Tuesday, December 4, 2018
Fasting for lab tests isn't good for patients with diabetes
Fasting before getting your blood drawn for cholesterol tests is common practice, but new research from Michigan State University shows it is a contributing factor of low blood sugar, or hypoglycemia, in patients who take diabetes medications.
The study, published in the International Journal of Endocrinology, shows that people with diabetes are more likely to experience FEEHD - fasting-evoked en route hypoglycemia in diabetes - than they would if they hadn't fasted. The "en route" comes from patients who have an episode while driving to a lab for blood work.
Saleh Aldasouqi, an endocrinologist in the College of Human Medicine, explained that eating before a lab test does not alter the results of the pivotal components of the cholesterol test as previously thought. In fact, fasting for these tests can incite hypoglycemia in patients with diabetes.
"Hypoglycemia is an overlooked problem that we see from time-to-time in patients with diabetes who show up for lab tests after skipping breakfast," Aldasouqi said. "Patients continue taking their diabetes medication but don't eat anything, resulting in low blood sugar levels that cause them to have a hypoglycemic event while driving to or from the lab, putting themselves and others at risk. Our new motto is 'Feed not FEEHD', to remind patients of this danger and get them to eat."
Hypoglycemia happens when blood sugar levels drop below 70 mg/dl and can cause faintness, confusion and even a loss of consciousness. Severe hypoglycemia can cause acute harm to the patient or others, especially if it causes falls or motor vehicle accidents.
Aldasouqi said that routine fasting is based off guidelines from the 1970s and newer studies show it may not be necessary anymore. Canada and Europe have already changed their guidelines and no longer require fasting for lipid tests, the most commonly ordered fasting labs. Similar U.S. guidelines have not yet become mainstream. In view of the risk of FEEHD, Aldasouqi hopes for diabetes organizations to take a lead in disseminating these emerging changes on lipid testing.
The study showed proper education about fasting and diabetes also is lacking. Only 35 percent of patients surveyed indicated having received any FEEHD prevention instructions from their doctor prior to their lab visit.
"We encourage patients who receive orders for a lab test to ask their doctor if fasting is really necessary, and if so, how they should handle their diabetes medications during the fasting period to account for the changes in their blood sugar levels," Aldasouqi said. "FEEHD is overlooked in clinical practice, and we aim to bring this problem to light and further educate doctors and patients about the consequences of fasting while on diabetes medications."
The study involved 525 patients with diabetes and was conducted at two endocrinology practices in Michigan. Patients completed a two-page survey and were excluded if data was missing or they reported no fasting labs in the previous 12 months. Aldasouqi plans to conduct a larger, population-based study to determine the prevalence of FEEHD in the general population.
Why patients lie to their doctors
Fear of being judged and embarrassed are among the reasons
When your doctor asks how often you exercise, do you give her an honest answer? How about when she asks what you've been eating lately? If you've ever stretched the truth, you're not alone.
60 to 80 percent of people surveyed have not been forthcoming with
their doctors about information that could be relevant to their health,
according to a new study. Besides fibbing about diet and exercise, more
than a third of respondents didn't speak up when they disagreed with
their doctor's recommendation. Another common scenario was failing to
admit they didn't understand their clinician's instructions.
When respondents explained why they weren't transparent, most said that they wanted to avoid being judged, and didn't want to be lectured about how bad certain behaviors were. More than half were simply too embarrassed to tell the truth.
"Most people want their doctor to think highly of them," says the study's senior author Angela Fagerlin, Ph.D., chair of population health sciences at U of U Health and a research scientist with the VA Salt Lake City Health System's Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation.
"They're worried about being pigeonholed as someone who doesn't make good decisions," she adds.
Scientists at University of Utah Health and Middlesex Community College led the research study in collaboration with colleagues at University of Michigan and University of Iowa. The results will be published online in JAMA Network Open on November 30, 2018.
Insights into the doctor-patient relationship came from a national online survey of two populations. One survey captured responses from 2,011 participants who averaged 36 years old. The second was administered to 2,499 participants who were 61 on average.
Survey-takers were presented with seven common scenarios where a patient might feel inclined to conceal health behaviors from their clinician, and asked to select all that they had ever happened to them. Participants were then asked to recall why they made that choice. The survey was developed with input from physicians, psychologists, researchers and patients, and refined through pilot testing with the general public.
In both surveys, people who identified themselves as female, were younger, and self-reported as being in poor health were more likely to report having failed to disclose medically relevant information to their clinician.
"I'm surprised that such a substantial number of people chose to withhold relatively benign information, and that they would admit to it," says the study's first author Andrea Gurmankin Levy, Ph.D., MBe, an associate professor in social sciences at Middlesex Community College in Middletown, Connecticut. "We also have to consider the interesting limitation that survey participants might have withheld information about what they withheld, which would mean that our study has underestimated how prevalent this phenomenon is."
The trouble with a patient's dishonesty is that doctors can't offer accurate medical advice when they don't have all the facts.
"If patients are withholding information about what they're eating, or whether they are taking their medication, it can have significant implications for their health. Especially if they have a chronic illness," says Levy.
Understanding the issue more in-depth could point toward ways to fix the problem. Levy and Fagerlin hope to repeat the study and talk with patients immediately after clinical appointments, while the experience is still fresh in their minds. Person-to-person interviews could help identify other factors that influence clinician-patient interactions. For instance, are patients more open with doctors they've known for years?
The possibility suggests that patients may not be the only ones to blame, says Fagerlin. "How providers are communicating in certain situations may cause patients to be hesitant to open up," she says. "This raises the question, is there a way to train clinicians to help their patients feel more comfortable?" After all, a healthy conversation is a two-way street.
When respondents explained why they weren't transparent, most said that they wanted to avoid being judged, and didn't want to be lectured about how bad certain behaviors were. More than half were simply too embarrassed to tell the truth.
"Most people want their doctor to think highly of them," says the study's senior author Angela Fagerlin, Ph.D., chair of population health sciences at U of U Health and a research scientist with the VA Salt Lake City Health System's Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation.
"They're worried about being pigeonholed as someone who doesn't make good decisions," she adds.
Scientists at University of Utah Health and Middlesex Community College led the research study in collaboration with colleagues at University of Michigan and University of Iowa. The results will be published online in JAMA Network Open on November 30, 2018.
Insights into the doctor-patient relationship came from a national online survey of two populations. One survey captured responses from 2,011 participants who averaged 36 years old. The second was administered to 2,499 participants who were 61 on average.
Survey-takers were presented with seven common scenarios where a patient might feel inclined to conceal health behaviors from their clinician, and asked to select all that they had ever happened to them. Participants were then asked to recall why they made that choice. The survey was developed with input from physicians, psychologists, researchers and patients, and refined through pilot testing with the general public.
In both surveys, people who identified themselves as female, were younger, and self-reported as being in poor health were more likely to report having failed to disclose medically relevant information to their clinician.
"I'm surprised that such a substantial number of people chose to withhold relatively benign information, and that they would admit to it," says the study's first author Andrea Gurmankin Levy, Ph.D., MBe, an associate professor in social sciences at Middlesex Community College in Middletown, Connecticut. "We also have to consider the interesting limitation that survey participants might have withheld information about what they withheld, which would mean that our study has underestimated how prevalent this phenomenon is."
The trouble with a patient's dishonesty is that doctors can't offer accurate medical advice when they don't have all the facts.
"If patients are withholding information about what they're eating, or whether they are taking their medication, it can have significant implications for their health. Especially if they have a chronic illness," says Levy.
Understanding the issue more in-depth could point toward ways to fix the problem. Levy and Fagerlin hope to repeat the study and talk with patients immediately after clinical appointments, while the experience is still fresh in their minds. Person-to-person interviews could help identify other factors that influence clinician-patient interactions. For instance, are patients more open with doctors they've known for years?
The possibility suggests that patients may not be the only ones to blame, says Fagerlin. "How providers are communicating in certain situations may cause patients to be hesitant to open up," she says. "This raises the question, is there a way to train clinicians to help their patients feel more comfortable?" After all, a healthy conversation is a two-way street.
Monday, December 3, 2018
Women reject a preventive drug for breast cancer
Around 72% said they were worried about the long-term effects of tamoxifen and 57% believed that the drug would give them unpleasant side-effects.
The researchers, led by a team from the University of Leeds, asked more than 400 healthy women at a higher-risk of breast cancer, from 20 centres across England, whether they thought they needed to take tamoxifen and their concerns about medication.
They discovered that almost a third (29%) of the women thought doctors prescribed too many medicines, and more than a third (35%) thought doctors would prescribe fewer drugs if they had more time. Around a quarter (24%) of the women had experienced bad reactions to medicines in the past.
Almost a quarter (24%) of the women thought people on medication should take regular breaks from the drugs; 23% said they were very sensitive to medicines and 17% believed natural remedies were safer than medicines.
In a follow-up questionnaire, answered by 250 of the women, researchers found that fewer than 15 per cent were taking tamoxifen** despite having discussed preventive therapy with a healthcare professional. Women who believed the medication was less necessary and had more concerns about its use were less likely to be taking tamoxifen at follow-up.
Lead author Dr Samuel Smith, from the University of Leeds, said: "Women in our study were rightfully considering the potential harms and benefits of using preventive therapy. But some beliefs about the use of medicine were very negative. This appears to be putting some women off tamoxifen, despite its proven ability to help prevent breast cancer in the long term.
"We need to make sure health care professionals are adequately equipped to discuss the potential benefits and harms of preventive treatment with their patients so that women are well informed before deciding whether or not to take a drug."
Dr Julie Sharp, Cancer Research UK's head of health information, said: "It's understandable that women considering taking a new medicine might have some concerns and that, for some, it won't be the right option. There are some potential side effects with tamoxifen, and other medications that can help prevent cancer, but it's vital that they have all the information, so they can make the best choice for them. If women in this situation have any questions or want more information, they can visit our website or call our cancer nurses for a chat. ***
Running a marathon can increase cardiac strain in amateur runners
Full marathons may significantly raise concentrations of several biomarkers of strain on the heart, according to new research in Circulation, Journal of the American Heart Association.
Investigators in Spain compared levels of cardiac biomarkers, including - troponin I and troponin T- in 21 groups of 3 runners each after each individually ran an endurance race of three different lengths - a full marathon, a half marathon and a 10K race. All of the 63 subjects were amateur runners. They also measured levels of biomarkers for cardiac tissue stress.
Although there was little difference in 10-year risk for cardiovascular events between the runners (average about 3 percent), the strain on the heart muscle, as measured by the biomarker levels, was much greater after a full marathon.
The incidence of cardiac arrests in marathoners is only about 1 in 50,000 runners who compete in races, but a high proportion of all exercise-induced cardiac events occur during marathons, especially in men 35 years of age and older.
The number of subjects in the study was not large enough to accurately assess differences in 10-year cardiovascular risk, but the researchers are planning to examine this in a larger group of runners, said lead investigator Juan Del Coso, Ph.D., director of the exercise physiology laboratory at Camilo José Cela University, in Madrid, Spain.
"We typically assume that marathon runners are healthy individuals, without risk factors that might predispose them to a cardiac event during or after a race. But with the growing popularity of long-endurance races, the exponential increase in the number of participants, and the lack of appropriate training in some cohorts of amateur runners, our findings suggest that running shorter endurance races might reduce the strain imposed on the myocardium during running competition," Del Coso said.
A Mediterranean diet in pregnancy is associated with lower risk of accelerated growth
This study, published in the Journal of Pediatrics, aimed at evaluating the association between adherence to a Mediterranean diet during pregnancy and growth patterns and cardiometabolic risk in early infancy.
The study was performed with data of over 2,700 pregnant women from Asturias, Guipúzcoa, Sabadell and Valencia, who are part of the INMA-Childhood and Environment cohort. The women filled in a questionnaire on dietary intake in the first and third trimester of pregnancy. In addition, the diet, weight and height of their offspring were followed-up from birth to age 4 years. Other tests such as blood analysis and blood pressure were also performed at age 4.
The results show that pregnant women with higher adherence to the Mediterranean diet had a 32% lower risk of having children with an accelerated growth pattern, as compared to offspring of women that did not follow such diet.
Sílvia Fernández, ISGlobal researcher and first author of the study, underlines that "mothers with lower adherence to the Mediterranean diet were younger, consumed more calories, and had higher probability of smoking and a lower education and social level," as compared to those women who did follow the diet".
"These results support the hypothesis that a healthy diet during pregnancy can have a beneficial effect for child development," concludes the study coordinator Dora Romaguera, researcher at ISGlobal and CIBEROBN. Regarding the mechanisms that underlie this association, the researcher mentions "possible epigenetic modifications that regulate foetal caridiometabolism, or shared eating patterns between mothers and children, although this deserves further investigation."
The study did not find a correlation between Mediterranean diet in pregnancy and a reduction in cardiometabolic risk (blood pressure or cholesterol) in early infancy. "The effects on cardiometabolic risk could appear later in childhood," explains Fernández.
Essential oils from garlic and other herbs kill 'persister' Lyme disease bacteria
Laboratory study hints that plant compounds may be better than current antibiotics at treating persistent Lyme bacteria and associated symptoms
The study, published October 16 in the journal Antibiotics, included lab-dish tests of 35 essential oils--oils that are pressed from plants or their fruits and contain the plant's main fragrance, or "essence." The Bloomberg School researchers found that 10 of these, including oils from garlic cloves, myrrh trees, thyme leaves, cinnamon bark, allspice berries and cumin seeds, showed strong killing activity against dormant and slow-growing "persister" forms of the Lyme disease bacterium.
"We found that these essential oils were even better at killing the 'persister' forms of Lyme bacteria than standard Lyme antibiotics," says study senior author Ying Zhang, MD, PhD, professor in the Department of Molecular Microbiology and Immunology at the Bloomberg School.
There are an estimated 300,000 new cases of Lyme disease each year in the United States. Standard treatment with doxycycline or an alternative antibiotic for a few weeks usually clears the infection and resolves symptoms. However, about 10 to 20 percent of patients report persistent symptoms including fatigue and joint pain--often termed "persistent Lyme infection" or "post-treatment Lyme disease syndrome" (PTLDS) that in some cases can last for months or years.
The cause of this lingering syndrome isn't known. But it is known that cultures of Lyme disease bacteria, Borrelia burgdorferi, can enter a so-called stationary phase in which many of the cells divide slowly or not at all. The slow-dividing or dormant cells are "persister" cells, which can form naturally under nutrient starvation or stress conditions, and are more resistant to antibiotics. Some researchers have sought other drugs or medicinal compounds that can kill persister Lyme bacteria in the hope that these compounds can be used to treat people with persistent Lyme symptoms.
Zhang and his laboratory have been at the forefront of these efforts. In 2014, his lab screened FDA-approved drugs for activity against persister Lyme bacteria and found many candidates including daptomycin (used to treat MRSA) that had better activity than the current Lyme antibiotics. In 2015, they reported that a three-antibiotic combination--doxycycline, cefoperazone and daptomycin--reliably killed Lyme persister bacteria in lab dish tests. In a 2017 study they found that essential oils from oregano, cinnamon bark, clove buds, citronella and wintergreen killed stationary phase Lyme bacteria even more potently than daptomycin, the champion among tested pharmaceuticals.
In the new study Zhang and his team extended their lab-dish testing to include 35 other essential oils, and found 10 that show significant killing activity against stationary phase Lyme bacteria cultures at concentrations of just one part per thousand. At this concentration, five of these oils, derived respectively from garlic bulbs, allspice berries, myrrh trees, spiked ginger lily blossoms and may change fruit successfully killed all stationary phase Lyme bacteria in their culture dishes in seven days, so no bacteria grew back in 21 days.
Oils from thyme leaves, cumin seeds and amyris wood also performed well, as did cinnamaldehyde, the fragrant main ingredient of cinnamon bark oil.
Lab-dish tests such as these represent an early stage of research, but Zhang and colleagues hope in the near future to continue their investigations of essential oils with tests in live animals, including tests in mouse models of persistent Lyme infection. If those tests go well and the effective doses seem safe, Zhang expects to organize initial tests in humans.
"At this stage these essential oils look very promising as candidate treatments for persistent Lyme infection, but ultimately we need properly designed clinical trials," he says.
'Benefits' of standing over sitting equate to little more than 9 calories an hour
Office employees who opt to stand when working are likely to be burning only fractionally more calories than their seated colleagues, according to new research from the University of Bath.
The study, published in the journal Medicine & Science in Sports & Exercise, reveals that the 'benefits' of standing over sitting equate to little more than 9 calories an hour - the equivalent of just one stalk of celery. In fact, purely for weight gain perspective, it would take individuals who opted to stand nearly the entire day to burn just one cup of coffee.
Prolonged sitting has become a major health concern, targeted via government policy and the increase in of height-adjustable workstations and wearable technologies that encourage standing. Yet despite these interventions, which have the potential to influence energy balance, remarkably little had been known of the true energy cost of sitting versus standing naturally.
For this study, which involved researchers at Bath and Westmont College (US), the team tested the resting metabolic rates of 46 healthy men and women. Participants were then asked to either lie down, sit down or stand up before measurements were taken of their expired gases in order to assess how many calories they burnt through the activity.
With only marginal gains in calories expended observed, the study questions the effectiveness of standing as an effective strategy for weight loss and in the treatment of obesity.
Professor James Betts of the University of Bath's Department for Health explains: "The biomechanics of standing means that more muscles are used to support a greater proportion of the body weight in an upright position, so should cost more energy than when sitting.
"Past research has shown this by comparing sitting and standing when completely motionless. Other research has also explored the energy costs of various daily activities that can be completed whether or not seated but also allow people to walk around, so may not tell us about the simple difference between siting versus standing per se.
"In the real-world people also do not usually have their bodily movements restricted but instead do spontaneously fidget to remain comfortable, so we saw an opportunity to understand the fundamental difference between sitting and standing naturally."
Collaborator, Professor Gregg Afman, Professor of Kinesiology at Westmont College (US) said: "We found that energy cost increase of 0.65 kJ per minute from sitting to standing naturally which equates to a 12% difference. However current interventions to reduce prolonged sitting like standing desks or wearable technologies only increase standing by a maximum of two hours per day. This limited time-frame would cause a person to expend less than 20 kcals more each day."
Dr Javier Gonzalez, who was also involved in the study from the University of Bath, added: "The very small increase in energy cost of standing compared to sitting that we observed suggests that replacing time spent sitting with time spent standing is unlikely to influence our waist lines in any meaningful way.
"To put this difference in context, it would require an additional 20 hours of standing time, on average, to burn of a medium latte. Many people are becoming aware of the negative health effects of prolonged sitting, and so may opt for standing desks. These people should be aware that whilst there are still some health benefits to standing more, they should not expect to see drastic changes in their body weight. In order to lose body weight, people should focus on increasing physical activity and focus on their diet too."
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