Global COPD Burden; Driving Restrictions After Fainting?

Allergies & Asthma

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 the best medications for insomnia, calorie labeling of supermarket foods, the global burden of chronic obstructive pulmonary disease (COPD), and restricting driving in people who faint.

Program notes

0:40 Fainting or syncope and driving restrictions

1:40 Followed after emergency department (ED) visit for 6 months

2:40 Not able to assess risk better

2:55 Pharmacologic treatment of insomnia

3:55 Two medications with favorable profile

4:55 Melatonin had no effect

5:20 Worldwide burden of COPD

6:20 More people with it even with declining percentage

7:25 Women disproportionately affected in low income countries

7:50 Labeling of prepared foods in supermarkets

8:50 Bakery and deli items decreased

9:50 Education not sufficient for behavior change

10:50 An app that might help

11:50 Business must be involved in change

12:39 End


Elizabeth: What’s the best pharmacologic intervention for insomnia?

Rick: The worldwide burden of what’s known as chronic obstructive pulmonary disease.

Elizabeth: Does labeling prepared foods in supermarkets help people consume less?

Rick: And should people that faint be restricted from driving a motor vehicle?

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, how about if we turn first to JAMA Internal Medicine? This is this issue of what you served up as fainting or known in the parlance as syncope. It happens to lots and lots of folks. Does it mean that they should stop driving?

Rick: Absolutely. As you mentioned, syncope is characterized by a sudden loss of consciousness. When these people present to the emergency department for evaluation, we try to ascertain what the cause is. There are a number of different things that can do that, but oftentimes they are instructed not to be driving after that.

What these investigators attempted to do was to say, “Well, gosh, is that really the case, especially compared not to the general population, but to other people that have also been to the emergency department recently?”

This is a population-based study. It’s a retrospective study — and it’s obviously observational — looking at motor vehicle crashes after the first episode of syncope. They looked at 6 different urban emergency departments of people that presented with syncope or collapse. They matched those to four control patients that came to the same emergency departments during the same time, but for a different condition.

They followed these individuals over the course of 6 months. After looking at over 44,000 patients, 20% of them had fainted and the other 80% had not. Those that have syncope did not have a different crash rate. Both groups had a 50% increased risk compared to the general population, but the fact that the person presented with syncope, or fainting, didn’t increase their risk over 6 months. In fact, it didn’t even increase over the first 30 days.

Elizabeth: Is the take-home here that everyone who comes to the ED ought to have driving restrictions?

Rick: That’s the interesting thing, Elizabeth. Should we be screening all of these individuals more carefully and trying to ascertain which of these are the highest risk of having a motor vehicle accident? About 10% had some motor vehicle accident in the first year after the emergency department visit. It’s a little bit higher than the general population, but it’s not astronomically high.

Elizabeth: I guess my concern here is that our population is aging, and we’re skewing into that group where this kind of thing is a whole lot more common. It’s a little disappointing to me that we’re not able to get our arms more around what kind of a risk this really represents.

Rick: That’s because there are multiple different causes.

Elizabeth: Let’s turn from here, then, to The Lancet. This is a look at another really huge public health problem, and that’s insomnia. This is a meta-analysis taking a look at medications that are employed for the treatment of insomnia and starts really with the very disheartening statement that because of a difficulty with providers — that is, there aren’t enough of them — medications get turned to more frequently for the treatment of insomnia worldwide than other interventions such as behavioral ones that are actually known to help as well.

They took a look — as I said, this is a meta-analysis — at 170 trials. They looked at all of these meds. They found that — and I’m not even going to cite all of them — they are generally more efficacious than placebo. They do finger benzodiazepines and all of their associated medications as more efficacious than melatonin and OTC kinds of things people try. However, lots and lots of side effects with those and specifically with benzodiazepines. They ultimately come down to that two medications had a favorable profile and those are eszopiclone and lemborexant.

But there is also some missing data relative to all of those things. Their upshot is that any medicine that’s used for the treatment of insomnia ought to be used at the lowest dose for the shortest possible duration. And of course, being famously averse to medications, I have to second that notion.

Rick: As you mentioned, a large study looking at over 30 different medications that fall in different categories. Those that act at the benzodiazepine receptor and therefore enhance the action of what’s called GABA — that’s. a neurotransmitter. Others look at the histamine receptor. These are medications acting in different ways all in the central nervous system.

The thing that really struck me is that although we have studies that look at short-term effects, very few studies look at the long-term effects. We know, for example, the benzodiazepines that are used a lot in the United States have long-term effects that are really quite problematic. I was surprised that melatonin had no effect just because it’s widely used.

Elizabeth: My own personal bias, of course, is that these methods for sleep hygiene that helped to improve people’s experience of insomnia are well worth giving a good old try.

Rick: Absolutely. This study didn’t evaluate the non-pharmacologic approaches, but generally they don’t have any side effects, they’re safe, and they’re also effective.

Elizabeth: We like that. Let’s turn to your next one. That’s in the BMJ.

Rick: The worldwide burden of chronic obstructive pulmonary disease. It’s a condition that results in a gradual deterioration of pulmonary symptoms. Once it’s occurred, it can’t be cured. We need to self-manage strategies that can lessen the burden of disease and improve the quality of life.

This study looked at the worldwide burden of chronic obstructive pulmonary disease. The classic symptoms are people have shortness of breath, cough, wheezing, and they produce a lot of phlegm, especially in the morning. You document that by doing breathing studies that establishes diagnosis and looks at prognosis as well.

It looked at the worldwide burden from 1990 to 2017. They looked at mortality, prevalence, and disability associated with it. Prevalence of COPD over that 27-year period decreased 8.7%. The death rate decreased about 42%. The disability adjusted life years decreased by about 40%.

You say, “That’s all good news.” Well, actually the numbers are actually increasing because we have more people in the world and an aging population. Even though the percentages go down, there is still an increased number of individuals.

There are 212 million prevalent cases of COPD globally and it accounted for 3.3 million deaths in 2019. In the United States, it’s most likely due to tobacco use. Worldwide, pollution ends up being a major cause or contributing factor. Ambient particulate matter pollution, occupational exposure to particulate matter, gases, and fumes all contribute to COPD.

Elizabeth: It’s so important. Of course, one of these issues that we have actually talked about before is the use of indoor cooking techniques and when they are poorly ventilated, that that can really result in an increase in this condition.

I guess I like the optimistic part, though. I’m so glad to know that it’s actually decreasing and that people are probably living longer, that our management strategies must be better.

Rick: Those things are all positive things. But as you mentioned, Elizabeth, in the low-income countries the household air pollution from solid fuels — that is, cooking with coal or wood or dung — is a leading risk factor for COPD. By the way, this disproportionately affects women in these countries because they are the ones more likely to be exposed. Elizabeth, as you know, my son spent 2 years in the Peace Corps in Peru, and part of what he was doing was making ovens that are vented to the outside or using solar ovens to decrease the COPD prevalence in a low-income country.

Elizabeth: Speaking of interventions, then, that might have large implications for populations, let’s turn back to JAMA Internal Medicine. This is a study — and it’s a big study — that’s taking a look at labeling of prepared foods in supermarkets and seeing whether this influences purchases that consumers make.

They gathered data from supermarket sales 2 years before the implementation of the labeling acts that were federally mandated and then 7 months after these labels were implemented from 173 supermarkets from a chain with locations all over sort of the northeastern United States. They were looking at mean weekly calories per transaction in the purchase of prepared foods. They identified those by food categories, including bakery, entrees and sides, or deli meats and cheeses, and things like prepared sandwiches.

They noted a 5.1% decrease in calories per transaction purchased from prepared bakery items and an 11% decrease from prepared deli items. They did not see a change for prepared entrees or sides. They calculated these calorie reductions as really being pretty modest, varying, really, between 1.2% and 3.9%. The editorialist basically concludes that, “Sure, we could disparage this as a really tiny change in calorie consumption for these folks, and we need to implement this along with lots of other strategies in order to address the obesity problem.”

Rick: To put this in perspective, Elizabeth, putting the calories in the supermarket — that’s where most deli and baked goods are bought — is that advertising the calories would decrease the caloric consumption. Although you provide it as a percentage, let me show where the rubber hits the road. There is a decrease of 10 calories per bakery item and 18 calories per prepared deli item. That’s hardly a spit in the ocean.

I do think as the editorialist mentioned education is necessary, but it’s really not sufficient for behavior change. It works better when it’s supported by policies — policies that set nutrition standards, that tax sodas, and that improve access to healthier foods.

By the way, he cited a study where it was done in a school, meaning they taught kids about physical activity, they avoided sugary beverages and junk food, they regularly measure their height and weight, they restricted sales of unhealthy snacks and drinks, and they actually engage the families as well in promoting healthy practices. After 1 year, there was an impressive 27% reduction in obesity prevalence among those children.

Elizabeth: I have one high-tech potential idea relative to this. I would say that in a couple of the places where I shop, they have these incredibly robust apps that really helped to chronicle everything, facilitate checkout, and all that sort of thing. I’m wondering if your own app could have something about your height, your weight, your BMI, and how many calories it’s appropriate for you to consume in a day. Those could all be individually tailored so that then when you go shopping it could say, “This represents X amount of your daily calories for today.” We could even expand that into things like sodium consumption also.

Rick: I think that’s a great idea. I think having that totality of information is helpful. It’s still education though. I would say that while that’s important, losing weight almost always requires both eating less and also increasing physical activity as well. But I think knowing what your caloric needs are each day and then watching how those end up in the supermarket basket is incredibly important.

Elizabeth: I know that if something was telling me, “Hey, Elizabeth, this is 30% of your daily calories,” I might think twice.

I do want to second another point that the editorialist makes, and this is about the role of business in this whole thing. In a very well-written part of the editorial, it says food is available for sale everywhere domestically, at all times of day, in large portions, in irresistibly delicious forms, and at relatively low cost. It especially promotes consumption of highly profitable, ultra-processed junk foods. Now we know that those are very inextricably associated with increased caloric intake, weight gain, and weight-influenced chronic disease.

Rick: I agree with you. It’s going to take a combination of taxes, warning labels, portion size, restrictions, and all of those things addressing this issue.

Elizabeth: 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.

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