Public Release: 

July/August 2016 Annals of Family Medicine tip sheet

American Academy of Family Physicians

Substantial and Growing Proportion of Healthy Weight Adults Have Prediabetes

Conventional thinking suggests that the obesity epidemic is driving the epidemic in diabetes, and that abdominal obesity is a particularly good marker of those at risk, but this study, which finds that one-third of non-obese people have prediabetes, is an important wake-up call. In the first study to examine the trends in prediabetes prevalence among individuals with a body mass index in the healthy range (18.5 to 24.99), researchers find the prevalence of prediabetes and abdominal obesity increased markedly in the 18 years since 1988. Analyzing data from the National Health and Nutrition Examination Survey 1988-1994 and the NHANES 2009-2012, researchers from the University of Florida found the prevalence of prediabetes among healthy-weight adults, aged 20 years and older without diagnosed or undiagnosed diabetes increased from 10 percent in 1988-1994 to 19 percent in 2012. Among individuals aged 45 years and older, the prevalence of prediabetes increased from 22 percent to 33 percent. Moreover, the researchers found the percentage of adults aged 20 years and older with an unhealthy waist circumference increased from 5 percent in 1988-1994 to 8 percent in 2012. Further analysis suggested that abdominal obesity did not appear to be the primary cause of the increase in prediabetes. The authors point out that the U.S. Preventive Services Task Force currently recommends screening for abnormal blood glucose in adults aged 40 to 70 years who are overweight or obese. The findings of this study suggest that following these recommendations, prevention efforts would miss a large number of people with prediabetes. They call for additional research to determine the primary cause of the rise in prediabetes and abdominal obesity, as well as alternative ways to detect prediabetes in primary care among healthy-weight adults.

Prevalence of Prediabetes and Abdominal Obesity Among Healthy-Weight Adults: 18-Year Trend

By Arch G. Mainous III, PhD, et al

University of Florida, Gainesville

Adequate Hydration May Play a Role in Weight

Inadequate hydration is associated with higher body mass index and obesity, according to this study out of the University of Michigan. Analyzing data from a nationally representative sample of 9,528 U.S. adults aged 18 to 64 years, researchers found that 33 percent of the sample was inadequately hydrated and that adults who were inadequately hydrated (as measured by urine concentration) had a mean BMI of 1.32 kg/m2 more than hydrated individuals, on average. Moreover, they found the odds of being obese were 1.59 times higher for inadequately hydrated individuals compared with hydrated individuals. The authors conclude that although causality and directionality cannot be established given the study design, this relationship has not previously been shown on a population level. They conclude the findings raise the possibility that drinking more water could be an important tool for addressing the obesity epidemic and call for additional investigation to examine the relationship between inadequate hydration and weight status.

Inadequate Hydration, BMI, and Obesity Among US Adults: NHANES 2009-2012

By Tammy Chang, MD, MPH, MS, et al

University of Michigan, Ann Arbor

Google Trends Data Demonstrate Seasonality of Ankle Swelling

Internet searches for ankle swelling and related terms are highly seasonal, with public interest peaking in midsummer. Analyzing Google Trends data of searches for "ankle swelling," "swollen ankles," "swollen feet," or "swollen legs" originating in the United States between 2004 and 2016, researchers found seasonality explained 86 percent of the variability in search volume with the peak of searches occurring in mid-June and the trough in mid-December. To confirm the findings, the researchers performed an identical analysis for Australia where the seasons are reversed, and found the same pattern. The authors note that heart failure admissions have been shown to exhibit the opposite seasonal trend, peaking in winter, which is consistent with their clinical observation that these patients seldom go on to develop cardiovascular disease. That said, the authors call for future research on patients with summertime ankle swelling to establish whether such patients have, or go on to develop, cardiovascular pathology. Further research, they add, is also needed to establish the mechanism behind the findings, which could potentially include seasonality in contributing factors, such as diet (including salt and water intake, increased activity in summer, or temperature dependent vasodilation).

Seasonality of Ankle Swelling: Population Symptom Reporting Using Google Trends

By Scott Garrison, MD, PhD, et al

University of Alberta Edmonton, Canada

Home-Based Intervention for Obese Patients Promotes Weight Loss and Physical Activity

A home-based weight loss and physical activity intervention for obese, sedentary adult primary care patients was effective in promoting weight loss and increasing physical activity, with effects peaking at 12 months but waning at 24 months. The randomized clinical trial of 211 patients with a mean body mass index of 38 kg/m2 and reporting 21 minutes a week of moderate to vigorous physical activity tested an enhanced intervention involving weekly telephone counseling calls, individually tailored educational materials and DVDs focused on diet and physical activity over the first year, with a tapered maintenance phase during the second year. By the end of the active treatment phase, almost half of the enhanced intervention group had lost more than 5 percent of baseline weight -- a clinically significant amount -- and one-third maintained the loss at 24 months. Specifically, the percentage of patients who had lost more than 5 percent of their baseline weight during active treatment was 37 percent EI vs. 13 percent SI at six months and 48 percent vs. 12 percent at 12 months, but was no longer significant during the maintenance phase at 18 months (31 percent vs. 27 percent) or 24 months (33 percent vs. 25 percent). The EI group also reported significantly more minutes of moderate to vigorous physical activity over time than the SI group. The differences in minutes per week at six months was 96 for the EI group vs. 68 minutes for the SI group; at 12 months, it was 126 vs. 74; at 18 months, 104 vs. 64, and at 24 months, 101 vs. 75. Similar trends were found for absolute weight loss and the percentage reaching national guidelines for physical activity. Overall, the benefits appeared to peak at 12 months for both weight loss and increasing physical activity, with no statistically significant difference in benefit between the groups at 24 months. The authors conclude that these findings suggest that referral by a primary care physician to a home-based program with limited face-to-face contact can lead to weight loss and increases in moderate to vigorous physical activity. They call for future research to examine the use of ancillary health care staff or peer counselors in combination with computerized tailoring software, as well as technology such as web e-mails, text messages, or smart phone apps to provide support and tailored content.

A Randomized Clinical Trial of a Tailored Lifestyle Intervention for Obese, Sedentary, Primary Care Patients

By Charles B. Eaton, MD, MS, FAHA, et al

Alpert Medical School of Brown University, Providence, Rhode Island

Researchers Develop Clinical Decision Rule to Improve the Diagnosis and Treatment of Urinary Tract Infection in Young Children in Primary Care

In the largest and most rigorous investigation of the diagnostic accuracy of urinary tract infection in young children, researchers in the United Kingdom developed a clinical decision rule for diagnosing urinary tract infection in children aged five years and younger. Given the scarcity of relevant evidence in primary care regarding which children should be suspected of having a UTI, the nonspecificity of UTI symptoms in young children and the difficulty in obtaining an uncontaminated urine sample, this risk-based approach can aid primary care clinicians in identifying children for investigation of UTI. Analyzing urine samples and culture results for 2,740 children, the researchers derived and validated a novel coefficient and points-based clinical rule, which they found to be superior to clinical diagnosis, to select children for urine sampling and antibiotic treatment. Data showed that previous UTI, increasing pain/crying on passing urine, increasingly smelly urine, absence of severe cough, increasing clinician impression of severe illness, abdominal tenderness on examination, and normal finding on ear examination were associated with UTI and can be used for deciding which children for whom a urine sample (step 1) and dipstick results would improve specificity for antibiotic treatment (step 2). The validated coefficient- and points-based model curves were 0.87 and 0.86, respectively, increasing to 0.90 and 0.90, respectively, by adding dipstick nitrates, leukocytes and blood. The researchers write that clinician preference should determine precisely how these findings are used. Some may use the risk factors to supplement clinical judgement while others may use a checklist approach and use the points-based clinical rule. They call for further research to distinguish pathogens from contamination and asymptomatic bacteriuria.

Improving the Diagnosis and Treatment of Urinary Tract Infection in Young Children in Primary Care: Results from the DUTY Prospective Diagnostic Cohort Study

By Alastair D. Hay, FRCGP, et al

University of Bristol, United Kingdom

Osteoporosis Screening Tool Cited by U.S. Preventive Services Task Force Underperforms Alternate Screen in Identifying Men at Risk

In its guidelines for osteoporosis screening, the U.S. Preventive Services Task Force cites the World Health Organization's Fracture Risk Assessment Tool for predicting the 10-year risk of hip or major osteoporotic fracture. However, when researchers evaluate its effectiveness as a screening strategy compared with the Male Osteoporosis Risk Estimation Score, they find the FRAX underperforms compared to the MORES. Analyzing data on a nationally representative sample of 1,498 men aged 50 years and older from the Third National Health and Nutrition Examination Survey, researchers found based on the MORES, 42 percent of the men in the sample would be referred for a follow-up dual-energy x-ray absorptiometry scan, of whom 10 percent had osteoporosis. In comparison, based on the FRAX, 12 percent of the men would be referred for DXA, of whom 14 percent had osteoporosis. Compared with the FRAX, the MORES had significantly higher sensitivity (0.96 vs. 0.39) but had lower specificity (0.61 vs. 0.89). Agreement between the two screening tools was poor. Notably, when the researchers integrated the MORES and FRAX, they were able to identify 82 percent of the men who were candidates for treatment. In light of these findings, the authors suggest that an integrated approach, which uses the MORES to identify men who should undergo a diagnostic DXA scan and uses the FRAX to guide treatment decisions, may be optimal, particularly for men with osteopenia. They posit that clinicians who refer men for DXA testing based on the MORES could, in a follow-up encounter to discuss the results, use the bone mineral density results to calculate the FRAX and engage patients in a shared decision about treatment. They conclude that MORES is a better screening tool for osteoporosis in men than the FRAX, whereas the FRAX is a valuable tool to guide treatment decisions.

Comparison of the Male Osteoporosis Risk Estimation Score (MORES) With FRAX in Identifying Men at Risk for Osteoporosis

By Alvah R. Cass, MD, SM, et al

The University of Texas Medical Branch, Galveston

High Sense of Coherence in Very Elderly Patients is Protective Against Adverse Health Outcomes

Very elderly patients who have a high sense of coherence -- a pervasive feeling of confidence that one's environment is predictable and that things will work out as well as can reasonably be expected -- have lower mortality rates and less functional decline. Analyzing data on 567 patients aged 80 years and older with multiple chronic diseases, researchers found that those with high SOC scores showed a higher cumulative survival than others, independent of other prognostic characteristics, including multimorbidity, depression, cognition, disability and sociodemographic characteristics. Moreover, a high SOC was shown to be protective against functional decline in the performance of daily activities, an effect that also was independent from the covariates under study. Given the protective effects of SOC, the authors conclude, it may be important to further explore interventions for increasing SOC in people with low scores so as to improve their capacity to cope with life stressors and maintain their health.

A High Sense of Coherence as Protection Against Adverse Health Outcomes in Patients Aged 80 Years and Older

By Pauline Boeckxstaens MD, PhD, et al

Family Physicians Provide Interconception Care at Well-Child Visits and Mothers Are Receptive to Advice

Well-child visits represent a ripe opportunity for care of mothers prior to their next pregnancy in order to reduce maternal risk factors for subsequent adverse birth and maternal outcomes. A survey of 658 mothers accompanying their child to well-child visits at family medicine practices finds that a substantial portion of mothers have risk factors for adverse subsequent birth outcomes, that family physicians routinely provide key elements of interconception care at well-child visits, and that mothers are highly receptive to advice from their child's physician even if they receive primary care elsewhere. Specifically, researchers found 17 percent of the mothers surveyed reported a previous preterm birth, 19 percent reported a history of depression, 25 percent were smoking, 26 percent were not using contraception, and 58 percent were not taking folic acid. Regarding advice, 80 percent of mothers who smoked were counseled to quit, 59 percent reported depression screening, 71 percent discussed contraception, and 44 percent discussed folic acid. Most mothers, nearly 95 percent, were willing to accept health advice from their child's physician regardless of whether a medical home was shared. The authors call for routine integration of interconception care at well-child visits.

Interconception Care for Mothers During Well-Child Visits With Family Physicians: An IMPLICIT Network Study

By Stephanie E. Rosener, MD, et al

Middlesex Hospital Family Medicine Residency Program, Middletown, Connecticut

Leveraging the Role of Administrative Clerks to Better Deliver Patient-Centered Primary Care

Researchers from the Iowa City VA Health Care System elucidate the important but largely underutilized contributions of clerical staff to patient-centered medical home outcomes. Drawing upon a prior ethnographic study of PCMH implementation in a large integrated delivery system, they posit that the PCMH can be further enhanced by enabling clerks to use administrative tasks as conduits for investing in long-term personalized relationships with patients that foster trust in the PCMH and the broader health care organization. Such relationships, they assert, are engendered through the care coordination activities clerks perform and may be bolstered by organizational investment in clerks as skilled health care team members. They conclude that the integration and support of clerks will make it possible for team-based initiatives such as medical homes to optimize their true potential of transforming how patient care is delivered.

The Critical Role of Clerks in the Patient-Centered Medical Home

By Samantha L. Solimeo, PhD, MPH, et al

Iowa City VA Health Care System, Iowa

Point/Counterpoint: Should Providers Recommend E-Cigarettes to Their Patients Who Smoke?

A pair of articles tackles the question of whether providers should recommend e-cigarettes to their patients who smoke. Ann McNeill, PhD, professor of tobacco addiction at King's College London, argues that for smokers who are struggling to quit or who do not want to quit, e-cigarettes, like other nicotine replacement therapies, offer a way of continuing to use nicotine but in a much less harmful way. She concludes that by encouraging smokers to use whatever support that is available to stop smoking, including e-cigarettes, providers will be helping to ensure that tobacco cigarettes and smoking and the associated massive mortality and morbidity burden become obsolete within our lifetime.

On the other side of the argument, Clare Meernik, MPH, and Adam O. Goldstein, MD, MPH, at the University of North Carolina at Chapel Hill assert that until more data on electronic nicotine delivery devices' safety and effectiveness emerges, providers should be advised against routinely recommending them to their patients who smoke. They point to inadequate evidence to support the safety of e-cigarettes (and evidence about potential and real harms), little evidence to support their effectiveness as a smoking cessation aid, lack of regulation, and an ethical framework in medicine to first do not harm. They conclude that until such time that medical evidence supports their safety and effectiveness and robust regulatory frameworks exist, providers should use other tools at their disposal that have been proven safe and effective.

Should Providers Recommend E-cigarettes to Their Patients Who Smoke? Yes.

By Ann McNeill, PhD

King's College London, United Kingdom

Should Providers Recommend E-cigarettes to Their Patients Who Smoke? No.

By Clare Meernik, MPH and Adam O. Goldstein, MD, MPH

University of North Carolina at Chapel Hill

All Types of Primary Care Physicians Tend to Retire in Their Mid-60s

To inform concerns about the future adequacy of the primary care workforce, researchers examine variation in the retirement age of primary care physicians and find the average retirement age of about 65 years varies little by specialty, practice location or gender. These findings suggest that changes in the composition of the primary care workforce will not have a remarkable impact on overall retirement rates in the near future. Analyzing data from the AMA Physician Masterfile for the most recent five years (2010-2014), researchers found the median age of retirement from clinical activity of all primary care physicians was 65 years and the median age of retirement from any type of professional activity (teaching, administration, and research) was 66 years. Retirement ages were generally similar across all primary care specialties. Females had a median retirement about one year earlier than males. The researchers found no substantive differences in retirement ages between rural and urban primary care physicians. Based on these findings, the authors suggest that strategies to lengthen careers, including quality-of-life accommodations such as a reduction in full-time work, weekend work, or on-call requirements, would be worthwhile for policymakers to explore.

When Do Primary Care Physicians Retire? Implications for Workforce Projections

By Stephen M. Petterson, PhD, et al

Robert Graham Center, Policy Studies in Family Medicine and Primary Care, Washington, DC

Group Concept Mapping a Viable Method for Engaging Patients in Clinical Quality Improvement

Although patient engagement is a primary care research and practice priority, little guidance exists on how best to engage patients in primary care practice improvement or how to measure the impact of their engagement. To address this void, researchers present a method of structured conceptualization called group concept mapping as a means to engage patients in primary care practice improvement. They detail the group concept mapping process as a tool for use in primary care practice improvement, research, and evaluation, and they suggest resources to enable researchers and practice leaders to use the tool in practice improvement. To illustrate the method, they present a practice-based quality improvement project conducted with patients and staff at a large urban academic primary care project. Based on their experience, the researchers conclude that concept mapping offers a feasible patient engagement technique that can also illustrate and quantify the convergence and divergence of patient and other stakeholder ideas, highlight the unique perspective that patients bring to practice improvement, and provide a basis for patient-centered practice improvements. They note that concept mapping may also be a powerful method for stakeholder engagement in other types of clinical research because it demonstrates and quantifies the effect of patient involvement in the process. They call for more research on the concept mapping process and outcomes.

Concept Mapping as a Method to Engage Patients in Clinical Quality Improvement

By Marianna LaNoue, PhD, et al

Sidney Kimmel Medical College and Thomas Jefferson University, Philadelphia, Pennsylvania

Best-Worst Scaling Survey Method Quantifies Patient Priorities in a Way That is Transparent and Accessible

Researchers explore the value of using best-worst scaling -- a survey method for assessing individuals' priorities by having them identify what they view as the best and worst or most and least important among a set -- and find it quantifies patients' priorities in a way that is transparent and accessible. To demonstrate an application of BWS in primary care, the authors surveyed 165 homeless women to assess the relative importance of different attributes on their decision whether or not to pursue Pap testing. They asked women to evaluate 11 sets of five attributes of Pap services and found that the biggest influence on their decision was the availability of support for issues beyond health followed by no-cost testing, and least important was the availability of accommodations for hygiene and the provider being familiar to the women. The authors conclude their application in this vulnerable population demonstrated that BWS is easily comprehendible by patients and relatively easy to administer. They posit that the approach can be applied to other health care areas where prioritization is helpful to guide decisions.

Using Best-Worst Scaling to Understand Patient Priorities: A Case Example of Papanicolaou Tests for Homeless Women

By Eve Wittenberg, PhD, et al

Harvard T.H. Chan School of Public Health, Boston, Massachusetts

Reflection: A Patient is More Than His Disease

A recent medical student graduate reflects on the most important lesson he learned during his internal medicine clerkship -- that a patient is more than his disease. The author posits that while much of medicine is spent evaluating patients' vital signs and laboratory results, the sign most vital to care is how much time clinicians actually spend caring. He asserts that physicians cannot fully appreciate how a patient is doing if they don't first appreciate who the patient is and what matters to him or her. Relating a story of how this important lesson later guided him in a very meaningful way to help another patient who was emotionally overcome by his disease, the author writes that paying attention to the little things is one of the most important things a physician can do because it can truly change how patients feel - and that is a very big thing.

A Dance With Mrs Chan

By Abraar Karan, MD

University of California Los Angeles

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Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Launched in May 2003, Annals is sponsored by seven family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group, and the College of Family Physicians of Canada. Annals is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal's website, http://www.annfammed.org.

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