TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of Texas Tech Health El Paso, look at the top medical stories of the week.
This week’s topics include patient views of statin therapy, MRI of shoulders, a planetary health diet, and food prescriptions in people with diabetes.
Program notes:
0:35 Diabetes and food prescriptions
1:35 Got a food card to purchase nutritious foods
2:32 More than half didn’t use it or used it less than 60%
3:00 Adequacy of a planetary health diet
4:00 Micronutrient intake and biomarkers
5:00 Doesn’t seem to compromise long-term health
6:12 Statin recommendations and patient preferences
7:00 Benefit/risk analysis for patients
8:00 Patient’s decisions are multifactorial
9:00 Resistance to daily medication
9:30 Findings on shoulder MRI
10:35 Rotator cuff abnormalities in almost 99%
11:35 Almost ubiquitous regardless of symptoms
12:25 Physical therapy best strategy
13:23 End
Transcript:
Elizabeth: Does a diet that emphasizes planetary health provide adequate micronutrients?
Rick: The gap between guidelines and what patients want regarding statins.
Elizabeth: Should we even use MRI to image shoulders?
Rick: And in people with diabetes who have food insecurity, does it help to give them a food prescription?
Elizabeth: That’s what we’re talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.
Rick: And I’m Rick Lange, president of Texas Tech Health El Paso.
Elizabeth: Rick, I’d like to turn first to this study that you served up as, “Gosh, for people with diabetes, what about a food prescription?” And that is in JAMA Internal Medicine.
Rick: More than 30 million people in the U.S. are affected by type 2 diabetes, and many of those have food insecurity — that’s limited access to sufficient nutritious foods. Dietary control of diabetes and sugar is incredibly important.
If someone has food insecurity, it means they’re more reliant on inexpensive foods, which oftentimes are very poor nutrients or calorie-dense. If we take these patients with diabetes who have food insecurity and we give them a subsidy — a card that allows you each week to get $80 of nutritious foods — will that lower your hemoglobin A1c? Will it mean that you’re less likely to go to the emergency department over the next 12 months? Does it improve your body mass index? Does it improve your blood pressure?
They took over 2,100 people who provided consent, were randomized, and were studied. About half of them just got the usual care, and the other half got a food card, and they could take it to the grocery store and buy nutritious foods. And they followed them over the course of a year.
What they discovered, unfortunately, was that the people in the prescription program did not have improved cardiometabolic health or healthcare utilization at 12 months. Their hemoglobin A1c wasn’t lower. In fact, it was a little bit higher, a little bit disappointing.
Elizabeth: Oh, very disappointing, I think, because I’ve been persuaded by some of the other studies we’ve talked about utilizing this strategy. I’m wondering if it was the lack of additional interventions like counseling or even cooking classes, for example, that would probably be helpful with that, or a personal shopper, which is what we’ve seen in previous studies, who goes to the grocery store. You come in, it’s almost like a pharmacy, and they go around with you and help you to select things.
Rick: As you mentioned, there are probably a number of things. One of the really interesting things is more than half of those who received the subsidy either did not use it or used it less than 60% of the time. Well, why was that? Well, unfortunately, this study does not tell why that is. What is clear is that just giving someone a subsidy card alone isn’t going to do what we want it to do.
Elizabeth: Disappointing, and I think we’re not done with this, though, because we’ve been hearing about this strategy for years. I suspect there’s going to be other iterations coming forward.
Speaking of diets, then, let’s turn to The Lancet. And this is a study looking at the nutritional adequacy of what’s called the EAT-Lancet diet, which is a diet that basically emphasizes plant-based foods, but also includes moderate amounts of animal-sourced foods. This is a diet that emphasizes planetary health. As I will remind you, Texas or not, beef is really a pretty terrible environmental food in terms of what it requires to produce it and it’s also not terribly good for us from a health perspective over the long haul.
So they did this study in Sweden from the Swedish Malmö Diet and Cancer cohort that included just shy of 26,000 participants. They looked at these folks and their dietary intake with a validated diet history method, and their nutrient intakes were calculated. It’s 7 different EAT-Lancet diet scores used to measure adherence. And then they looked at associations with micronutrient intake and nutrient biomarkers: folate, vitamin D, selenium, zinc, and hemoglobin. Because one criticism of this diet has been, “Do we have sufficient micronutrients if we consume this particular diet?”
So what they found was that adherence to this diet was generally associated with nutrient intakes that were above the recommended intake. Although they also admit that depending on their scoring method, they saw some variation in that. This diet increased the likelihood of adequate intake for vitamin A, vitamin E, thiamine, B6, folate, vitamin C, calcium, magnesium, potassium, iron, and zinc. So as far as the micronutrients are concerned, things were good.
They did note a slightly, and I would say very slightly, increased risk for anemia, slight anemia, in women. Looking like, “Hey, this might be a good thing to do from a planetary perspective, and it doesn’t seem that it compromises long-term health.”
Rick: Yeah. This takes the diet to a new level. We talk about diets that improve your cardiovascular outcome, lower your risk of diabetes, and lower blood pressure. And then this diet not only tries to do what’s good for the person taking it, but also what’s good for the planet as well. A lot of people said, “Well, you know what? It’s good for the planet, maybe good for your health. But are you really getting enough of the essential micronutrients?” We need them for the different body functions. If you’re deficient, then it actually affects health. What they showed, as you mentioned, except for a little bit of anemia, not too bad, it does meet the needs. That’s really good news.
Elizabeth: It is good news. I would love to see a calculation that would compare adherence to this diet to adherence to other diets that have a good deal more ultra-processed foods or meat.
Rick: That would be an interesting study. I do think that closes the book on this particular diet. It’s effective for the things we want and also safe probably long-term as well.
Elizabeth: You’re going to try to adhere to a diet that’s more like this one?
Rick: So, Elizabeth, that’s a really interesting question. But I can tell you, eating a Texas diet, I don’t worry about micronutrient deficiency.
Elizabeth: And back to JAMA Internal Medicine.
Rick: A gap, or the difference between, what’s in the guidelines and what the patient preferences are regarding statins.
When we develop guidelines, we take a look at all the science. We say, “What does the evidence say?” And based upon that, we make recommendations.
We look at what someone’s 10-year risk of cardiovascular disease is. If they have a risk over 10 years of 7.5% of having some cardiovascular event, we recommend that they go on a statin to lower that risk. That’s what the guidelines suggest. The patient now has access to all the information about what the benefits of the statin is, but also the side effects. And the patient makes a decision, “Okay, am I going to take it or not?” They weigh the risk-benefit ratio. Do they do that with regard to statins in the same way that the guidelines would suggest?
Basically, they surveyed a bunch of people and they said, “Okay, here’s the benefit. It’s going to lower your cardiovascular risk by 25%. And here are the potential side effects. How high does your risk have to be before you’re willing to take it?”
They looked at both a U.S. population and a Japanese population. People said if the baseline risk was low, if it was 2%, they wouldn’t take statins, even if there were no side effects at all. Half of them would not take a statin unless it reduced their 10-year risk by 7.5 percentage points or more. Well, your risk has to be pretty high — it has to be 50% or 75% — for that to occur. What that says is that a large number of individuals, somewhere, depending on what your risk is — either low, moderate, or high — somewhere between 50% and 70% of the patients said, “It’s just not worth it and I’m just not going to do it.” That’s the gap between the guidelines and the patients.
Elizabeth: Are you surprised by this?
Rick: Elizabeth, I am because I like to think when I walk into a patient’s room, and I make a recommendation, they say, “Oh, doctor, you really know best and I’d like to follow what you say.” But now I realize that we talk about shared decision-making. Patients’ decision is based upon not only what I talk to them in the room about, but also what they’re getting over the internet and what they’re looking up as well. So, for example, I had a patient yesterday who said, “I just decided to stop my medications.” And I said, “Bad choice. You can’t stop all of them.” But their perceived risk-benefit ratio, they didn’t think it was very favorable.
Elizabeth: It’s unclear to me exactly how to overcome that, particularly when people have been doing research and they’re paying attention to a lot of the data that’s out there, and they make that decision.
Rick: Yep. And especially for something like high blood pressure or hypercholesterolemia, where there are no symptoms involved. Again, I think it’s best to talk to the patient, sit down, and say, “Here’s your risk. Here’s what the benefits are of this particular medication.” And if they say, “I don’t want to take a statin,” I say, “Do you want to take something natural? Do you want to take something different? Do you want to change your lifestyle? How do we want to do this together?”
Elizabeth: I still would say that I hear a lot in lots of different venues about people’s resistance to having to take a medicine on a daily basis, almost irrespective of what the indication is.
Rick: You’re right. And so for many of those things affected by lifestyle, obesity, diet, exercise, activity, sleep, if I could engage our patients in doing those on a regular basis, I’d much prefer that to giving a medication. Despite that, there are still some patients that need medication. Most patients aren’t compliant with those things that we know are healthy, so that’s where medications become important.
Elizabeth: An ongoing issue. Remaining then in JAMA Internal Medicine, something that I found really rather astonishing, using MRI at shoulders. And shoulders get really painful. In fact, they’re one of those things that people identify as orthopedic problems that end up being very troubling, especially as we age. It’s so common and it’s frequently attributed to rotator cuff abnormalities. Almost always, particularly in this country, we use some kind of imaging in order to assess that.
So this is a study that looked at adults aged 41 to 76 years who underwent standardized clinical assessment and bilateral, 3-Tesla (3T) MRI imaging of the shoulders; 602 participants, again, with that wide age range, many of whom were asymptomatic. And they said, “What’s this MRI showing us? Is the shoulder normal, tendinopathic, a partial thickness tear, or a full thickness tear?” About half and half, men and women.
Of 602 participants, they found rotator cuff abnormalities in 595 of them. That is almost 99%. I was blown away by that statistic. I don’t know if you were. Of that number, a quarter of them were tendinopathies, 62% were partial thickness tears, and 11% were full thickness tears.
Those rotator cuff abnormalities were present in 96% of asymptomatic shoulders. So people who weren’t even complaining that they were having a problem, sure enough, they had an abnormality identified on MRI. And 98% of symptomatic shoulders, slightly more prevalent in those, actually about twice as often in those who were symptomatic compared to those who were not, in terms of full-thickness tears. Gosh, should we really even be doing MRI on these folks? It’s not really predictive and it’s present in everybody that we’re going to identify an abnormality.
Rick: Elizabeth, I was astounded, too — 99% of individuals have some abnormality we think is associated with rotator cuff tears. If you’re using that to gauge whether someone ought to have surgery or not, then you’re subjecting a lot of people to surgery. And as you mentioned, most of them don’t have symptoms at all.
Most symptomatic individuals respond very well to physical therapy over the course of time. And so if most people have MRI abnormalities, if individuals with rotator cuff problems are sent to MRI, we know most of them are going to be abnormal. And if that’s the justification for doing surgery, we’re overtreating with surgery. So we need to take a step back and say, “Okay, you have rotator cuff problems. Physical therapy is oftentimes the initial and best answer. It will avoid unnecessary surgery.” Very seldom do you find 99% of individuals have incidental findings.
Elizabeth: I was truly amazed by this. It says if we go out there and look for it, sure enough, we’re going to find it. And should that inform our decision-making regarding management or treatment? And the answer is, to me at least, resoundingly no.
Rick: That’s true. And so if you suspect it, especially if it’s not responding to physical therapy, an MRI can be helpful for two things. One is confirming it and also gives some insight in what the surgical approach should be.
Elizabeth: Yeah. It says to me PT ought to be tried first, and that’s almost no matter what your musculoskeletal complaint is.
On that note then, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.
Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.