An apple a day could keep obesity away

Scientists at Washington State University have concluded that nondigestible compounds in apples – specifically, Granny Smith apples – may help prevent disorders associated with obesity. The study, thought to be the first to assess these compounds in apple cultivars grown in the Pacific Northwest, appears in October’s print edition of the journal Food Chemistry.

“We know that, in general, apples are a good source of these nondigestible compounds but there are differences in varieties,” said food scientist Giuliana Noratto, the study’s lead researcher. “Results from this study will help consumers to discriminate between apple varieties that can aid in the fight against obesity.”

Golden Delicious, Gala, Granny Smith and Red Delicious apples. (Photo courtesy of USDA ARS)

The tart green Granny Smith apples benefit the growth of friendly bacteria in the colon due to their high content of non-digestible compounds, including dietary fiber and polyphenols, and low content of available carbohydrates. Despite being subjected to chewing, stomach acid and digestive enzymes, these compounds remain intact when they reach the colon. Once there, they are fermented by bacteria in the colon, which benefits the growth of friendly bacteria in the gut.

The study showed that Granny Smith apples surpass Braeburn, Fuji, Gala, Golden Delicious, McIntosh and Red Delicious in the amount of nondigestible compounds they contain.

“The nondigestible compounds in the Granny Smith apples actually changed the proportions of fecal bacteria from obese mice to be similar to that of lean mice,” Noratto said.

The discovery could help prevent some of the disorders associated with obesity such as low-grade, chronic inflammation that can lead to diabetes. The balance of bacterial communities in the colon of obese people is disturbed. This results in microbial byproducts that lead to inflammation and influence metabolic disorders associated with obesity, Noratto said.

“What determines the balance of bacteria in our colon is the food we consume,” she said.

Re-establishing a healthy balance of bacteria in the colon stabilizes metabolic processes that influence inflammation and the sensation of feeling satisfied, or satiety, she said.

Dietary polyunsaturated fatty acids linked to smaller risk of coronary heart disease

A recent study completed at the University of Eastern Finland shows that dietary polyunsaturated fatty acids may reduce the risk of coronary heart disease. The sources of polyunsaturated fatty acids include fish, vegetable oils, and nuts. The findings were published in Arteriosclerosis, Thrombosis & Vascular Biology, an esteemed journal of the American Heart Association.

Recent studies have not found an association between the consumption of saturated fats and the risk of cardiovascular diseases. It seems that the mere reduction of saturated fats from the diet does not reduce the risk of cardiovascular diseases. In fact, what is added to the plate in place of saturated fat seems to be more important. Earlier research has found that the risk of cardiovascular diseases reduces when saturated fats are replaced with polyunsaturated fats. However, this has not been observed when replacing saturated fats with carbohydrates. For example, the new Nordic Nutrition Recommendations that were published in early 2014 now recommend that saturated fats should be replaced with polyunsaturated fats.

The dietary habits of 1,981 men aged between 42 and 60 were assessed at the baseline of the Kuopio Ischaemic Heart Disease Risk Factor Study (KIHD) at the University of Eastern Finland in 1984-1989. During a follow-up of 21.4 years, 565 men were diagnosed with a coronary heart disease. Out of these, 183 were cardiac events resulting in the death of the patient.

The study used computational replacement models to study how the replacement of fatty acids with other types of fatty acids or carbohydrates affects the risk of coronary heart disease. These models showed that the consumption of polyunsaturated fatty acids was especially linked to reduced risk of dying of heart disease, no matter whether they replaced saturated fats, trans fats, or carbohydrates in the diet. However, replacing saturated fats with carbohydrates did not affect the risk of heart disease. Furthermore, the quality of carbohydrates, measured by the glycemic index, was irrelevant in these replacement models. A surprising observation was that the consumption of monounsaturated fatty acids was linked to a higher risk.

Similar links as those of cardiovascular disease mortality were observed also when studying the relationship of different fatty acids with carotid atherosclerosis.

The study gives new insight into how different fatty acids affect the risk of coronary heart disease, as the amount of saturated fat in the diets of the participants in the present study, i.e. men living in eastern Finland, was higher than in most other study populations. Furthermore, only a few of the similar studies have taken the quality of carbohydrates into consideration. The present study shows, in line with earlier research, that the risk of cardiovascular diseases can be reduced by replacing saturated fats with polyunsaturated fats

Study of allergic deaths in US finds medications are main culprit

Medications are the leading cause of allergy-related sudden deaths in the U.S., according to an analysis of death certificates from 1999 to 2010, conducted by researchers at Montefiore Medical Center and Albert Einstein College of Medicine of Yeshiva University. The study, published online today in the Journal of Allergy and Clinical Immunology, also found that the risk of fatal drug-induced allergic reactions was particularly high among older people and African-Americans and that such deaths increased significantly in the U.S. in recent years.

Anaphylaxis is the term used for a severe, potentially life-threatening allergic reaction that can occur within seconds or minutes following exposure to an allergen. Until now, data on trends in anaphylactic deaths—or even the number of yearly deaths from anaphylactic shock—has not been well-defined. One reason: unlike countries such as the UK, the U.S. doesn't maintain a national registry for anaphylaxis deaths.

"Anaphylaxis-related deaths in the U.S. have not been well understood in recent years," said Elina Jerschow , M.D., M.Sc. director, Drug Allergy Center, Allergy and Immunology Division of Medicine, Montefiore Medical Center, and assistant professor of medicine, Albert Einstein College, the lead author of the study. "We hope these findings will help in identifying specific risk factors and allow physicians to formulate preventative approaches."

Dr. Jerschow and colleagues analyzed death certificates from the U.S. National Mortality Database and found that medication-related anaphylaxis was the most common cause of death (58.8 percent). Additional causes identified included unspecified anaphylaxis (19.3 percent), venom (15.2 percent) and food (6.7 percent). Further analyses revealed fatal anaphylaxis due to medications, food and unspecified allergens was significantly associated with African American race and older age; and fatal anaphylaxis rates due to venom was more common in white, older men.

Of the 2,458 deaths identified between 1999-2010, culprit drugs were not specified in most of the cases (approximately 74 percent). However, among those with an identified culprit drug, nearly half were antibiotics, followed by radiocontrast agents used during diagnostic imaging procedures and chemotherapeutics that are used in treatment of cancer.

During the years studied, there was a significant increase in fatal drug anaphylaxis, from 0.27 per million in 1999-2001 to 0.51 per million in 2008-2010. The increase in medication-related anaphylaxis deaths likely relates to increased medication and radiocontrast use, enhanced diagnosis and coding changes.

"Anaphylaxis has been dubbed 'the latest allergy epidemic,'" said Dr. Jerschow. "The U.S. and Australia have some of the highest rates of severe anaphylaxis among developed countries. We hope these results bring increased awareness of the need for a better understanding of anaphylaxis deaths."

Americans undergo colonoscopies too often, study finds

Colonoscopies are a very valuable procedure by which to screen for the presence of colorectal cancer. However, it seems that healthy Americans who do undergo this sometimes uncomfortable examination often have repeat screenings long before they actually should. Gina Kruse of Massachusetts General Hospital in the US and colleagues advise that endoscopists stick to the national guidelines more closely. Their findings¹ appear in the Journal of General Internal Medicine², published by Springer.

Current national guidelines strongly recommend that adults aged 50 and older should be screened every ten years, while surveillance colonoscopies should be performed more frequently in adults with pre-cancerous polyps called adenomas. Concern has been raised that these guidelines are not being followed. Kruse’s research team therefore set out to measure if screening and surveillance colonoscopies among average-risk adults are really overused, and why this might be so. They used electronic health record data of 1,429 adults between the ages of 50 to 65 years old who underwent an initial colonoscopy for cancer screening between 2001 and 2010. Subsequent exams were done in 871 cases, on average six years after the initial procedure.

They found that 88 percent of the follow-up screening colonoscopies and one in every two surveillance colonoscopies (49 percent) were done earlier than guidelines recommend. People who had no signs of abnormal growths such as polyps the first time around were again examined on average 6.9 years later. Cases where benign polyps (non-adenomas) were found were re-examined on average 5.9 years later.

The researchers say this means that patients who are enrolled in a screening program from the age of 50 to 74 years actually undergo one additional colonoscopy in their lifetimes compared to what is recommended by current guidelines. On the flipside, one in every four exams in which pre-cancerous tumors were initially detected was not followed up within the recommended guideline interval.

The researchers found a strong association between endoscopist recommendations and early follow-up interval for colonoscopy, consistent with prior research indicating many endoscopists do not agree with the follow-up intervals recommended in the guidelines. They therefore advise that healthcare systems consider monitoring follow-up recommendations as an important lever for discussion and potential reduction in overuse of colonoscopy.

Senior study author Thomas Sequist of Brigham and Women’s Hospital in the US said, “Examining practice variation and establishing locally endorsed standards among endoscopists may be a way to target interventions to reduce overuse.”

“The idea that a large proportion of the 14 million screening colonoscopies performed annually in the US are actually done unnecessarily is especially concerning in light of the 28 million Americans between 50 and 74 who are not up to date in colorectal cancer screening,” says Gina Kruse. “The overused colonoscopies on the patients in this study alone represent a potential excess of over $1 million in health care spending—resources that might benefit those who are overdue for colon cancer screening.”

References: 
1. Kruse, G.R. et al (2014). Overuse of Colonoscopy for Colorectal Cancer Screening and Surveillance, Journal of General Internal Medicine. DOI 10.1007/s11606-014-3015-6
2. The Journal of General Internal Medicine is the official journal of the Society of General Internal Medicine.

Risks of opioids outweigh benefits for headache, low back pain, other conditions

According to a new position statement from the American Academy of Neurology (AAN), the risk of death, overdose, addiction or serious side effects with prescription opioids outweigh the benefits in chronic, non-cancer conditions such as headache, fibromyalgia and chronic low back pain. The position paper is published in the September 30, 2014, print issue ofNeurology®, the medical journal of the American Academy of Neurology.

Opioids, or narcotics, are pain medications including morphine, codeine, oxycodone, methadone, fentanyl, hydrocodone or a combination of the drugs with acetaminophen.

"More than 100,000 people have died from prescription opioid use since policies changed in the late 1990s to allow much more liberal long-term use," said Gary M. Franklin, MD, MPH, research professor in the Department of Environmental & Occupational Health Sciences in the University of Washington School of Public Health in Seattle and a Fellow with the AAN. "There have been more deaths from prescription opioids in the most vulnerable young to middle-aged groups than from firearms and car accidents. Doctors, states, institutions and patients need to work together to stop this epidemic."

Studies have shown that 50 percent of patients taking opioids for at least three months are still on opioids five years later. A review of the available studies showed that while opioids may provide significant short-term pain relief, there is no substantial evidence for maintaining pain relief or improved function over long periods of time without serious risk of overdose, dependence or addiction.
The AAN recommends that doctors consult with a pain management specialist if dosage exceeds 80 to 120 (morphine-equivalent dose) milligrams per day, especially if pain and function have not substantially improved in their patients.

The statement also provides the following suggestions for doctors to prescribe opioids more safely and effectively:

• Create an opioid treatment agreement
• Screen for current or past drug abuse
• Screen for depression
• Use random urine drug screenings
• Do not prescribe medications such as sedative-hypnotics or benzodiazepines with opioids
• Assess pain and function for tolerance and effectiveness
• Track daily morphine equivalent dose using an online dosing calculator
• Seek help if the morphine-equivalent dose reaches 80 to 120 milligrams and pain and function have not substantially improved
• Use the state Prescription Drug Monitoring Program to monitor all prescription drugs the patient may be taking

"More research and information regarding opioid effectiveness and management is needed, along with changes in state and federal laws and policy to ensure that patients are safer when prescribed these drugs," said Franklin.

Comparison of Caffeine and Music as Fatigue Countermeasures

Research has shown that drinking caffeinated beverages and listening to music are two popular fatigue-fighting measures that drivers take, but very few studies have tested the usefulness of those measures. New research to be presented at the HFES 2014 Annual Meeting in Chicago evaluates which method, if either, can successfully combat driver fatigue. 

In their paper titled “Comparison of Caffeine and Music as Fatigue Countermeasures in Simulated Driving Tasks,” human factors/ergonomics researchers ShiXu Liu, Shengji Yao, and Allan Spence designed a simulated driving study that measured driver fatigue levels against the use of caffeine, music, or no stimulant. Twenty participants completed three 120-minute driving sessions over a three-day span at the same time each day, then scored their fatigue levels on a questionnaire. 

Results indicated that drivers who used either caffeine or music as a stimulant felt significantly less tired than those who did not. The researchers noted, however, that those who drank a caffeinated beverage to stay awake performed their driving tasks much better than those who listened to music or those in the control group. 

“Even though both caffeine and music keep drivers feeling more awake, caffeine also helps them maintain good driving performance,” said Liu, a graduate student in McMaster University’s Department of Mechanical Engineering. “Music, on the other hand, can distract drivers, which may explain why driving performance is not significantly improved when it is used as a fatigue countermeasure.”

Rising prevalence of sleep apnea in U.S. threatens public health

Public health and safety are threatened by the  increasing prevalence of obstructive sleep apnea, which now afflicts at least 25 million adults in the U.S., according to the National Healthy Sleep Awareness Project. Several new studies highlight the destructive nature of obstructive sleep apnea, a chronic disease that increases the risk of high blood pressure, heart disease, Type 2 diabetes, stroke and depression.“Obstructive sleep apnea is destroying the health of millions of Americans, and the problem has only gotten worse over the last two decades,” said American Academy of Sleep Medicine President Dr. Timothy Morgenthaler, a national spokesperson for the Healthy Sleep Project. “The effective treatment of sleep apnea is one of the keys to success as our nation attempts to reduce health care spending and improve chronic disease management.”

Data previously published in the American Journal of Epidemiology show that the estimated prevalence rates of obstructive sleep apnea have increased substantially over the last two decades, most likely due to the obesity epidemic. It is now estimated that 26 percent of adults between the ages of 30 and 70 years have sleep apnea.

Findings from new studies emphasize the negative effects of sleep apnea on brain and heart health; however, these health risks can be reduced through the effective treatment of sleep apnea with continuous positive airway pressure therapy:

A neuroimaging study in the September issue of the journal Sleep found that participants with severe, untreated sleep apnea had a significant reduction in white matter fiber integrity in multiple brain areas, which was accompanied by impairments to cognition, mood and daytime alertness. One year of CPAP therapy led to an almost complete reversal of this brain damage.

A study published online ahead of print Sept. 21 in the journal NeuroImage found functional and anatomical changes in brainstem regions of people with sleep apnea.

A study in the October issue of Anesthesiology shows that diagnosing sleep apnea and prescribing CPAP therapy prior to surgery significantly reduced postoperative cardiovascular complications - specifically cardiac arrest and shock - by more than half.

A study published online ahead of print Sept. 19 in the Journal of Hypertension found a favorable reduction of blood pressure with CPAP treatment in patients with resistant hypertension and sleep apnea.

A Brazilian population study published online ahead of print Sept. 23 found that nocturnal cardiac arrhythmias occurred in 92 percent of patients with severe sleep apnea, compared with 53 percent of people without sleep apnea. The prevalence of rhythm disturbance also increased with sleep apnea severity.

Common warning signs for sleep apnea include snoring and choking, gasping, or silent breathing pauses during sleep.  The American Academy of Sleep Medicine, Centers for Disease Control and Prevention, Sleep Research Society and other partners in the National Healthy Sleep Awareness Project urge anyone with signs or symptoms of sleep apnea to visit www.stopsnoringpledge.org to pledge to “Stop the Snore” and talk to a doctor about sleep apnea.

ReferencesPeppard PE, Young T, Barnet JH, et al. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol 2013 May 1;177(9):1006-14. Epub 2013 Apr 14.

Castronovo V, Scifo P, Castellano A, et al. White matter integrity in obstructive sleep apnea before and after treatment. SLEEP 2014;37(9):1465-1475.

Lundblad LC, Fatouleh RH, Hammam E, et al. Brainstem changes associated with increased muscle sympathetic drive in obstructive sleep apnea. Neuroimage 2014 Sep 21 [Epub ahead of print].

Mutter TC, Chateau D, Moffatt M, et al. A matched cohort study of postoperative outcomes in obstructive sleep apnea: could preoperative diagnosis and treatment prevent complications? Anesthesiology. 2014 Oct;121(4):707-18.

Iftikhar IH, Valentine CW, Bittencourt LR, et al. Effects of continuous positive airway pressure on blood pressure in patients with resistant hypertension and obstructive sleep apnea: a meta-analysis. J Hypertens 2014 Sep 19 [Epub ahead of print].

Cintra FD, Leite RP, Storti LJ, et al. Sleep Apnea and Nocturnal Cardiac Arrhythmia: A Populational Study. Arq Bras Cardiol 2014 Sep 23 [Epub ahead of print].

Why I Hope to Live Beyond 90

Many of you may have seen, or heard a report about, this Atlantic article: Why I Hope to Die at 75 
in which the author argues that life after 75 is full of misery.

But he's wrong about a lot of what he says:

This Vox report:

The case against dying at 75

sends us to A National Bureau of Economics Report summarized here:

Longer, Healthier Lives

Poor physical functioning is being increasingly compressed into the period just before death.

Life expectancy in the United States has risen sharply in recent decades. Some scholars have worried that the extra years of life could be "low quality" if longer life span is accompanied by longer periods of disability. Fortunately, that does not seem to be the case. In Evidence for Significant Compression of Morbidity in the Elderly U.S. Population(NBER Working Paper No. 19268), David Cutler, Kaushik Ghosh, and Mary Beth Landrum report that although those over the age of 65 are reporting that they have more diseases than those of similar age in the past, "the severe disablement that disease used to imply has been reduced" and “poor physical functioning is being increasingly compressed into the period just before death."

Life expectancy at age 65 increased from 17.5 years to 18.2 years between 1992 and 2005, while "disability-free life expectancy" rose by even more, from 8.8 years to 10.4 years. The result is an increase in the fraction of the lifetime that is disability-free, and a decline of 0.9 years in the expected number of years of disability. The gains in disability-free life expectancy were consistent for men and women, and across races, with non-whites and whites gaining 1.8 and 1.6 disability-free years respectively. Disability declined by roughly 3 percent for people 12 to 24 months from death, by about 6 percent for those who were 25 months or more from death, and by almost 25 percent for those who were eight or more years from death.

The authors analyze data from the Medicare Current Beneficiary Survey, a representative sample of the U.S. elderly population that includes between 10,000 and 18,000 individuals each year between 1991 and 2009. By linking this database to death records through 2008, the authors were able to categorize the health status of nearly 200,000 people at various numbers of years before death. Within 12 months of death, about 80 percent of the elderly had at least one major health condition. Heart disease afflicted about 38 percent of respondents. Three other conditions each affect about one quarter of the respondents: cancer, chronic degenerative diseases like Alzheimer’s disease and pulmonary disease, and recoverable acute conditions such as heart attack and stroke.

The authors find that the prevalence of any disability has declined even though the prevalence of major disease has been constant in the elderly population. While the proportion of the elderly population afflicted by acute conditions such as heart disease, stroke, and hip fracture fell from about 40 percent to about 30 percent, the prevalence of chronic disabilities such as Alzheimer’s and pulmonary disease, and of disabling but generally non-fatal chronic diseases like arthritis or diabetes, has increased. Although over 60 percent of the elderly report having arthritis or diabetes, the probability of reporting such a condition is not related to remaining years of life.

Disability may result from difficulty in physical functioning, such as the inability to walk a reasonable distance or to carry an object of moderate weight. The incidence of such functional limitations declined by 2.7 percent between 1991 and 2009. Disability may also be caused by an inability to carry out an Activity of Daily Living such as bathing or dressing, or by a problem with an Instrumental Activity of Daily Living such as doing light housework or managing money. The incidence of these disabilities declined by 22 percent.

The American Academy of Pediatrics (AAP) recommends IUDs as the first choice for teens

It took quite a bit of time to get around to it, but the American Academy of Pediatrics (AAP) has finally made "the recommendation that the first-line contraceptive choice for adolescents who choose not to be abstinent is a Long Acting Reversible Contraceptive (LARC), which is an intrauterine device or a sub-dermal implant."

Here is some history, and today's new recommendation.

In 2011 The American College of Obstetricians and Gynecologists released the following statement:

IUDs Implants Are Most Effective Reversible Contraceptives Available 

June 20, 2011
Washington, DC -- Long-acting reversible contraceptive (LARC) methods—namely intrauterine devices (IUDs) and implants—are the most effective forms of reversible contraception available and are safe for use by almost all reproductive-age women, according to a Practice Bulletin released today by The American College of Obstetricians and Gynecologists (The College). The new recommendations offer guidance to ob-gyns in selecting appropriate candidates for LARCs and managing clinical issues that may arise with their use. 

"LARC methods are the best tool we have to fight against unintended pregnancies, which currently account for 49% of US pregnancies each year," said Eve Espey, MD, MPH, who helped develop the new Practice Bulletin. "The major advantage is that after insertion, LARCs work without having to do anything else. There's no maintenance required." 

More than half of women who have an unplanned pregnancy were using contraception. The majority of unintended pregnancies among contraceptive users occur because of inconsistent or incorrect contraceptive use. LARCs have the highest continuation rates of all reversible contraceptives, a key factor in contraceptive success. 

IUDs and contraceptive implants must be inserted in a doctor's office. Two types of IUDs—small, T-shaped devices that are inserted into the uterus—are available. The copper IUD, which effectively prevents pregnancy for 10 years, releases a small amount of copper into the uterus, preventing fertilization. In addition, copper interferes with the sperm's ability to move through the uterus and into the fallopian tubes. The device can also be used for emergency contraception when inserted within five days of unprotected sex. 

Women using the copper IUD will continue to ovulate, and menstrual bleeding and cramping may increase at first. Though data suggest that these symptoms lessen over time, heavy menstrual bleeding and pain during menstruation (dysmenorrhea) are main causes of discontinuation among long-term copper IUD users. Women considering IUDs should be informed of this adverse effect beforehand. 

The hormonal IUD releases progestin into the uterus that thickens cervical mucus and thins the uterine lining. It may also make the sperm less active, decreasing the ability of egg and sperm to remain viable in the fallopian tube. The hormonal IUD may make menstrual cycles lighter and is also FDA-approved for the treatment of heavy bleeding. The hormonal IUD prevents pregnancy for five years. 

The contraceptive implant is a matchstick-sized rod that is inserted under the skin of the upper arm and allows the controlled release of an ovulation-suppressing hormone for up to three years. It is the most effective method of reversible contraception available with a pregnancy rate of 0.05%. 

Despite the many benefits of LARC methods, the majority of women in the US who use birth control choose other methods. Fewer than 6% of women in the US used IUDs between 2006 and 2008. According to The College, lack of knowledge about LARCs and cost concerns may be to blame. "Women need to know that today's IUDs are much improved from earlier versions, and complications are extremely rare. IUDs are not abortifacients—they work before pregnancy is established—and are safe for the majority of women, including adolescents and women who have never had children. And while upfront costs may be higher, LARCs are much more cost-effective than other contraceptive methods in the long run," Dr. Espey said.

In 2012 the American Academy of Pediatrics issued this statement:

AAP Recommends Emergency Contraception Be Available to Teens 

11/26/2012 For Release:  November 26, 2012
Teen pregnancies have declined over the past few decades, but the United States continues to see substantially higher teen birth rates compared to other developed countries. A new policy statement by the American Academy of Pediatrics (AAP) discusses the use of emergency contraception and how it can reduce the risk of unintended pregnancy in adolescents. The statement, “Emergency Contraception,” will be published in the December 2012 Pediatrics and released online Nov. 26. According to the AAP, adolescents are more likely to use emergency contraception if it’s prescribed in advance.  

Many teens continue to engage in unprotected sexual intercourse, and as many as 10 percent are victims of sexual assault. Other indications for use include contraceptive failures (defective or slipped condoms, or missed or late doses of other contraceptives). When used within 120 hours after having unprotected or under-protected sex, selected regimens for emergency contraception, such as Plan B, Next Choice, etc., are the only contraceptive methods to prevent unwanted pregnancy.  

According to the AAP, pediatricians can play an important role in counseling patients and providing prescriptions for teens in need of emergency contraception for preventing pregnancy. Patients should also know that emergency contraception does not protect against sexually transmitted infections (STIs), and pediatricians should discuss the importance of STI testing, or treatment if needed. The AAP also encourages pediatricians to advocate for better insurance coverage and increased access to emergency contraception for teens, regardless of age.

And today tthe American Academy of Pediatrics issued this statement: 

AAP Updates Recommendations on Teen Pregnancy Prevention 

9/29/2014
Over the past 10 years, a number of new contraceptive methods have become available. The American Academy of Pediatrics (AAP) continues to review and update its recommendations on contraceptive methods to provide pediatricians with the information they need in order to counsel and prescribe contraception for adolescents. 

 In an updated policy statement and accompanying technical report in the October 2014 Pediatrics, “Contraception for Adolescents,” (published online Sept. 29), the AAP recognizes the pediatrician’s role as a trusted advisor and source of sexual health information, and supports adolescents and their families to discuss and ask questions about sensitive issues such as sexual health and relationships. 

According to AAP recommendations, pediatricians will conduct a developmentally-targeted sexual history, assess risk for sexually transmitted infections, and provide appropriate screening and/or education about safe and effective contraceptive methods. 

Regardless of which method of contraception is chosen, pediatricians should stress that all methods of hormonal birth control are safer than pregnancy, allow adolescents to consent to contraceptive care, and become familiar with state and federal laws regarding disclosure of confidential information in minors. 

New in this report is the recommendation that the first-line contraceptive choice for adolescents who choose not to be abstinent is a Long Acting Reversible Contraceptive (LARC), which is an intrauterine device or a subdermal implant.  

The past decade has demonstrated that LARCs, which provide 3 to 10 years of contraception, are safe for adolescents. Pediatricians should be familiar with counselling, insertion, and /or referral for LARCs. Additional updates to the policy statement focus on patients with special health care needs, including physical or developmental disabilities, medically complex illness, and obesity.  

It is important for pediatricians to regularly update patients’ sexual histories and allow sufficient time for follow up appointments when needed. Pediatricians are also encouraged to promote healthy sexual health decision-making, such as abstinence and proper condom use.  

Risk of esophageal cancer decreases with height

Taller individuals are less likely to develop esophageal cancer and it's precursor, Barrett's esophagus, according to a new study1 in Clinical Gastroenterology and Hepatology, the official clinical practice journal of the American Gastroenterological Association. 

"Individuals in the lowest quartile of height (under 5'7" for men and 5'2" for women) were roughly twice as likely as individuals in the highest quartile of height (taller than 6' for men and 5'5" for women) to have Barrett's esophagus or esophageal cancer," said Aaron P. Thrift, PhD, lead study author from the Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA. "Interestingly, the relationship between height and esophageal cancer is opposite from many other cancers — including colorectal, prostate and breast — where greater height is associated with an increased risk."

Researchers conducted a large pooled analysis using data from 14 population-based epidemiologic studies within the International Barrett's and Esophageal Adenocarcinoma Consortium (BEACON), including 1,000 cases of esophageal cancer and twice as many cases of Barrett's esophagus, and twice as many controls. The researchers conducted multiple analyses, including using Mendelian randomization (which incorporates genetic information with traditional approaches) to overcome issues of confounding and bias. The results from all analyses consistently demonstrated an inverse association between height and Barrett's esophagus or esophageal cancer. There were no differences in these estimates based on sex, age, education, smoking, GERD symptoms or body mass index. Adjusting for abdominal obesity yielded similar results.

"The identification of risk factors, such as height, will allow us to create more sophisticated and accurate methods to quantify patient risk, which will hopefully be used in the future to decide who should undergo endoscopic screening for these conditions," added Dr. Thrift.

The researchers report no obvious explanation for the association between short height and Barrett's esophagus or esophageal cancer. Future studies investigating the potential causal mechanisms by which risk for Barrett's esophagus or esophageal cancer might be influenced by height are justified.

Esophageal cancer incidence increased eight-fold in the U.S. from 1973 to 2008. Almost all cases arise from Barrett's esophagus. Learn more about the management of Barrett's esophagus in the American Gastroenterological Association medical position statement.