AstroNutrition Health & Fitness Blog

Nicole Johnson, MPH, would like physicians to be a little more positive. And as a former beauty queen and current diabetes activist, she hopes that telling doctors this will enhance the care she and other patients receive.

Johnson was diagnosed with type 1 diabetes in 1993, when she was a 19-year-old college sophomore. Her physician told her to drop out of school and stop entering beauty pageants. Those activities, he said, were now too stressful. She also should forget about bearing children.

"I was told my life was over ... and the worst part was that I believed it," she said, during a plenary session at the American Academy of Family Physicians' scientific assembly in San Diego, Sept. 17-21. After long-fought efforts to get her disease under control, she earned two master's degrees and won the 1999 Miss America Pageant. And she is a mother.

Johnson was one of several well-known people who detailed their experiences as part of the AAFP's new "Face of Disease" program. These lectures were paired with clinical insights by experts in the field.

"We wanted to try new types of learning, and this is one avenue we hadn't tried. We always hear from experts and family physicians. We never really get it from the patients," said Bradley P. Fox, MD, chair of the AAFP's subcommittee for scientific programming and a family physician in Erie, Pa.

Suicide attempts are more common in patients with bipolar disorder than in those with unipolar depression.

The patients who spoke at the meeting generally praised the physicians in their lives, but also offered suggestions.

Johnson, for example, urged physicians and other health professionals to look at her face and see her as a human being, not just a list of blood glucose numbers. She also felt that outcomes would improve if efforts were made to get patients more engaged in the treatment processes.

"Healing can come to patients' hearts and minds when they are offered a chance to be a part of the circle of care -- when you're not just part of the problem, when you can help be part of the solution," said Johnson.

Such involvement was supported by Steven Edelman, MD, professor of medicine in the division of endocrinology, metabolism and diabetes at the University of California, San Diego. He was the expert who spoke after Johnson. Dr. Edelman, who also has type 1 diabetes, teaches patients to figure out their own insulin dosages. "It gets them motivated," he said.

The therapeutic value of listening

When she was in her late teens, actress Patty Duke began experiencing extreme mood swings -- steep lows followed by equally extreme highs, a cycle that continued until she was diagnosed as having bipolar disorder. She started taking lithium at age 35. Before taking this medication, there would be months when she couldn't get out of bed, followed by periods of extravagant spending and anonymous sexual experiences.

"I remember wishing the doctor would listen to me, even if what I had to say was gobbledygook," said Duke. She urged physicians to ask patients more often about suicidal tendencies. "There isn't anything you could ask a person like me that could make me worse."

Stanley Oakley Jr., MD, a bipolar disorder expert who spoke after Duke, said it was vital to distinguish this illness from unipolar depression, and suggested several signs that may differentiate the two. Bipolar disorder tends to have a stronger family history, and suicide attempts are more common, said Dr. Oakley, an associate professor of psychiatry at East Carolina University's Brody School of Medicine.

He also advocated checking metabolic factors, such as thyroid function, and reviewing medication side effects to hunt for a possible root cause. "We want to make sure we're not causing [bipolar symptoms]."

The family may be hurting, too

Duke and others implored physicians not to forget about patients' families when they are addressing specific health issues.

James "Butch" Rosser Jr., MD, chief of minimally invasive surgery at Beth Israel Medical Center in New York, had gastric bypass surgery eight years ago to treat his morbid obesity.

The 1999 Miss America advocates for patients with diabetes.

But his wife, Dana Rosser, for years withstood the collateral damage brought about by his weight problem. She curtailed her social life because her husband could not fit in the seats of many venues. She also held herself responsible for his weight.

"I stopped doing a lot of social things. That really hurt me," she said. "And I felt that the pressure was on me to cook meals that were delicious and nutritious. If I didn't make the meals correctly and he gained weight, it would be my fault."

Dr. Rosser spoke of the stigma and shame that can be attached to the outward manifestations of his condition.

"The victims of obesity have no place to hide," said Dr. Rosser, who weighed as much as 460 lbs. before his surgery. "I was so embarrassed. There was sadness in my heart."

Other speakers included actress Sally Field, who has osteoporosis, and Grace Anne Dorney Koppel, a lawyer and wife of journalist Ted Koppel, who spoke about chronic obstructive pulmonary disease.

The usefulness of having patients complete written screening tests while in the waiting room may be limited by a lack of understanding of the questions, according to a pair of papers presented at the American College of Surgeons 94th Annual Clinical Congress in San Francisco, Oct. 12-16.

"There is a true epidemic of health illiteracy in this country. Do not assume that your patients are literate with either prose or numeracy," said Viraj A. Master, MD, PhD, one of the authors and an assistant professor of urology at Emory University School of Medicine in Atlanta.

Researchers enrolled two cohorts of men older than 40. One group of 300 men completed the seven-question International Prostate Symptom Score -- once by themselves and a second time with the assistance of an interviewer.

About 16% understood all the questions, and 38% comprehended at least half. Another 18% could handle fewer than half. Twenty-eight percent misunderstood all of the questions.

A lack of education made literacy problems more likely. Age, income, employment, race and language did not seem to play a role.

Studies indicate patients often don't understand questions in written screening tests.

A second cohort of 266 men completed the prostate health screening test and a three-question numeracy quiz. About 68% were bad with numbers, and this group was more likely to misclassify their symptoms. They also were four times more likely to misunderstand this screening tool.

"Being innumerate, in addition to being illiterate, results in high levels of misunderstanding that severely limit access to appropriate health care," Dr. Master said.

Health literacy has long been a concern of public health agencies and medical societies. The American Medical Association recognized low health literacy as a barrier to effective medical diagnosis and treatment in 1998.

Through the AMA Foundation, the AMA has organized numerous educational opportunities and materials for physicians. The Foundation report, "Assessing the Nation's Health Literacy," was released in July.

The National Institutes of Health has awarded nearly $2.5 million in grants to determine the genes that make serious muscle problems more likely for patients taking statin drugs. The grants also will support efforts to develop tools physicians can use to identify those who are most at risk.

"We want to find what makes them different from people who take statins and have no problems," said Georgirene D. Vladutiu, PhD, head of the research group at the University at Buffalo in New York that received the grants. "And if people could be tested in advance of taking statins, it would lead to or contribute to personalized medicine. That's where we're headed."

This project, approved this summer and announced Oct. 2, is one of a handful seeking to investigate side effects associated with these medications. Physicians and researchers who focus on this area say such research is necessary. Statins have a track record and are considered safe, although myopathy is listed as a possibility on the label. The rates of the severe form of this adverse event are low, although lesser versions are more common. Also, the majority of symptoms resolve if patients stop taking the drug. But with so many people taking the medication at ever-higher doses, the actual number impacted is large.

"It's an important question, and I think that we should look at this," said Bruce R. Gordon, MD, director of the Rogosin Institute's Comprehensive Lipid Control Center in New York. "The statins are important drugs, and there's not a physician who doesn't have patients who complain about this." He also researches the genes that determine the variability of the cholesterol-lowering effect of these drugs as well as the chance of adverse events.

In recognition of the need for answers, the National Heart, Lung and Blood Institute awarded two grants to the University at Buffalo, including $2 million to study the association between various genes and statin-induced myopathy and $110,000 to determine the commercial viability of a product to identify them in patients. The National Institute of Arthritis and Musculoskeletal and Skin Diseases provided $383,000 for characterizing the genes associated with statin myopathy.

Rates of severe myopathy from statins are low; less severe forms are more common.

Researchers suspect that the genes most likely to be contributing factors are associated with other muscle disorders. Prior research has suggested various recessive variants that are somehow activated by these drugs.

"We think that there are a higher number of people who have an underlying muscle disease that's simply been triggered by the statins," said Vladutiu, a professor of pediatrics, neurology, pathology and anatomical sciences . Her previous studies have shown that certain genetic polymorphisms are more common among those with statin-induced myopathies.

Still, it's unknown whether those who carry these genes have a greater chance of developing this problem. "What we have not proven is: Are all carriers going to be at increased risk?" she said.

While this research has the potential for significant payoff, challenges exist. For example, a standard definition of statin-induced myopathy is lacking, making it difficult to compare one study to another. In response, Vladutiu is using part of the grant to establish a scoring system to make assessment more precise.

"We need to qualify and quantify what severe means," she said.

This potential side effect also can be tough to diagnose. These drugs are primarily used by older people, and it's not always clear whether a new ache or pain is due to initiating statin therapy or age. In addition, several studies have found that physicians may discount patient complaints of myalgia after starting these drugs.

"Patients who complain of muscle weakness are not all loopy. There really is something going on," said Paul D. Thompson, MD, director of preventive cardiology at Hartford Hospital in Connecticut. He also has NHLBI funding to investigate the effect of statins on muscle strength.

Washington -- A new study gives more evidence that infection with Clostridium difficile is not necessarily preceded by the use of antibiotics. This suspicion was first raised in 2005 by the Centers for Disease Control and Prevention.

Researchers at McGill University in Montreal found that more than half of the 836 patients they studied had not been exposed to antibiotics in the 45 days before their hospitalizations for C. diff. The study is in the Oct. 7 Canadian Medical Assn. Journal.

Physicians need to maintain a high level of suspicion that the microbe may be the cause of patients' severe diarrhea even without the long-recognized contributions of antibiotics, the researchers said.

The frequency of infection with community-associated C. diff is rising. The rate per 100,000 person-years among people 65 and older in Quebec rose from 0.5 in 1997 to 57.2 in 2004, the Canadian researchers found. The number of fatalities among the most vulnerable also continues to grow.

Quebec has weathered particularly large outbreaks of the infection in recent years, and nearly everyone who arrives at a hospital with diarrhea is tested for the bacteria, said the study's lead author, Sandra Dial, MD, assistant professor of medicine at McGill. "I think we have a higher index of suspicion after what we've been through."

The rate of C. diff infections in Quebec rose from 0.5 to 57.2 in 7 years.

Outbreaks also have been common in the United States. When Ohio in 2006 mandated the reporting of C. diff among nursing home and hospital patients, the tally topped 14,000.

David Classen, MD, a clinical infectious diseases specialist and associate professor of medicine at the University of Utah's School of Medicine in Salt Lake City, said that awareness of the virulent microbe was high in his practice and that physicians are testing for it.

The Canadian researchers analyzed only C. diff infections acquired outside the hospital by Quebec patients ages 65 and older.

The infections also were serious enough to require hospital admittance. Patients with hospital-acquired C. diff were excluded because of the increased risk of infection and antibiotic use in hospitals.

Washington -- Virtual colonoscopies are poised to take off as a major screening tool for colorectal cancer -- the nation's second-leading cause of cancer death.

Findings from the American College of Radiology Imaging Network National CT Colonography Trial demonstrated that the noninvasive technique is as accurate as traditional colonoscopies at finding colorectal cancer and large precancerous polyps. Results from this large, multicenter study were published in the Sept. 18 New England Journal of Medicine.

The hope is that the wide adoption of virtual colonoscopies will encourage more people to be screened. Although screenings have increased in recent years to nearly 61% of those 50 and older, people still fall through the cracks, according to Centers for Disease Control and Prevention data.

In addition, a study published Sept. 8 in Cancer indicates that many colorectal cancer survivors do not receive recommended follow-up screenings.

The promise of CT colonography for screening has been building in recent years. In March, the American Cancer Society, the American College of Radiology and the U.S. Multi-Society Task Force added virtual colonoscopies to their list of recommended tests to detect cancer and polyps. The task force includes representatives of the American College of Gastroenterology, the American Gastroenterological Assn. and the American Society for Gastrointestinal Endoscopy.

Only 61% of adults 50 and older get colonoscopies.

"I think the clinical validation of the technique is complete," said C. Daniel Johnson, MD, lead investigator of the ACRIN trial and chair of the radiology department at Mayo Clinic's Scottsdale, Ariz., facility. In disclosures for the article, Dr. Johnson and other ACRIN investigators reported links to firms working on screening aids and techniques.

"Indeed, this study provides another push for noninvasive/minimally invasive screening by CT colonography," said David Kim, MD, assistant professor of abdominal imaging at the University of Wisconsin School of Medicine and Public Health. Dr. Kim, who was not involved in the ACRIN trial, was lead author of another study published last year in NEJM showing that colonoscopy and colonography had similar detection rates for large polyps. He reported serving on the advisory board for a laxative manufacturer and receiving lecture fees from a diagnostic software firm.

The ACRIN trial is the largest so far to compare the two technologies. It enrolled more than 2,600 men and women 50 and older at 15 sites across the country. The participants were scheduled for a standard screening colonoscopy and then agreed to have a virtual colonoscopy, or CT colonography, on the same day. The day before the exams, participants underwent colon-cleansing procedures prescribed by gastroenterologists.

The virtual and traditional screening results were compared, and researchers found that the virtual screenings identified 90% of the large polyps found by colonoscopies.

A cautionary note

In marking the study's findings, gastrointestinal specialists raised some cautions. "Colonoscopy is the only test that can both detect cancer at an early curable stage and prevent cancer by removing precancerous polyps," said a statement from the American Gastroenterological Assn.

The findings "underscore the reality that many patients who have polyps detected by CT colonography will still have to undergo complete colonoscopy," said American College of Gastroenterology President Amy Foxx-Orenstein, DO.

CT colonography does not eliminate the need for pretest bowel cleaning.

Plus, the virtual procedure also might cause some discomfort, she said, because it requires that the abdomen be insufflated with air or gas. Patients are not sedated for this procedure as they are for a colonoscopy.

"It is important for patients to understand that CT colonography does not at present represent a painless or risk-free procedure, nor does it eliminate the need for bowel cleaning, which patients report as a barrier to screening," she added.

The AGA statement also said CT colonography was less likely to detect small polyps measuring 5 mm to 9 mm. But it's not clear whether those smaller polyps pose a risk.

Additional obstacles must be overcome before virtual colonoscopy hits the mainstream. "The professional organizations need to review and adopt the evidence and insurance companies need to agree to cover it," Dr. Johnson said. To that end, "the Centers for Medicare and Medicaid Services are currently reviewing the technique for reimbursement."

"Once reimbursement has been established, it is anticipated that the use of [CT colonography] in screening will dramatically increase," Dr. Kim predicted.

Currently, only a few large-scale screening programs use colonography, he noted. Among them is a program at the University of Wisconsin where local HMO coverage for virtual screenings has been established. The Wisconsin program began in 2004 and has screened more than 5,000 people, he said. A few military hospitals also have established programs.