USPSTF: Diet and exercise counseling not routinely recommended for healthy adults

- Jennifer Middleton, MD, MPH

I was surprised to come across the United States Preventive Services Task Force (USPSTF) update in the June 15 AFP this weekend regarding nutrition and physical activity counseling for healthy adults:

[E]xisting evidence indicates that the health benefit of initiating behavioral counseling in the primary care setting to promote a healthful diet and physical activity is small. 

And, they listed a potential harm to providing this counseling:

Harms may include the lost opportunity to provide other services that have a greater health effect.

As a family physician, I want to help my patients to live the best lives they can, and I feel strongly that good nutrition and exercise are both critical to doing so.  So, this is a difficult USPSTF recommendation for me to absorb.

Of course, to clarify, the USPSTF only said that counseling regarding these matters is not effective. They did not make any value statements about diet and exercise.  But given how important many medical professionals feel diet and exercise is to good health, why is our counseling so ineffective?  Is it that we just don't counsel well?  Or, is something more than just counseling necessary to effect behavior change?

A review article from 1999 and a more recent systematic review suggest that individual, computerized nutrition counseling may result in positive changes. Telephone interventions may also be effective for improving nutrition and exercise habits.  Targeting counseling about nutrition that focuses on two concepts from health behavior theory, self-efficacy ("I believe I have what I need to make the change") and outcome expectations ("Making this change will result in a good outcome") also can make a difference. 

Perhaps we need to both 1) make our counseling more effective, and 2) employ a more interdisciplinary approach to help our patients make sustainable changes.

This AFP USPSTF update is included in the AFP By Topic for Health Maintenance and Counseling.  There is a lot of nice information there about health counseling in general (I especially like this Family Practice Management article on motivational interviewing).

Will this USPSTF update change your approach to diet and exercise counseling in the office?

Rosiglitazone for diabetes: helpful, harmful, or neither?

- Kenny Lin, MD, MPH

Last week, an advisory panel convened by the U.S. Food and Drug Administration (FDA) voted to relax safety restrictions on the diabetes drug rosiglitazone (Avandia) that were put in place in response to previous evidence that rosiglitazone may increase the risk of heart attacks and cardiovascular deaths. American Family Physician first highlighted these safety concerns in its March 15, 2008 Tips From Other Journals, which Dr. Kenneth Moon concluded:

There is substantial circumstantial evidence that rosiglitazone is associated with higher risks of heart failure and myocardial infarction. Despite the awkwardness of persuading a patient to use a drug that may provide similar benefits but pose greater risks than other proven agents, the legitimate concerns raised by these studies make this a serious issue. Until there is conclusive evidence about the safety of rosiglitazone, many physicians and their patients may be more comfortable using alternative treatments.

Subsequent AFP articles on management of blood glucose in type 2 diabetes and rosiglitazone vs. pioglitazone reinforced cautionary messages about rosiglitazone. However, the results of a large randomized trial published in 2009 found similar risks for cardiovascular hospitalizations and death in patients using rosiglitazone compared to patients taking other oral diabetes drugs. This trial, which was sponsored by rosiglitazone's manufacturer GlaxoSmithKline, was criticized for methodological problems, but an independent re-analysis of the trial's data persuaded the FDA advisory panel that the drug's safety risks had been exaggerated in previous studies.

If the FDA acts on the advisory panel's recommendations and makes rosiglitazone more widely available, should family physicians prescribe it? It is worth noting that the panel considered only the drug's safety, not its effectiveness. A previous AFP Journal Club reminded readers that the disease-oriented outcome of improved glycemic control does not necessarily lead to patients living longer or better. Rosiglitazone causes more weight gain and congestive heart failure than metformin, and is more expensive than metformin and sulfonylureas. For those reasons, it should be a second- or third-line drug choice for patients with type 2 diabetes.

The safety risks of backyard trampolines

- Jennifer Middleton, MD, MPH

I've been watching trampolines sprout up in backyards all over our neighborhood this spring, and seeing them has resurrected some memories from residency.  Like many family physicians, I spent time in a children's emergency department (ED) as a resident.

What I saw during my rotation made me wonder about the safety of these bouncy backyard devices.  I saw an injury related to backyard trampolines during nearly every shift that summer.  These children typically either fell off the trampoline onto the ground or got caught in the gap between the mat and the metal support.  Some of these injuries were just contusions and sprains, but I also helped evaluate several broken bones and a couple of head injuries.

It turns out that my ED experiences were not atypical.  The American Academy of Pediatrics (AAP) has been advising against recreational backyard trampoline use since 1977, with their most recent update last fall. (1)  Similarly, the American Academy of Orthopedic Surgeons also has a position statement against backyard trampoline use. (2) Despite these recommendations, trampoline use and trampoline injuries in the US are on the rise, from an average of about 41,000/year in the early 1990s to about 88,000/year in the early 2000s. (3) More children are injured directly on the mat, though around a third of injuries are from falls to the ground. (4,5)

I could find no rigorous evidence base to demonstrate that counseling against backyard trampoline use reduces injuries, but at least one literature review suggests that physician counseling about other childhood safety issues does reduce injuries. (6)  And, here's a recent AFP article about unintentional childhood injury prevention: http://www.aafp.org/afp/2013/0401/p502.html.  

My suspicion is that many parents remain unaware of these dangers (perhaps like this mother was), and a brief question about trampoline use would be a simple addition to our safety counseling at well child visits.

Is this topic worth discussing with families in the office?  I welcome your thoughts.


(1) Trampoline Safety in Childhood and Adolescence.  Council on Sports Medicine and Fitness.  Pediatrics; originally published online September 24, 2012. http://pediatrics.aappublications.org/content/early/2012/09/19/peds.2012-2082.full.pdf+html
(2) http://www.aaos.org/about/papers/position/1135.asp
(3) Linakis et al. Emergency department visits for pediatric trampoline-related injuries: an update. Acad Emerg Med. 2007 Jun;14(6):539-44. Epub 2007 Apr 20. http://www.ncbi.nlm.nih.gov/pubmed/17449791
(4) Black and Amadeo. Orthopedic injuries associated with trampoline use in children. Can J Surg. 2003 June; 46(3): 199–201.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3211739/
(5) McDermitt, Quinlin, Kelly. Trampoline injuries in children. J Bone Joint Surg Br. 2006 Jun;88(6):796-8. http://www.ncbi.nlm.nih.gov/pubmed/16720776
(6) Bass et al. Childhood injury prevention counseling in primary care settings: a critical review of the literature. Pediatrics. 1993 Oct;92(4):544-50. http://www.ncbi.nlm.nih.gov/pubmed/8414825

Is routine stress testing necessary for resolved chest pain?

- Kenny Lin, MD, MPH

Last week, the family medicine residency inpatient service that I supervise admitted several patients from the emergency department with acute chest pain that had resolved. Most of them had no history of cardiovascular disease, but were deemed to have enough risk factors to undergo pre-discharge cardiac stress testing after they had "ruled out" for acute coronary syndrome with normal cardiac enzymes. Rationales for the American Heart Association's recommendation for routine stress testing in patients with resolved chest pain include reducing malpractice liability, improving cardiac risk stratification, and initiating appropriate interventions earlier in high-risk patients. Although this practice is widely accepted, there is no evidence that it  improves patient-oriented outcomes compared to outpatient management, and some researchers have argued that randomized trials are needed to prove that the benefits actually exceed the harms.

A recent study published in JAMA Internal Medicine adds fuel to this debate by presenting prospectively collected outcomes of adult patients evaluated in the emergency department chest pain unit of Mount Sinai Medical Center from 2004 to 2010. A total of 4181 patients underwent stress testing (512 with exercise ECG tests and the rest with nuclear perfusion imaging), and 470 tests suggested potential myocardial ischemia. 123 patients underwent cardiac catheterizations; 60 of these patients were found to have normal coronary arteries. Of the 63 patients whose catheterizations showed obstructive coronary artery disease, only 28 had lesions that warranted stenting or coronary artery bypass grafting according to expert consensus guidelines.

There are at least two ways to view this study's results. A positive interpretation is that cardiac stress testing led to in the presumptive diagnosis of coronary artery disease in more than 10 percent of patients, who could then have received medical interventions shown to improve outcomes. On the other hand, the high false positive rates on coronary angiography suggest that up to half of these diagnoses were incorrect (and, consequently, that more than 150 patients would have received therapy inappropriately). Nearly 90 percent of patients were exposed to significant radiation doses through nuclear imaging, but less than 1 percent had coronary artery lesions that warranted revascularization. So are the benefits of routine pre-discharge stress testing in patients with resolved chest pain worth the harms? If not, is reducing medical liability risk enough reason to continue a low-value practice?

Are IUDs a reasonable option for birth control in adolescents?

- Jennifer Middleton, MD, MPH

What kind of contraception options do you discuss with adolescents?

A study by Rubin, Davis, and McKee from the Annals of Family Medicine's last issue explored the views of family physicians, pediatricians, and OB/GYNs on this issue.  Some might be tempted to dismiss this study because the n only equaled 28 docs, but this study was a qualitative study, not a numbers-crunching quantitative study.  The researchers used a semi-structured interview guide and interviewed as many physicians as it took to reach saturation, or the point where they were not recording any new themes.  (Low ns are fairly typical of qualitative studies.)

Although this study discussed both the intrauterine device (IUD) and implantable contraception (Implanon), I'm going to focus on the IUD findings for today's post.

It turns out that only about half of these physicians were recommending IUDs to their teenage patients.  The researchers found that this was due to "knowledge gaps" and "limited access to the device."

The "knowledge gaps" mostly related to the suitability of an IUD for a teen.  We know that 1 in 4 teens get a sexually transmitted infection (STI) each year.  IUDs were previously thought to increase the risk for pelvic inflammatory disease following an STI, but more recent research disputes that assumption with the current IUD devices available in the US.(1,2) And, despite all of the levonorgestrel-releasing intrauterine system (Mirena) commercials stating that it's only for women who have "had at least one child," the American College of Obstetrics and Gynecology reasonably asserts that IUDs are safe and reasonable to use in nulliparous women of all ages.

The "limited access to the device" is exactly what it sounds like; only 60% of the family docs, and none of the pediatricians, were providing this service in their offices.  Pediatricians, especially, were uncomfortable with any type of birth control besides oral contraceptive pills.  Long-acting contraception like the IUD, though, is a perfect fit for many teens who may be less than reliable at remembering to pop a pill every day. (Let's face it - many adults aren't any better at remembering to take daily meds.)

A look at the recent evidence regarding IUD use in adolescents shows that IUDs are easily inserted in most teens and nulliparous women, though the insertion process can be more uncomfortable. (3)  NSAIDs are a reasonable option for controlling this discomfort. Adolescents may be at slightly higher risk for IUD expulsion than older women, but current data suggests that the difference is probably not very large. (4,5)

There is a useful AFP By Topic collection on family planning and contraception available at http://www.aafp.org/afp/topicModules/viewTopicModule.htm?topicModuleId=71.  The IUD article does date to 2005, so please take its recommendations in the context of the evidence cited above, but the collection has many helpful resources to assist busy family doctors regarding this increasingly complex topic.

What are your thoughts about the IUD for teens?  If you are recommending it, what spurred you to do so?  If not, what is making you hesitate?

1. Faundes A, Telles E, Cristofoletti ML, Faundes D, Castro S, Hardy E. The risk of inadvertent intrauterine device insertion in women carriers of endocervical Chlamydia trachomatis. Contraception 1998;58:105–9.
2. Skjeldestad FE, Halvorsen LE, Kahn H, Nordbo SA, Saake K. IUD users in Norway are at low risk for genital C. trachomatis infection. Contraception 1996;54:209–12.
3. Andersson K, Odlind V, Rybo G. Levonorgestrel-releasing and copper-releasing (Nova T) IUDs during five years of use: a randomized comparative trial. Contraception 1994;49:56–72.
4. Deans EI, Grimes DA. Intrauterine devices for adolescents: a systematic review. Contraception 2009;79:418–23.
5. Lyus R, Lohr P, Prager S. Use of the Mirena LNG-IUS and Paragard CuT380A intrauterine devices in nulliparous women. Board of the Society of Family Planning. Contraception 2010;81:367–71.

How do family physicians provide cost-effective care?

- Kenny Lin, MD

Research studies have documented strong associations between U.S. primary care physician supply, better population health outcomes, and lower health care spending. Among adult primary care specialties, national survey data suggest that family physicians provide more cost-effective care. However, little research has examined how family physicians provide effective care at lower cost than other physicians. Is it because we are more likely to follow evidence-based guidelines? Order fewer inappropriate imaging tests? Are less likely to offer non-beneficial tests and treatments?

In the May issue of Family Medicine, Dr. Richard Young and colleagues reported a qualitative analysis of interviews with 38 Texas family physicians about decision-making practices that may contribute to delivery of cost-effective care. Participants provided examples of experiences that they felt exemplified differences in the ways they approached patients compared to approaches of less cost-effective specialists. Two major themes emerged from these interviews: 1) cost-effective care is an inherent value in family medicine; 2) knowledge of the whole patient through continuous relationships enabled efficient decision-making.

Family physicians in this study emphasized the importance of the history and physical examination, conservative testing strategies in low-risk patients, being comfortable with managing complexity, and assigning less importance to "making the diagnosis" than relieving patients' symptoms. Physicians were also attuned to potential behavioral causes of physical symptoms and placed considerable weight on financial and medical harms that could result from aggressive care.

As the authors point out, these findings are limited by the relatively small number of participants, who may or may not represent the general attitudes of family physicians in other areas of the U.S. Do you think that Dr. Young and colleagues identified all of the important ways that family physicians provide cost-effective care? If not, what other factors would you add from your own patient care experiences?