459 - Targeted Obesity Prevention, Polio Vaccine for Adults, Emotional PPE

From the Guidelines

1)    Behavioral Counseling for Obesity Prevention in Women 40-60

More than 70% of women aged 40-60 in the US have a body mass index (BMI) that is categorized as either overweight (BMI 25 to 29.9) or obese (BMI >30). Obesity rates vary across racial and ethnic groups and are highest among non-Hispanic Black women (56.9%), followed by Alaska Native/American Indian (48.1%), Hispanic (43.7%), non- Hispanic White (39.2%), and Asian (17.2%) women.

Women are particularly susceptible to weight gain during midlife, averaging a yearly weight gain of 1.5 pounds. Weight gain during the menopausal transition is common and can be attributed to factors unique to this life stage, including aging, hormonal changes, reduced physical activity, and changes in body composition, among others. Compared with other hormonally driven changes in women, such as menarche and pregnancy, hormonal changes influencing weight gain during midlife often correspond to increases in fat mass and abdominal adiposity, which are independent risk factors for cardiovascular disease. Additional contributors to weight gain include individual factors, such as genetics, health behaviors, dietary patterns, and comorbid illnesses, and societal factors, such as environment, education, income, and food marketing. Overall, less than 20% of women meet physical activity (PA) recommendations for aerobic exercise or muscle strengthening activity.

Despite the unique characteristics of this demographic, there are currently no clinical recommendations on obesity prevention for women in midlife. This systematic review, performed by the Women’s Preventive Services Initiative (WPSI), a national coalition of women’s health professional organizations and patient advocacy representatives launched by ACOG in 2016 (and including representation from the AAFP and the ACP), was carried out to address this gap by evaluating evidence on the effectiveness and harms of behavioral interventions to prevent weight gain and obesity and improve function, quality of life, and obesity-related health outcomes in women aged 40 to 60 years without obesity.

Seven RCTs in 12 publications (n = 51 638) were included. Four RCTs showed statistically significant favorable differences in weight change for counseling interventions versus control groups (mean difference of weight change, −0.87 to −2.5 kg), whereas 1 trial of counseling and 2 trials of exercise showed no differences; 1 of 2 RCTs reported improved quality-of-life measures. Interventions did not increase measures of depression or stress in 1 trial; self-reported falls (37% vs. 29%; P < 0.001) and injuries (19% vs. 14%; P = 0.03) were higher with exercise counseling in 1 trial.

Trials were generally small, heterogeneous, and lacked data on harms, long-term health outcomes, and specific patient populations.

The WPSI concluded that given the prevalence and burden of obesity in women, the increased risk for weight gain during midlife, the potential to prevent many chronic health conditions, and supportive evidence of benefit of behavioral interventions to prevent weight gain with minimal harms, they recommend counseling midlife women aged 40 to 60 years with normal or overweight BMI (18.5 to 29.9 kg/m2) to maintain weight or limit weight gain to prevent obesity and its associated health conditions.  Counseling may include individualized discussion of healthy eating and physical activity. This may result in modest differences in weight change without causing important harms.

Mark’s Comments:

This article caught my attention both because of where it was published and also because of its targeted and preventive premise. I greatly appreciate the author’s attempt to destigmatize weight gain for women in midlife. This is important for this particular group.

However, it is essential to note what is not addressed by the authors based on their focused population. According to the most recently published data from the National Health and Nutrition Examination Survey (NHANES), in 2017–2018, the age-adjusted prevalence of obesity in adults was 42.4%, and there were no significant differences between men and women among all adults or by age group. Thus, it appears that weight gain in midlife is a cultural problem, not a gender problem, and while causes and targeted interventions may be gender-specific, it’s not a stretch to believe these findings regarding lifestyle interventions are applicable across our entire US population.

Weight gain for midlife adults in the US is not inevitable, but when looking at obesity trends over the past 20+ years, it often seems that way. Overcoming that momentum will require active, intentional, and relentless intervention at the level of the individual, the family, the community, and the culture as a whole. As leaders in health care and in our communities, we owe it to those we care for to do nothing less.

References:

·         Chelmow D, et al. Preventing Obesity in Midlife Women: A Recommendation From the Women’s Preventive Services Initiative. Ann Int Med. Published Online August 2, 2022. Link

·         Canter A, et al. Preventing Obesity in Midlife Women: A Systematic Review for the Women's Preventive Services Initiative. Ann Intern Med. Published Online 2 August 2022. Link

From the Centers for Disease Control and Prevention (CDC)

2)    Can and Should Unvaccinated Adults Get the Polio Vaccination?

Before the news of a case of polio in New York a couple of weeks ago, we rarely thought of polio vaccination for adults. The standard CDC recommendations for polio vaccination are: “Most adults do not need polio vaccine because they were already vaccinated as children and their risk of exposure to polioviruses in the US is minimal.”

The first case of polio in the US in a decade is instructive – the unvaccinated individual from New York acquired a strain of poliovirus that was descended from an attenuated oral poliovirus strain used in vaccination campaigns outside the US. This strain had mutated back to a virulent form. Of note, health officials in New York are bracing for additional cases as the virus has been found in wastewater surveillance in two counties in the area.

We stopped giving oral poliovirus vaccination in the US in 2000 because the only cases that occurred in the US were vaccine-associated and because our rates of vaccination were felt to be high enough (over 80%) to prevent significant spread if the virus appeared in a community.

The New York State Health Department is recommending that previously unvaccinated adults in the area get vaccinated with injectable poliovirus vaccine (IPV) and are hosting local vaccination clinics. A significant barrier to obtaining this vaccine for adults is the heterogeneous insurance coverage of the vaccine. It has been viewed mostly as a travel vaccine for adults, and therefore inconsistently (usually not) covered by insurance. The cost for a single IPV vaccine is estimated to be between $50 and $150. The recommended schedule for an adult is a series of 3 doses: 2 doses of IPV administered at an interval of 4–8 weeks and a third dose administered 6–12 months after the second. In the setting of a local outbreak, public health agencies will typically offer free vaccines.

John’s Comments:

It is probably worthwhile to advise your unvaccinated adults to check their insurance coverage and local public health agencies for poliovirus vaccination. The virus can circulate in communities undetected until it causes paralysis in a vulnerable individual, so promoting high rates of vaccination for children and adults in your community is the best strategy.

References:

·         Shanahan E. New York May Face ‘Tip of the Iceberg’ With Polio, Health Chief Says. The New York Times. Published August 5, 2022. Accessed August 10, 2022. Link

·         Ask the Experts: Polio Vaccines. Accessed August 10, 2022. Link

From PeerRxMed ( www.PeerRxMed.org )

3)    Restocking Your E-PPE

“When dealing with people, remember you are not dealing with creatures of logic, but with creatures of emotion.”            Dale Carnegie

“Will this #&@$ pandemic ever end!?!” So were the honestly transparent emotions shared by a colleague who had 2 care team members out with positive COVID tests this past week. I didn’t bother to try and answer the question, but certainly could relate to the sentiments. Last year our collective will and emotional reserves were running on fumes. Little did I know that one year later, staff turnover and an overall lack of staffing would be the catalyst for an emotional breaking point for so many.

Here’s what I’m seeing (and often experiencing): anger, frustration, resignation, fear, demoralization, agitation, angst, weariness, exasperation, guilt, shame – just to name a few. While a year ago many of us were emotionally raw, we now seem to be feeling more emotionally spent. We’ve just “had enough.” As I hear of more and more colleagues “losing it” in the midst of clinical responsibilities (and I think, “Yeah, I get it even as I know it’s wrong.”), it becomes painfully obvious how many others are teetering on that same edge as they struggle to hold it together. I can see it in their eyes.

With the many “pseudo-ends” of the pandemic past us and as our seemingly unrelenting challenges continuing, the resulting spread of negative emotional contagion demands that we heighten our “protection” yet again, both for ourselves and others. As such, maintaining an adequate supply of emotional PPE (E-PPE), donning it appropriately, and stocking up for the fall is essential to our present and near-future well-being. Here’s how that might look:

Mask – Allow your E-PPE mask to be a reminder that words matter. Watch yours carefully, being mindful to not spread any negative emotions to others. Additionally, insist that others wear their “word filters” around you in order to block the spread of any of their own negative emotions. Because it can sometimes be difficult to understand the speech of those wearing masks, clarify anything that sounds concerning to you and assume positive intent. And look for opportunities to “unmask” for smiles and laughter. We sure need those now more than ever.

Goggles/Face Shield – While most of us have abandoned our physical goggles or face shield, your E-PPE version is more essential now than ever. Have an even greater awareness of making eye contact when speaking to others. While wearing these, sometimes your vision can become foggy, so be sure to regularly seek the perspective of others to clarify what it is you think you are experiencing.

Gloves and gown – Use appropriate E-PPE protection and distancing when necessary, but don’t allow caution to become a barrier to essential relationships and life-giving connection, including the vital human need for physical touch, be it a fist pump, elbow bump or hug.

Remember, even as physical PPE appears to be in sufficient supply for the short-term, it is our collective emotional PPE that is more important than ever for the protection of ourselves and others. The good news is that we don’t need to depend on a supply chain to replenish our stocks. Emotional PPE is in abundant supply, so if you feel yours is running low, a colleague (your PeerRxMed buddy for one!) is always there to help.

Commiserate as needed, and then support each other to get to a more life-giving place. In these emotionally laden times, we need to be remembering that now more than ever. No one should care alone … ever ….

NOTE: For those of you who may be struggling emotionally, please access the many resources available to you, included the Emotional PPE Project, a free mental health service started by some colleagues during the pandemic. Here’s the Link

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org