488 - Eczema Self-Management, “Dirty Dozen” 2023, Removing Your Mask?

From the Literature

1)  Online Resource for Eczema Self-Management Support

Eczema (atopic dermatitis) is one of those conditions that I’m not sure we pay enough attention to. The global prevalence varies widely, with a reported prevalence in Sweden of 47%! In the US, the prevalence rates are: children 0-5 ~20%, older children ~15%, and adults ~7-10%. The impacts of poorly controlled eczema include: risk of infection, quality of life, self-image, overuse of oral steroids, etc. Treating eczema involves a lot of education and self-management – avoiding triggers, consistent use of emollients, deliberate and careful use of steroids and other flare control agents.

An academic collaboration from the United Kingdom developed an online education and self-management support platform (https://www.eczemacareonline.org.uk/) using solid behavioral theory and implementation science principles. The site targeted both young people with eczema and caregivers for smaller children with eczema.

They then conducted a very elegant and largely remote evaluation of the effectiveness of this website in patients (and caregivers). The study enrolled young people (age 13-25 years) or caregivers of younger patients (age 0-12 years) with at least moderate eczema as rated on the POEM scale (patient-oriented eczema measure), an internationally validated standard patient-reported outcome measure for eczema. The researchers also used this scale as the primary outcome measure, looking for a minimum clinically important difference of 2.5 points on the 28-point scale.

They randomized the participants into usual care and website use in two separate studies – one for young people and one for caregivers. The study procedures were otherwise the same. The study could not be blinded, but all randomized subjects were accounted for, and there was careful attention to the procedures in the study so as not to bias the groups. The investigators measured POEM score and a variety of secondary measures monthly throughout the active 24-week intervention and through 52 total weeks of follow up.

The groups using the website each achieved a statistically significant reduction in POEM score by 1.5 points for caregivers and 1.9 points for young people (although this was below the minimal clinically important difference cited above) at the 24-week endpoint. The authors then examined the number of subjects in each trial that did achieve the 2.5 point minimal difference and found significant benefit from the website. For caregivers, 58% of website users and 39% of controls decreased their POEM score by 2.5 - odds ratio (OR) 2.1, absolute risk difference (ARD) 19%, number needed to treat (NNT) 6, 95% confidence interval (CI) 3 to 13. For young people, the numbers were 56% of website users, 39% of controls – OR 2.0, ARD 17%, NNT 6, 95% CI 4 to 18. The differences between users and controls in both trials persisted through 52 weeks.

There were no harms recorded in either group. The secondary outcomes did not show significant differences except for more consistent emollient use by self-report for website users in the caregiver trial. The authors note that the trial was limited by no observational outcomes but point out that the visits required for direct observation of eczema status would constitute an intervention and could dilute the effectiveness of the online education.

John’s Comments:

I really like how simple this trial is. It’s not necessarily the cure for eczema, but both the trials and the website were well-designed and free of pharma influence, and using the site did seem to help (with an NNT of 6!). I plan to include the website (https://www.eczemacareonline.org.uk/) in my eczema education smart phrase. And who knew “POEM” meant both “patient-oriented outcomes that matter” (our favorite usage) and “patient-oriented eczema measure”?

References:

·        Hadi HA, Tarmizi AI, Khalid KA, Gajdács M, Aslam A, Jamshed S. The Epidemiology and Global Burden of Atopic Dermatitis: A Narrative Review. Life (Basel). 2021;11(9):936. Link  

·       Santer M, Muller I, Becque T, et al. Eczema Care Online behavioural interventions to support self-care for children and young people: two independent, pragmatic, randomised controlled trials. BMJ. Published online December 7, 2022:e072007. Link

From the Environmental Working Group (EWG)

2)  The Fresh Produce “Dirty Dozen” 2023

The Environmental Working Group (EWG) is a nonprofit organization focused on human health and the environment.  Since 2004, EWG researchers have published an annual report regarding pesticide content in fruits and vegetables called the “Dirty Dozen” and the “Clean 15,” creating the rankings based on laboratory tests done by the FDA and the U.S. Department of Agriculture's Pesticide Testing Program.

The 2023 guide includes data from 46,569 samples of 46 fruits and vegetables. The USDA peels or scrubs and washes produce samples before testing, whereas the FDA only removes dirt before testing its samples. Even after these steps, the tests still found traces 251 different pesticides.  Some of the USDA’s tests show traces of pesticides long since banned by the Environmental Protection Agency. 

The 2023 “Dirty Dozen” list, in descending order, is:  1. Strawberries; 2. Spinach; 3. Kale, Collard, and Mustard Greens ; 4. Peaches; 5. Pears; 6. Nectarines; 7. Apples; 8. Grapes; 9. Bell and Hot Peppers; 10. Cherries; 11. Blueberries; 12. Green Beans;

A total of 210 different pesticides were found on Dirty Dozen items.  Of those, over 50 different pesticides were detected on every type of crop on the list, except cherries.  More than 90%t of samples of strawberries, apples, cherries, spinach, nectarines and grapes tested positive for residues of two or more pesticides.  Kale, collard and mustard greens, as well as hot peppers and bell peppers, had the most pesticides detected of any crop — 103 and 101 pesticides in total, respectively.  The neurotoxic organophosphate insecticide acephate, prohibited from use on green beans in 2011, was detected on six percent of green bean samples.

The 2023 "Clean 15'' is a list of the produce least likely to contain pesticide residue. The 2023 list, in descending order, is:  1. Avocados; 2. Sweet corn; 3. Pineapples; 4. Onions; 5. Papayas; 6. Sweet Peas; 7. Asparagus; 8. Honeydew Melons; 9. Kiwis; 10. Cabbages; 11. Mushrooms; 12. Mangos; 13.  Sweet Potatoes; 14. Watermelon; 15. Carrots

Almost 65 percent of the Clean 15 samples had no detectable pesticide residues.  Avocados and sweet corn were the cleanest produce – less than 2% of samples showed any detectable pesticides. Just over 10% of Clean 15 samples had residues of two or more pesticides.  No sample from the first six Clean 15 items tested positive for more than three pesticides.

Mark’s Comments:

EWG’s Dirty Dozen is meant to help customers who are concerned about pesticide consumption understand which conventionally grown produce is most contaminated with pesticide residues.  It is difficult to estimate the extent of the health hazard from this, as there are many variables (amount of exposure, type of toxin, etc.). Unfortunately, there are no cleaning processes that can effectively eliminate toxins but washing with water has been shown to be beneficial in at least removing some of the pesticide residue.

Critics not involved in the report say they worry the list will discourage people from eating fruits and vegetables.  Certainly, minimizing exposure as much as possible would seem to be prudent, which may mean avoiding or buying organic for the “dirty dozen.”  However, the EWG does recommend eating produce even from the Dirty Dozen rather than foods or snacks that are less healthy, such as processed foods laden with fat, sugar or additives.

Note that the government labels as “organic” food grown without synthetic chemicals or fertilizers, genetic engineering, radiation, and sewage sludge.  In general, organic food is more expensive and not accessible to many. 

References:

·       Environmental Working Group.  EWG’s 2023 Shopper’s Guide to Pesticides in Produce™.  March 15, 2023.  Link

·       Frequently Asked Questions about Produce and Pesticides: FAQ

From PeerRxMed ( www.PeerRxMed.org )

3)  Masking Optional!  Time to Remove Yours? 

“Wearing a mask wears you out. Faking it is fatiguing.” – Rick Warren

It finally happened!  On March 13^th, literally 3 years from the day it went into effect, the “mask mandate” in our organization was lifted.  What I thought would be a day of great elation was rather a bit strange and uncomfortable for me, and for many others as well.   It was literally the first time I had ever seen the faces of some of our care team – and they mine!  I felt a bit “exposed,” almost as if I needed to retrain my face as I tried to remember who the “real me” is behind my mask ….

Masks are a visual representation of something we’ve been doing our entire professional lives.  Our “professional persona” masks are part of the “medical attire” that we were trained and encouraged to wear from early on in our professional identity formation.  Just as it may not be easy for some of us to become immediately comfortable removing our “COVID” masks, as they have served as a form of “protection,” removing our professional identity mask is even more challenging, as it has helped get us where we are and can often serve as “protection” from the worlds within and beyond medicine.

Recently a colleague and friend “called me out” regarding some mask-wearing that I was doing with them around a dynamic at work for which I feel very passionate, but around which I was glossing over some strong and challenging emotions I was feeling, including disappointment and anger.  After our conversation, I was reminded of some wise words shared with me a few years ago by Corey Martin, MD, another colleague who is one of my PeerRxMed partners (https://www.innovationsinresilience.com).  He also “called me out” regarding some mask-wearing that I was doing with him when I was experiencing a bit of an emotional pity party around a health issue but was deflecting his overtures to offer support.  Here’s some of what Corey wrote to me about my “mask” after our call (shared with permission and gratitude): 

“The story you tell yourself is that people don’t really want to hear about it so just suck it up.  I will tell you that being on the other side and listening to you through this time what I wanted more than anything from you was for you to REALLY open up and let me know about how much it sucked.  That’s what connecting is for me and makes me feel like we are all in this together.  It also gives me the opportunity to try to help….  When we open up and talk about the dark underbelly of our life it may feel like it’s easier to put on the happy face but opening up really is what gets us what we so crave in life and need… love and connection.  When we put on the happy face, we are also denying others the joy of being able to help us through tough times…. When we don’t talk about our pain, who do we think we are to deny someone who cares about us the joy of helping us?!  Opening up is something we as physicians are not great at so we need to encourage this and call each other out when necessary.  That’s my ask of you as well.” 

Thanks for the gift, Corey.  You are so right!  While wearing my “COVID mask” has indeed worn me out, it has not done so nearly as much as wearing my “professional mask” has.  I’m blessed to have colleagues who will “call me out” when I put mine on, but too many of us continue to be quite skilled at hiding behind our professional mask, even as we remove our literal ones.  Be sure you’re not one of them.  Invite your PeerRx partner to help you “remove your mask” – or at least allow them a glimpse behind it.  It is behind that mask where our healing journey and authentic life begin … and they’re waiting with eager anticipation.  

______________

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