Heat and Cardiovascular Death; Time-Restricted Eating or Caloric Restriction in T2D

TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, 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.

This week’s topics include heat and cardiovascular death, time-restricted eating or caloric restriction in people with with type 2 diabetes (T2D), managing nasal airway obstruction, and getting nurses involved in managing opioid use disorder.

0:43 Nasal airway obstruction management

1:44 Measured airflow

2:44 Due to septal deviation septoplasty preferred

3:09 Heat and cardiovascular death

4:09 What is likely to happen?

5:09 Elderly and Black even more increased risk

6:10 Increased cytokine release

6:36 Time-restriction or reduced intake for folks with T2D

7:36 Both had decreased HbA1c

8:36 No increased hypoglycemia

8:44 Engaging nurses in treating OUD in primary care practices

9:44 Engaged physicians to prescribe

10:40 Helped in patients new to the clinic

11:40 Very large number of deaths

13:04 End

Transcript:

Elizabeth: Increasing heat and increasing cardiovascular death.

Rick: Which is better, time-restricted eating or caloric restriction in people with diabetes?

Elizabeth: Getting nurses involved in managing opioid use disorder.

Rick: And managing nasal airway obstruction.

Elizabeth: That’s what we’re talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.

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

Elizabeth: Rick, I’m kind of interested in this paper that’s in the BMJ that’s looking at, “Gosh, how do you manage somebody’s nasal airway obstruction?”

Rick: This is interesting. As you mentioned, it’s from the U.K. There, the National Health Service is interested in directing medical care based upon studies that show that a treatment is effective or not effective.

For example, when someone has nasal obstruction, that’s usually due to a deviated septum. There are two possibilities. One is to treat it medically. That medical treatment can be saline spray and nasal steroids, or the other is to do surgery, called septoplasty. Believe it or not, there aren’t any good randomized trials showing whether one is more effective than the other. Many practitioners in the United Kingdom recommend that we try medical therapy first and reserve surgery for those that don’t respond.

To settle this for once and all, they looked at 378 adults who all had symptoms of nasal obstruction due to septal deviation, and randomized them to either medical therapy or to septoplasty. Their outcome was the score on the Sino-Nasal Outcome Test. That’s called a SNOT test. That is hilarious by the way. They also looked at quality of life and they actually measured airflow.

What they discovered was that the individuals that had surgery had a much better outcome with regard to the SNOT test, they had a better quality of life, and they had better airflow. What’s the downside? Well, about 4% of the individuals that had surgery had to be readmitted to the hospital for bleeding. Those that had medical therapy were more likely to require antibiotics for infections. Overall, what the United Kingdom now is saying is the septoplasty is going to be the preferred initial treatment rather than medical therapy.

Elizabeth: Now, there is a really unique outcome, isn’t it? Most of the time we kick that can down the road and we say, “Let’s see if it gets worse, and then we’ll go to the more invasive kind of an intervention.”

Rick: Yeah. There are several different reasons why someone can have nasal obstruction. We mentioned one, a deviated septum. Some have chronic sinusitis or have allergies. These things probably aren’t responsive or as responsive to surgery as to medical therapy. But for those whose nasal obstruction is due to septal deviation, septoplasty is the preferred therapy.

Elizabeth: My understanding is that the actual procedure has improved significantly, so that there is less bleeding and there is also no need to really pack all of the cavities after the procedure is over.

Rick: Right, and there is more than one procedure. It’s fairly common — they estimated that in the UK there are almost 170,000 of these procedures performed.

Elizabeth: Let’s turn to Circulation. This is rather concerning and it’s something one of the projections relative to climate change that it’s raising this red flag that we all probably need to be paying attention to.

This is a modeling study. It’s “Projected Change in the Burden of Excess Cardiovascular Deaths Associated With Extreme Heat by Midcentury,” so they accord that as 2065, “in the Contiguous United States.”

What the authors did was obtained data on cardiovascular deaths among adults and the number of extreme heat days, which they call a temperature greater than or equal to 90 degrees Fahrenheit in each county — a lot of data here! — in the contiguous United States from 2008 to 2019. Then they looked at model greenhouse gas emissions and shared socio-economic pathways in this same kind of a method all over the United States and said, “OK, given what we know, what is likely to happen going forward?”

Extreme heat was associated with 1,651 excess cardiovascular deaths per year from 2008 to 2019. If we have a relatively modest increase in our greenhouse gases and extreme heat events, by midcentury they expect that to increase to 4,320 excess deaths annually. That’s an increase of 162%.

If we have a more dramatic increase in these greenhouse gases, then the projection is that just shy of 5,500 annual excess deaths will take place. That’s an increase of 233%. We know this already, of course; elderly folks have a greater impact as a result of excess heat. They are going to have a 3.5 times greater increase in deaths under the more conservative scenario compared with those who are not elderly and Black adults are projected to have almost a 5 times greater increase compared with non-Hispanic white adults.

Rick: Those numbers sound pretty daunting. I don’t want to minimize this, because this is something that we can control as a country and globally as well. However, if you look at the big picture, only about 0.2% of all cardiovascular deaths are thought to be attributed to excess or extreme heat. The number is relatively small — the absolute number — but the percentage looks a little bit large.

There are several plausible biologic mechanisms. Excess heat increases heart rate. It increases contractility of the heart. For individuals that already have heart disease, that may be a problem. It also increases inflammation and the risk of thrombosis, or clots forming. These projections make some assumptions that the rate that we see now is going to continue, but we know the medicines are better. I hope we’re around in 20 or 30 years so we can compare these projections to what’s happening actually.

Elizabeth: I agree with that. They also say that this increased cytokine release is something that happens as a result of the excess heat and they counterbalance that with the observation that thermo-protective agents may include statin as something that would help to ameliorate this risk.

Rick: To all our listeners, this may not be on your mind now as we head into winter, but it should be something that heads into your mind as we head into summer about how to protect your heart during times when there is extreme heat.

Elizabeth: Let’s turn now to JAMA Network Open and this look at, “Gosh, should you just cut down on what you eat or is time restriction going to be helpful?” This in folks with type 2 diabetes.

Rick: Elizabeth, we’ve reported on time-restricted eating before, just in terms of overall weight reduction: is it better than other types of diets? I think the general consensus is, in the general population there is really no difference.

This is a study that’s done in adults with type 2 diabetes: time-restricted eating versus caloric reduction. They took three groups. One of the groups they said, “We want you to reduce your calories by 25%.” In the other group, they said, “Listen, we only want you to eat from noon to 8:00 p.m.” In the other group, they just did nothing. That was the control group.

They followed these individuals over a period of 6 months. Those that embarked on time-restricted eating had significantly increased weight reduction compared to those that were on caloric reduction. Both groups had a decrease in hemoglobin A1C and both had similar changes in cholesterol and blood pressure as well.

When you looked at the caloric intake, it was 313 calories less with time-restricted eating and only 197 calories less with caloric reduction. Furthermore, those that did the time-restricted eating, it was easier to follow.

Elizabeth: First of all, I’ll just point out that we only had 75 participants in this study and they were kind of younger, which is a nice thing to see, a mean age of 55 years. What would be the mechanism by which time-restricted eating would be beneficial in people with type 2 diabetes versus those with, I’m going to call it, typical physiology?

Rick: Elizabeth, I don’t have an answer for that. I wish I did and your point is well taken. This is a relatively small study, 25 patients in each group. If we roll this out to a larger group, will we see the same results? I don’t know. The other thing that oftentimes people worry about is, if you’re not eating during 16 hours of the day and you’re diabetic, will those individuals develop hypoglycemia? That wasn’t the case in this study.

Elizabeth: Let’s turn now to JAMA Internal Medicine and this is a look at trying to engage nurses in the treatment of opioid use disorder in primary care practices. It turns out that very few primary care practices treat patients with medications for opioid use disorder even though we’ve got some stuff that really seems to help. There have been some previous barriers to physicians in primary care using some of these medications, but those have been largely eliminated, so it’s questionable why that continues, although it’s just sort of one more thing that I’m sure primary care docs are like, “Wow, I got enough on my plate already.”

There is a model that was originally developed in Massachusetts where nurses get involved in the management of opioid use disorder in primary care practices. They used either buprenorphine or extended-release injectable naltrexone.

They implemented this particular model in six diverse health systems across five U.S. states. They also engaged the physicians into the prescription of these particular medicines. They call this the PROUD intervention model. That stands for Primary Care Opioid Use Disorders treatment trial. They had three components: a full-time opioid use disorder nurse care manager; technical support and training for this nurse care manager; and three or more primary care clinicians who agreed to prescribe buprenorphine.

They found out ultimately that these clinics ended up providing 8.2 more patient years of outpatient opioid use disorder treatment per 10,000 primary care patients compared with those practices that were the control groups. Most of this benefit accrued in only two of these health systems that they studied and here is the really important caveat. In patients who were new to these clinics, it did not impact on the utilization of healthcare resources by people who had opioid use disorder, but they wonder if that had something to do with the relatively short follow-up.

Rick: We’re throwing a lot of resources. We’re trying to make it personalized. We have individuals that have special training with respect to this and that’s our focus. We’re still not able to make a large dent. Why is that?

Elizabeth: When I was reading this study, I recall a patient that I had in the chaplain role who had lost her upper extremity on the left side because of opioid use disorder. I asked her about it. I said, “Is this just so amazing that every time you do it, it’s so compelling that you can’t not do it?” She said, “No, it’s not that. It’s that every time I do it, I’m trying to get back to the experience I had with it the first time.”

I also see so many people who are reversed with naloxone. I feel like we got to do something and so that’s why this study caught my attention. We have reported on the really unbelievable number of opioid deaths that continue to take place. All that to say, maybe it is that there is this relative lack of long-term follow-up with regard to efficacy and this particular strategy.

Rick: From the standpoint of the clinician who is doing their best to decrease acute care utilization among patients with opioid use disorders, this is both disconcerting and disappointing as well.

Elizabeth: Absolutely, and I agree. I think that we need to go back somehow to the drawing board, and maybe that means actually inquiring of people with opioid use disorder, “Hey, how can we best help you?” This, of course, not a new idea. But maybe one thing that’s happening here is a lack of engagement with the person who actually is experiencing this disorder.

Rick: Right. I hope there are additional studies that help us find an effective treatment plan.

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

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