479 - Whole Health for Long COVID, Pediatric Obesity, Metta not Meta

From the Veterans’ Administration

1)     VA “Whole Health” Approach to Long COVID-19

The VA has released a “guide” (not a guideline, since the Department of Defense/VA have a very structured process for evidence-based guideline production) for the management of long COVID-19 symptoms. This guide is 31 pages of dense information, which we will only summarize and highlight here (see the link in the reference below for the full guide). The Office of Research and Development at the VA and the VA Long COVID “Community of Practice” call this guide “evidence-informed” and will be updating this document as new evidence is available.

The document lists the several definitions of long COVID from multiple organizations but starts with the NIH and CDC definition: “new or worsening symptoms” from “4 weeks

after onset” of COVID-19 infection. Other definitions are like this one, but with different time frames. There are no other restrictions – there is a long list of different symptoms that may comprise this syndrome and the symptoms may wax and wane and improve or resolve at different times.

Below is a list of the symptoms most particular to long COVID sequelae with some diagnostic and management highlights for each. For the other long COVID symptoms (headaches, cough, fatigue, depression/anxiety), workup and management does not differ from those without antecedent COVID-19, and it is important to ask about the presence of these symptoms prior to COVID-19 infection. Referral may be needed if the symptoms are difficult to manage or are particularly severe.

Anosmia/Dysgeusia – 46% at 4 weeks, 16% at 2-3 months.

·         Can be associated with other neurologic symptoms, or dysosmias (abnormal smells).

·         Consider sinusitis/persistent rhinitis as etiology.

·         Consider speech-swallowing referral or occupational therapy for smell retraining, ENT, or neurology for accompanying symptoms.

Autonomic Dysregulation – 48 to 60% have some symptoms at 4 weeks

·         Palpitations, lightheadedness, dizziness, fatigue, blurry vision, falling, presyncope and decreased exercise tolerance

·         Orthostasis (hypotension or tachycardia) is key – test with orthostatic vital signs

·         Rule out causes from dehydration, deconditioning, neurologic conditions, cardiac and pulmonary disorders.

·         Treatment is like that for POTS (postural orthostasis-tachycardia syndrome) - fluid intake, judicious use of salt (ensure no heart failure), and lifestyle modification to prevent/manage dizziness episodes.

·         Recumbent exercise progressing in graded fashion to upright exercise

·         Frequent, small meals, avoid alcohol

Chest Pain – 5% after 12 weeks.

·         High risk of both coronary artery disease and myo-/pericarditis and venous thromboembolic disease – low threshold to evaluate for these

·         For pleuritic pain not associated with disease – diaphragmatic breathing, stretching, short course NSAIDs.

Cognitive Impairment – 60% at 4 weeks, 23% at 8 months in some studies.

·         Symptom subcategories include Attention (Brain fog, lost train of thought, concentration problems), Processing Speed (Slowed thoughts), Motor Function (Slowed movements), Language (Word finding problems, reduced fluency), Memory (Poor recall, forgetting tasks), Mental Fatigue (Exhaustion, brain fog), Executive Function (Poor multitasking and/or planning), Visuospatial (Blurred vision, neglect). Assess each subcategory.

·         Consider workup for other causes of dementia/cognitive impairment, including medications, sleep disturbance, substance use. Labs (consider B12, thyroid, RPR and glucose), but unless other neurologic symptoms are present, MRI/CT are not helpful.

Additional symptom categories include fatigue, cough, dyspnea, headaches, and mental health. Again, the evaluation of these symptoms should very similar to usual practice.

The final “cardiometabolic and autoimmune” symptom category in this guide notes the increased risk of most cardiovascular disease (CAD, CHF, etc.), diabetes, CKD, and rheumatoid arthritis in post-COVID patients. More frequent testing and/or a low threshold for additional testing is recommended as one way to manage these risks.

Throughout the guide, the authors recommend shared decision-making for each symptom complex and workup. In addition, as a “whole health” guide, they caution to be mindful of pregnancy and lactation concerns with any management options and include possible complementary and alternative treatments for the symptoms.

John’s Comments:

As we navigate the winding down of this pandemic, more patients will present to us with persistent symptoms. This sort of guide can help organize our thoughts about and workup of persistent symptoms so that we can primarily care for these patients in our practices, rather than shuffling them around to clogged specialist offices. This guide is not exclusively “evidence-based,” but most of the recommendations for both diagnosis and management are well within the scope of primary care.

Reference:

·         Office of Public/Intergovernmental Affairs, Veterans’ Administration. VA releases whole health approach to Long COVID. Accessed January 11, 2023. Link

From the Guidelines and the American Academy of Pediatrics (AAP)

2)      Evaluation and Treatment of Obesity in Children and Adolescents

The current and long-term health of 14.4 million children and adolescents is affected by obesity, making it one of the most common pediatric chronic diseases. Long stigmatized as a reversible consequence of personal choices, obesity has complex genetic, physiologic, socioeconomic, and environmental contributors. As the environment has become increasingly obesogenic, access to evidence-based treatment has become even more crucial.

To that end, the AAP recently published a clinical practice guideline (CPG) aimed at informing clinicians who provide pediatric health care about the standard of care for evaluating and treating children with overweight and obesity and related comorbidities. The CPG promotes an approach that considers the child’s health status, family system, community context, and resources for treatment to create the best evidence-based treatment plan and is based on a comprehensive evidence review of controlled and comparative effectiveness trials and high-quality longitudinal and epidemiologic studies.

Based on this evidence, the CPG provides Key Action Statements (KASs), and Appendix 1 in the CPG contains an algorithm to guide care based on these KASs (See references). KASs are supplemented by Consensus Recommendations that provide expert opinion on topics not covered in the original technical reports. These are supported by AAP-endorsed guidelines, clinical guidelines, and/or position statements from professional societies in the field of obesity, and an extensive literature review.

Evidence Quality (A, B, C) and Strength of Recommendation (Strong, Moderate, Weak) are included for each KAS. The KASs include:

·         Should measure height and weight, calculate BMI, and assess BMI percentile using age- and sex-specific CDC growth charts or growth charts for children with severe obesity at least annually for all children 2-18 y/o to screen for                        overweight (BMI ≥85th to <95th percentile), obesity (BMI ≥95th percentile), and severe obesity (BMI ≥120% of the 95th percentile for age and sex). (B/Moderate)

·         Evaluate 2-18 y/o with overweight and obesity for obesity-related comorbidities by using a comprehensive history, mental and behavioral health screening, SDoH evaluation, physical exam, and diagnostic studies. (B/Strong)

·         Treat overweight or obesity and comorbidities concurrently. (A/Strong)

·         In children > 10 with overweight and obesity, evaluate for dyslipidemia, abnormal glucose metabolism, and NAFLD by obtaining a fasting lipid panel (B/Strong), ALT (A/Strong), and fasting plasma glucose, 2-h plasma glucose after 75-g            oral glucose tolerance test (OGTT), or HA1c) (B/Moderate). May evaluate for dyslipidemia in children 2-9 with obesity. (C/Moderate)

·         Evaluate for hypertension by measuring blood pressure at every visit starting at age 3 for those with overweight and obesity. (C/Moderate)

·         Treat overweight and obesity following the principles of the medical home and the chronic care model, using a family-centered and nonstigmatizing approach that acknowledges obesity’s biologic, social, and structural drivers.                              (B/Strong)

·         Use motivational interviewing (MI) to engage patients and families in treating overweight and obesity. (B/Moderate)

·         Provide or refer children > 6 (Grade B) and may provide or refer children 2 -5 (Grade

C) with overweight and obesity to intensive health behavior and lifestyle treatment, which is more effective with greater contact hours. The most effective treatment includes 26 or more hours of face-to-face, family-based, multicomponent treatment over a 3-12 month period.

·         Offer adolescents > 12 with obesity weight loss pharmacotherapy, according to medication indications, risks, and benefits, as an adjunct to health behavior and lifestyle treatment. (B)

·         Offer referral for adolescents > 13 with severe obesity for evaluation for metabolic and bariatric surgery to local or regional comprehensive multidisciplinary pediatric metabolic and bariatric surgery centers. (C)

Additional Notable Consensus Recommendations (abridged):

·         Obtain a sleep history, including symptoms of snoring, daytime somnolence, nocturnal enuresis, morning headaches, and inattention, among those with obesity to evaluate for OSA.

·         Obtain a polysomnogram for those with obesity and at least one symptom of disordered breathing.

·         Evaluate for menstrual irregularities and signs of hyperandrogenism (ie, hirsutism, acne) among female adolescents with obesity to assess risk for PCOS.

·         Monitor for symptoms of depression in those with obesity and conduct annual evaluation for depression for those > 12 with a formal self-report tool.

Mark’s Comments:

This guideline takes a rather substantial turn from the last comprehensive AAP guideline in 2006. Though there have been documents encouraging incremental shifts since then, the AAP appears ready to tackle this individual, family, and public health issue head on rather than tiptoeing around it with a previous quite unsuccessful approach that could best be described as “watchful waiting.” One significant challenge is that the infrastructure to provide many of the services advocated for don’t exist today, at least in any consistent fashion. There will also likely be reimbursement issues to navigate and biases regarding childhood obesity that will have to be overcome.

Of note, the FDA approved the GLP-1 receptor agonist semaglutide (Wegovy) on December 23, 2022 for teens ages > 12 who have a BMI at or above the 95th percentile for their age and sex. Combined with aggressive lifestyle interventions, perhaps we have now entered a new era for the management of this pervasive challenge. Stay tuned for a follow-up guideline from the AAP on the prevention of obesity soon.

References:

·         Hampl SE, et al. Executive Summary: Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents with Obesity. Pediatrics. January 9, 2023; DOI: 10.1542/peds.2022-060640. Link

·         Algorithm for Diagnosis and Management: Algorithm Link

From PeerRxMed ( www.PeerRxMed.org )

3)      It’s Metta (not Meta) Time

“ … upping your love game is anything but boring. It’s countercultural because it cuts against the never-enoughness and always-behindness that society seems to want us to feel.” Dan Harris, Author and Journalist

Much has been made of the name change of the parent company of Facebook from Facebook, Inc., to Meta Platforms, Inc. (“Meta” for short) to reflect its focus on building the “metaverse.” The metaverse, in science fiction, is a hypothetical iteration of the Internet as a single, universal, and immersive virtual world that is facilitated using virtual reality (VR) and augmented reality (AR) headsets – a world that would form an alternate, parallel version of “reality” which for many has the potential to serve as an “escape.”

There is another concept that is intended to alter our perceptions of “reality” in a way that can truly enhance social connection as well as provide many other benefits. While it is pronounced the same as meta, Metta, a word that originated in ancient India and became popularized through Buddhism, is not some science fiction construct, but rather the expression of a desire for benevolence, loving-kindness, and good will toward all living beings – a universal, unselfish, and all-embracing love. For those who embrace Metta, their desire is not to “escape” their present reality, but rather to change their perception of it, starting by changing how they view themselves.

The doorway to this transformation is through Metta Meditation, a structured process that allows an emotional shift to occur by directing thoughts of well-being, happiness, safety, and peace toward oneself, others, and the world. With regular practice, one can develop this intentional expression of compassion and love like any other skill so that it becomes natural and habitual. Doing so has been shown, among other positive effects, to attenuate the stress response, increase compassion, decrease bias, and curb self- criticism, all with lasting impact through ongoing use.

It is this form of Metta that I practice routinely and tap into on those days when I’ve exceeded my tolerance threshold and feel frustration spilling over, whether it be with challenging circumstances, other people, or my own imperfections. By doing so, I bring a more compassionate, open-hearted self to the world. “May I be happy,” I repeat as I take a moment to reground myself. “May I be well, may I be free from suffering … may you be happy, may you be well …”

Given the present challenges within healthcare (and the wider world), there are plenty of opportunities for such a practice to come in quite handy. That has certainly been my experience. Why not give it a try with this video guide! Afterall, embracing a Metta mindset has the potential to bring about life-giving interconnection that a wearing a virtual reality headset will never achieve. I’m in …

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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