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Medicaid and Pregnancy; Sedentary Behavior: It’s PodMed Double T!

PodMed Double T is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week. A transcript of the podcast is below the summary.

This week’s topics include metformin for long term weight loss, glucose control and fetal health, Medicaid expansion and pregnancy outcomes, and sedentary behavior in the U.S.

Program notes:

0:41 Metformin and long term weight loss

1:43 At one year, intensive lifestyle appeared best

2:43 Increased indications for metformin

3:32 One in 200 women with type 1 diabetes and preterm birth

4:30 The higher your sugar the more likely preterm birth

5:30 Affects both mother and fetus

5:40 Medicaid expansion and birth outcomes

6:40 Did not see a benefit except in racial disparity

7:44 What the causative factors might be?

8:10 Sedentary behavior in U.S. population

9:20 Computer use increased

10:25 Do not offset deleterious impact of sitting

11:44 End


Elizabeth Tracey: Can the diabetes medicine metformin help with long-term weight loss?

Rick Lange, MD: How has sedentary behavior changed over the last 15 years?

Elizabeth: Does Medicaid expansion improve earth outcomes?

Rick: Controlling sugar in diabetics to prevent pre-term birth.

Elizabeth: That’s what we’re talking about this week on PodMed TT, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a medical journalist at Johns Hopkins, and this will be posted on April 26th, 2019.

Rick: And I’m Rick Lange, President of the Texas Tech University Health Sciences Center in El Paso, where I’m also Dean of the Paul L. Foster School of Medicine.

Elizabeth: Rick, why don’t we turn first to Annals of Internal Medicine. What about long-term weight loss with metformin? Metformin, of course, is actually the first-line treatment for people when they’re first diagnosed with type 2 diabetes. Oral agent, we know lots about it. It’s generic. There’s so many things that are persuasive about it, and now in this case, they’re taking a look at long-term weight loss in people who are taking it. This is part of the Diabetes Prevention Program — a big program where they enrolled thousands of people and they took a look at them over a very long period of time.

In this case, they had follow up at 1 year where they looked at who was taking metformin, who was taking intensive lifestyle intervention, and who was on the placebo group and they said, “What is their weight?” They found that there were variable numbers in each of these groups who had lost at least 5% of their weight, about 30% of those taking metformin, about 63% of those in the intensive lifestyle group, and about 13% in the placebo group.

And then they looked at them in years 6 and 15 in the follow-up, and they found that, in fact, it was metformin that was the best with regard to being able to maintain weight loss. It was still not great, but among those agents that we can use to help control diabetes and weight, it sounds like metformin has got some benefit.

Rick: These were adults who were overweight to begin with and they had high blood sugar levels, and they were at risk for type 2 diabetes, but they didn’t have it. Metformin and the intensive lifestyle delayed the onset of diabetes in 38% to 53% of individuals. So this follow up looks specifically at the weight loss, and as you suggested, it looks like the intensive lifestyle gives the most immediate response over the first year, but long term, metformin was more beneficial in keeping the weight down.

Elizabeth: We’ve been seeing an awful lot of information about metformin, of course, and its potential for lots of other indications. As I also said, right now for those who do have frank diabetes, it’s the #1 agent that’s turned to to try to keep that under control. For right now, what would you say about people who are at risk for developing type 2 diabetes? We know that weight is also another factor there. I’m not sure that this study helps us to really determine the relative importance of those things.

Rick: The nice thing is you don’t have to choose between the two. There’s no reason someone can’t be involved with intensive lifestyle modifications, better diet, exercise to decrease the risk of diabetes, and at the same time take metformin. But this is a conversation that the physician or primary care provider can have with a patient who’s at risk for diabetes.

Elizabeth: Why don’t we stay in Annals of Internal Medicine and your next one.

Rick: About 1 in 200 or 1 in 250 women that are pregnant actually have type 1 diabetes, and several studies have linked type 1 diabetes to preterm birth and to adverse outcomes. And actually, preterm birth is the second most common cause of death in children under 5 years of age, so we want to prevent it. Now what’s not clear is whether strict glucose or strict glycemic control can actually decrease the risk of preterm birth. To address this, this was a Swedish study that compared almost 2,500 women with type 1 diabetes who were pregnant with a single child to over 1 million reference infants born to women without diabetes.

So the first thing they did was to compare the preterm birth rate. What they determined was in those that had diabetes it was about 22%, and about 5% in those without diabetes. And it was clearly related to glycemic control. The higher your sugar, the more likely she was to experience preterm birth. Having said that, even in women in whom the hemoglobin A1c was low, that is less than 6.5 or 6, there was still an increased risk.

Elizabeth: When you speculate on the reasons for that, what do you think, and then I guess I would also ask for women who are already being intensively followed because when women are pregnant, of course, they are, what are the barriers to good glycemic control in these folks?

Rick: Oftentimes, women don’t have access to good prenatal care or they’re not taking their medications or they’re not following a diet or the recommended weight gain, so all of those things can contribute to poor glycemic control. It needs to be followed and it needs to be followed very closely. In addition to preterm birth, the increased sugar was associated with the infant having hypoglycemia, respiratory distress, and even stillbirth.

Why could this be? There are effects on the mother, increased oxidative stress that may actually cause increases in chemicals that cause preterm labor. It also induces hyperinsulinemia in the child, and it affects their growth as well, so it affects both the mother and the fetus. The most important thing is to both identify and monitor and then keep it as low as possible.

Elizabeth: And since we’re talking about birth outcomes, let’s turn to the Journal of the American Medical Association. This was a study taking a look at Medicaid expansion and varying rates of low birthweight and other preterm birth outcomes all over the country, both overall and by race and ethnicity, including Hispanics and African Americans or blacks.

They used U.S. population-based data from the National Center for Health Statistics, really a very large number, 15+ million, almost 16 million births, and distributed, as I said, among these different ethnic groups. They had some from the District of Columbia and also from 18 states that expanded Medicaid and 17 states that did not. And they took a look at these outcomes including preterm birth, very preterm birth, low birthweight, very low birthweight, and they said, “If we expand Medicaid, does this help to ameliorate the burden of this?”

So looking between 2011 and 2016, they did not see that Medicaid expansion was very helpful with regard to changing any of these outcomes, although they did see that relative disparities between black infants compared to Caucasian infants in states that expanded Medicaid were reduced, and since we’ve been spending so much time taking a look at those racial disparities and health outcomes, this seems like a pretty reasonable outcome. That, however, was not seen among the Hispanic population.

Rick: This ends up being important because black infants die of complications associated with prematurity and low birthweight at about four times the rate of white infants. And even those children that survive, we know that low birthweight and premature births are associated with complex medical situations really throughout childhood and even into adulthood. So I was surprised that the Medicaid expansion didn’t reduce preterm births in the general population, but was pleased to see, in this particular group, that in the African American or black children, it was a benefit.

Elizabeth: I’m not sure what this suggests, though, and I also am struggling to understand what the causative factors might be.

Rick: That’s one of the limitations of the study. It just identifies there’s a decrease in the disparity, but it really doesn’t get to really what the underlying cause of that is.

Elizabeth: And one, I guess, we’re going to have to follow up in another study. Let’s stay in the Journal of the American Medical Association and turn to your final one, which is looking at sedentary behavior in the U.S. population.

Rick: Prolonged sitting and particularly either watching television or videos has been associated with an increased risk of a number of different diseases and mortality. However, changes in sedentary behavior, especially over the last 15 to 20 years, really haven’t been described well in the United States, so that’s what these investigators undertook. That is a serial cross-sectional analysis of the NHANES, the National Health and Nutrition Examination Survey, among children ages 5 to 11, among adolescents ages 12 through 19, and then adults 20 years or older.

This is over the years from about 2001 to 2016, and they looked at the prevalence of sitting or watching television or videos for 2 hours or more per day. They looked at computer use outside work or school and then total sitting time. What they discovered is when they looked over the 15 years, television watching of 2 hours or more per day, it remained relatively stable, but it was really high, about 60% to 65% of all of those groups spent 2 hours or more per day watching television.

Now the estimated prevalence of computer use outside of school or work for at least an hour a day increased to about 50% to 60% among those groups, and the total sitting time increased from about 7 to 8 hours per day among adolescents and about 5.5 to 6.5 hours per day among adults. So in the U.S. population, it looks like the sedentary behaviors generally remained stable, and they remained high, and in many cases, increased among all age groups over the last 15 years.

Elizabeth: And they tie this to what outcomes?

Rick: No outcomes in particular here, but when you look down the road, we know that sedentary behavior increases the risk of cardiovascular disease and cancer and obesity and hypertension. And importantly, when they looked at specific groups, there were groups in which the sedentary behavior or the increase was particularly high. It was particularly high in men, in blacks, and those individuals that were overweight or already obese.

Elizabeth: We, of course, have also taken a look at lots of other studies that have suggested that even when people get up and move around, and even with people who have largely sedentary jobs, that those things do not offset the deleterious impact of sitting. So what are we going to do about this sitting situation?

Rick: It’s pretty clear that we need to spend less time in sedentary behavior. Now how do you do that? It’s clear that we’ve increased our use of computer time outside of work or school, so that’s an obvious place to reclaim part of that time. As a society, as we increase our sedentary behavior, our chronic diseases are going to increase and our mortality is going to increase as well. These are individual choices we all need to make, but the first thing is to recognize, “Yes, I’m spending too much time in front of the TV or in front of the computer, and I ought to be out doing something, and not only doing something, but socializing as well.”

Elizabeth: Yep, and I would say I guess another part of the long-term solution is changes to the built environment so that people have to walk further when they park their car or buy their groceries or do whatever so that they’re moving.

Rick: Absolutely — take the stairs, a number of different things. We spend minutes driving around the parking lot trying to find a closer parking spot when we ought to be parking further away and doing more walking.

Elizabeth: On that note, that is a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.

Rick: I’m Rick Lange. Y’all listen up and make healthy choices.