Patrick Campbell

The latest analysis of the CARDIA study is detailing a troubling link between presence of diabetes and hypertension with cognitive declines in middle age.

Results of the analysis, which assessed adults aged 50 years and older without dementia at baseline, indicate hypertension increased likelihood of accelerated cognitive decline by 87% while a diagnosis of diabetes more than tripled a person’s risk of accelerated cognitive decline.

“Cardiovascular risk factors, especially high blood pressure and diabetes, become more common in midlife. We found those two risk factors, as well as smoking, are associated with higher odds of having accelerated cognitive decline, even over just a short span of five years,” said lead investigator Kristine Yaffe, MD, of the University of California, San Francisco (UCSF) and a member of the American Academy of Neurology (AAN), in a 

While previous studies have established associations between midlife cardiovascular risk factors and risk of dementia, few have examined whether these risk factors influence cognition in midlife. With this in mind, Yaffe and a team of colleagues hoped to examine potential associations between risk factors, including hypertension, dyslipidemia, diabetes, and obesity, on declines in midlife cognitive abilities from patients in the Coronary Artery Risk Development in Young Adults (CARDIA) study.

For the purpose of analysis, investigators only included participants who completed cognitive testing at year 25 of the study, which was considered baseline for the current analysis, and 5 years later. In total, investigators identified 2675 middle-aged adults for inclusion in their study. The mean age of patients included in the study was 50.2±3.6 years, 57% of participants were female, and 45% were black.

Among the study population, 31% had hypertension, 11% had diabetes, 43% were considered obese, 9% had high cholesterol, and 15% were current cigarette smokers at baseline. For the purpose analysis, patients were categorized into groups based on the number of risk factors present—defined as 0, 1, 2, and 3 or more.

Over the follow-up period, which lasted a mean of 5.02±0.34 years, accelerated decline occurred in 143 participants. Upon analysis, investigators found diabetes (aOR, 2.45; 95% CI, 1.54-3.88), hypertension (aOR, 1.87; 95% CI, 1.26-2.75), and smoking (aOR, 1.65; 95% CI, 1.00-2.71) were associated with increased likelihood of accelerated decline in multivariable adjusted analyses. Conversely, obesity and high cholesterol did not appear to be associated with increased risk of accelerated decline.

“Surprisingly, people who were considered obese and those with high cholesterol did not have a greater risk of cognitive decline,” Yaffe added, in the aforementioned statement. “Other studies have shown a link between obesity and dementia, but mostly in older adults. Meanwhile, the studies that examine high cholesterol and dementia have had mixed results, so our research adds to those studies.”

When examining likelihood of accelerated decline based on number of risk factors present, investigators found presence of 1-2 risk factors (aOR, 1.77; 95% CI, 1.02-3.05) and presence of 3 or more risk factors (aOR, 2.94; 95% CI, 1.64-5.28) were both associated with increased likelihood compared to those with 0 risk factors. Additionally, results of the analysis indicated a Framingham Coronary Heart Disease Risk Score of 10 or more was also associated with increased likelihood (aOR, 2.29; 95% CI, 1.21-4.34).

Investigators noted multiple limitations to consider. Limitations included inability to assess every cognitive domain, the Framingham Coronary Heart Disease Risk score was developed in a more homogeneous cohort, and characterization of cognitive change in middle-aged adults is not well-defined.

Cardiovascular Risk Factors and Accelerated Cognitive Decline in Midlife: the CARDIA Study,

Articles

New research provides an overview of the impact diabetes and cardiovascular risk factors can have on cognition in middle-aged patients. 

Diabetes, Cardiovascular Risk Factors Linked to Early Declines in Cognition

A new analysis of more than 120 published studies is highlighting the increased risk of cardiovascular disease and death in patients with 

Results of the analysis, which was conducted by investigators from the George Institute and Shunde Hospital at Southern Medical University, suggest patients with a diagnosis of prediabetes were at a 13% increased risk of all-cause mortality and a 15% increased risk of 

"The prevalence of prediabetes and diabetes is rising rapidly in epidemic proportions, especially in low- and middle-income countries. Early detection and proper treatment can have enormous benefits, but left unaddressed, the life-long complications and health impacts can be devastating," said Yuli Huang, MD, PhD, associate professor of cardiology at Southern Medical University in Shunde, China, 

The issue of prediabetes is one that has been thrust into the spotlight in recent years. With the prevalence of prediabetes expected to rise swiftly between now and 2030 and the majority of these patients developing type 2 diabetes, prediabetes represents a present and urgent public health issue.

To further understand the current burden of prediabetes, Huang and a team of colleagues designed a meta-analysis to assess associations between prediabetes and risk of all-cause mortality and cardiovascular disease in populations with and without a history of atherosclerotic cardiovascular disease. Using the PubMed, Embase, and Google Scholar databases, investigators searched for studies associated with there the terms “blood glucose” and “cardiovascular disease” or “mortality” from inception through April 25, 2020.

For inclusion in the meta-analysis, studies need to be prospective cohort studies or post hoc analyses of clinical trials in individuals aged 18 years or older and report adjusted risk of associated events. Studies were excluded if enrollment not from the general population or patients with atherosclerotic cardiovascular disease.

In total, the investigators searched returned 31,662 articles. After screening and application of inclusion criteria, a total of 129 studies, involving 10,069,955 individuals, were included in the analysis.

The primary outcomes of the analysis were risk of all-cause mortality and a composite of cardiovascular events in the general population and those with atherosclerotic cardiovascular disease, respectively. Secondary outcomes for the analysis were risk of coronary heart disease and stroke in those with prediabetes versus the with normoglycemia.

Results of the analysis indicated prediabetes was associated with an increased risk of all-cause mortality (Relative risk [RR], 1.13; 95% CI, 1.10-1.17; 

<.05), composite cardiovascular disease (RR, 1.15; 95% CI, 1.11-1.18); 

 <.05), coronary heart disease (RR, 1.16; 95% CI, 1.11-1.21; 

=.24), and stroke (RR, 1.14; 95% CI, 1.08-1.20; 

 <.05) over a median follow-up period of 9.8 years.

When comparing patients with prediabetes to those with normoglycemia, results indicated the absolute risk difference in prediabetes for all-cause mortality (7.36; 95% CI, 9.59-12.51), composite cardiovascular disease (8.75; 95% CI, 6.41-10.49), coronary heart disease (6.59; 95% CI, 4.53-8.65) and stroke (3.68; 95% CI, 2.10-5.26) were all greater in patients with prediabetes when assessing risk per 10,000 person-years.

Among patients with established atherosclerotic cardiovascular disease, prediabetes was associated with an increased risk of all-cause mortality, composite cardiovascular disease, and coronary heart disease in a follow-up period lasting a median of 3.2 years. However, investigators noted there was no difference in stroke among this patient population.

When comparing those with prediabetes versus those with normoglycemia in patients with atherosclerotic cardiovascular disease, prediabetes was associated with an absolute risk increase for all-cause mortality (66.19; 95% CI, 38.60-99.25), composite cardiovascular disease (189.77; 95% CI, 117.97-271.84), coronary heart disease (40.62; 95% CI, 5.42-78.53), and stroke (8.54; 95% CI, 32.43-61.45) when assessing risk per 10,000 person-years. Investigators noted there was no significant heterogeneity found for risk of all outcomes seen among different definitions of prediabetes in those with atherosclerotic cardiovascular disease (

“Considering the high prevalence of prediabetes, as well as its strong link to health risks seen in our study, successful intervention in this large population could have a major public health impact,” Huang added.

Association between prediabetes and risk of all cause mortality and cardiovascular disease: updated meta-analysis

Results of a meta-analysis are detailing the current risk prediabetes poses on the cardiovascular health and overall well-being of patients. 

Study Outlines Risk of Death, Cardiovascular Disease in Prediabetes

A new study from the University of Michigan is providing clinicians with a more accurate overview of the level of involvement primary care providers have in 

Performed in an effort to develop a greater understanding of primary care involvement and confidence in thyroid cancer survivorship care, results offer clinicians greater insight into the potential role of primary care providers after surviving thyroid cancer.

“Our findings expand on prior cancer survivorship literature by characterizing PCP involvement in caring for thyroid cancer survivors. Delivering high-quality, coordinated cancer survivorship care has been challenging In general, there remains a lack of clarity and guidance around which provider—cancer specialist or PCP—handles cancer survivorship care,” investigators wrote.

With data indicating rates of thyroid cancer diagnoses have more than tripled in the past 5 decades and a shortage of endocrinologists, investigators hoped to assess the involvement and confidence of primary care providers in the care of patients who survive thyroid cancer. Investigators also note previous research suggests more than half of primary care providers surveyed support a more collaborative approach to care with cancer specialists.

As part of the Georgia and Los Angeles Surveillance, Epidemiology and End Results (SEER) registries, participants were asked to identify a doctor most involved in their treatment decision making other than their surgeon or endocrinologist. Using the clinicians identified, investigators obtained a cohort of primary care providers as possible participants in their study.

After sending surveys to the aforementioned group of clinicians, investigators received responses from a total of 162 primary care providers. The main goals of the survey were to assess primary care providers’ involvement in long-term surveillance and the primary care providers’ confidence in handling thyroid cancer survivorship care.

Of note, investigators pointed out additional measures were added to the survey to assess attitudes and beliefs of primary care providers in regard to their role in thyroid cancer survivorship care.

Upon analysis, investigators found most of the respondents (76%) reported being involved in long-term surveillance. Among those who reported involvements, clinical guidelines were cited as the most influential source in guiding treatment (OR, 4.29; 95% CI, 1.56-11.82).

When examining primary care providers reporting high confidence in handling long-term survivorship care varied depending on the situation examined. Specifically, 39% reported confidence in referring patients to a specialist, 36% reported confidence in understanding the role of neck ultrasound, 27% reported confidence when assessing random thyroglobulin levels, and 14% reported confidence in knowing when to end long-term surveillance.

Additionally, investigators pointed out primary care providers reporting involvement were more likely to report high confidence in discussing the role of random thyroglobulin levels (33.3% vs 7.9%; 

“While PCPs reported being involved in long-term surveillance, gaps remain in their confidence in handling survivorship care. Thyroid cancer survivorship guidelines that delineate PCP roles present one opportunity to increase confidence about their participation,” investigators wrote in their conclusion.

Investigators pointed out there were multiple limitations with their study. Limitations within the study included a small sample size, the cross-sectional nature limits conclusion regarding temporality and causality, and lack of information surrounding parameters of the survivorship period.

Primary care provider involvement in thyroid cancer survivorship care

The Journal of Clinical Endocrinology and Metabolism.

New research is defining how primary care providers view their role in long-term survivorship care of patients with thyroid cancer.

Primary Care's Perception of Role in Thyroid Cancer Survivorship Care 

Results from a new study suggest people with public insurance are paying more than privately insured patients when undergoing bariatric weight loss surgery.

The first study to examine the surgeries by insurance payer type, results of the study raise a red flag on a trend with serious real-world implications given the continued rise in obesity and bariatric procedures in the US.

"Bariatric surgery is becoming more common, but there's increasing evidence that bariatric surgery is not happening consistently across all payer types, and there might be cost differences by payer type," said lead investigator Janani Thapa, PhD, an assistant professor of health policy and management in UGA's College of Public Health, 

Currently, treatment of obesity represents a unique and pressing issue in the US and aboard. While data indicates more than one-third of US citizens are considered obese, disparities in prevalence based on socioeconomic status as well as race and ethnicity.

"The hoops that they have to jump through may be more (than others) to access the surgery and that was our motivation to look into this,” added Thapa.

With these patient populations more likely to use public insurance, investigators sought to assess potential disparities based on insurance type and surgical treatment using data form the National Inpatient Sample (NIS).

Using NIS data from 2011-2014, investigators obtained data related to adult patients 18 years of age and older with a diagnosis of obesity, which were verified using ICD-9-CM codes. With this data, investigators carried out their 3-part analysis.

The first part of the analyses examined trends in prevalence of diagnosed obesity among all hospitalizations and proportion of bariatric surgeries among those patients. The second portion assessed these trends according to age groups, sex, race, and payer types. The final portion of the analysis was designed to assess the cost per input-patient hospitalization for bariatric surgery by payer type and estimated total costs.

Age groups for the analysis were defined as 18-34 years, 35-54 years, 55-64 years, and 65 years or older. Payer types were classified as Medicaid, Medicare, private, and self-insured or other.

Results of the analysis indicated the prevalence of obesity and number of obesity surgeries increased across all subgroups examined during the study period. Overall, bariatric surgeries were most common in patients 33-54 years old with private insurance—however, an in-patient obesity diagnosis was most likely among women, non-Hispanic Blacks, and those with public insurance.

Results of the analysis also indicated patients with private insurance were more than twice as likely to undergo bariatric surgery than their counterparts with Medicare or Medicaid (

 <.001)—privately insured patients were also more likely to undergo bariatric surgery than those classified as self-insured or other.

Additionally, results indicated patients with Medicare or Medicaid had higher average in-patient costs for bariatric surgery than their counterparts with private insurance. Investigators pointed out this pattern was consistent across all 4 years examined in the study.

In-patient obesity diagnosis, use of surgical treatment and associated costs by payer type in the United States: Analysis of the National Inpatient Sample, 2011 through 2014

New research from the University of Georgia found private insurance was associated with a greater frequency of bariatric surgery and lower cost of surgery than public insurance.  

Author | Patrick Campbell

Articles

Diabetes, Cardiovascular Risk Factors Linked to Early Declines in Cognition

Study Outlines Risk of Death, Cardiovascular Disease in Prediabetes

Primary Care's Perception of Role in Thyroid Cancer Survivorship Care

Bariatric Surgery More Common, Less Expensive with Private Insurance