Step Count and CVD; Unionizing Medical Workers

News

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 daily steps and cardiovascular disease, income and child health, a genetic basis for obesity and maladaptive behavior, and unionizing medical workers.

Program notes:

0:45 Steps and cardiovascular disease

1:42 40-50% lowered risk

2:45 Consider an electronic device to help

3:20 Family income and morbidity and mortality in children

4:20 Association with lower income and health outcomes

5:20 Wasn’t due to differential access to medical care

6:20 Cessation of expanded credit

6:40 Association of serotonin receptor with obesity and behavior

7:40 Receptor in the hypothalamus

8:45 Can increase suppressant molecule

9:00 Unionization among healthcare workers

10:08 More likely to have employer-paid health insurance

11:01 Only 8% of physicians unionized

12:05 May offer leverage if they are corporate employees

12:58 End

Transcript:

Elizabeth: Family income and morbidity and mortality in U.S. children and adolescents.

Rick: The association of daily steps with cardiovascular disease.

Elizabeth: Should healthcare workers be unionized?

Rick: And the genetic reason for obesity and maladaptive behavior.

Elizabeth: That’s what we’re talking about this week on TT HealthWatch, 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: 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. Where do you want to start?

Elizabeth: I’m going to give you a soft toss and we’re going to go right to the journal Circulation and talk about this issue that … how would you serve that up again?

Rick: Steps and cardiovascular disease.

Elizabeth: Where many of us who are thinking about our New Year’s resolutions, maybe this is going to provide some new information.

Rick: Even though we’re wildly promoting 10,000 steps per day because that’s been associated with a lower risk of all-cause mortality, there haven’t been very many good studies that have looked at the relationships of steps and cardiovascular disease — and more importantly, can fewer steps be helpful?

What these investigators did was a meta-analysis looking at eight prospective studies that included over 20,000 adults over the age of 18. They all had devices to measure steps. They followed them for cardiovascular disease events. The average age was 63 years. About half were women, and they followed them for an average of about 6 years.

Those individuals that took more steps had increasing benefit with regard to cardiovascular disease, specifically among those over the age of 60. Those that walked 6,000 to 9,000 steps per day were associated with a 40% to 50% lower risk of cardiovascular disease compared with those that took less than 2,000 steps per day. If you took more than 9,000 steps, there was an increased benefit as well.

Elizabeth: I want you to talk about before we go on this title of this paper, “Prospective Association of Daily Steps With Cardiovascular Disease: A Harmonized Meta-Analysis.” For the nerds among us, including me, what in the world is a harmonized meta-analysis?

Rick: An analysis is, you take a group of studies and you try to group both the populations and the outcomes together. You look to see how alike or unlike the studies are. If they are unlike each other, there is a large amount of heterogeneity and the results are less robust. If they are more like each other, then they are harmonized and the results are more likely to be true.

The harmony of these particular studies is they all use wearable devices. It was done prospectively. The interesting thing is these benefits were more obvious in the older adults.

Elizabeth: As I suggested, I believe it was as recently as last week, those who are looking for a Christmas present for themselves might consider one of these devices that helps them to substantiate how much exercise they’re getting. I guess I would also note though that we have seen this trend in the past where we see kind of this big bang for your buck in the sweet spot, and then the more you do the less benefit you really get.

Rick: That was true for the younger individuals. They seem to peak around about 8,000 steps as the maximal benefit. But in the older individuals, the greatest benefit were those that walked 2,000 to 9,000. But even from 9,000 to more than 15,000, there was benefit as well.

Elizabeth: Let’s turn to JAMA and let’s look at this rather sobering issue of what is the association of family income with morbidity and mortality in U.S. lower-income children and adolescents. We’ve known for a while, of course, and have asserted that family income is associated with children’s health.

This study wanted to look at the association of family income with claims-based measures of morbidity and mortality in lower-income families in the U.S. These were folks who were enrolled in Medicaid or the Children’s Health Insurance Program, CHIP.

The analysis included 795,000 participants, 5 to 17 years of age, who were Medicaid enrollees. They were living in families with incomes below 200% of the federal poverty threshold. Their follow-up ended in December 2021. They looked at a number of outcome measures including codes for infection, mental health disorder, injury, asthma, anemia, substance use disorder, and death records.

Among these folks, they found 33% had a diagnosed infection, 13% mental health disorder, 6% with injury, 5% with asthma and declining numbers, and then there were 0.6% who died between 2011 and 2021.

They definitely saw in the 5- to 9-year age group that higher family income was associated with lower adjusted prevalence of all of these outcomes except mortality. Then except for injury and anemia, associations were more pronounced among those age 10 to 17 years than those in the 5- to 9-year-old age group. This provides us with more data that in fact this issue of income is an important factor relative to children’s health.

Rick: Elizabeth, usually we associate higher income with better access to healthcare. But in this particular group of individuals you’re describing in this study, they all had the same access to Medicaid and to CHIP as well. This relationship between income and health wasn’t due to differential access to medical care. Well, then what is it due to?

As you described, the authors here showed that the lower-income children had more injuries and more infection. This is what people in the industry refer to as health shocks. It appears that lower-income families are less able to protect these kids from health shocks than higher-income individuals. It could be due to worse nutrition, inferior housing, chronic stress, violence, exposure to environmental pollutants — those kinds of things. It confirms there is a relationship between income and health outcomes in children but, more importantly, it’s not due alone to differential access to medical care.

Elizabeth: Right, and so clearly we need to figure out how we can impact on those factors.

Rick: One of the factors obviously is reduced child poverty. The editorialists mentioned they expanded the childcare tax credit and that was implemented in 2020. Data from the Census Bureau showed that it helped reduce child poverty by more than 40% such that in 2021 child poverty reached a record low of 5.2%. Unfortunately, that expanded credit was allowed to expire at the end of 2021.

Elizabeth: I am definitely in favor of a minimum income that would be provided all over the country, because I think it would help ameliorate a lot of this — not just for kids, but also for adults.

Rick: Since we’re talking about kids. I want to talk next about a study that’s in Nature Medicine that talks about the association of a serotonin receptor with obesity and maladaptive behavior. This was actually described in kids. We know that the neurotransmitter serotonin, the serotonin receptors, there are at least 14 different ones of those, they regulate not only mood, but they also regulate body weight.

What these investigators did was they looked at kids that had severe early-onset obesity at less than 10 years of age. They analyzed your genetic structure, looking at what’s called exome sequencing and targeted resequencing of over 2,500 of these kids, and they discovered 13 different rare variants in the genetic makeup in 19 different unrelated individuals.

These were all related to abnormalities in the serotonin receptor. This particular serotonin receptor lives up in the hypothalamus. These kids also had developmental delays and behavioral issues, emotional lability, frequent outbursts of crying or aggressive behavior, and maladaptive behavior.

They further took this same serotonin receptor abnormality, did a genetic testing in mice where they inserted this, and demonstrated the same behavior. The mice were overeating and the mice had maladaptive behaviors. By identifying the pathway, we can actually target medications that could potentially both decrease obesity in youngsters and address the maladaptive behavior as well.

Elizabeth: Is there any relationship in just garden-variety obesity and the presence or absence of these particular variants of these serotonin receptors? Also, we’ve had kind of a lackluster record with when we try to mess around with serotonin because it’s so ubiquitous in the body. I guess that’s another concern that I have.

Rick: Two very good points. This particular serotonin receptor is a serotonin [5-HT]2C receptor. This is the one that’s isolated in the brain. When you lose function of it, it prevents secretion of molecules that suppress the appetite. By the way, we know that there are other medications that we currently have on the market that can actually increase that suppressant molecule.

Elizabeth: Finally, let’s go back to JAMA. I served it up as should we unionize healthcare workers? That’s not really what this study is about. This study is about how often are healthcare workers unionized right now.

They took a look at this current population survey, an annual social and economic supplement from 2009 through 2021. They found almost 15,000 self-identified healthcare workers who were a part of this survey and they said, “Well, all right, how many of these folks are unionized? Has this trend changed at all?”

About 13%, just over that, of their respondents who were in the healthcare worker category did report that they were part of a union or they were under union coverage. There was really no significant trend between 2009 through 2021.

They also looked at racial and ethnic minorities. They found out that they were slightly more disproportionately represented and also that if you lived in a metropolitan area you were slightly more likely to be a part of the union. Folks who were part of the union were associated with significantly higher reported weekly earnings. They had a higher likelihood of having a pension and having employer-sponsored, full premium covered health insurance, and they experienced no additional work hours in comparison to their nonunion counterparts.

It looks like this is kind of a flat trend, and one reason that I’m really interested in it is because I have seen especially during the pandemic that disproportion has really been emphasized a lot among all the healthcare workers I see in the hospital. I’m wondering if it’s going to be a mechanism that would be useful to try to decrease some of that disproportion. Sure enough, the editorialists talk about physicians and how many physicians are currently union members. That’s only 6% to 8%.

However, physician employment, as we know, is changing a lot. It used to be that physicians were sort of in their own practices, and they had a whole lot of autonomy and self-determination. Right now, 52%-plus of physicians are employed by hospitals or health systems and an additional almost 22% are employed by other corporate entities. The editorialist suggests that unionization among physicians might be a way for physicians to be able to have control over the work environment that they may not enjoy otherwise.

Rick: When they looked at the individuals from healthcare who had joined the union, 85% were nurses, therapists, technicians, and support staff. Very few physicians or dentists, or very few advanced practitioners, had joined a union. Corporate entities, oftentimes their focus is on financial aspects of the business.

What could unions offer physicians and dentists? Well, what this study shows is overall those in the union received a little bit more pay. They more often had benefits. For physicians and advanced practitioners, those benefits aren’t going to accrue, and perhaps the only advantage for unions in that group is when they do become employed by hospitals or corporate entities, maybe the union can help the physician group force those entities to focus on the professional aspects of providing care rather than the financial aspects. But that’s unproven at this particular point.

Elizabeth: We’ve got to, I think, have some kind of strategy to make sure that there is a balance there, not just caring for the patient and what’s best for the patient, but also for the practitioners, where I think it’s important that they feel that they have some kind of a voice in this going forward.

Rick: Elizabeth, you’re right. These large hospital systems oftentimes emphasize billing and coding and other burdensome things. Studies have shown that actually drives physician burnout and that’s not a recipe for success in the future.

Elizabeth: On that note, happy 2023! That’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.

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

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