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Content 7


The Doctor and the Pharmacist

Radio Show Articles:
July 5, 2014

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Red Meat and Breast Cancer: Long Term Follow-Up Adds to the Evidence
Higher Protein Consumption Linked to Lower Stroke Risk
Is the Obesity Paradox a Valid Concept for Stroke?
ADA Recommends Stricter HbA1c Targets for Type 1 Diabetes
Increasing Prevalence of Diabetes in American Youth
Weight Gain Increases Among Some Schoolchildren During Summer Months
Canola Oil Linked to Improved Glucose Control in Type 2 Diabetes
How Can We Help Parents Reduce Liquid-Medication Dosing Errors?

MM: A good mix of animal and plant based protein is most likely the optimal diet. Additionally, exchange in the diet for red meat of chicken/poultry and fish has been demonstrated with the Mediterranean diet to be especially beneficial.
Red Meat and Breast Cancer: Long Term Follow-Up Adds to the Evidence
By Kelly Young
Edited by David G. Fairchild, MD, MPH, and Richard Saitz, MD, MPH, FACP, FASAM

High red meat consumption in early adulthood is associated with increased risk for breast cancer, according to longer-term follow-up from the Nurses Health Study II, published in BMJ.
Researchers assessed intake of red meat and other protein sources among nearly 90,000 premenopausal women using food-frequency questionnaires. During 20 years of follow-up, some 2800 cases of invasive breast cancer were diagnosed. After multivariable adjustment, women in the top quintile of red meat consumption (1.6 servings/day) had a 22% increased breast cancer risk, compared with women in the bottom quintile (0.2 servings/day). Swapping out red meat for poultry or legumes one meal a day was associated with significant risk reductions.
The authors conclude: "Consistent with the American Cancer Society guidelines, replacement of unprocessed and processed red meat with legumes and poultry during early adulthood may help to decrease the risk of breast cancer."
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MM: There is a lot of promotion of plant based diets and the benefits associated with that approach to lifestyle. Unfortunately most of those dietary protocols are heavily focused on carbohydrates and fats and tend to be protein deficient. A well balanced diet with an emphasis on plant is likely one of the best approaches but we can't forget about adequate protein intake and this study endorses the benefits of animal protein over plant protein. It also emphasizes a protein that contains less saturated fats such as focusing on fish as a protein source rather than red meat.
Higher Protein Consumption Linked to Lower Stroke Risk
By Kelly Young
Edited by Susan Sadoughi, MD, and Lorenzo Di Francesco, MD, FACP, FHM
Higher protein intake is associated with reduced stroke risk, according to a meta-analysis in Neurology.
Researchers assessed the results of seven prospective cohort studies in roughly 250,000 participants. During a median follow-up of 14 years, participants with the highest self-reported protein intake had a 20% reduced risk for stroke after multivariable adjustment, compared with those with the lowest intake. For every additional 20 grams of protein consumed daily, there was a 26% reduction in stroke risk. Animal protein appeared to confer greater protection than vegetable protein.
The researchers note that in three of the studies, fish was a major source of protein, indicating that "stroke risk may be reduced by replacing red meat with other protein sources such as fish."
Editorialists conclude: "It seems that evidence tilts toward the Cretan Mediterranean diet, although the amount of protein is yet to be determined. In other words, eating vegetables, fruits, and protein every day will help to keep stroke away!"
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MM: The obesity paradox may be due to obese patients experiencing strokes at an earlier age than those who are at a lower BMI. This may the reason for the statistical anomaly. I would not recommend that a person who is at risk for a stroke gain weight in the belief that the extra weight would protect them in the event of a cerebral event.
JAMA Neurol 2014 Jun
Is the Obesity Paradox a Valid Concept for Stroke?
New evidence sheds light on this mysterious concept.
For some chronic diseases, including stroke, studies have suggested that overweight or obese patients have a survival advantage over normal weight or underweight patients. This concept is referred to as the obesity paradox because it is at odds with conventional thinking, since obesity is strongly associated with multiple deleterious health conditions, such as diabetes mellitus, hypertension, and sleep apnea. To test whether the obesity paradox in stroke is caused by patient selection bias, investigators assessed stroke patient data entered in the Danish Stroke Register, covering the years 2003 through 2011, and identified those with an index stroke followed by death within 1 month (identified through the Danish Registry of Causes of Death). The authors assessed the rates of death according to category of body-mass index (BMI), classified as underweight (<18.5), normal (18.5–25), overweight (>25–30), and obese (>30).
Of the 71,617 patients available for analysis, 11% died within the first month, 70% of these due to stroke. BMI was inversely related to age at stroke onset (P<0.001). After adjustment for major predictors of stroke outcomes such as age and stroke severity, obese and overweight patients had no significantly increased likelihood of death compared with normal-weight patients, within either 1 week or 1 month after stroke onset.
Comment: The obesity paradox has been perplexing because it flies in the face of conventional medical thinking. Some investigators claim it represents an artifact of biased patient selection. However, there could be valid reasons for obese patients to have lower short-term mortality, including younger age at onset and increased tendency for lacunar strokes. The Danish Registry is known for its completeness of case ascertainment. The younger age at onset for obese stroke patients and the lack of a correlation between BMI and short-term stroke outcomes after adjustment for age and other important confounders render the obesity paradox not so mysterious.
Citation(s): Dehlendorff C et al. Body mass index and death by stroke: No obesity paradox. JAMA Neurol 2014 Jun 2; [e-pub ahead of print].
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ADA Recommends Stricter HbA1c Targets for Type 1 Diabetes
By Kelly Young
Edited by David G. Fairchild, MD, MPH, and André Sofair, MD, MPH
In a position statement, the American Diabetes Association now says that all children with type 1 diabetes should strive for a hemoglobin A1c target of less than 7.5%. Previously, different pediatric age groups had different targets, and targets could be as high as 8.5%.
The change was made as more evidence was published regarding the potential harms from prolonged hyperglycemia in children.
The ADA emphasizes that treatment should still be individualized based on patient age, diabetes duration, comorbid conditions, and other factors to achieve the best glycemic control while also reducing the risks for severe hyperglycemia and hypoglycemia.
The article, published in Diabetes Care, covers other aspects of diabetes management as well.
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MM: These numbers seem to parallel the numbers that tend to be associated with growing presence of type 2 diabetes and socio-economic status. Our poorer citizens are eating more poorly with a higher rate of carbohydrate and fat consumption, greater growth of obesity and subsequent increasing rate of metabolic syndrome and the health problems that are commonly associated with that condition. The way to battle this is through education and example. We can't merely offer lip service, we must make healthier lifestyles a part of people's lives by providing education and healthy options to children at a young and impressionable age when long term eating habits are being developed. And, with that we need to continue this support through the grade schools and high schools. Community event that promote healthier lifestyles should be as prominent as funnel cakes and fried food at fairs and events.
JAMA 2014 May 7; 311:1778
Increasing Prevalence of Diabetes in American Youth
Between 2001 and 2009, the prevalence of type 1 diabetes and type 2 diabetes increased by 21% and 31%, respectively
Diabetes is among the most common chronic diseases in children. Using the SEARCH database from four geographic regions, one healthcare based region, and selected American Indian reservations in the U.S., investigators examined the prevalence of type 1 diabetes (among >3 million youth aged <20 years) and type 2 diabetes (among 1.7 million youth aged 10–19 years) in 2001 and 2009.
Between 2001 and 2009, the prevalence of type 1 diabetes increased by an adjusted 21% — from 1.48/1000 youth to 1.9/1000. Prevalence was highest among white youth (2.66/1000) and lowest among American Indian youth (0.35/1000). The prevalence of type 2 diabetes increased by 31% — from 0.34/1000 youth to 0.46/1000. Prevalence was highest among American Indian youth (1.2/1000), followed by black (1.07/1000), Hispanic (0.70/1000) and white youth (0.17/1000). During the same time period, the prevalence of diabetes increased in both sexes and in Hispanic, black, and white youth. Neither type of diabetes increased significantly in Asian Pacific Islander or American Indian youth.
Comment: Both type 1 and type 2 diabetes are important health issues for children and adolescents. We must develop models of care that are cost-efficient and provide excellent outcomes for the increasing number of children with diabetes.
Citation(s): Dabelea D et al. Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009. JAMA 2014 May 7; 311:1778. (http://dx.doi.org/10.1001/jama.2014.3201)
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MM: Talk about a paradox and a shift in the paradigm of traditional activity and weight gain. I remember when it was common to leave school in the spring and come back in the fall to find your classmates had slimmed down, gotten taller and seemed much healthier. Perhaps the advent of video gaming, the preponderance of unhealthy snacks and a purported lack of parental guidance has led to this phenomena of children becoming less fit and fatter in the summer months.
Weight Gain Increases Among Some Schoolchildren During Summer Months
By Amy Orciari Herman
Edited by André Sofair, MD, MPH, and William E. Chavey, MD, MS
Summertime may mean accelerated weight gain for some schoolchildren, according to a meta-analysis in Preventing Chronic Disease.
Researchers examined seven studies among roughly 10,000 children aged 5 to 12 years. The two nationally representative U.S. studies found faster weight gain during the summer months than during the school year; one of these studies found the effect amplified among black and Hispanic children. In addition, six of the seven studies showed evidence of accelerated weight gain in the summer among children who were already overweight or obese.
The authors offer "purely speculative" reasons for faster summer weight gain: "decreased physical activity, increased sedentary behaviors, increased access to unhealthy snacks, unstructured schedules and boredom, less self-monitoring, irregular sleep patterns, and less access to healthier meals through school breakfast and lunch during the summer relative to the school year."
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MM: I am almost universally suspect of industry funded research as it is so difficult to eliminate bias from any study, let alone a study that is dependent upon a specific outcome. This study is no different. I don't like the structure, design or parameters of the study. I will need to see something more substantive before I jump on the canola oil band wagon.
Canola Oil Linked to Improved Glucose Control in Type 2 Diabetes
By Kelly Young
Edited by Susan Sadoughi, MD, and Jaye Elizabeth Hefner, MD
A low glycemic-load diet supplemented with canola oil is associated with slight improvements in glycemic control in type 2 diabetes, compared with a diet emphasizing whole grain. The industry-funded study was published in Diabetes Care and was presented at the American Diabetes Association's annual conference.
Roughly 140 patients with type 2 diabetes were randomized to receive either the intervention diet (4.5 slices of canola oil-enriched whole wheat bread daily plus advice to consume foods low on the glycemic index) or the control diet (7.5 slices of whole-wheat bread without canola oil plus advice to replace white-flour foods with whole grains).
Over 12 weeks, the intervention diet was associated with a modest reduction in HbA1c relative to the control diet (–.47% vs. –.31% HbA1c units). Patients with elevated systolic blood pressure saw the biggest gains. Patients consuming the intervention diet also had greater improvements on their Framingham risk scores.
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MM: As a pharmacist, I understand the importance of proper dosing and especially in the pediatric population where liquid dosage forms are so prevalent it is very easy to make an error. Pharmacists can help by providing oral dosing syringes that have been pre-marked to the appropriate measurement so that the caregiver is less likely to make an error. The pharmacists at Mark Drugs routinely work with these dosing tools and assist and instruct patients and caregivers on their use.
Pediatr 2014 May–Jun; 14:262
How Can We Help Parents Reduce Liquid-Medication Dosing Errors?
The combination of advanced counseling and a dosing instrument reduced dosing errors by 30%
Incorrectly administering liquid medications is a common error with children (NEJM JW Pediatr Adolesc Med Jan 27 2010). In a cross-sectional analysis of data from two urban emergency departments, researchers interviewed 400 parents of children younger than 9 years who received prescriptions for liquid medications.
Parents were questioned about medication counseling — including advanced counseling (teachback, drawings or pictures, demonstrations, or showback) — and whether they received a dosing instrument (oral syringe, measuring cup, or dosing spoon). A personal interview within 8 weeks included an observation of the parent's dosing practice.
Roughly 40% of parents made a dosing error: 80% underdosed and 20% overdosed the prescribed dose. Although most parents received instructions on liquid dosing, only advanced counseling significantly reduced dosing errors. Receiving a dosing instrument also resulted in fewer dosing errors (22% vs. 46%).Receiving both counseling and dosing instrument significantly reduced errors compared with receiving neither (adjusted odds ratio, 0.3); however, after adjustment for factors including health literacy and socioeconomic status, neither advanced counseling nor a dosing instrument alone reduced the odds for error. Subgroup analyses indicated that the combination of advanced counseling and a dosing instrument was associated with fewer errors in those with adequate health literacy and in English-speaking parents, but not in those with low health literacy or in Spanish-speaking parents.
Comment Reducing medical errors and improving patient safety is critical to quality care. Learning advanced counseling and providing a dosing instrument appears to be an effective intervention in some families.
Citation(s): Yin HS et al. Liquid medication dosing errors in children: Role of provider counseling strategies. Acad Pediatr 2014 May–Jun; 14:262.

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