Excess body fat, particularly around the waist, is a major risk factor for premature death among Hispanics

Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information.

1. Excess body fat, particularly around the waist, is a major risk factor for premature death among Hispanics

Hazards of overweight assessed reliably, refuting previous claims of little risk

Abstract: http://annals.org/aim/article/doi/10.7326/M18-3502

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Both general and abdominal obesity were strongly associated with mortality among Mexican adults. Each 5 kg/m2 increase in BMI above 25 kg/m2 was associated with a 30 percent increase in mortality. These findings refute previous research showing that being overweight was not strongly associated with mortality in Hispanic populations. Findings from a prospective study are published in Annals of Internal Medicine.

The World Health Organization (WHO) defines being overweight as having a BMI of 25 to <30 kg/m2. Previous studies have shown that the higher the BMI, the greater the risk for death in most populations. However, the associations of BMI with mortality may be different in populations with substantially higher mean BMI than those originally studied, such as in Hispanic populations.

Researchers from the Mexican Health Ministry followed more than 115,000 adults aged 35 and older in two Mexico City districts for up to 14 years to assess the causal relevance of body fat to mortality. Mean BMI was 28.0 kg/m2 in men and 29.6 kg/m2 in women. To limit the extent to which associations between baseline adiposity and mortality were distorted by any effects of diabetes or other diseases on the baseline measurements, the researchers' main analyses looked at deaths occurring more than 5 years after the baseline measurements and excluded participants with an HbA1c level of 7 percent or greater, previously diagnosed with diabetes, or other chronic diseases at recruitment. The researchers found that both general obesity and carrying excess fat around the midsection were major risk factors for premature death, with strengths of association that were similar to those observed in high-income populations. In addition, the waist-to-hip ratio was found to be of substantial additional relevance to mortality, suggesting that central obesity is particularly harmful.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with senior author Sir Richard Peto, please contact Sheena Cameron at sheena.cameron@ndph.ox.ac.uk.

2. Using racemic drugs over newer single-enantiomer versions could save Medicare billions of dollars

Abstract: http://annals.org/aim/article/doi/10.7326/M19-1085

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Medicare and its beneficiaries could have realized an estimated $17.7 billion in savings through substitution of 12-single-enantiomer drugs with their racemic precursors. Without evidence demonstrating that single-enantiomer drugs improve outcomes compared to racemic versions, this substitution offers a clear opportunity for Medicare drug savings. Findings from a brief research report are published in Annals of Internal Medicine.

Most new drugs are marketed as single enantiomers but many older agents are still available in racemic form. Chiral switching is a commercial strategy in which manufacturers develop a single-enantiomer drug that can be substituted for its already-marketed racemic version. While it has been suggested that the newer single-enantiomer versions may offer greater safety and efficacy, there is no evidence that the newer drugs are better and they are also more expensive.

Researchers from Yale School of Medicine reviewed a CMS database to estimate the potential savings associated with using racemic precursors instead of their single-enantiomer versions to the Medicare Part D drug benefit program and its beneficiaries. The researchers identified 12 single-enantiomer drugs with FDA-approved racemic precursors that had associated Medicare spending. Between 2011 and 2017, Medicare Part D spending on those 12 single-enantiomer drugs totaled $19.3 billion. Had their racemic precursors been substituted, Medicare could have saved $16.6 billion.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with authors, Alex Egilman, BA, or Joseph Ross, MD please contact Ziba Kashef at ziba.kashef@yale.edu.

3. Anemic U.S. political response to mass gun violence may be a product of culture

Abstract: http://annals.org/aim/article/doi/10.7326/M19-1567

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The dominant gun culture in the U.S. may influence the country's anemic political response to mass gun violence. The U.S. response stands in stark contrast to that of New Zealand, a country that quickly changed its gun laws to address gun violence following a devastating mass shooting. A commentary examining the differences between the two countries' responses to gun violence is published in Annals of Internal Medicine.

Authors from the Naval Postgraduate School, Monterey California and the University of Canterbury, Christchurch, New Zealand point out that both countries have high gun ownership. The estimated number of civilian-owned firearms in the U.S. is more than one per person and in New Zealand is about one firearm for every four citizens. The difference seems to be cultural. In the U.S., gun ownership is protected by the 2nd Amendment and considered to be a right. In New Zealand, gun ownership is considered a privilege, according to officials. Gun deaths in New Zealand are rare, especially compared to the U.S., where total gun fatality and suicide rates are the highest among all high-income countries. According to the authors, these differences make the U.S. and New Zealand "worlds apart" when it comes to reacting to and preventing gun violence.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, Andrew Anglemyer, PhD, please contact him directly at andrew.anglemyer@gmail.com.

4. ADA adds new section on diabetes technology to its Standards of Medical Care in Diabetes

Abstract: http://annals.org/aim/article/doi/10.7326/M19-1638

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The American Diabetes Association (ADA) has added a new section on diabetes technology to its Standards of Medical Care in Diabetes recommendations. A summary of guidance related to the use of technology in treating diabetes is published in Annals of Internal Medicine.

Diabetes technology refers to the devices, hardware, and software that persons with diabetes use to help manage blood glucose levels. Such technology includes pens or pumps that administer insulin and meters or continuous glucose monitors that measure blood glucose. Most recently, devices have been developed to both monitor glucose and deliver insulin.

Researchers from St. Mark's Diabetes Center, Salt Lake City, reviewed the ADA Standards of Medical Care in Diabetes to summarize guidance on using technology in treating diabetes. To develop the guidelines, the Professional Practice Committee of the ADA reviewed published research through November 2018 for studies that were related to each section and had been published since October 2017. Recommendations for each section, including the section on technology, were revised to incorporate new evidence, clarify the prior recommendation, or align the strength of the wording to that of the evidence. Authors from St. Mark's Diabetes Center focused on summarizing recommendations addressing self-monitoring of blood glucose, continuous glucose monitors, and automated insulin delivery systems. The key takeaway message for technology was that self-monitoring with continuous glucose monitoring (CGM) is recommended and can inform care for patients on intense insulin regimens.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, please contact Krista Numbers at Krista.Numbers@Mountainstarhealth.com.

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