Counseling patients to eat less meat: should we bring climate change into the conversation?

- Jennifer Middleton, MD, MPH

The current issue of AFP features a Practice Guideline summarizing the Dietary Guidelines Advisory Committee's 2015-2020 Dietary Guidelines for Americans, and its contents are unlikely to surprise readers: 1) choose mostly nutrient-dense foods, 2) don't over-consume them, and 3) limit sugar, saturated fats, and salt intake. An accompanying AFP editorial by Dr. Caroline Wellbery, however, brings up what may be a more controversial angle; reducing meat intake would not only be beneficial for our nation's health, but it may also slow climate change.

This topic seems to be a hot one, lately, with the Washington Post running a similarly themed article this past week asserting many of the same points Dr. Wellbery does. The Washington Post article reviews a recent study titled "Analysis and valuation of the health and climate change cobenefits of dietary change," which ran predictive models of various population diet patterns to see how they might affect healthcare costs and greenhouse gas emissions. The study authors predicted that if we all ate less meat, the longer we would live, the less we would spend on health care, and the less we would contribute to greenhouse gases.

This issue tends to stir up heated emotions on both sides of the climate change debate, as a quick glance at the online comments for both the Washington Post piece and Dr. Wellbery's editorial reveals. Stepping back from the precipice of soapboxes and unbridled passions for a moment, though, how might we as family physicians choose a thoughtful approach to counseling our patients about their nutrition?

I suspect most of us would agree that encouraging our patients to adopt healthier dietary habits is a good thing (even if we disagree about some of the reasons why); unfortunately, our patients receive a lot of mixed messages about just what those habits should be, and finding the time to incorporate that counseling into our busy days can be challenging. Helping our patients focus on evidence-based recommendations, such as consuming less sugar and eating less meat while choosing more fruits, vegetables, and whole grains is a good start; working with them to set even one behavioral change goal (such as drinking less soda pop or eating one less serving of meat a week) per visit may feel more realistic to both docs and patients alike, too.

Here are some additional resources that might make nutrition counseling feel a little more doable:

• AFP By Topic on Nutrition (includes this 2015 article on nutrition myths) 
• This AFP Community Blog post from 2015 includes a list of nutrition apps to recommend to patients
• This still relevant 2000 AFP article on helping patients change behavior applies to eating healthier - and a lot more
• These familydoctor.org patient information handouts cover the gamut from interpreting food labels to fad diets
• This Family Practice Management article on promoting healthy lifestyles incorporates the entire office into helping patients
• And, maybe it's even worth incorporating a nutrition professional into your practice, as this AFP Community Blog post from 2011 suggests...

(Remember that you can add any of these links to your AFP home page "Favorites" button if you'd like to be able to refer to them quickly on the fly.)

What office strategies have you found successful in helping patients choose healthier diets?

Tackling the long-term impact of concussions

- Kenny Lin, MD, MPH

After years of publicly denying that football players who sustain repeated concussions are at increased risk for degenerative brain disorders such as chronic traumatic encephalopathy (CTE), the National Football League (NFL) did a dramatic "about face" last week in a hearing before the House of Representatives' Energy and Commerce Committee. Responding to a legislator's question about whether there is a link between CTE and football, Jeff Miller, the NFL's executive vice president of Health and Safety Policy, said, "The answer to that is certainly, yes."

There were other recent signals that the NFL had finally gotten serious about shedding its unscientific and defensive approach to concussions. Last year, the NFL Foundation partnered with the American Academy of Family Physicians (AAFP) to sponsor a series of 3 webcasts for primary care clinicians and a patient brochure addressing head injuries in sports at all levels. Although the long-term effects of concussions in professional football players have been well-documented, there is an urgent need to collect information on the outcomes of concussions in recreational athletes, especially in children and adolescents. In a recent JAMA study, one-third of Canadian children reported persistent somatic, cognitive, or behavioral symptoms 28 days after being diagnosed with an acute concussion in the emergency department.

According to a 2012 AFP article on subacute to chronic mild traumatic brain injury (TBI), patient groups more likely to experience persistent postconcussive symptoms include women, older adults, persons with less education, and persons with a previous mental health diagnosis. Surveillance data from the National Collegiate Athletic Association (NCAA) show that in most comparable sports (soccer, basketball, softball), female athletes experience concussions at significantly higher rates than male athletes. Pink Concussions, which supports research into female concussions caused by sports, abuse, or military service, sponsored an international summit on concussion and TBI at Georgetown University in February.

The coming years will hopefully provide more research findings to inform parents, coaches and health professionals on best practices to minimize the long-term impact of concussions. In the meantime, family physicians can access additional educational resources and clinical tools, including relevant AFP content, on the AAFP's website.

Which medications lower mortality in type 2 diabetes?

- Jennifer Middleton, MD, MPH

The list of medications that help diabetic patients live longer (and not just lower their A1C) got a little longer recently. The March 1 issue of AFP includes a POEM demonstrating reduced mortality with empagliflozin in patients with type 2 diabetes and known cardiovascular disease (CVD). 

In this trial, about 7000 patients with both type 2 diabetes and CVD were randomized to receive either one of two doses of empagliflozin, a sodium-glucose co-transporter inhibitor, or a placebo. All-cause mortality in both empagliflozin groups was 3.7% compared to 5.9% in the placebo group, with a number needed to treat of 38 to reduce mortality over a 3.3 year period. Interestingly, there was no difference between the empagliflozin groups and the placebo group regarding rates of heart attack or stroke, so it's unclear as yet just what is responsible for that mortality benefit. There was no difference in efficacy between the two doses, but the higher dose caused more adverse events. In the AFP POEM, Dr. Ebell points out that generalizing this finding to patients with type 2 diabetes who do not have CVD is not appropriate.

Of the other medications shown to lower mortality in type 2 diabetes, metformin may be the best known. Metformin has a proven mortality benefit for all patients with type 2 diabetes, even those patients on insulin. Metformin is so beneficial that a recent AFP article recaps recommendations to only consider discontinuing it if a patient's GFR is less than 44 mL/min, not necessarily just because the creatinine is > 1.5 in men or >1.4 in women as previously thought.

Ramipril and the combo of perindopril and indapamide have been specifically shown to help type 2 diabetics live longer, and a 2014 meta-analysis suggests this benefit is a generalizable to the entire ACE inhibitor class. Also, ACE inhibitors have a clear mortality benefit in diabetics who have diabetic nephropathy, though only at maximum tolerated doses and not so-called lower "renal protective" doses.

While hypertension control helps diabetics live longer, over-control may be harmful. A recent meta-analysis found that lowering systolic blood pressure in type 2 diabetics already at or below 140 mmHg was associated with an increased risk of mortality. This meta-analysis calls into question the common practice of prescribing those low "renal protective" doses of ACE inhibitors to type 2 diabetics with systolic blood pressures (SBPs) <140 and normal renal function. 

Certainly, other medications may help lower morbidity and improve quality of life in patients with type 2 diabetes; to read more about diabetes treatment check out the AFP By Topic on Diabetes: Type 2 which includes this 2016 Practice Guideline on Preventing CVD in Adults with Type 2 Diabetes Mellitus. Diabetes also figures prominently in some of AFP's newer features, including this recent Medicine by the Numbers article on glycemic control goals and the January 15, 2016 AFP podcast. 

The promise and challenges of telehealth

- Kenny Lin, MD, MPH

Last fall, I attended a conference on patient-centered medical homes where one of my fellow attendees shared how after-hours videoconferencing with a primary care physician had allowed him to avoid spending a night with his child in the emergency department. This story made me wonder if primary care practices without virtual visit capabilities might someday be viewed as anachronisms, something like banks before automated teller machines and smartphone check depositing apps.

According to a Graham Center Policy One-Pager in the January 15th issue of AFP, only 15% of family physicians surveyed in 2014 were using telehealth (defined as "the use of medical information exchanged from one location to another via electronic communications to improve a patient's health"), even though most agreed that it improves access and continuity of care. Geographical and generational differences influenced telehealth use; according to the original study report, telehealth users were more likely to see patients in rural settings and have practiced for 10 or fewer years than non-users. Non-users were more likely to cite barriers such as equipment cost, lack of reimbursement, lack of training, and potential liability issues.

Private insurers have been gradually expanding coverage for telehealth services, according to a recent article in Modern Healthcare. Since Medicare has traditionally been less willing to reimburse such services, bipartisan legislation, the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act, was recently introduced in the U.S. Congress to remove many of the program's current restrictions. Family physicians and other primary care clinicians are poised to benefit from these changes. In recognition of the changing payment landscape, the American College of Physicians, the American Academy of Family Physicians, and the American Academy of Pediatrics all published policies or position papers on appropriate telemedicine use and reimbursement last year.

Other than payment, what should family physicians consider in deciding whether or not to treat patients virtually? A 2015 article in Family Practice Management reviewed the most common elements of care that have implications for telehealth services:

1) Formation of a doctor-patient relationship
2) Proper evaluation and treatment
3) Responsible prescribing
4) Protection of the patient
5) Safeguarding patient privacy

If you are a family physician who currently offers telehealth servcies, how has this capability benefited your patients and your practice? If you don't, what has been holding you back?