Common Sense: Lifestyle Intervention in Gastroesophageal Reflux Disease

Posted on February 24, 2016 by gutsandgrowth

“Common sense is not so common” –Voltaire

A recent study (E Ness-Jensen et al. Clin Gastroenterol Hepatol 2016; 14: 175-82) reviewed the literature and identified 15 original studies which met inclusion criteria regarding lifestyle interventions in gastroesophageal reflux disease (GERD).

Key findings:

Weight loss lowered esophageal acid exposure in 2 RCTs: 5.6% –>3.7% and 8.0%–>5.5% and reduced reflux symptoms in prospective observational studies
Tobacco cessation reduced reflux symptoms in normal-weight individuals in a large prospective cohort study OR 5.67
Head-of-the-bed elevation decreased supine acid exposure from 21% to 15%.
Early evening meals decreased supine acid exposure by 5.2% point change.

My take: With the increasing incidence of obesity, these type of lifestyle modifications need to be implemented in our teenagers with GERD. For those who want to decrease use of medications, these interventions, if emphasized with conviction, are a good first step.

Do deductibles work to improve smart spending on health care?

Posted on February 23, 2016 by gutsandgrowth

According to a recent NY Times article –the answer is no.

The problem:

With high deductible plans, people reduce both high-value and low-value care
Many people cannot afford very valuable care due to their deductibles

Link: The Big Problem With High Health Care Deductibles

Here’s an excerpt:

Some health economists say the solution to the problem may be smarter but more complicated forms of health insurance that provide patients with important care free, but charge them for treatments with fewer proven benefits. Mr. Chernew, for one, argues that ordinary deductibles are too “blunt” an instrument, but smarter insurance plans could harness economic incentives to reduce wasteful health spending without discouraging needed care. If such plans held down costs as well as deductibles, they could keep insurance affordable without as many risks. The theory behind such plans is compelling, but given how bad people are at shopping for health care, more empirical evidence is needed to know how well it works in practice.

Celiac Studies

Posted on February 22, 2016 by gutsandgrowth

Three reports on celiac disease:

KM Simmons et al. J Pediatr 2016; 169: 44-8.
NR Reilly et al. J Pediatr 2016; 169: 40-54
MMS Wessels et al. J Pediatr 2016; 169: 55-60.

In the first study, the authors examined bone mineral density (BMD), glycemic control with hemoglobin A1c, and celiac autoimmunity in children with type 1 diabetes (T1D). This was a cross-sectional study of 252 children with T1D; 123 had positive serology were anti-tissue transglutaminase (tTG) antibody. In addition, another cohort (n=141) of children without T1D were examined who carried HLD-DR, DQ genotypes with (n=71) and without (n=70) tTG. Key findings:

Children with T1D: those positive for tTG had significantly worse BMD L1-L4 (-0.45 ± 1.22 vs 0.09 ± 1.10, P= .0003). Higher tTG and higher HgbA1c were independent predictors of lower BMI.
In children without T1D: no differences in BMD were found based on tTG status.
The authors concluded that celiac autoimmunity and hyperglycemia had synergistic effects on low BMD.

In the second study, the researchers used a population-based cohort study and compared 958 individuals with both T1D and celiac disease (CD) to 4598 similar individuals with T1D alone. Key finding: Over a 13 year period, 12 patients with both T1D and CD had a fracture (1 osteoporotic fracture). CD did not influence the risk of any fracture (aHR 0.77) in patients with T1D. The researches concluded: “CD does not seem to influence fracture risk in young patients with T1D.”

My take: Looking at these studies in juxtaposition shows how important it is to consider multiple studies and how frequent discrepant results occur. While the second study does not show a significant fracture risk, the preponderance of evidence does show an association between celiac disease and low BMD particularly in adults. In addition, a gluten free diet has been shown to reverse low BMD in those with CD.

Relevant studies:

Gastroenterology 2010; 139: 763.
Aliment Pharmacol Ther 2000; 14: 35-43.
JPGN 2003; 37: 434-6.
Gut 1996; 38: 322-7.

In the third study, the investigators looked at “complementary” investigation in children with CD. These included tests like hemoglobin, ferritin, folate, vitamin B12, calcium, vitamin D, and thyroid assays. Between 2009-2014, 182 children were evaluated included 119 with new diagnosis. Key findings:

At time of diagnosis: Iron deficiency (28%), iron deficiency anemia (9%), folate deficiency (14%), vitamin B12 (1%), and vitamin D deficiency (27%) were identified. No hypocalcemia or thyroid dysfunction was found.
At followup: iron deficiency (8%), iron deficiency anemia (2%), folate (3%), vitamin D (25%) were identified and no other abnormalities were evident.
The investigators concluded that these complementary tests “are relevant at the time of diagnosis of CD but have little diagnostic yield during followup-visits” after institution of gluten-free diet.

My take: Particularly at followup, identification of nutrient deficiencies is typically similar to the general population.

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Feeding Aversions -A Personal Journey

Posted on February 21, 2016 by gutsandgrowth

A terrific article in NY Times Magazine explains the difficulties of feeding aversions and describes some of the approaches, including feeding tubes and behavior feeding programs.

Link: When Your Baby Won’t Eat

For families struggling with feeding problems and for feeding programs, this article is well worth the read.

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Emergency Medical Information -Easy Access on Your iPhone

Posted on February 20, 2016 by gutsandgrowth

When I purchased a new iPhone, one of my sons was eager to show me all of the cool features. If you do not have a teenager (i.e. house IT specialist) in the house, you may not have taken advantage of the health app built into the iPhone 6. This can be very useful for you and your patients.

One feature of the health app is that it allows you to store emergency contact information and health information that’s accessible from your device’s Lock screen. First responders or good Samaritans will be able to call the emergency contacts listed in Medical ID. This health app also can function as an activity tracker.

Here’s a link with additional information: How to set up your emergency medical ID

“Supplements and Safety”

Posted on February 19, 2016 by gutsandgrowth

There is a Frontline report (initially aired Jan 19th) on supplements. A preview is available from the NY Times.

“Supplements and Safety” –link includes a 5 minute video on fish oil. Here’s an excerpt:

The Frontline documentary investigates large outbreaks of disease tied to tainted vitamins and fat-burning supplements, including one case in which a workout supplement was linked to more than 70 cases of liver damage. The company whose products were at the center of that outbreak, USPlabs, is among 117 companies and individuals that the Justice Department filed criminal and civil enforcement actions against last year…

Despite their popularity, some studies have found that roughly three-quarters of fish oil supplements on the market do not contain the amount of omega-3 fatty acids advertised on their labels. Some have also found that fish oil supplements are prone to becoming rancid.

Fish oil supplements are widely marketed as beneficial to cardiovascular health. But the film points out that such claims are debatable at best. A majority of clinical trials have found no evidence that they protect against heart disease, according to a study published in JAMA Internal Medicine in 2014.

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Systematic Review of Gluten Introduction

Posted on February 18, 2016 by gutsandgrowth

A recent systematic review/meta-analysis (MI Pinto-Sanchez et al. J Pediatr 2016; 168: 132-43) identified 15 eligible studies among an initial search of 1982 studies.

Key findings:

There was a 25% increase in celiac disease risk with late (>6 months) vs recommended (4-6 months) gluten introduction.
There was no significant effect of breastfeeding or not breastfeeding.

The authors state there is no evidence on whether early introduction (<4 months) of gluten would affect the risk of celiac disease. Late introduction (>6 months) is associated with increase risk of celiac disease.

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Piling on PPIs -Now Concerns about Dementia

Posted on February 17, 2016 by gutsandgrowth

A recent study (see abstract below -from Mike Hart) indicates the possibility that proton pump inhibitors (PPIs) could increase the risk of dementia to a small degree. Despite the big numbers, this study cannot adequately control for numerous factors that could influence these results. As is often said, association does not prove causation. Nevertheless, this study is another reminder to use PPIs when indicated and to use them for the appropriate length of therapy.

Here’s NBC News Narrative: Popular Heartburn Drugs Linked to Dementia

ONLINE FIRST

Association of Proton Pump Inhibitors With Risk of Dementia: A Pharmacoepidemiological Claims Data Analysis

Willy Gomm, PhD¹; Klaus von Holt, MD, PhD¹; Friederike Thomé, MSc¹; Karl Broich, MD²; Wolfgang Maier, MD^1,3; Anne Fink, MSc^1,4; Gabriele Doblhammer, PhD^1,4,5,6; Britta Haenisch, PhD¹

JAMA Neurol. Published online February 15, 2016. doi:10.1001/jamaneurol.2015.4791

ABSTRACT

Importance Medications that influence the risk of dementia in the elderly can be relevant for dementia prevention. Proton pump inhibitors (PPIs) are widely used for the treatment of gastrointestinal diseases but have also been shown to be potentially involved in cognitive decline.

Objective To examine the association between the use of PPIs and the risk of incident dementia in the elderly.

Design, Setting, and Participants We conducted a prospective cohort study using observational data from 2004 to 2011, derived from the largest German statutory health insurer, Allgemeine Ortskrankenkassen (AOK). Data on inpatient and outpatient diagnoses (coded by the German modification of the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision) and drug prescriptions (categorized according to the Anatomical Therapeutic Chemical Classification System) were available on a quarterly basis. Data analysis was performed from August to November 2015.

Exposures Prescription of omeprazole, pantoprazole, lansoprazole, esomeprazole, or rabeprazole.

Main Outcomes and Measures The main outcome was a diagnosis of incident dementia coded by the German modification of the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. The association between PPI use and dementia was analyzed using time-dependent Cox regression. The model was adjusted for potential confounding factors, including age, sex, comorbidities, and polypharmacy.

Results A total of 73 679 participants 75 years of age or older and free of dementia at baseline were analyzed. The patients receiving regular PPI medication (n = 2950; mean [SD] age, 83.8 [5.4] years; 77.9% female) had a significantly increased risk of incident dementia compared with the patients not receiving PPI medication (n = 70 729; mean [SD] age, 83.0 [5.6] years; 73.6% female) (hazard ratio, 1.44 [95% CI, 1.36-1.52]; P < .001).

Conclusions and Relevance The avoidance of PPI medication may prevent the development of dementia. This finding is supported by recent pharmacoepidemiological analyses on primary data and is in line with mouse models in which the use of PPIs increased the levels of β-amyloid in the brains of mice. Randomized, prospective clinical trials are needed to examine this connection in more detail.

Related blog post: Proton Pump Inhibitors Webinar

Unrelated article (from Ben Gold): J Molina-Infante et al. Am J Gastroenterol 2015; 110: 1567-1575. This study examined 75 patients (mean age 38 years) with proton-pump inhibitor responsive esophageal eosinophilia (PPI-REE). 55 (73%) had long-term sustained histologic remission with low-dose PPI therapy (20 mg once or twice daily). In addition, the article noted that 9 of 10 relapsers with distal eosinophilia were noted to have a CYP2C19 rapid metabolizer genotype and regained histologic remission with dose intensification.

Briefly noted: AI Sharara et al. Clin Gastroenterol Hepatol 2016; 14: 317-21. Among 414 who met inclusion criteria (at least 6 months of PPI usage and at least 1 serum magnesium level), 57 (13.8%) had at least 1 low serum magnesium –44 of these patients had recognizable causes (eg. diuretics, chronic diarrhea). Of the remainder who continued with PPI therapy, the level was normal at final measurement and only mildly low levels were noted previously. Thus, in patients without other reasons for low magnesium, the authors found that use of a PPI does not appear to be associated with hypomagnesemia.

Trends in Non-medical Opiod Use and Heroin Addiction

Posted on February 16, 2016 by gutsandgrowth

Almost all physicians use opiods in their practice and need to keep up with the challenges of pain management and addiction. An update on the problem of non-medical opiod use and heroin addiction from NEJM:

Full article link: Relationship between Nonmedical Prescription-Opiod Use and Heroin Use

An excerpt:

The transition from nonmedical use of prescription opioids to heroin use appears to be part of the progression of addiction in a subgroup of nonmedical users of prescription opioids, primarily among persons with frequent nonmedical use and those with prescription opioid abuse or dependence. Although some authors suggest that there is an association between policy-driven reductions in the availability of prescription opioids and increases in the rates of heroin use,16,18 the timing of these shifts, many of which began before policies were robustly implemented, makes a causal link unlikely…

In the majority of studies, the increase in the rates of heroin use preceded changes in prescription-opioid policies, and there is no consistent evidence of an association between the implementation of policies related to prescription opioids and increases in the rates of heroin use or deaths, although the data are relatively sparse. Alternatively, heroin market forces, including increased accessibility, reduced price, and high purity of heroin appear to be major drivers of the recent increases in rates of heroin use…

Fundamentally, prescription opioids and heroin are each elements of a larger epidemic of opioid-related disorders and death. Viewing them from a unified perspective is essential to improving public health. The perniciousness of this epidemic requires a multipronged interventional approach that engages all sectors of society.

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