diagnosed with prediabetes. With more study, adiposity-based chronic disease might someday become a useful term, but the current case for more widespread use is unconvincing.

Tuesday, January 3, 2017

Guest Post: I have a new patient

- Donna J. Schue, MD

I've been in a busy rural private practice for 15 years. Outside of new obstetrical patients, the children I deliver, and the occasional close relative or close friend of an existing patient, my practice has been full.

I received a phone call on a Saturday from one of our Emergency Department physicians. Our practice was listed that day to provide an ED follow-up visit for those patients who were seen and had no physician. My colleague had just seen a delightful and independent 80 year-old woman who had come to the ED, not having seen a physician for over 25 years. She had discovered a breast lump about two years before. She had witnessed her husband die of cancer 15 years before despite all attempts at treatment, and had decided that she would continue to have good days until she wasn't having good days anymore. The ED evaluation had revealed an obvious large breast cancer, extensive ascites, and a large pleural effusion. A CT scan showed scattered bony metastases. She did not want to see an oncologist and did not want to be admitted to the hospital, but knew she would need care in the months to come. I told him I would accept her as a patient and saw her in my office on Monday.

Now, four months later, my new patient has undergone a thoracentesis and several paracenteses. She is beginning to have discomfort related to metastases, and we are managing her pain. She has completed a Medical Order for Life-Sustaining Treatment form and prepared her legal affairs. She has also continued to live independently, attend daily Mass, volunteer at a hospice home and a clothing donation center, and has visited out of town family three times. She has told no one of her diagnosis. She does not want those around her to worry. She tells me repeatedly that she is grateful that it is winter and her sweaters can hide the changes to her body that would be more obvious otherwise.

The clinician in me wonders what might have been the outcome if she had presented to care earlier. However, having had two patients die in the last year from opportunistic infections while immunocompromised due to chemotherapy, I remind myself that treatment does not guarantee longer survival.

We talk at each visit about telling her family. As I lost my own mother due to side effects of cancer treatment a few years ago, I share with her that as a daughter I would want to know that this was happening to my mother. She agrees that at some point she will tell them, but not yet. She mentions that she may need help with that when the time comes.

I remain impressed by her fortitude to continue her daily routines. I realize, again, that sometimes we family physicians are called to comfort and not cure. I see how filling her remaining days by helping others continues to bring her a sense of purpose. I have learned a great deal from her in a short time and am grateful that I accepted a new patient.

Wednesday, December 21, 2016

The top 10 AFP Community Blog posts of 2016

- Jennifer Middleton, MD, MPH and Kenny Lin, MD, MPH

It's that time of year when we give thanks to our readers and highlight our most read posts of 2016. This list reflects the AFP Community Blog's growing audience; as compared to last year, when only one post was viewed more than 1000 times, this year five passed that mark.

1. Is Vitamin D supplementation good for anything? (January 12) - 2093 views

The next time a healthy adult of any age asks me if he or she should be taking a vitamin D supplement, I plan to answer: we don't know for sure, but probably not - and we don't need to know what your vitamin D level is, either.

2. 25 podcast episodes every family physician should listen to (July 18) - 1666 views

Podcasts, and their ability to make us engage with others’ stories, might be useful to physicians as they look for ways to take in new information, and above all, try to stay tuned in to the underlying messages their patients are sharing.

3. To rapid strep test or not to rapid strep test? (July 5) - 1416 views

Because the rapid strep test produces either a false positive or a false negative result a significant minority of the time, it is most useful in patients with an intermediate pre-test probability of having strep pharyngitis.

4. For acute low back pain, naproxen alone works best (February 22) - 1308 views

Prescribe naproxen alone for most patients with acute low back pain and no contraindications to nonsteroidal anti-inflammatory drugs (NSAIDs); reserve cyclobenzaprine for patients who can't use NSAIDs; and prescribe oxycodone/acetaminophen only in patients who can't tolerate NSAIDs or cyclobenzaprine.

5. Which medications lower mortality in type 2 diabetes? (March 14) - 1284 views

Metformin has a proven mortality benefit for all patients with type 2 diabetes, even those on insulin. Metformin is so beneficial that clinicians should only consider discontinuing it if a patient's GFR is less than 44 mL/min, not just because the serum creatinine level is > 1.5 in men or >1.4 in women as previously recommended.

6. Hyaluronic acid injections don't help knee DJD (April 25) - 953 views

Unfortunately, the placebo effect with hyaluronic acid comes with cost and risk; injections can cost hundreds of dollars for one dose, and typical therapeutic regimens involve a series of 3-5 injections over several weeks.

7. New USPSTF and ACP guidelines on depression screening and treatment (February 8) - 847 views

A new clinical practice guideline reviewed the comparative effectiveness of treatment for major depressive disorder and recommended that "clinicians select between either cognitive behavioral therapy or second-generation antidepressants after discussing treatment effects, adverse effect profiles, cost, accessibility, and preferences with the patient."

8. What we say when we don't give an antibiotic matters (April 11) - 837 views

This study will change the way I speak with parents and adult patients about my decision not to prescribe antibiotics. I will make sure not to trivialize their concerns or refer to an illness as "just" a virus, and I will aim to use objective language to describe my rationale either way.

9. Myth-busting and fact-sharing about Family Medicine (February 1) - 792 views

Medical students, other specialists, and even the lay public often have questions about Family Medicine. Kozakowski et al answer these questions and many more in "Responses to Medical Students' Frequently Asked Questions About Family Medicine."

10. Have your female patients asked you about ROCA? (June 6) - 739 views

Offering a screening test directly to consumers prior to establishing its clinical utility is presumptuous at best and exploitative at worst; hopefully our patients will discuss the shortcomings of this test, and ovarian cancer screening in general, with us prior to spending $295 on it.

Thursday, December 15, 2016

How can medical educators support students' well-being?

- Kenny Lin, MD, MPH

Even twenty years later, I remember well the pervasive despair that engulfed me for much of my first two years of medical school. Even with a personal support system that included my family and several former college roommates and friends who lived in the same city, I struggled to find my bearings, academically and emotionally. Now that I spend much of my time teaching first-year medical students, I have wondered if the learning environment that I and other faculty provide contributes negatively or positively to their well-being.

A recent systematic review in JAMA examined the self-reported prevalence of depression, depressive symptoms, and suicidal ideation in medical students from 43 countries who were surveyed from 1982 to 2015. Longitudinal studies showed that students' mental health worsened significantly after starting medical school, with a median absolute increase in symptoms of 13.5%. On average, 27 percent of students reported depression or depressive symptoms, but only 16 percent of those students sought formal treatment. In contrast to my own experience, which was feeling much happier once I began third-year clerkships, there was no significant difference in depression prevalence between the preclinical and clinical years. Most alarmingly, 11 percent of students in these studies reported having suicidal thoughts during medical school.

A second systematic review examined associations between learning environment interventions and medical student well-being. The evidence base was limited: only 3 of 28 included studies were randomized trials, and most studies were conducted at a single site. Interventions that appeared to be effective in improving students' well-being included pass/fail grading systems, increased time with patients during the preclinical years, mental health programs, wellness programs including mind-body stress reduction skills, and formal advising/mentoring programs. In an accompanying editorial, Dr. Stuart Slavin observed that the educational culture of some medical schools is often an obstacle to implementing these kinds of reforms:

When signals of problems involving student mental health arise, the reaction in medical education has commonly been failure to recognize that the main problem is often with the environment, not the student. The response has often been limited, such as advising students to eat well, exercise, do yoga, meditate, and participate in narrative medicine activities. These approaches ... may distract educators from recognizing that the learning environment is at the core of the problem, and more must be done to improve it.

To be sure, maximizing student well-being is not the only or even the most important goal of medical education. But just as it is possible to create positive practice environments that protect clinicians from burnout, educators can prepare students to practice medicine competently in learning environments that are least likely to harm their mental health.

Monday, December 5, 2016

Getting started with pet therapy

- Marselle Bredemeyer

The conclusion in AFP’s latest Curbside Consultation is unlikely to come as a surprise to anyone with a pet at home: animal companions do more than make us happy. They can be valuable for enhancing our health, too. The benefits of having a pet are strong enough that a recent article on pet-related infections is careful to dispel misconceptions about whether it is necessary to rehome an animal because of a zoonotic disease.

Asking about pets during an office visit can serve a larger purpose than preventing or treating a cause of infection, however. These conversations can help motivate patients who are striving to meet personal wellness goals, including quitting smoking. Such areas of overlap between animal and human health are common. In fact, worldwide, advocates for the One Health initiative increasingly encourage clinicians and veterinarians to recognize their interests in their patients as a shared project.

Pets’ positive impact on loneliness is one of many areas that researchers have looked into as they explore how to optimize health for humans and animals. Loneliness is especially prominent among older adults, with those older than age 80 years at the highest risk. The deleterious effects of prolonged feelings of social isolation have been well reported in the media, and include serious harms such as cognitive decline and even early mortality. Patients who are experiencing chronic loneliness may be reluctant to admit it, however. In these cases, a question about contact with animals becomes a potentially valuable way to explore patients’ day-to-day social interactions.

Pablo, my bichon frise, poses with AFP's November 15 issue.

What should physicians do if they suspect a patient is lonely and he or she doesn’t have a pet at home? This could identify patients who need help developing deeper social connections. Higher rates of loneliness among those who live by themselves and are without a pet could indicate a need to follow-up with the patient about how lack of contact with others might be affecting quality of life.

Patients who otherwise reply that they have interest in getting a pet but are not sure about caring for one in their older age will find reassurance from a physician useful. If there are no major contraindications to pet ownership, physicians can check that patients with limited access to transportation are aware of mobile veterinary and grooming services, and recommend contacting a local veterinarian’s office about free or low-cost animal care programs in the area. Additionally, many nonprofits are committed to helping older persons care for pets. Some U.S. shelters receive funding specifically for this purpose, and others are involved in foster networks that place animals with senior citizens while a permanent home is sought. Many of the nation’s Meals on Wheels programs will even deliver pet food to the people they serve if they have a pet at home.

Do you have a pet that’s improved your well-being as you’ve worked to improve your patients’? Listeners of AFP Podcast recently tweeted pictures of some of family medicine’s animal friends at the show’s Twitter account. With a dog of my own at home (see photo), I am always grateful that I can count on getting some “pet therapy” time at the end of every day, especially when there’s been a deadline.


Marselle Bredemeyer is Associate Editor, AFP Online.

Tuesday, November 29, 2016

More guidance on statins for primary CVD prevention

- Kenny Lin, MD, MPH

Previous AFP Community Blog posts discussed the 2013 American College of Cardiology/American Heart Association cholesterol treatment guideline, provided additional perspectives on its 7.5% 10-year CVD event risk threshold for starting a statin, and noted that existing cardiovascular risk calculators tend to overestimate risk by significant margins. The ACC/AHA guideline has remained controversial in primary care. The American Academy of Family Physicians gave it a partial endorsement with qualifications (disclosure: I am a member of the AAFP Commission that made this recommendation), and a 2014 guideline from the U.S. Departments of Veterans Affairs and Defense recommended higher thresholds for considering (6%) or starting (12%) statins.

Two weeks ago, the U.S. Preventive Services Task Force weighed in with a new recommendation statement on the use of statins for primary prevention of cardiovascular events. The recommendations are similar to those from the ACC/AHA; the USPSTF recommends initiating low- to moderate-dose statins in adults aged 40 to 75 years with at least one CVD risk factor (dyslipidemia, diabetes, hypertension, or smoking) and a calculated 10-year CVD event risk of 10% or greater ("B" recommendation). They recommend shared decision making and selective statin prescribing for similar adults with a 7.5% to 10% CVD risk ("C" recommendation).

The USPSTF's higher risk thresholds for statin therapy compensate for uncertainty regarding the accuracy of CVD risk calculators, and the "C" recommendation recognizes that in persons at lower risk, the benefits of statins are less likely to outweigh the harms, which include liver enzyme abnormalities and muscle toxicity and a small increased risk of new-onset type 2 diabetes.

Although a prior USPSTF statement had recommended screening for lipid disorders in adults as early as 20 years of age, a new systematic review found no direct evidence on the benefits and harms of screening for or treatment of dyslipidemia in adults aged 21 to 39 years. So when should family physicians start checking cholesterol levels in asymptomatic adults, if statins don't become a treatment option until age 40? This is an area to exercise one's clinical judgment on a case-by-case basis, keeping in mind that healthy lifestyle counseling is more likely to be beneficial in adults with CVD risk factors than in adults without known risks.