Day: July 29, 2024

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Lessons Learned from Combating Smoking and Other Market-driven Epidemics

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Researchers share insights from US reduction of cigarette, sugar, and opioid consumption

Photo by Sara Kurfess on Unsplash

A case definition of market-driven epidemics (MDEs) could help address critical barriers to timely, effective prevention and mitigation, according to a study published this week in the open-access journal PLOS Global Public Health by Jonathan Quick from Duke University School of Medicine, US, and colleagues.

The misuse and overconsumption of certain consumer products have become major global risk factors for premature deaths at all ages, with their total costs in trillions of dollars. Progress in reducing such deaths has been difficult, slow, and too often unsuccessful. To address this challenge, Jonathan Quick and colleagues introduced a case definition of MDEs, which arise when companies aggressively market products with proven harms, deny these harms, and actively oppose mitigation efforts. To demonstrate the application of this concept, the researchers selected three MDE products: cigarettes, sugar, and prescription opioids. Based on the histories of these three epidemics, the researchers described five MDE phases: market expansion, evidence of harm, corporate resistance, mitigation, and market adaptation.

From the peak of consumption to the most recent available data, US cigarette sales fell by 82%, sugar consumption by 15%, and prescription opioid prescriptions by 62%. In each case, the consumption tipping point occurred when compelling evidence of harm, professional alarm, and an authoritative public health voice or public mobilisation overcame the impact of corporate marketing and resistance efforts. Among the three epidemics, the gap between suspicion of harm and the consumption tipping point ranged from one to five decades – much of which was attributable to the time required to generate sufficient evidence of harm. Market adaptation to the reduced consumption of target products had both negative impacts (eg, geographical shift of corporate marketing efforts) and positive impacts (eg, consumer shift away from sugar-sweetened beverages).

According to the authors, this is the first comparative analysis of three successful efforts to change the product consumption patterns of millions of people – and, over time, some of the associated adverse health impacts of these products. The MDE epidemiological approach of shortening the latent time between phases provides the global health community with a new method to address existing and emerging potentially harmful products and their health, social, and economic impacts.

While the specific product and circumstances are unique to each MDE, understanding the epidemiology of consumption and health impacts, and epidemic milestones, should help public health leaders combat current MDEs and more swiftly recognise future MDEs. Given the similar patterns among different MDEs, public health leaders, researchers, civil society and others can apply the mitigation strategies presented in the review article to save lives and lessen the impact of continuing and emerging MDEs.

The authors add: “The use of cigarettes and other unhealthy products costs the world millions of lives and trillions of dollars each year.  An analysis of U.S. progress against three such market-driven epidemics demonstrates that we can save lives through earlier, more decisive action by public health leaders, researchers, and public mobilization,” concluding: “The use of cigarettes and other unhealthy products often follow patterns similar to infectious disease epidemics, causing widespread harm before any public health response. We can save lives by recognizing these market-driven epidemics earlier and acting more decisively to control them.”

Provided by PLOS

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Recent Steps in Treatment and Management Show Promise in Stemming the Rise of Diabetes

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Photo by Photomix Company on Pexels

A new paper surveying advances in diabetes pathogenesis and treatment explores the complex factors contributing to the onset and progression of the disease, suggesting that an understanding of these dynamics is key to developing targeted interventions to reduce the risk of developing diabetes and managing its complications.

In a paper in a special 50th anniversary issue of the peer-reviewed journal Cell, the authors surveyed hundreds of studies that have emerged over the years looking at the causes underpinning types 1 (T1D) and 2 (T2D) diabetes and new treatments for the disease. They examine the role that genes, environmental factors, and social determinants of health play and diabetes’ effect on cardiovascular and kidney disease.

What they found shows there are many advances in treatments that could stem the tide of a disease that has struck millions of people around the globe and continues to grow. In addition, some of these advances could be used to treat other disorders. But there are still challenges ahead.

“As the prevalence of diabetes continues to grow around the world, it is important to understand the latest advancements in research so that clinicians can provide the best care to their patients, and patients can make informed choices that support improved health outcomes,” said lead author Dr E. Dale Abel, chair of the UCLA Department of Medicine. “This is an educational resource that integrates the latest research and trends in diabetes management, which may have implications for clinical practice as the diabetic patient population continues to grow.

“This review will be the go-to reference for physicians and researchers, providing a state-of-the-art update of where the field is currently, and where it is headed,” Abel added.

Most people are affected by type 2 diabetes, for which inadequate diet and obesity are important underlying causes. Type 1 diabetes accounts for fewer than 5% of all cases. As of 2021 about 529 million people around the world were diagnosed with diabetes, representing about 6.1% of the global population, or about one in 16 people. Prevalence in some regions is as high as 12.3%. Type 2 diabetes comprises about 96% of cases, with more than half due to obesity. Some 1.31 billion people are projected to have the disease by 2050, with prevalence rising as high as 16.8% in North Africa and the Middle East and 11.3% in Latin America and the Caribbean, the researchers write.

Genetics, the central nervous system, and the interplay between various organs as well as social and environmental factors such as food insecurity and air pollution play a role in development of diabetes.

But some recent discoveries represent significant strides toward managing and perhaps even reversing the disease. For instance, a 2019 study found that a 14-day course of the antibody teplizumab delayed the progression of type 1 diabetes from stage 1 to stage 3 by 24 months. A follow-up analysis in 2021 showed that the delay could be up to 32.5 months.

Based on these results, the U.S. Food and Drug Administration approved teplizumab as the first disease-modifying therapy for type 1 diabetes, the researchers write.

Advances in insulins with optimised pharmacokinetics, algorithm-driven subcutaneous insulin pumps, continuous glucose monitoring, and improved tools for self-management have significantly improved the quality of life and outcomes for people with stage 3 type 1 diabetes.

In addition, stem cells could replace insulin-producing cells that are lost in type 1 diabetes, Abel said.

For type 2 diabetes, three classes of glucose-lowering medicines that were introduced in the last 20 years – GLP1RAs (glucagon like peptide-1 receptor agonists), DPP-4 inhibitors, and SGLT-2 inhibitors – have enabled people to control their glucose levels without gaining weight and with a low risk of developing hypoglycaemia. Personalised and precision medicine approaches are being explored to target the molecular mechanisms behind diabetes. However, they must demonstrate that benefits are clinically superior to standard care and are cost-effective. Also, it remains to be seen if precision approaches can be implemented in all settings worldwide, including those with few resources.

Combinations of GLP1Ras and with molecules that target other receptors such as GIP have shown even greater efficacy in treating diabetes. Recent trials have also shown that they are very effective in treating obesity, certain types of heart failure and even sleep apnoea, in part because of their potency to induce weight loss and reduce inflammation. Clinical trials are now underway to test their efficacy in treating other disorders such as Alzheimer’s disease, Abel said.

“Advances in therapy now raise the hope of preventing or curing T1D and treating T2D in ways that not only improve metabolic homeostasis, but also concretely reduce the risk and progression of cardio-renal disease,” the researchers write. “Finally, as we understand and develop tools for discerning the underlying heterogeneity leading to diabetes and its complications, the stage will be set for targeting therapies and prevention strategies to optimize their impact, in ways that will be broadly applicable across diverse populations and availability of health care resources.”

Source: UCLA Health

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Targeting Inflammation may Not Help Reduce Liver Fibrosis in MAFLD

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Source: CC0

Researchers at UCLA Health uncovered new information about the role inflammation plays in mitigating liver fibrosis, which is associated with metabolic-associated fatty liver disease (MAFLD).  While inflammation in the liver has long been considered a prerequisite to developing liver fibrosis, the scarring and thickening of tissue that can impair the liver’s ability to function, this new research, published in the Journal of Clinical Investigation, suggests that reducing inflammation may not influence the extent of fibrosis. 

“Liver fibrosis is the critical feature that creates chronic liver disease and liver cancer. If we can keep fibrosis in check then we can meaningfully impact liver disease,” said Tamer Sallam, MD, corresponding author of the study and vice chair and associate professor in the department of medicine at the David Geffen School of Medicine at UCLA. 

“For decades we have believed that targeting inflammation is one of the most important ways to reduce MAFLD. But this new research indicates that inflammation, while still important, may not be the main driver of fibrosis.”

The study looked specifically at a protein called lipopolysaccharide binding protein (LBP), which is involved in the body’s immune response, and how LBP functions in mice. Findings showed that mice without LBP in their liver cells had lower levels of liver inflammation and better liver function but no change in fibrosis. 

In addition to mouse models, the researchers also studied genetic analyses from large human datasets and human tissue samples from MAFLD patients at different stages in the disease, to examine the consequence of loss of LBP function. The evidence combined showed that the LBP does not alter scar tissue markers. 

Sallam indicated a need to further explore how LBP influences inflammation and whether other factors can offer a more potent reduction in inflammation and have an impact on reducing fibrosis. 

“Reducing scar burden is one of the holy grails in the treatment of advanced liver diseases,” Sallam said. “These results suggest that certain ways of targeting inflammation may not be a viable option and that more directed therapies against other pathways could help us better target fibrosis and improve outcomes for patients.”

Source: UCLA Health

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Meeting at Eye Level in Hospitals Improves Patient Experience and Outcomes

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Review of research suggests patients feel better when providers sit or crouch during bedside conversations

Photo by National Cancer Institute on Unsplash

Doctors and other healthcare workers, you may want to sit down for this news. A systematic review of studies suggests that getting at a patient’s eye level when talking with them about their diagnosis or care can really make a difference. 

Their findings, published in the Journal of General Internal Medicine, revealed that sitting or crouching at a hospitalised patient’s bedside was associated with more trust, satisfaction and even better clinical outcomes than standing, according to the review of evidence.

The study’s authors, from the University of Michigan and VA Ann Arbor Healthcare System, note that most of the studies on this topic varied with their interventions and outcomes, and were found to have high risk of bias. 

So, the researchers sat down and figured out how to study the issue as part of their own larger evaluation of how different nonverbal factors impact care, perceptions and outcomes.

Until their study ends, they say their systematic review should prompt clinicians and hospital administrators to encourage more sitting at the bedside. 

Something as simple as making folding chairs and stools available in or near patient rooms could help – and in fact, the VA Ann Arbor has installed folding chairs in many hospital rooms at the Lieutenant Colonel Charles S. Kettles VA Medical Center.

Nathan Houchens, MD, the U-M Medical School faculty member and VA hospitalist who worked with U-M medical students to review the evidence on this topic, says they focused on physician posture because of the power dynamics and hierarchy of hospital-based care. 

We hope our work will bring more recognition to the significance of sitting and the general conclusion that patients appreciate it.”

-Nathan Houchens, M.D.

An attending or resident physician can shift that relationship with a patient by getting down to eye level instead of standing over them, he notes. 

He credits the idea for the study to two former medical students, who have now graduated and gone on to further medical training elsewhere: Rita Palanjian, M.D., and Mariam Nasrallah, M.D. 

“It turns out that only 14 studies met criteria for evaluation in our systematic review of the impacts of moving to eye level, and only two of them were rigorous experiments,” said Houchens. 

“Also, the studies measured many different things, from length of the patient encounter and patient impressions of empathy and compassion, to hospitals’ overall patient evaluation scores as measured by standardised surveys like the federal HCAHPS survey.”

In general, he says, the data paint the picture that patients prefer clinicians who are sitting or at eye level, although this wasn’t universally true. 

And many studies acknowledged that even when physicians were assigned to sit with their patients, they didn’t always do so – especially if dedicated seating was not available. 

Houchens knows from supervising U-M medical students and residents at the VA that clinicians may be worried that sitting down will prolong the interaction when they have other patients and duties to get to. 

But the evidence the team reviewed suggests this is not the case. 

He notes that other factors, such as concerns about infection transmission, can also make it harder to consistently get to eye level. 

“We hope our work will bring more recognition to the significance of sitting and the general conclusion that patients appreciate it,” said Houchens. 

Making seating available, encouraging physicians to get at eye level, and senior physicians making a point to sit as role models for their students and residents, could help too. 

A recently launched VA/U-M study, funded by the Agency for Healthcare Research and Quality and called the M-Wellness Laboratory study, includes physician posture as part of a bundle of interventions aimed at making hospital environments more conducive to healing and forming bonds between patient and provider. 

In addition to encouraging providers to sit by their patients’ bedsides, the intervention also includes encouraging warm greetings as providers enter patient rooms and posing questions to patients about their priorities and backgrounds during conversations.

The researchers will look for any differences in hospital length of stay, readmissions, patient satisfaction scores, and other measures between the units where the bundle of interventions is being rolled out, and those where it is not yet.

Source: University of Michigan

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Do Non-statin Cholesterol-lowering Drugs Affect Liver Cancer Risk?

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Like statins, cholesterol absorption inhibitors are linked with a lower risk of developing liver cancer.

Photo by Towfiqu Barbhuiya on Unsplash

Past studies have suggested that taking cholesterol-lowering statin drugs may lower the risk of developing liver cancer. In a new study of non-statin cholesterol-lowering medications, one type was linked to lower risks of liver cancer. The findings are published by Wiley online in CANCER, a peer-reviewed journal of the American Cancer Society.

Cholesterol absorption inhibitors, bile acid sequestrants, fibrates, niacin, and omega-3 fatty acids are types of non-statin cholesterol-lowering medications prescribed to manage cholesterol and lipid levels. The different classes of drugs work in different ways. A team led by Katherine A. McGlynn, PhD, MPH, of the National Cancer Institute, looked for associations between these five types of non-statin cholesterol-lowering medications and risk of liver cancer, the sixth most commonly occurring cancer globally and the third leading cause of cancer mortality.

The investigators used information from the Clinical Practice Research Datalink (CPRD), a primary care database that covers approximately 7% of the United Kingdom population. Their analysis included 3719 liver cancer cases and 14 876 matched controls without cancer. Additional matches were also made based on individuals’ type 2 diabetes and chronic liver disease status.

Use of cholesterol absorption inhibitors was associated with 31% lower odds of liver cancer risk in the overall analysis. These medications were also linked with a lower risk of liver cancer in analyses based on diabetes and liver disease status. The study also confirmed that statins were associated with 35% lower odds of liver cancer.

No associations with liver cancer risk were observed for fibrates, omega-3 fatty acids, or niacin. While bile acid sequestrant use was associated with higher odds of liver cancer risk in the overall analysis, the results of analyses based on diabetes and liver disease status were inconsistent, suggesting that replication of these observations is important.

“As few studies have examined the effects of non-statin cholesterol-lowering drugs on liver cancer risk, the results of our study require replication in other populations. If our findings are confirmed in other studies, however, our results may inform liver cancer prevention research,” said Dr. McGlynn.

Source: Wiley