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Vol. 3 No. 50

Gait-and-balance training is touted
as key aspect to prevention of falls

NORTH HAVEN, CONN. – Training, awareness of patients’ balance-and-gait limitations, emulation of everyday tasks, and knowledge of the Medicare “clock” are among the tools at medical practitioners’ fingertips when it comes to helping fall-prone community-dwelling seniors.

Professor Rick Pope, (PA-C), Quinnipiac University, Department of PA Studies, North Haven, Conn., points to research published last year in the Cochrane Database of Systematic Reviews establishing the benefits of certain exercises.

The study published January, 2019, indicates that exercise mainly involving balance-and functional-training reduced falls for community-dwelling people over average age 76, including 77% women, and they were compared to those in control groups with no activity. The researchers report that certain types of exercise reduced the number of falls over time by 23% and cut the number of people experiencing one-or-more falls by 15% compared to control.

“This suggests that gait-and-balance training is important in preventing falls, with a ‘high degree of certainty of evidence’,” says Pope, founder and past president of the Society of Physician Assistants in Rheumatology (SPAR), and faculty member of the Metabolic & Endocrine Disease Summit (MEDS). “A review like this can give nurse practitioners (NPs) and physician assistants (PAs) a more confident view when it comes to ordering physical therapy (PT).”

“Trainers,” he adds, “as well can institute gait-and-balance training as exercise, either at patient’s homes or PTs in physical-therapist offices. All of this helps for those who have lost muscle mass or feel that their gait-and-balance are off and are more likely to fall. This is especially helpful for older osteoporotic patients who are at a higher risk of falling or who have fallen and risk fracture.”

Also noteworthy in this review, reflecting data involving more than 23,000 participants, Pope says, “is that it shows evidence that these exercises help those who haven’t fallen and can help those who have fallen. It is critical that we know what types of exercises work, which ones that physical therapists and trainers should focus on.”

“PAs and NPs need only know which older patients are at risk of falling. They can perform simple tests during office visits for likelihood of falling, by having them sit in a chair, then turn them in a circle, perform a ‘TUG’ test as well as heel-to-toe walking, balancing on one leg, lower-extremity reflex testing and looking at muscle mass and tone and decide which patients would benefit from PT.”

One obstacle is to identify that often in primary care that “osteoporosis is among the last things on the list, after other diagnosis such as hypertension, heart disease, diabetes and weight-maintenance/loss; all of these often take priority over osteoporosis.”

The study reports greater exercise-driven fall-prevention rates when intervention is provided by health-care professionals, in contrast to community-exercise programs, though both types reduce fall incidents. This information, Pope asserts, helps NPs and PAs, since “knowing what is going to work, as evidence-based, and communicating that to our patients. I will be adding this Cochrane Review to my osteoporosis lectures, to spread the word.”

What doesn’t work, Pope notes, “is surprising: Flexibility, dance, endurance, walking. Exercise of any type is helpful, though, for cardiovascular and other reasons, but not for fall prevention. Walking, for instance, helps those with knee osteoarthritis, bone health, although not fall prevention.”

“Tai chi shows some evidence in fall prevention, but not to the same level as balance-and-functional training. Multi-directional lunges, which mimic many household tasks were one of the exercises that was mentioned, and I found compelling. Knowing these exercises emulate household tasks such as gardening, vacuuming, and house-cleaning makes sense, and should be encouraged.”

Pope stresses, “people who exercise, who practice gait training, and go to PT are better off. However, I order these all the time and I have believed it was helping, I didn’t know until now that these really do help. My patients tell me that the exercises help, and these conversations are reinforcing, but now we have with a ‘high degree of certainty’ that they really do help as per this review.”

“If I see that a patient doesn’t have good balance, or stable gait, I ask them if they want to return to PT, and most say yes. This is particularly true for Medicare patients, when, on Jan. 1 each year, the clock is re-set for payment for PT. They are motivated, and they understand the potential downfalls of falling at their age. It really is important as we get older not to forget these simple things.”

CITATION: Sherrington C, Fairhall NJ, et. al. Exercise for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews. 2019. Issue 1. Published: 31 January 2019.


Obesity-cancer study ties racial disparity
to social, behavioral, biological factors

TUCSON, ARIZ. – A study published in January in Cancer Epidemiology, Biomarkers & Prevention indicates that diet quality, physical activity and their combined effect aren’t associated with obesity-related cancer risk and mortality among black women enrolled in the Women’s Health Initiative (WHI).

Its authors---including Joy J. Chebet and Cynthia A. Thomson, University of Arizona, Tucson, Ariz.---also report that other social, behavioral and biological factors may contribute to racial disparities observed in obesity-related cancer rates.

The researchers noted that obesity-related cancers disproportionately affect the black community, and analyzed data from post-menopausal (50-to-79 years of age) black women enrolled in WHI clinical trials or observational studies.

Exposure variables included baseline physical activity and diet quality, with outcomes including adjudicated obesity-related cancer incidence and mortality.

Cox proportional-hazard models were used to evaluate the association between moderate-to-vigorous physical activity (MVPA) and healthy eating index (HEI)-2015 and obesity-related cancer risk and mortality.

The analytical sample included 9,886 black women.

Over an average of 13 years of follow-up, 950 obesity-related cancer cases were observed, with 313 resulting in death.

Physical activity, diet quality, and their combination were not associated with risk for any or site-specific obesity-related cancers.

These health behaviors had no association with mortality.

CITATION: Joy J. Chebet, Cynthia A. Thomson, et. al. Association of Diet Quality and Physical Activity on Obesity-Related Cancer Risk and Mortality in Black Women: Results from the Women's Health Initiative. Cancer Epidemiology, Biomarkers & Prevention. Received September 4, 2019. Revision received October 13, 2019. Accepted December 17, 2019. Published online first: January 8, 2020.


Research links early menarche age
to an increased risk of type 2 diabetes

CAMBRIDGE, ENGLAND – Earlier age at menarche (AAM) is consistently associated with higher type 2 diabetes/impaired glucose tolerance (T2D/IGT) risk, independent of adiposity, according to a study involving data on more than one million subjects.

The research published in January in PLOS Medicine also indicates that a substantial proportion of T2D in women is related to early menarche, which would be expected to increase in light of global secular trends towards earlier puberty timing.

The study’s authors---including Tuck Seng and Felix R. Day, University of Cambridge, Cambridge, England---state that their findings highlight the need to identify underlying mechanisms linking early menarche to T2D/IGT risk.

They noted that emerging studies have investigated the association between puberty timing, particularly AAM, and T2D, but added that whether this association is independent of adiposity is unclear.

The authors searched PubMed, Medline, and Embase data-bases for publications until February, 2019, on the timing of any secondary sexual characteristic in boys or girls in relation to T2D/IGT.

Inverse-variance-weighted random-effects meta-analysis was used to pool reported estimates, and meta-regression was utilized to explore sources of heterogeneity.

Twenty-eight observational studies were identified. All assessed AAM in women (combined total of 1,228,306); only one study additionally included men.

In models without adjustment for adult adiposity, T2D/IGT risk was lower per-year-later AAM and higher for early-versus-later menarche. Associations were weaker but still evident in models adjusted for adiposity.

Associations were stronger among white than Asian women, and in populations with earlier average AAM. The estimated population attributable risk of T2D in white UK women due to early menarche un-adjusted and adjusted for adiposity was 12.6% and 5.1%, respectively.

Findings in this study are limited by residual and un-measured confounding, and self-reported AAM.

CITATION: Tuck Seng Cheng, Felix R. Day, et. al. Association of puberty timing with type 2 diabetes: A systematic review and meta-analysis. PLOS Medicine. Published: Jan. 6, 2020.


Asthma assessment associates HRQoL,
comorbidities with uncontrolled disease

UXBRIDGE, MIDDLESEX, ENGLAND – Controlled severe asthma (SA) was infrequently achieved in a patient sample in the IDEAL study, with about 80% of SA patients having some form of uncontrolled disease.

In research published in January in the Journal of Asthma, classification of uncontrolled SA was primarily based on symptoms and clinically-significant exacerbations; patients also had poor lung function and, ultimately, very poor health-related quality of life (HRQoL).

Comorbidities and HRQoL were significantly associated with uncontrolled disease, with a history of frequent exacerbations.

The authors---including Hana Mullerova, GSK, Stockley Park, Uxbridge, Middlesex, England, and Sarah M. Cockle, GSK House, Brentford, Middlesex, England---report that identifying differences in clinical characteristics and factors associated with un-controlled SA and frequent exacerbations can help support individualized asthma-management development of future targeted-and-more-effective therapeutics for SA patients.

Post-hoc analysis of the observational IDEAL study included patients with SA, at least 12 years of age, receiving high-dose inhaled corticosteroids plus additional controller(s) for at least one year.

Un-controlled SA was defined by Asthma Control Questionnaire (ACQ)-5 scores of at least 1.5 or at least one exacerbation (prior year), and further stratified by exacerbation frequency.

Associated factors were determined using multivariate-logistic regression.

Of 670 patients with SA, 540 were un-controlled. Uncontrolled patients had lower lung function and worse HRQoL than controlled patients; 37% experienced frequent exacerbations (prior year).

CITATION: Hana Mullerova, Ph.D., Sarah M. Cockle, Ph.D., et. al. Clinical characteristics and burden of illness among adolescent and adult patients with severe asthma by asthma control: the IDEAL study. Journal of Asthma. Received 31 Jan. 2019.
Accepted 17 Dec. 2019. Accepted author version posted online: 24 Dec. 2019. Published online: 09 Jan. 2020.


Fall risk is said to impact isolation
among patients on hemodialysis

GHENT, BELGIUM – Recent research indicates that, more than muscle strength, lack of coordination-and-balance as witnessed by the risk of falls contributes to social isolation and health-related quality of life (HRQoL) among hemodialysis (HD) patients.

The study published in January in BMC Nephrology also indicates that mental fatigue is less common than expected, and reports a decrease in subjective-and-objective physical function.

Its authors---including Karsten Vanden Wyngaert, Ghent University, Ghent, Belgium, and Amaryllis H. Van Craenenbroeck, University of Antwerp, Antwerp, Belgium--- conducted a cross-sectional multi-center study on patients on maintenance HD.

Physical function, fall risk, and HRQoL were measured and analyzed descriptively, by general-linear models and logistic regression.

Of 113 HD patients enrolled, a majority had impaired quadriceps force (86.7%) and six- minute walking test (92%), and an increased risk of falls (73.5%).

Whereas muscle strength and exercise capacity were associated with global HRQoL and fall risk, the risk of falls itself was related to psycho-social domains such as depression and social participation, rather than to the physical domains of HRQoL.

Objective measures of physical function were not associated with subjective fatigue, nor with subjective appreciation of health status.

The authors advise health-care providers to include balance training and fall-risk prevention strategies in the standard care of patients on HD in an effort to improve other domains of the quality of life compared to conventional exercise training.

CITATION: Karsten Vanden Wyngaert, Amaryllis H. Van Craenenbroeck, et. al. Associations between the measures of physical function, risk of falls and the quality of life in haemodialysis patients: a cross-sectional study. BMC Nephrology. Received 26 April 2019. Accepted 23 Dec. 2019. Published 06 Jan. 2020.



Vol. 3 No. 49

Asthma assessment bolsters viewpoint
that biggest risk factors are modifiable

BOISE, IDAHO – The results of a recent study pointing to such factors in poor-asthma outcomes as incorrect inhaler use, previous severe exacerbation, and high short-acting beta agonist (SABA) use underscores one health-care professional’s assertion that “the biggest risk factors are modifiable.”

The research published in September in the Journal of Asthma and Allergy assessed data involving more than 12,000 patients---mostly in Hungary, but also in Japan, Turkey, and in the United States. Its authors conclude that the presence of real-risk factors for poor-asthma outcomes listed by the Global Initiative for Asthma (GINA) document significantly-influenced actual control.

Brian K. Bizik, MS, PA-C, physician assistant, Terry Reilly Health Center, Boise, Idaho, notes that “this study and others point to where we are lacking in asthma treatment and forced the hand of GINA. The U.S. hasn’t had guidelines since 2007 other than GINA. And the Food and Drug Administration (FDA) doesn’t always recognize international guidelines.”

New GINA guidelines, as published in the European Respiratory Journal, were issued in 2019.

Bizik, past president, Association of PAs in Allergy, Asthma and Immunology, and a faculty member of Cardiovascular, Allergy, & Respiratory Summit (CARPS), adds that “U.S. guidelines have not been updated in over a decade, so they have not looked at modifiable risk factors the way GINA has. In the January, 2019, guideline update, GINA dropped the term bronchoconstriction from their guidelines---reminding us that airway inflammation and mucous production are paramount factors to control if asthma is to be managed effectively. They also put the over-use of rescue inhalers at the center of the risk-factor discussion.”

Bizik adds that “incorrect-inhaler use is the number one cause of poor control, then previous severe exacerbation, then SABA over-use. All three of these are very close. The study shows a look at these risk factors that lead to poor-patient outcomes. Poor asthma control leads to poor outcomes. This was mostly taken in Hungary, but also in the U.S., Japan, and Turkey, and would have been the same in terms of results if it was done entirely in the U.S.”

He points out that “a third of patients are well-controlled, a third in the middle, and a third poorly controlled. Many risk factors are modifiable, including inhaler techniques. The biggest risk factors are modifiable.”

Bizik cautions that “with poor-inhaler technique, rescue-inhaler over-use, or exacerbation, you are at higher risk. A diagnosis doesn’t tell you whether you will wind up in the emergency room. You have to follow the risk factors.”

Following those factors involves looking at them with a focus on outcomes.

Health-care professionals, Bizik says, and “providers need to ask patients about control at every appointment, about use of their rescue inhaler, how often they use it, and most important, why they use it. If rescue inhalers are used more than twice a week, or if patients go through more than two inhalers in a year, their risk for adverse outcomes is much higher than those patients with less rescue-inhaler use.”

He invokes the “the rule of two,” which encourages using less than two rescue inhalers in a year, and using a rescue inhaler less than two times per week when not sick. When patients stick to this rule, he explains, the risk for a visit to the ER is reduced; tracking asthma-rescue inhalers, he says, helps reduce ER visits for asthma.

In addition, Bizik says, patients’ exercise-tolerance should be evaluated. Ask patients whether they can they climb a flight of stairs without having to stop and cough halfway or have shortness-of-breath at the top.

“Attaining control,” he says, “is the key. When control is less than ideal, ask why. Is it lack of a good controller, are they on inhaled steroids at the same time, as they should be? Rescue-inhaler over-use is too much of a false security.”

When health-care providers change the way they handle patients, he adds, “having standing orders in your practice where all asthma patients are given asthma-control test questionnaires helps show if there is control, the same way, for instance, with diabetes, providers use A1C tests. Control should be assessed at all visits before the health-care provider is even in the room.”

“Inhaler technique should be addressed at each appointment, also before the provider is in the room. Videos can be shown on inhaler use, and providers can change therapies. We don’t want patients just to say how they feel; control must be assessed.”

CITATION: Tomisa G., Horvath A., et. al. Prevalence and impact of risk factors for poor asthma outcomes in a large, specialist-managed patient cohort: a real-life study. Journal of Asthma and Allergy. Received: 5 April 2019. Accepted for publication: 2 July 2019. Published: 23 September 2019. Volume 2019: 12 Pages 297-307. Helen K. Reddel, J. Mark FitzGerald, et. al. GINA 2019: a fundamental change in asthma management. European Respiratory Journal. 2019 53: 1901046.



Mild-moderate kidney-function reduction
is linked to fracture risk for older women

MALMO, SWEDEN – Recent research indicates that older women with mild-moderate reduction of kidney function are at increased risk of fractures, but not those with the worst function.

The study published in November in Osteoporosis International supports the value of osteoporosis assessment and indicates the possibility that, in this age group, age-related decline of kidney function has limited contribution compared with bone mineral density (BMD).

Its authors---including Fiona E. McGuigan, who is affiliated with Lund University, Malmo, Sweden---followed kidney function and fracture risk for 10 years and noted that a mild- moderate decline in kidney function is associated with fracture, but not in advanced age, and that chronic kidney disease (CKD) is associated with increased fracture risk.

The researchers used cystatin C-based kidney-function estimates available at age 75 (981 subjects) and 80 (685).

Women were categorized by kidney function:

  • normal (CKD stages 1 and 2)
  • mild-moderate (3a)
  • poor (3b-5)
  • imminent, short- and long-term fracture risk investigated

BMD measurements and kidney function for risk prediction were also evaluated; women were categorized by both reduced kidney function (stages 3-5) and osteoporosis status.

In the short term, two-to-three years, mild-moderate kidney dysfunction was associated with the highest-risk increase: osteoporotic fractures, and also up to five years. Hip-fracture risk was similarly increased.

This association was not observed from age 80, nor for women with poorest kidney function.

Reduced kidney function was associated with higher risk even without osteoporosis; risk increased by having both osteoporosis and reduced function.

CITATION: Malmgren L, McGuigan FE, et. al. Kidney function and its association to imminent, short- and long-term fracture risk-a longitudinal study in older women. Osteoporosis International. 2019 Nov. 21. Epub ahead of print. PMID: 31754754.



Cardiovascular events, supplement use
addressed in vascular-calcification study

KINGSTON, ONTARIO – An assessment of nearly 300 subjects indicates that older female calcium-supplement users have significantly-higher abdominal aorta calcification (AAC) progression over five years, but without any significant bone mineral density (BMD) preservation.

The study published in December in Atherosclerosis suggests that vascular calcification may contribute to cardiovascular events observed in calcium-supplement users.

Its authors---including Maggie Hulbert and Mandy E. Turner, Queen’s University, Kingston, Ontario---found that:

  • calcium supplements used to prevent osteoporosis have been linked to cardiovascular events
  • females using calcium supplements have greater progression of aortic calcification over five years
  • females using calcium supplements do not have preserved BMD
  • calcification may contribute to cardiovascular events in calcium-supplement users

The study addresses the relationship between calcium-supplement use and the five-year progression of AAC in participants from one center of the Canadian Multi-Centre Osteoporosis Study (CaMOS).

The 296 participants, including 217 women, had lateral spine X-rays and DEXA BMD scans (femoral neck, lumbar spine and total hip) taken at two time points within a five-year interval.

AAC was detailed using the Framingham Method. Calcium-supplement use was assessed by a facilitated health-history questionnaire and medication inventory.

AAC significantly increased over five years, and AAC progression was significantly greater in calcium-supplement users, as compared to non-users, overall, and in females. The amount of calcium was positively correlated to AAC progression.

A multi-variable linear-regression model was generated for women only, as there were not enough men for multi-variable modeling.

Calcium-supplement use and amount remained significantly associated with AAC progression after adjustment for age, hypertension, diabetes and smoking history.

Change in AAC score was not associated with change in BMD T-Score. In univariate analyses of males, calcium-supplement use was associated with a significantly greater BMD loss at the lumbar spine, hip, and femoral neck.

CITATIONS: Maggie Hulbert, Mandy E. Turner, et. al. Changes in vascular calcification and bone mineral density in calcium supplement users from the Canadian Multi-center Osteoporosis Study (CaMOS). Atherosclerosis. Published online: Dec.11, 2019. Accepted: Dec. 6, 2019. Received in revised form: Oct. 17, 2019. Received: Aug. 27,



Research: Breast-cancer prevention seen
as a strong motivator for loss of weight

ATLANTA – Research published in December in the Journal of the National Cancer Institute suggests that even modest sustained weight loss is associated with lower breast-cancer risk for women aged 50-and-over, and that breast-cancer prevention may be a strong weight-loss motivator for overweight-or-obese American women.

Its authors---including Lauren R. Teras, Ph.D., and Alpa V. Patel, Ph.D., American Cancer Society, Atlanta---noted that excess body weight is an established cause of
post-menopausal breast cancer.

Associations between weight change and breast-cancer risk were examined among women at least 50-years-of-age in the Pooling Project of Prospective Studies of Diet
and Cancer

In 10 cohorts, weight assessed on three surveys was used to examine weight-change patterns over approximately 10 years (interval one median, 5.2 years; interval two
median, 4.0 years).

Sustained weight loss was defined as at least 2kg lost in interval one that was not regained in interval two.

Among 180,885 women, 6,930 invasive breast cancers were identified during follow-ups.

Compared with women with stable weight (plus-or-minus 2kg), women with sustained weight loss had a lower risk of breast cancer.

This risk reduction was linear and specific to women not using post-menopausal hormones.

Women who lost at least 9kg and gained some (but not all) of it back were also at a lower risk of breast cancer. Other patterns of weight loss and gain over the two intervals had a similar breast-cancer risk for women with stable weight.

CITATION: Lauren R. Teras, Ph.D., Alpa V. Patel, Ph.D., et. al. Sustained weight loss and risk of breast cancer in women ≥50 years: a pooled analysis of prospective data. Journal of the National Cancer Institute. Received 09 Nov. 2018. Revision received: 01 July 2019. Revision received: 23 Oct. 2019. Accepted: 03 Dec, 2019. Published: 17 Dec. 2019.



Diet-and-education interventions touted
for BMI decreases among diabetes patients

NOTTINGHAM, ENGLAND – Research reflecting data on more than 12,000 participants indicates that low‐calorie, low‐carbohydrate meal replacements or diets
combined with education may be the most promising interventions to achieve the largest weight-and-body mass index (BMI) reductions for type 2 diabetes patients.

Authors of the study published in November in Diabetic Medicine include Asiya Maula and Joe Kai, who are affiliated with the University of Nottingham, Nottingham, England.

Their review showed that maintenance interventions can be effective in helping prevent weight regain, and that these need to be incorporated into any weight-loss intervention---while there is still a need to improve lifestyle-maintenance interventions.

The researchers set out to determine the effectiveness of community‐based educational interventions for weight loss in type 2 diabetes.

They undertook a systematic review and meta‐analysis of randomized controlled trials (RCTs) in obese or overweight adults, aged 18-to-75, with a diagnosis of type 2

Primary outcomes were weight and/or BMI. CINAHL, MEDLINE, Embase, Scopus and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from
inception to June, 2019.

Trials were classified into specified a priori comparisons according to intervention type. A pooled standardized mean difference (SMD) (from baseline to follow‐up) and 95% confidence intervals (95% CI) between trial groups were estimated through random‐effects meta‐analyses using the inverse-variance method.

Some 7,383 records were screened; 228 full‐text articles were assessed and 49 RCTs (12,461 participants) were included in this review, with 44 being suitable for inclusion into the meta‐analysis.

CITATION: Asiya Maula, Joe Kai, et. al. Educational weight loss interventions in obese and overweight adults with type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials. Diabetic Medicine. First published: 30 Nov. 2019.



Vol. 3 No. 48

Pre-diabetes knowledge-gap study
highlights importance of teamwork


LAGUNA NIGUEL, CALIF. – A study pinpointing gaps in primary-care physician (PCP) knowledge of pre-diabetes shines a light on the advantages that nurse practitioners (NPs) and physician assistants (PAs) can provide this patient population.

So says Ji Hyun Chun, PA-C, BC-ADM, immediate past president of the American Society of Endocrine Physician Assistants (ASEPA), noting his medical experience as well as research on the quality of care provided by PAs and NPs published in Medical Care in June, 2017, The American Journal of Medicine in September, 2017, and Pharmacotherapy in March, 2018.

The PCP research, published in the Journal of Internal Medicine, based on a PCP survey answered by 298 participants, notes gaps in knowledge of pre-diabetes risk factors, laboratory-diagnostic criteria for pre-diabetes, and management recommendations.

Chun---who is affiliated with OptumCare Medical Group, Laguna Niguel, Calif., and is a faculty member of Metabolic & Disease Summit (MEDS)---says “the key to modern medicine is a teamwork approach: By having more health-care providers like NPs and PAs on the team, medical professionals may supplement each other’s knowledge, strength, and weaknesses to provide more comprehensive care.”

The first step in communicating type 2 diabetes (T2D) prevention with patients is to acknowledge their risk factors. A more important skill, he adds, “would be how to deliver the message. As weight, for instance, can be a sensitive topic for patients, this should be approached with non-judgmental verbiage and tone. Perhaps mentioning some biological factors (i.e., family history, age, race) and physical findings (i.e., acanthosis nigricans) first can be helpful as you present more objective findings.” That done, Chun explains, NPs and PAs can then “carefully bring up lifestyle factors, current weight status, and what can be done to lower the risk of T2D progression.”

He points to a study from 2011 noting that just acknowledging---even without further counseling on weight management---patients’ overweight/obese states has an impact on weight loss. “The same strategy,” Chun adds, “can be applied for pre-diabetes state.”

Chun also asserts that “having the right resource to help patients is paramount. This could be, ideally, the clinicians themselves, but, if not, knowing who can render this service for you is very important. In busy primary-care clinics, clinicians are often limited in time, resources, and discussing pre-diabetes prevention may seem time-consuming, with low ‘return-on-investment.’ If so, you need to be able to refer to those who can provide that service well to the patient.” Chun notes that lifestyle modification “is hard, as it is a lifelong process, rather than a short-term plan. Essentially, it has to be the patient who wants to do it. Motivational interviewing is a great tool to help patients get to that state-of-mind. It is after that when all the other tools (nutrition, physical activity, behavioral modification, pharmacotherapy, surgery) will really work.”

As for PAs and NPs and their roles, Chun says “recognition of NPs/PAs’ competence has significantly improved, and continues to improve with the quality of care they provide. Pointing to the aforementioned studies on NPs and PAs, he adds that “much evidence shows that they provide equivalent care to their physician colleagues.” Finally, Chun supports the notion of PAs and NPs working with PCPs to improve pre-diabetes awareness as a practice that “allows the opportunity to expand everyone’s awareness.”

He says “medicine is changing fast, and it can be challenging to keep up with all the changes, especially for a busy PCP who covers general medicine. Having more colleagues on your team allows each to have their special interest in certain disease states, and can supplement each other’s knowledge and provide up-to-date evidence-based care.”

CITATION: Eva Tseng, MD, Raquel, MD, et. al. National Survey of Primary Care Physicians’ Knowledge, Practices, and Perceptions of Prediabetes. Journal of General Internal Medicine. First online: 09 September 2019. Post RE, Mainous AG 3 rd , et. al. The influence of physician acknowledgement of patients’ weight status on patient perceptions of overweight and obesity in the United States. Archives of Internal Medicine. 2011 Feb 28;171(4):316-21. Yang Y, Long Q, et. al. Nurse Practitioners, Physician Assistants, and Physicians Are Comparable in Managing the First Five Years of Diabetes. The American Journal of Medicine. 2018 Mar;131(3):276-283.e2. Epub 2017 Sep. 8. Kurtzman ET, Barnow BS, et. al. A Comparison of Nurse Practitioners, Physician Assistants, and Primary Care Physicians’ Patterns of Practice and Quality of Care in Health Centers. Medical Care. 2017 Jun;55(6):615-622. Jiao S, Murimi IB, et. al. Quality of Prescribing by Physicians, Nurse Practitioners, and Physician Assistants in the United States. Pharmacotherapy. 2018 Apr;38(4);417-427. Epub 2018 Mar. 26.



BPAQ scores said most consistently linked
to tibial-bone parameters in older women

CLAYTON, AUSTRALIA – Recent research indicates that Bone-Specific Physical Questionnaire (BPAQ) scores are most consistently associated with tibial-bone parameters in older women, with past physical activity (PA) having lasting benefits for
trabecular micro-architecture---and current PA positively associated with cortical bone.

Authors of the study published in November in Osteoporosis International include Lachlan McMillan, who is affiliated with Monash University, Clayton, Australia.

The researchers set out to compare associations of current-and-past self-reported bone-specific PA, and current accelerometer-determined PA, with bone structure (bone mineral density [BMD] and micro-architecture) in post-menopausal women withosteopenia or osteoporosis.

Fifty community-dwelling post-menopausal women (mean age 64.4 ± 7.7) with hip-or-spine BMD T-scores less than minus 1.0 standard deviation (SD) were recruited for an exercise intervention.

At baseline, current, past and total BPAQ scores were self-reported, and percentages of sedentary-, light- and moderate-to-vigorous PA (MVPA) were objectively determined by accelerometer measurements.

Bone structure was assessed by lumbar spine and hip dual-energy X-ray absorptiometry (DXA), 3D modelling algorithms (3D-SHAPER) of hip DXA scans and distal tibial high-resolution peripheral quantitative computed tomography (HR-pQCT)

Current BPAQ scores and MVPA were significantly positively-associated with femoral neck areal BMD, following multi-variable adjustments. MVPA was also positively associated with femoral cortical surface BMD and mean cortical thickness.

Past and total BPAQ scores demonstrated positive associations with tibial trabecular number, and negative associations with trabecular separation, and distribution.

Current BPAQ scores were positively associated with tibial cortical periosteal perimeter.

CITATION: C.A. Ng, L.B. McMillan, et. al. Associations between physical activity and bone structure in older adults: does the use of self-reported versus objective assessments of physical activity influence the relationship? Osteoporosis International. First Online: 13 November 2019.



Anticipation of obesity prevalence associated
with efforts in gains in primordial prevention

BALTIMORE – Research involving data on more than 470,000 subjects indicates that an increase in obesity prevalence in the Latin American and Caribbean region has been paralleled with an un-equal distribution and a shifting burden across socio-economic groups.

The study published in December in The Lancet Global Health also indicates that anticipation of the establishment of obesity among low socio-economic groups could provide opportunities for societal gains in primordial prevention. Its authors---including Safia S. Jiwani, Johns Hopkins Bloomberg School of Public Health, Baltimore, and Rodrigo M. Carrillo-Larco, Rodrigo M. Carrillo-Larco, Imperial College London, London---note larger increases among rural residents and the most disadvantaged groups.

They also report that the prevalence of obesity has been increasing not only among the poor, least-educated, rural populations, but also among the rich, highly-educated, and urban populations.

The researchers also note that, among women, the obesity gap by wealth, education, and area of residence has stayed constant or widened in Argentina, Bolivia, Peru, and Mexico, but has narrowed in Haiti by education and area of residence.

They point out that the anticipation of the establishment of obesity among the low socio- economic status groups offers opportunities for societal gains in primordial prevention, and state that these findings can support efforts towards adequate monitoring of obesity by socio-economic status groups that would allow anticipation of the transitions in obesity across societies.

The study involved data from 479,809 adult men and women. Obesity prevalence across countries, the authors state, has increased over time, with distinct patterns emerging by wealth-and-education indices. In the most recent available surveys, obesity was most prevalent among women in Mexico in 2016, and the least prevalent among women in Haiti that year.

The largest gap between the highest-and-lowest obesity estimates by wealth was observed in Honduras among women, and among men in Peru.

Urban residents consistently had a larger burden than their rural counterparts in most countries.

The trend analysis done in five countries suggests a shifting of the obesity burden across socio-economic groups and different patterns by gender.

CITATION: Safia S. Jiwani, Rodrigo M. Carrillo-Larco, et. al. The shift of obesity burden by socioeconomic status between 1998 and 2017 in Latin America and the Caribbean: a cross-sectional series study. The Lancet Global Health. Volume 7, Issue 12, PE1644- E1654, December 01, 2019.



Non-dialysis CKD patients with fractures
seen as having greater disease burdens

NEWTON, AUSTRALIA – A recent study involving data from nearly 150,000 patients indicates that Australian non-dialysis chronic kidney disease (CKD) patients with hospitalized fractures are older, have greater disease burdens, and similar rates of fracture and associated mortality compared to international CKD cohorts.

The research published in November in Nephrology (Carlton) also indicates that implications of fracture requiring hospitalization are considerable, with longer admissions, greater health-care costs, lower likelihood of discharge home, and significant mortality.

Its authors---including Raymond Lin, The George Institute for Global Health, Newtown, and Nigel D. Toussaint, The Royal Melbourne Hospital, Parkville, Australia---also note that as fracture prevention in the CKD population evolves, treatment algorithms should account for those at greatest risk.

The researchers set out to describe the trends and impact of hospitalized fractures in an Australian population of non-dialysis CKD patients.

Retrospective-observational data was derived through data linkage. Fracture rates, trends in hospital admissions, comorbidity burden, and mortality were analyzed in a non-dialysis CKD population between 2000 and 2010 in the Australian state of New South Wales (NSW).

Hospitalized patients with CKD and fractures were compared with CKD patients without fractures.

A total of 149,839 hospitalized patients with CKD was included, of whom 9,898 experienced at least one fracture.

Patients with fractures were older, and more likely to be female, with a higher comorbidity burden than those without fractures.

Hospital admissions involving fractures were longer than non-fracture admissions (14.3 versus 5.9 days), and patients were less likely to be discharged home (28.3% versus 80.9%).

The 12-month mortality rate was high, at 41%.

CITATION: Lin R, Toussaint ND, et. al. Hospitalised fracture rates amongst patients with chronic kidney disease in Australia using data linkage. Nephrology (Carlton). 2019 Nov 19. Epub ahead of print. PMID: 31743530.



Triple therapy is cited as a top option
to cut mortality for stable COPD patients

SEOUL, SOUTH KOREA – A recent study indicates that triple therapy can potentially be the best option for stable chronic obstructive pulmonary disease (COPD) patients in terms of reducing exacerbation and all-cause mortality.

The study published in November in PLOS Medicine features a systematic review (SR) and Bayesian network meta-analysis (NMA) concluding that triple therapy with inhaled corticosteroids (ICS), long-acting muscarinic antagonists (LAMA), and long-acting beta- agonists (LABA) can be the most appropriate pharma-cotherapeutic option in terms of reducing the risk of exacerbations and all-cause mortality in patients with stable COPD.

Its authors---including Hyun Woo Lee and Jimyung Park, Seoul National University Hospital, Seoul, South Korea---suggest further studies are needed to determine whether any specific sub-group can benefit from triple therapy the most.

They searched Medline, EMBASE, the Cochrane Central Register of Controlled Trials,, the European Union Clinical Trials Register, and the official web sites of various pharmaceutical companies (from inception to July 9, 2019).

The eligibility criteria were:

  • parallel-design randomized controlled trials (RCTs)
  • adults with stable COPD
  • comparisons among LAMAs, LABAs, ICSs, combined treatment (ICS/LAMA/LABA, LAMA/LABA, or ICS/LABA), or a placebo
  • study duration of at least 12 weeks

The main limitation of the research is that there were few (RCTs), including only less symptomatic patients or patients at a low risk.

CITATION: Hyun Woo Lee, Jimyung Park, et. al. Comparisons of exacerbations and mortality among regular inhaled therapies for patients with stable chronic obstructive pulmonary disease: Systematic review and Bayesian network meta-analysis. PLOS Medicine. Published: November 15, 2019.


Clinician Reviews article notes benefits
of motivational interviewing for diabetes

An article posted in Clinician Reviews details ways in which diabetes patients may benefit from motivational interviewing (MI). Written by Courtney Bennett Wilke, MPAS, PA-C, Florida State University College of Medicine, Tallahassee, Fla., the story explains that MI empowers patients to modify lifestyle choices, battle ambivalence, and better align goals with actions. Research indicates that MI improves clinician-patient relationships, with patients noting greater empathy from medical providers. The story can be accessed at


Vol. 3 No. 47

Expert sees ‘no magic pill’ for dealing
with kidney issues of weight and diet

ST. PETERSBURG, FLA. – While the results of a recent study indicating the importance of diet in kidney-disease management don’t surprise one expert on the disease, its conclusions strike a chord in efforts to improve both treatment and approach.

Research published in May in the Clinical Journal of American Society of Nephrology reflecting data involving nearly 15,000 middle-aged adults enrolled in the Atherosclerosis Risk in Communities study concludes that high adherence to healthy plant-based directives like the Mediterranean diet is linked to favorable kidney-disease outcomes.

Kim Zuber, PA-C, executive director of the American Academy of Nephrology PAs and past chair of the National Kidney Foundation/Council of Advanced Practitioners, raises two vital aspects of kidney-disease treatment brought to mind by this study:

  • challenges many patients encounter in buying and preparing healthy foods
  • medical practitioners, including physician assistants (PAs) and nurse practitioners (NPs), are all-too-often paid when their patients continue to be sick, rather than when they become or remain healthy

Zuber, of St Petersburg, Fla., a faculty member of the Metabolic & Endocrine Disease Summit (MEDS), echoes the study’s point that associations between a healthy and less-healthy plant-based diet are significant only among normal-weight participants (“not many of my patients are thin and eating a healthy diet”) and underscores the importance of weight management.

“As an example,” Zuber says, “my brother-in-law is a pediatrician in California. He works with an adolescent obesity clinic, and he sees that both kids and parents lose weight when diet changes are made by the family. We need to treat the whole patient, not just the medical aspect.” “It’s a matter of getting the message across, in office visits, in handouts, in paperwork,” she adds. “The study shows that a plant-based, Mediterranean diet is good, which is not news. However, insisting on plant-only diets have issues, because, by the time someone is on dialysis, their protein levels are so low that they are malnourished. They need protein, too---it’s a pull-push kind of thing with this diet, Mediterranean, plus protein (in any form) is best.”

“There is no magic pill,” Zuber says. “The study notes that a Mediterranean diet slows progression to kidney failure, deals with healthy-weight patients eating diets that are plant-based---careful eaters who don’t wind up on dialysis. But that isn’t the population most of us deal with. And one problem is that much of the population can’t get this food; they live in food deserts.”

“We know that a Mediterranean diet is good, but it’s hard to get fresh fruits and vegetables for many patients, and there’s the issue with cost or how to cook it---I’ve found that patients aren’t aware that they shouldn’t fry vegetables, or make them with cheese, or that they are better off with frozen vegetables than with canned. Dietary habits are often based on what you grow up with.”

One oasis in the food desert is the Produce Rx voucher program. Launched in 2019 in Washington, D.C., by Giant food, AmeriHealth Caritas District of Columbia, and the D.C. Department of Health, the program allows medical professionals to prescribe (with a written prescription) fresh fruit and vegetables to patients with chronic illnesses.

The program, which also offers clinics for those living in poverty, as well as professional dietary advice, “can get people off of medication,” says Zuber, who cautions that “this kind of food, unfortunately, is more available in the D.C. suburbs than in the city.”

Another government-sponsored effort to improve health care that Zuber touts is an effort by Medicare and Medicaid to encourage health-care practitioners to keep patients healthy.

“We get paid for taking care of patients,” Zuber says, “but keeping them healthy works against us. We should make more by keeping people healthy---which isn’t often the case. Medicare, though, has a comprehensive-care plan in which we are paid more to keep people healthy.”

Currently, she says, “I’m paid more each time a patient is hospitalized. I’d rather be paid to keep patients healthy and out of the hospital. Better to get part of the savings if patients are healthy. Now, we make more money if we do a crappy job; better to pay practitioners to keep their patients healthy. In this Medicare model, we keep the patient healthy, they live longer, and the money saved is split between the Accountable Care Organization (ACO) and the medical professional.”

CITATION: Hyunju Kim, Laura E. Caulfield, et. al. Plant-Based Diets and Incident CKD and Kidney Function. Clinical Journal of the American Society of Nephrology. CJASN May 2019, 14 (5) 682-691. Food as medicine: doctors are prescribing broccoli and bananas alongside beta blockers. Washington Post. May 17, 2019.

Innovation Models/Center for Medicare & Medicaid Information.



Research pinpoints children’s risks
of asthma-related ICU re-admissions

RABAT, MOROCCO – A recent study indicates that, compared to children not admitted to intensive-care units (ICUs), those admitted to ICUs for asthma are at increased risk of asthma-related re-admission, with certain risk factors conferring an even higher risk.

The retrospective-cohort study published in September in the Journal of Asthma was designed to compare the time to asthma-related re-admission between children admitted to ICUs for asthma and those with non-ICU hospitalization in the United States and to explore risk factors associated with re-admission among children admitted to ICUs.

Its authors---including Imane Jroundi, University of Mohammed V of Rabat, Rabat, Morocco, and Sze Man Tse, Montreal University, Montreal---assessed information on subjects aged two-to-17 years in the State Inpatient Database (2005-to-2014) from four U.S. states who were hospitalized for asthma.

They compared the time to asthma-related re-admissions and emergency department (ED) visits between children admitted and not admitted to the ICU using the log-rank test.

A total of 66,835 children were hospitalized for asthma, with 14.0% admitted to the ICU, and 12,844 were re-admitted for asthma, while 22,915 had asthma-related ED visits.

The time to asthma-related re-admission was shorter in the ICU group compared to the non-ICU group, but the time to asthma-related ED visit did not differ between the two groups.

Being pre-school-aged, female, black, and having lower household income and a longer length of stay during the initial hospitalization conferred a higher risk of asthma-related re-admission among children admitted to the ICU.

Pre-school age and Medicaid were Florida-specific risk factors while Hispanic ethnicity was New York-specific.

CITATION: Imane Jroundi, MD, MPH, Ph.D, Sze Man Tse , MDCM, MPH, et. al. Long-term asthma-related readmissions: comparison between children admitted and not admitted to the intensive care unit for critical asthma. Journal of Asthma. Received 29 April 2019. Accepted 31 Aug. 2019. Accepted author version posted online: 06 Sept. 2019. Published online: 20 Sept. 2019.



Study: Obese neuromuscular patients
getting PSFs likelier to face infection

COLUMBUS, OHIO – A recent study indicates that obese neuromuscular patients undergoing posterior spinal fusion (PSF) have higher odds of experiencing adverse outcomes, particularly surgical-site infections, urinary-tract infections, and re-admissions.

The retrospective, evidence-level three study published in October in Spine also indicates that providers should promote prevention strategies, such as dietary modification and/or early physical activity, in these high-risk patients to minimize the risks of complications in the acute post-operative period.

Its authors---including Azeem Tariq Malik, The Ohio State University Wexner Medical Center, Columbus, Ohio---assessed the impact of varying severity of body mass index (BMI) on 30-day outcomes following PSFs in neuromuscular scoliosis.

The 2012-to-2016 American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) data-base was queried using Current Procedural Terminology codes 22800, 22802, and 22804 to identify patients undergoing PSF for neuromuscular scoliosis only.

BMI was classified into four groups based on the Centers for Disease Control (CDC) BMI-for-age percentile chart: normal weight, underweight, overweight, and obese.

Multivariate regression models were built to understand the impact of varying BMI severity classes on 30-day outcomes.

A total of 1,291 patients underwent PSF for neuromuscular scoliosis; 695 were normal weight, 286 were underweight, 145 were overweight, and 165 were obese.

Obese-versus-normal weight patients were at a significantly higher risk of:

  • surgical-site infections
  • wound dehiscence
  • urinary-tract infections
  • 30-day re-admissions

Overweight-versus-normal weight subjects had higher odds of cardiopulmonary complications; no significant associations were seen for varying BMI and other 30-day outcomes.

CITATION: Malik AT, Tamer R, et. al. The Impact of Body Mass Index (BMI) on 30-day Outcomes Following Posterior Spinal Fusion in Neuromuscular Scoliosis. Spine (Phila. Pa. 1976). 2019 Oct 1;44(19):1348-1355. PMID: 3121270.



Assessment boosts use of FLS context
in leading to a lower rate of mortality

MALAGA, SPAIN – Recent research indicates that patients treated with anti- osteoporotic drugs in a Fracture Liaison Service (FLS) context have a lower mortality rate than patients managed before FLS implementation.

Authors of the study published in September in Osteoporosis International---including David Gonzalez-Quevedo, Regional University Hospital of Malaga, Malaga, Spain---did not observe significant one-year-mortality differences after hip fracture between patients treated before FLS implementation and those treated post-implementation.

Nor did they find that the FLS application affected the risk of suffering a second osteoporotic fracture.

The researchers analyzed the effect of the FLS model over the first-year mortality rates following a hip fracture by conducting a prospective-cohort study on patients over 60 years of age who suffered hip fractures during two consecutive years, before-and- after the implementation of the FLS between January, 2016 and December, 2017.

Patients'39; information was drawn from a local data-base. Patients were followed for one year after the hip fracture. Mortality and re-fracture rates were compared between the two groups using a multivariate Cox proportional hazard model.

Seven-hundred-twenty-four individuals were included in this study (357 before FLS implementation and 367 after).

Anti-osteoporotic drugs were more frequently prescribed after FLS implementation; 74 patients after FLS implementation and 92 before implementation died during the follow-up period.

Second fractures occurred in 17 patients after FLS implementation and 13 before FLS implementation.

Patients treated with anti-osteoporotic drugs after FLS implementation had a lower one-year mortality compared with patients managed before implementation of the FLS protocol (treated or not treated with anti-osteoporotic drugs).

CITATION: D. Gonzalez-Quevedo, D. Bautista-Enrique, et. al. Fracture liaison service and mortality in elderly hip fracture patients: a prospective cohort study. Osteoporosis International. First online: 11 September 2019.


Coverage for insulin, test strips targeted
in tracking progress for diabetes patients

SYDNEY – No less-resourced country had even near-complete coverage for insulin, and coverage was worse for test strips, according to a study demonstrating the utility of this framework which could be developed as a means of tracking progress in meeting the needs of diabetes patients.

Authors of the study published in September in Diabetes Research and Clinical Practice---including Emma Louise Klatman, Life for a Child Program, Sydney, and Martin McKee, London School of Hygiene & Tropical Medicine, London---note that global governments have committed to achieve Universal Health Coverage (UHC), ensuring access to quality and affordable health care for all.

Such care, they note, is fundamental for those with type 1 diabetes mellitus, who require daily access to both insulin and blood-glucose test strips to survive. This group, the researchers state, risks being left behind by global initiatives that fail to consider these needs.

A questionnaire was distributed to key informants in 37 less-resourced countries. Seven high-income countries were also included.

The authors drew on a World Health Organization (WHO) framework developed to assess progress towards UHC to create scales on three dimensions: population covered, services provided and direct costs. A fourth dimension, availability, was added.

The study indicates that 65% of the less-resourced national-health systems provided insulin, with medians of 67% for service provision, 55% direct costs covered, and 75% availability. Test strips were only provided in 14% of the less-resourced systems, with medians 42% (less than two strips per day), 76%, and 88% respectively.

Six patterns of provision were identified. Progress correlated with income level, yet some low-income countries are achieving provision for insulin and test strips for those enrolled in health insurance.

CITATION: Emma Louise Klatman, Martin McKee, et. al. Documenting and visualising progress towards Universal Health Coverage of insulin and blood glucose test strips for people with diabetes. Diabetes Research and Clinical Practice. Published online: Sept. 20, 2019. Accepted: Sept.13, 2019. Received in revised form: Sept. 5, 2019. Received: July 17, 2019.


Difference between proteinuria, albuminuria
is explained in an article in Clinician Reviews

A Q&A posted in October in Clinician Reviews details the difference between proteinuria and albuminuria. Written by Cynthia A. Smith, DNP, CNN-NP, FNP-C, APRN, FNKF, of Renal Consultants, PLLC, South Charleston, W.Va., the article notes the importance of assessing for proteinuria, a marker for chronic kidney disease (CKD). Proteinuria indicates an elevated presence of protein in urine, while albuminuria is an abnormal loss of albumin in urine---and is common in CKD patients. The article also notes that if non-albumin proteinuria is suspected, testing for specific-urine proteins is recommended. It can be accessed at


Vol. 3 No. 46

‘Exciting finding’ indicates T2D benefits
from long-term testosterone therapy

LAGUNA NIGUEL, CALIF. – Long-term testosterone therapy (Tth) completely prevents pre-diabetes progression to type 2 diabetes (T2D) among men with hypogonadism, according to a recent study that also indicates that it improves glycemia, lipids, and Aging Males’ Symptoms (AMS) scale scores.

The research published in March in Diabetes Care is deemed “an exciting finding” by
Ji Hyun Chun, PA-C, BC-ADM, president of the American Society of Endocrine Physician Assistants (ASEPA).

Chun---who is affiliated with OptumCare Medical Group, Laguna Niguel, Calif., and is a faculty member of Metabolic & Disease Summit (MEDS)---notes that the observational study concludes that Tth offers potential for men with pre-diabetes and hypogonadism, and looks for validations from future research.

“I would love to see the study replicated in other studies and settings to draw conclusions which can further guide us on this topic matter,” he says. “We would especially need a well-designed randomized-controlled trial so we have a better matched placebo group.”

As the study, which involved 316 men with pre-diabetes and symptoms of hypogonadism, notes that pre-diabetes represents a window of opportunity for intervention to prevent T2D, Chun suggests that this “window” can best be utilized through careful screening for potential hypogonadism, and appropriate work-ups.

“Keep in mind,” he urges, “that ‘active’ testosterone (free and/or bio-available testosterone) levels need to be checked in this setting. Many patients with dysglycemia are overweight or obese, which lowers sex-hormone binding globulin (SHBG), and thereby have lower total testosterone, but might have normal ‘active’ testosterone levels.”

Chun adds that “another important point mentioned in the study is the presence of symptoms of hypogonadism in treatment decision-making.”

“If patients with pre-diabetes have true hypogonadism (biochemical and symptomatic), and other reversible causes are ruled out,” he says, “Tth may improve their metabolic health and help them from progressing to overt diabetes.”

While Chun calls this research and its conclusion “an exciting finding from an observational study,” he also urges caution.

“As in any study results,” Chun says, “one should carefully review the study setting (in this case, an observational study that was non-blinded, non-randomized, not propensity matched, and funded by industry) and acknowledge its strength (i.e., real-world data) and weakness before drawing a conclusion.”

One aspect of the study is its mention of the importance of weight loss, as pre-diabetics are urged to aim at 10% weight loss, with Tth yielding nearly that (9%).

“As we have seen the overlap of obesity and diabetes,” Chun says, “we know that weight management is the cornerstone in managing metabolic syndrome regardless of its stage (euglycemia, prediabetes, diabetes). It is very intriguing to see this significant improvement in weight, and more importantly, its sustainability in this particular registry. I am curious on what is different in this population other than the Tth that led to this significant weight benefit.”

“We all know,” he adds, “that just going on testosterone would not drop someone's weight. We have to give adequate guidance on the needed lifestyle intervention to achieve that. It is plausible to think that Tth would make patients with symptomatic hypogonadism feel better, and have more energy to increase their physical-activity levels, and would be more likely to keep and build lean muscles with exercise and thereby improve their metabolic health.”

Chun also asserts that “discussing this needed lifestyle intervention and setting the right expectation by nurse practitioners (NPs) and physician assistants (PAs) is very important.”

He concludes, too, that, in wake of this study, “there certainly will be an increase in interest and requests from patients in both checking testosterone and using testosterone. Unlike other chronic disease states (i.e., diabetes, hypertension, dyslipidemia, osteoporosis) where patients’ perceived risks outweigh benefits, it is exactly the opposite in hypogonadism---patients are more willing to get on treatment. It is left to us to carefully listen to our patients’ symptoms, concerns, and expectations and guide them to what's best for their overall health.”

CITATION: Aksam Yassin, Ahmad Haider, et. al. Testosterone Therapy in Men With Hypogonadism Prevents Progression From Prediabetes to Type 2 Diabetes: Eight-Year Data From a Registry Study. Diabetes Care. Published online March 18, 2019.


Osteoporosis study notes good calibration
in FRAX-predicted versus MOF probability

LOS ANGELES – A study published in August in the Journal of Bone and Mineral Research indicates good calibration in Fracture Risk Assessment Tool (FRAX)-predicted versus observed 10-year major osteoporotic fracture (MOF) and hip-fracture probability.

The study’s authors---including Carolyn J. Crandall, David Geffen School of Medicine at University of California, Los Angeles, and John T. Schousboe, University of Minnesota, Minneapolis---examined, among women 40-and-older, the performance of the FRAX and FRAX-based osteoporosis-treatment thresholds under the U.S. National Osteoporosis Foundation (NOF) and UK National Osteoporosis Guideline Group (NOGG) guidelines.

They used registry data for all women aged 40-and-over in Manitoba, Canada, with baseline bone mineral density (BMD) testing (54,459 patients). Incident MOF, hip fracture, and clinical fracture were assessed from population-based health-services data, with a mean follow-up of 10.5 years.

Age-stratified hazard ratios (HRs) were estimated from Cox regression models. The researchers assessed the sensitivity, specificity, positive predictive value (PPV), number needed to screen (NNS), and number needed to treat (NNT) to prevent a fracture for osteoporosis-treatment thresholds under the NOF and NOGG guidelines.

Femoral neck T-score and FRAX (with-and-without BMD) predicted all fracture outcomes at all ages.

The gradient of risk for fracture prediction from femoral neck T-score and FRAX (with- and-without-BMD) as continuous measures was strong across the age spectrum. The sensitivity and PPV of the strategies based on dichotomous cut-offs were low, especially among women aged 40-to-49 years (who have lowest incidence rates).

The researchers conclude that threshold-based approaches should be reassessed, particularly among younger women.

CITATION: Crandall CJ, Schousboe JT, et. al. Performance of FRAX and FRAX-Based Treatment Thresholds in Women Aged 40 Years and Older: The Manitoba BMD Registry. Journal of Bone and Mineral Research. 2019 Aug;34(8):1419-1427.


Mid-life obesity linked to higher mortality
even when BMI normal in early adulthood

MELBOURNE, AUSTRALIA – Mid-life obesity is associated with higher mortality even when body mass index (BMI) is normal in early adulthood, according to recent research highlighting the importance of weight management throughout adulthood.

The prospective-cohort study published in August in BMJ Open also indicates that prolonged borderline obesity is associated with elevated risk of death from all-causes and obesity-related cancers relative to maintaining lower-normal BMI across adulthood.

Its authors---including Yi Yang and Pierre-Antoine Dugué, University of Melbourne, Melbourne, Australia---report that since chronic obesity will probably be a major health issue for future generations, policies and prevention programs are needed to target obesity beginning early in life.

The researchers assessed data on 29,881 adults enrolled in the Melbourne Collaborative Cohort Study aged from 40-to-70 between 1990-and-1994, with BMI data for at least three time points. Outcomes included deaths from any cause before March 31, 2017, and deaths from obesity-related cancers, cardiovascular diseases (CVDs) and other causes before Dec. 31, 2013.

The authors identified six group-based BMI trajectories:

  • lower-normal stable (TR1)
  • higher-normal stable (TR2)
  • normal-to-overweight (TR3)
  • chronic-borderline obesity (TR4)
  • normal-to-class I obesity (TR5)
  • overweight-to-class II obesity (TR6)

Generally, compared with maintaining lower-normal BMI throughout adulthood, the lowest mortality was experienced by participants who maintained higher-normal BMI; obesity during mid-life was associated with higher all-cause mortality even when BMI was normal in early adulthood, and prolonged borderline obesity from early adulthood was also associated with elevated mortality.

These associations were stronger for never-smokers and for death due to obesity-related cancers. Being overweight in early adulthood and becoming class II obese was associated with higher CVD mortality relative to maintaining lower-normal BMI.

CITATION: Yi Yang, Pierre-Antoine Dugué, et. al. Trajectories of body mass index in adulthood and all-cause and cause-specific mortality in the Melbourne Collaborative Cohort Study. BMJ Open. Received February 26, 2019. Revised June 7, 2019. Accepted July 8, 2019. First published August 10, 2019. Online issue publication August 10, 2019.


Research into heart failure, CKD issues
ties C‐terminal FGF23 levels, mortality

GRONINGEN, NETHERLANDS – Recent research indicates that exogenous erythropoietin increases C‐terminal FGF23 levels markedly over a period of 50 weeks---elevated levels of which, even at baseline, are significantly associated with an increased mortality risk.

Results of the study published in August in the Journal of the American Heart Association underline, in a randomized-trial setting, a strong relationship between erythropoietin and FGF23 physiology in patients with chronic heart failure and chronic kidney disease (CKD).

The authors---including Michele F. Eisenga, University of Groningen, Groningen, Netherlands, and Mireille E. Emans, Ikazia Hospital, Rotterdam, Netherlands---report that baseline cFGF23 levels are strongly associated with an increased risk of mortality. They also state that the currently-identified association between exogenous EPO and cFGF23 levels could be the potential link between exogenous EPO and detrimental outcomes in this patient setting.

The authors recommend further research to establish whether adverse outcomes associated with EPO treatment are truly attributable to a direct effect of exogenous EPO on cFGF23 levels.

Using the Erythropoietin in CardioRenal Syndrome (EPOCARES) study, the researchers randomized 56 anemic patients with both chronic heart failure and CKD into three groups, of which two received epoetin beta 50 IU/kg per week for 50 weeks;  the third group served as control.

Measurements were performed at baseline, and after two, 26, and 50 weeks. Data were analyzed using linear mixed‐model analysis. After 50 weeks of erythropoietin‐stimulating agent treatment, hematocrit and hemoglobin levels increased.

Similarly, C‐terminal FGF23 levels, in contrast to intact FGF23 levels, rose significantly due to erythropoietin‐stimulating agents as compared with controls.

During median follow‐up for 5.7 years, baseline C‐terminal FGF23 levels were independently associated with increased risk of mortality.

CITATION: Michele F. Eisenga, Mireille E. Emans, et. al. Epoetin Beta and C‐Terminal Fibroblast Growth Factor 23 in Patients With Chronic Heart Failure and Chronic Kidney Disease. Journal of the American Heart Association. Originally published 17 Aug. 2019.


Severe-asthma patient assessment backs
multi-disciplinary pulmonary rehabilitation

TRADATE, ITALY – Authors of a study published in August in the Journal of Asthma indicate that their research on a large sample of severe-asthma patients provides evidence that a multi-disciplinary pulmonary rehabilitation (PR) program is effective in terms of exercise capacity and symptoms.

The researchers---including Elisabetta Zampogna and Rosella Centis, Istituti Clinici Scientifici Maugeri, IRCCS, Tradate, Italy---also report that exercise capacity improves in the presence of bronchiectasis and/or obstructive sleep apnea (OSA).

The authors, noting that PR is a multi-modal treatment that is poorly investigated in severe asthma where respiratory symptoms remain uncontrolled despite intensive pharmacological therapy, investigated the effectiveness of PR on functional exercise, dyspnea, and muscle fatigue in severe-asthma patients.

They assessed 317 patients affected with severe asthma according to Global Initiative for Asthma (GINA) guidelines who underwent a multi-disciplinary three-week rehabilitation program with an adherence of more-than-80% to PR, and who could complete a Six Minute Walking Test (6MWT).

PR included:

  • endurance training
  • educational meetings
  • chest physiotherapy
  • breathing exercises
  • psychological support

Six-minute walking distance and Borg scale for dyspnea and muscle fatigue were recorded before-and-after rehabilitation.

Of the 371 patients analyzed, 39 had bronchiectasis, 163 OSA, and 17 had both. PR significantly improved 6MWT distance, Borg dyspnea and muscle fatigue, and mean peripheral capillary oxygen saturation (SpO2) recorded during 6MWT.

CITATION: Elisabetta Zampogna MSc, Rosella Centis, BScEcon, et. al. Effectiveness of pulmonary rehabilitation in severe asthma: a retrospective data analysis. Journal of Asthma. Received 25 Feb. 2019. Accepted 16 July 2019. Accepted author version posted online: 18 July 2019. Published online: 13 Aug. 2019.


Clinician Reviews article offers advice
on ways to cut patients’ insulin costs

A Q-and-A posted recently in Clinician Reviews offers suggestions to reduce patients’ insulin costs. Written by Alyssa Kanagaki Greenleaf, BA, MHS, PA-C, Hartford Healthcare Medical Group Endocrinology in Southington and New Britain, Connecticut, the article offers such advice as: trying older insulins, switching to a syringe and vial, patient-assistance programs, co-pay cards, and shopping for the best deal. The writer cautions that patients “must be advised that not taking their prescribed insulin, or taking less insulin than prescribed, is not a safe alternative.” The article can be accessed at



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