2 Minute Medicine Rewind June 3, 2019

Ultra-processed food intake and risk of cardiovascular disease: prospective cohort study (NutriNet-Santé)

The consumption of ultra-processed food has increased substantially over the last several decades. These foods often have higher proportions of total and saturated fat, added sugar, energy density and salt, and lower proportions of fibre and vitamin density. Limited cross-sectional data has suggested associations with obesity, metabolic syndrome, functional gastrointestinal disorders, hypertension, breast and all cancers with increased ultra-processed food intake. In this population-based cohort study, 105,159 participants age 18 years and older completed repeated 24-hour dietary intake assessments, detailing their usual consumption of 3,300 food items. Participants were followed up for a median of 5.2 years to assess the association between ultra-processed food consumption and cardiovascular (CVD) risk. Food items were categorized using the NOVA food and drink classification system according to degree of processing. Yearly health questionnaires, check-up questionnaires every three months, study website entries, patient-provided medical records and medical professional or facility-provided information were used to ascertain major health events, and general population based cohort data was linked to medico-administrative national health insurance data and the French national cause-specific mortality registry. Researchers found that ultra-processed food intake was associated with a higher risk of overall CVD (HR 1.12, 95% CI 1.05 to 1.20, p<0.001), coronary artery disease risk (HR 1.13, 95% CI 1.02 to 1.24, p=0.02), and cerebrovascular disease (HR 1.11, 95% CI 1.01 to 1.21, p=0.02). Incidence rates for overall CVD were also increased in individuals consuming high amounts of ultra-processed foods when compared to low consumers. The results of this study therefore demonstrate an association between ultra-processed food consumption and CVD, coronary and cerebrovascular diseases.

Estimates of all cause mortality and cause specific mortality associated with proton pump inhibitors among US veterans: cohort study

Proton pump inhibitors (PPIs) are widely used in the management of gastroesophageal reflux. However, several studies have demonstrated serious adverse events associated with PPI use including cardiovascular disease, acute kidney injury, chronic kidney disease, dementia, pneumonia, gastric cancer, Clostridium difficile infection, and increased risk of fracture. Recent evidence has also suggested an increased risk of all-cause mortality. To estimate all-cause and cause-specific mortality with acid suppression, a longitudinal cohort study of 214,467 United States veterans newly using histamine H2 receptor antagonists (H2RAs) (n=157,625) or PPIs (n=56,842) between July 2002 and June 2004 was conducted. Department of Veterans Affairs databases were used to obtain data regarding demographic characteristics, encounters with the healthcare system (both inpatient and outpatient), comorbidities, procedures, surgeries, laboratory results, outpatient prescription records, and date and underlying cause of death. With a 10-year follow-up, 45.20 excess deaths per 1,000 patients taking PPIs were reported (95% CI 28.20 to 61.40). PPI use was also associated with increased circulatory system diseases (number of attributable deaths per 1000 patients 17.47, 95% CI 5.47 to 8.80), neoplasms (12.94, 95% CI 1.24 to 24.28), infectious and parasitic diseases (4.20, 95% CI 1.57 to 7.02) and genitourinary system diseases (6.25, 95% CI 3.22 to 9.24). Cumulative duration of PPI use was associated with increased all-cause mortality. The results of this study therefore suggest an increase in cardiovascular disease, chronic kidney disease and upper gastrointestinal cancer-related death with PPI use, warranting greater stewardship regarding PPI prescription and usage.

Association of step volume and intensity with all-cause mortality in older women

The 2018 Physical Activity Guidelines Advisory Committee has recently identified steps per day as an important measure of physical activity that can promote walking across all ages and levels of fitness. While a goal of 10,000 steps per day is commonly perpetuated, limited evidence exists regarding how many daily steps are associated with clinically important endpoints and mortality. To examine associations between the number of steps per day and stepping intensity with all-cause mortality, 18,289 women in the United States were enrolled in an ancillary prospective cohort study to the Women’s Health Study. Participants were instructed to wear accelerometer devices for 7 consecutive days, which were used to determine daily step volume and measures of stepping intensity. An annual health questionnaire was used to obtain data regarding socioeconomic demographics, health habits as well as personal and family medical histories. Information from family members, postal authorities, medical records, death certificates and the National Death Index were used to identify and confirm data regarding deaths. Including 16,741 women with a mean age of 72 years (SD 5.7 years), a mean step count of 5,499 was recorded. A total of 504 women died over a mean follow-up of 4.3 years. Researchers found that hazard ratios associated with mortality progressively declined with higher mean steps per day until approximately 7,500 steps/day: HR 0.59 (95% CI 0.47 to 0.75), 0.54 (95% CI 0.41 to 0.72) and 0.42 (95% CI 0.30 to 0.60), in order from low to high quartiles of steps per day. No significant associations were found comparing highest versus lowest quartiles for higher stepping intensity, peak 1 and 30 minute cadence, maximum 5 minute cadence and time spent at a stepping rate of >=40 steps/minute after adjusting for steps per day. The findings of this study therefore suggest that increased steps per day up to 7,500 steps/day is significantly associated with lower mortality rates, and as few as 4,400 steps/day may have significant implications for mortality rates.

Effect of intraoperative high positive end-expiratory pressure (PEEP) with recruitment maneuvers vs low PEEP on postoperative pulmonary complications in obese patients: a randomized clinical trial

Protective intraoperative mechanical ventilation has been associated with reduced postoperative pulmonary complication risk. Obesity is associated with an increased risk of atelectasis and impaired respiratory function. In this setting, high positive end-expiratory pressure with alveolar recruitment maneuvers have been proposed for routine intraoperative mechanical ventilation to prevent these physiologic alterations. Limited data exists regarding whether this approach has benefit in terms of postoperative outcomes. Examining whether an intraoperative mechanical ventilation strategy with higher PEEP and alveolar recruitment maneuvers reduces the incidence of postoperative pulmonary complications within the first five postoperative days in obese surgical patients, The Protective Intraoperative Ventilation With Higher Versus Lower Levels of Positive End-Expiratory Pressure in Obese Patients (PROBESE) trial randomized 2013 adult non-cardiac, non-neurological surgical patients with body mass indices of 35 or greater with substantial postoperative pulmonary complication risk across a high level PEEP group with alveolar recruitment maneuvers (n=989) or a low level PEEP group (n=987). The primary outcome was a composite of pulmonary complications within the first five postoperative days. Based on an intention-to-treat analysis, the primary outcome was reported in 21.3% of patients in the high PEEP group versus 23.6% in the low PEEP group (difference -2.3%, 95% CI -5.9% to 1.4%; RR 0.93, 95% CI 0.83 to 1.04). High PEEP was also associated with a decreased incidence of hypoxemia (5.0% vs. 13.6%; difference -8.6%, 95% CI -11.1% to 6.1%, p<0.001). The findings of this study therefore show no significant reduction in postoperative pulmonary complications with higher level of PEEP for intraoperative mechanical ventilation in obese surgical patients undergoing general anesthesia.

Low rates of specialized cancer consultation and cancer-directed therapy for noncurable pancreatic adenocarcinoma: a population-based analysis

Eighty percent of patients with advanced or metastatic pancreatic adenocarcinoma are not candidates for surgical resection and require noncurative therapy, including multi-agent chemotherapy regimens, radiation therapy, nerve blocks and other symptomatic relief modalities. Despite having established benefits for patients, a large proportion of pancreatic adenocarcinoma patients are unable to access these treatments due to barriers and disparities in cancer-directed therapy delivery. Using administrative healthcare data, eligible 10,881 patients with newly diagnosed noncurative pancreatic adenocarcinoma in Ontario, Canada, between the years 2005 and 2016 were followed up to examine patterns and factors associated with access to specialized cancer care and receipt of cancer-directed therapy in this patient population. With a median age at diagnosis of 72 years (IQR 62 to 80 years), median survival was reported to be 3.3 months (IQR 1.2 to 8.5 months). Researchers found that 26.6% of patients received systemic chemotherapy, 11.5% received chemoradiation, and 61.9% received best supportive care. In terms of specialized cancer consultations, 64.9% had a consultation with a medical oncologist, 35.1% with a hepatopancreatico-biliary surgeon and 24.7% with a radiation oncologist following diagnosis. Thirty-eight percent of patients received cancer-directed therapy, representing 58.6% of those who had consults with medical oncology. Of those who did not receive cancer-directed therapy, only 44.4% had a consultation with medical oncology. Older age and lowest income quartile were associated with lower likelihood of cancer-directed therapy, and consultation with medical or rational oncology was associated with a significantly higher likelihood of a cancer-directed therapy pathway compared to a surgical pathway. The findings of this study therefore suggest persistent disparities in specialized cancer consultation and systemic cancer-directed therapy receipt in patients with non-curable pancreatic adenocarcinoma in Ontario, underlining important gaps to be addressed from a health systems perspective.

Image: PD

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