The NACE Clinical Highlights Show
Engage with expert NACE faculty for discussions about current clinical strategies for common and rare health conditions that you can use in clinical practice immediately, and that work for you and your patients.
The NACE Clinical Highlights Show
NACE Journal Club #18
The NACE Journal Club with Dr. Neil Skolnik, provides review and analysis of recently published journal articles important to the practice of primary care medicine. In this episode Dr. Skolnik and guests review the following publications:
1. Adverse Outcomes Associated With Inhaled Corticosteroid Use in Individuals With Chronic Obstructive Pulmonary Disease. Annals of Family Medicine 2025. Discussion by:
Guest:
Barbara Yawn, MD, MSc, MPH
Adjunct Professor, Department of Family and Community Health
University of Minnesota
Former Chief Scientific Officer at the COPD Foundation
2. Optimal dietary patterns for healthy aging. Nature Medicine. Discussion by:
Guest:
Jessica Stieritz, MD
Resident– Family Medicine Residency Program
Jefferson Health – Abington
3. Amount and intensity of daily total physical activity, step count and risk of incident cancer. British Journal of Sports Medicine. Discussion by:
Guest:
William Callahan, D.O.
Associate Director – Family Medicine Residency Program
Jefferson Health – Abington
Medical Director and Host, Neil Skolnik, MD, is an academic family physician who sees patients and teaches residents and medical students as professor of Family and Community Medicine at the Sidney Kimmel Medical College, Thomas Jefferson University and Associate Director, Family Medicine Residency Program at Abington Jefferson Health in Pennsylvania. Dr. Skolnik graduated from Emory University School of Medicine in Atlanta, Georgia, and did his residency training at Thomas Jefferson University Hospital in Philadelphia, PA.
This Podcast Episode does not offer CME/CE Credit.
Please visit http://naceonline.com to engage in more live and on demand CME/CE content.
Welcome to the NACE Journal Club, where we go over some of the most important articles to come out in the medical literature relevant to primary care every month. I'm Dr. Neal Skolnick. This month, We have a really exciting group of articles, beginning with an article from Annals of Family Medicine that looks at the adverse effects from inhaled corticosteroids, that's ICS, used for COPD. And you're going to be surprised at these results. Then an article on optimal dietary patterns for healthy aging published in Nature Medicine. And wow. you're going to find out that you might be able to improve the likelihood substantially of living to age 75 completely healthy just by eating right. And then a discussion of physical activity and how good physical activity can decrease substantially your risk of developing a number of different types of cancer. And that was from the British Journal of Sports Medicine. For our first article, we're going to discuss an article published in the Annals of Family Medicine titled Adverse Outcomes Associated with Inhale Corticosteroid Use in Individuals with COPD. Joining us to discuss this article is one of the authors, Dr. Barbara Yon, who is an adjunct professor in the Department of Family and Community Health, University of Minnesota, and is the former chief scientific officer at the COPD Foundation. She is a clinical researcher. She's been an author on over 400 publications, three books, and is, I can tell you, an amazing primary care educator who just spans detailed knowledge of specialty care with our needs as primary care clinicians. Barbara, welcome to our podcast. Thank you for having me join you. Barbara, can you go over the background on this issue? Why did you all choose to study this?
SPEAKER_02:Certainly. There's been a lot of attention in asthma of corticosteroids and the potential side effects. and then also COPD. But most of that attention has been on systemic corticosteroids, oral prednisone, for example. But we wanted to see about inhaled corticosteroids because they're used very, very widely. Almost 60% of the prescriptions for first-time COPD diagnosis include an inhaled corticosteroid. And we know the indications for inhaled corticosteroid or ICS are really limited. It's only if someone has also features of asthma like COPD, asthma overlap syndrome, or if they have a high eosinophil count and have lots of exacerbations, frequent, moderate, and severe exacerbations, and they've failed on lava-lama therapy with dual bronchodilator therapy. Then there are candidates for
SPEAKER_01:ICS. And Barbara, it's so important that you went over and thank you for going over it in that detail because I think a lot of people in primary care get confused, frankly, between the treatment algorithms for asthma where ICS is a foundational therapy and COPD where it's not. The details are what you just said. So that Even when people I know I have taught on this, when I explain this, people go, but ICS, not a big deal. Well, tell us how you went ahead and looked at that question. And that's exactly what we
SPEAKER_02:were responding to is people saying it's no big deal. So we use this large dark net data set from multiple health care systems. that they use for practice improvement. And it has a lot of primary care patients in it. We included everybody over the age of 45. We had a few exclusion criteria, like being treated actively for a malignancy or if you had TB. But otherwise, everybody was included. And we took two groups. The prevalence group, those were people who had COPD diagnosis, any time during our period of observation, which was actually almost six years, and people who had a new diagnosis of COPD called the inception cohort after six months. So we could look at people who had ongoing therapy with ICS, people who had new therapy with ICS, and people who had no therapy with ICS with their COPD. And what we did is divide them into people who had 24 months or longer ICS exposure, people who had less than four months, including no exposure, and we compared several outcomes, the kinds of outcomes we care about for corticosteroids like diabetes, pneumonia, fractures, cataracts, and compared what happened in the shorter term and the longer term exposures.
SPEAKER_01:And Barbara, there's no doubt that primary care docs had input into organizing this because even the way you said it, you know, outcomes that we care about is what the way we like to organize our thinking. What were the results?
SPEAKER_02:What the results showed is that in the group more than 24 months, they had clear indications of increased risk for all of these things. We use a composite outcome for our primary outcome, and that was, did you have either new onset diabetes, new cataracts, new osteoporosis, new fracture, or new pneumonia? And that was clearly over two and a half times more common But then we went on to look at each of those individually, because sometimes, you know, when you have a huge data set, a 1% or even a 5% increase and you get statistical significance. Well, we wanted to show, was this really clinically significant? And just to give you a couple of quick examples, the diabetes, for example, in the long-term prevalence cohort, 13.3%. 5% developed new-onset diabetes, as opposed to short-term, 4%. So, more than four times as many. The osteoporosis was 5 versus 3.3. The fractures, which I think are really important because, as you know, hip fractures have high mortality, about 2.8 versus 1.3. So we're not talking just a little half a percent or 10% increase. We're talking very large increases. And in fact, the number needed to harm was only five. That means that you only have to treat five people to have one of these adverse outcomes occur once. in a period of 24 to 25 months, starting at 24 months.
SPEAKER_01:Robert, this is such an important set of results, and thanks for clarifying that it's not just an increase in relative risk, but a very important clinically relevant increase in absolute risk. Now, what would you say, before we get on to clinical implications, if one of our listeners were to say, but wait a minute, I thought in the clinical trials that There was not a big difference in side effects between people who got ICS and those who don't. They're right. There wasn't. But how
SPEAKER_02:long do those clinical trials last? Most of them last 12 months or less. It is extremely rare to find, and we couldn't find anything in the literature, reporting outcomes longer than 12 months in those
SPEAKER_01:clinical trials. So it's really important that real-world studies have an important place in looking at longer-term implications of treatment. What do you see as the clinical implications of these results?
SPEAKER_02:Well, I think first we have to realize, you say, oh, I'm just going to start ICS. But when you start ICS, it almost never gets stopped. So you start ICS, and people with COPD don't live just a year or two. They live 5, 10, 15, 20 years with their condition, and that could mean that long of an ICS exposure. So I think the clinical implications are you need to do a risk-benefit assessment. If these people truly have recurrent exacerbations, especially if they're in the hospital, ICS is absolutely something you want to try and see if it helps. But if these people are not having exacerbations, and that's somewhere between 40% and 60% of people with COPD, then realize that these risks we're talking about are significant risks. They're risks for loss. They're risks for morbidity. and their risks for mortality. And so think about it and help present the patient the understanding of the risks and benefits of starting that ICS.
SPEAKER_01:Dr. Barb Rion, I think this is one of those papers that go on my list of ones that I will quote to the residents when we're on rounds so that they know this well. I want to thank you so much for joining us. Thank you for having me. Our next article was published in Nature Medicine and is titled Optimal Dietary Patterns for Healthy Aging. Joining us to discuss this really important article is Jessica Sturitz, who is a resident in the Family Medicine Residency Program at Jefferson Health Edmonton. Welcome, Jessica. Hi, thank you so much. Jessica, this is such an important topic because We are not and should not be just about treating disease. We should also be about helping people stay healthy for as long as possible. Can you give us a little bit of background on why they looked at this?
SPEAKER_00:Absolutely. As we know in the United States, as well as globally, the population is aging. And as part of that, the population as a whole has more chronic disease burden. In fact, 80% of older adults have at least one chronic health condition. So it's a population issue that we'll be seeing more and more in all of our offices moving forward. And as you alluded to, the WHO recently shifted focus from the traditional disease-centric approach to aging to prioritizing the preservation of functional ability, preventing capacity decline, and And in general, just prioritizing overall health and well-being as a central model for healthy aging. So as we're moving towards this model, we're thinking about ways that we can achieve this from a primary care standpoint. And diet is actually the first leading behavioral risk factor modification for non-communicable diseases or mortality burden globally. In fact, it surpasses tobacco use in the United States adults. as behavioral risk factor modification that can make a substantial impact on adult health. And so this topic of diet in moving forward in the aging model, as well as just overall health for all individuals, will become increasingly important, I think, as we dive more and more into the literature and the research behind this.
SPEAKER_01:And that's impressive. And I don't think that most of us recognize that it's the leading behavioral risk factor for non-communicable diseases. And therefore, it's important. In many ways, I've seen more emphasis on healthy aging in the lay literature. And this has become something that's out there a lot now than I have in the medical literature. So it's so important that in some ways, we catch up to where our patients want to be. How do they look at the question of what is an optimal diet that leads to healthy aging?
SPEAKER_00:Yeah, absolutely. So they took longitudinal questionnaire data from these groups of people, particularly the Nurses' Health Study and the Health Professionals' Follow-Up Study. And essentially, these were large pools of data that were able to be followed over a long period of time, up to 30 years in some cases. And the follow-up rate was over 90%, so really good retention data, really important data to be able to look at. And essentially, they mailed out questionnaires to these participants every four years to measure their dietary intake. And they asked them, how frequently did you consume these foods in the past 12 months? And then based on these nutrient and food intakes, they calculated, they divided the groups into eight dietary pattern scores. And for each individual, they calculated their score for each of the eight dietary patterns.
SPEAKER_01:And... And they related that to healthy aging. What did they find?
SPEAKER_00:Yeah. So essentially, the overarching finding of the article is that long-term adherence to any of the dietary patterns is associated very strongly with healthy aging. And they define healthy aging as surviving to the age of 70 years without the presence of 11 major chronic diseases and The 11 major chronic diseases were selected because they are the primary causes of mortality in the United States or are considered to be highly debilitating. So they include things like COPD, diabetes, MI, things that you or I would think of naturally as participating strongly in the chronic disease burden for people.
SPEAKER_01:Yeah, and it's interesting because when we think about the patients we see, so many people have one or more of those diseases.
SPEAKER_00:Absolutely. Yeah, so essentially, healthy aging is then surviving to the age of 70 without one of those 11 things and no impairment in cognitive function, physical function, or mental health.
SPEAKER_01:And so what did they find with regard to the magnitude of effects? They defined these different healthy eating patterns, and we're going to guess that it made at least a little bit of difference. What was the magnitude of effect? What'd they find?
SPEAKER_00:Yeah. So essentially, as we talked about, they did score eight of these things. And all eight, like I had mentioned before, were associated with greater odds of healthy aging. But I wanted to highlight one, which was the AHEI. Essentially, they found that the statistical analysis gets into the weeds a little bit, and I don't think it's salient to this discussion. But They compared the top quintile scorers for the AHEI to the lowest quintile scorers for the AHEI. And they found that people in the top quintile had an 86% greater odds in achieving healthy aging using an age cutoff of 70 years. And even further than that, 2.24 times greater odds when they increase the age cutoff to 75 years. So if you think about that, 86% is a really high, really strong number that we're talking about.
SPEAKER_01:And we're talking about things that are common. So when you see an 86% improvement or up to age 75, over twofold better odds of achieving our goal, healthy aging, when we talk about that level of effect in something that's very rare, we go, okay, it's important, relative risk, but not absolute. This is... fairly common. There are a lot of people that age healthily, fortunately, and this could enormously increase the number. Now, to better understand this, when you talk about that alternative healthy diet, what was it called and what is it?
SPEAKER_00:Yeah, so the AEGI score is called Alternative Healthy Eating Index. And essentially, that score in particular is composed Thank you so much. And trans fats and fatty acids. So just overall a healthy eating picture that they then score.
SPEAKER_01:Yeah. And that's so important because it's one of those things that what I love about this is we can remember those foods.
SPEAKER_00:Yeah, absolutely. Those are foods that are in our diet. repertoire already, like knowing that these are the healthy foods that we want to gravitate towards in our diet.
SPEAKER_01:So what's nice about that Alternative Healthy Index, it's not something complicated. I don't need to memorize the different components. It's a lot of things that we know to be important. Is that right?
SPEAKER_00:Yeah, that's absolutely correct. People don't need a lot of health literacy or even experience with diets to know that things like fruits, vegetables, these things that are emphasized in the diet are naturally healthy for them. And so it will be easy to speak to patients about this because they do have some level of understanding of the basics of this diet kind of going in. And I think that's really important, especially in the primary care setting, because you don't want to overcomplicate things too much or it's difficult for the patients to follow and stick to the plan. So that's the benefit of these types of scoring indices because they use items that we already know to be true, emphasizing fruits and vegetables and minimizing things like alcohol, trans fats, sugary beverages, or simple sugars in the diet in general.
SPEAKER_01:Now, I think this has a lot of clinical implications for us, both, as you said in the introduction, recognizing that diet is the number one cause of non-communicable chronic diseases, basically of chronic disease, and then recognizing from this study that having a healthier diet is meaningful. What do you see? How does this affect the way you approach patients?
SPEAKER_00:Yeah, I think it's really important. And when I learned that diet is the number one risk factor modification that we can make, I was astounded at that because if you think about how much time you put into your day talking about smoking cessation for people and how much intention you put behind that, and at least personally, I'm not doing the same thing in my practice, my primary care practice in terms of diet, it's really reframed how I think about diet as a really powerful tool in our arsenal to help people achieve healthy aging, and just overall quality of life that right now I'm leaving largely untouched. So I think in the future, it's really motivated me to use diet and incorporate diet into my daily workflow and hopefully be able to help people at least establish early eating habits that then can carry them through the rest of their lives and help them achieve the type of healthy aging that we're all hoping to achieve.
SPEAKER_01:I think you're so right, Jessica. It's interesting. Have you talked about diet? And I don't think we're going to see that as a care gap soon. I definitely think we should, in our own minds, think of it as a care gap. If we have not sat down and talked in a serious way to our patients about the benefits of, I'll call it clean eating, healthy eating, the importance of fruits, vegetables, whole grains, nuts, legumes, all that you said, and to stay away at all costs from sugary foods, processed foods, processed meats, then we aren't truly giving our patients all that we can. I
SPEAKER_00:think that's absolutely true. And I think for me, moving forward, my goal will be to try to figure out concrete ways to help patients to incorporate these foods into their diets. Because I think telling people, fruits and vegetables are healthy for you is one thing which we all already know, but figuring out a way to incorporate into my practice tangible goals that the patients can look to achieve to help move forward and improve their diet overall, as well as keeping them accountable to these diets with good follow-up visits.
SPEAKER_01:You're so right. You mentioned to me earlier, Jessica, that if there was a medicine that we could prescribe that would double the chances of someone being completely healthy by the time they're 75. We'd all be trying to prescribe it and we'd figure out ways to petition insurance companies to pay for it. There isn't such a medicine, but we can do that with diet. Dr. Jessica Steretz, thank you so much for joining us.
SPEAKER_00:Thank you so much for having me.
SPEAKER_01:for our final discussion this month we're going to look at two articles which further our discussion about lifestyle medicine both of these articles are from the british journal of sports medicine the first article is titled amount and intensity of total daily physical activity step count and the risk of incident cancer the second one is wearable device measured physical activity and the Development of Cardiovascular Disease in Cancer Survivors. Joining us to discuss these two articles, I am so pleased to have on with us Dr. Bill Callahan, who is an Associate Director and a Clinical Assistant Professor of Family Medicine in the Family Medicine Residency Program at Jefferson Health Abington. Welcome, Bill. Thank you, Neil. Bill, can you give us some background on why they even thought to look at these questions. Cancer is a big problem, right? We see a lot of lifestyle associated cancers in the United States. And thankfully, the UK Biobank gave us a ton of data to look at regarding the development of cancer in a general population. So the UK Biobank, just for some background, looked at people, 500,000 people starting at the age of 40, and measured in this population, What would the development of cancer look like based on exercise? That'll be our first study. And the second, they look at the development of cardiovascular disease in those with a history of cancer, which is important because we don't really have great guidelines on what type of exercise should people who have already had cancer be getting. All of our guidelines are primarily focused on a general population. And so this study really sought to look at this niche of the population and should we What type of exercise should we be recommending for them with regard to both the development of cardiovascular disease as well as the development of the second cancer? So really important questions that they sought to answer. Let's go over the results one at a time, starting with the first article on the amount and intensity of total physical activity and the risk of developing cancer. What'd they find? So this article I just love. So this article looked at 85,000 people. These people were provided an accelerometer, which they were on their wrists, a non-dominant hand, which is where most of us wear wristwatch. So consider a smartwatch. And using that data over a period of seven days, they measured both the intensity measured in milligravity units as well as step. Now, I don't think it's necessary. that we go into how to calculate intensity using those specific units. But step counts is something that we all hear about all the time from our patients. How many steps should I be getting? So they set as a baseline 5,000 steps. They said that this would be expected throughout a person's day. And that was basically a baseline for someone who's not getting a ton of exercise. And what they found was that anything about the 5,000 was really helpful. So for those who got 7,000 steps, which is for just consideration would be about a mile of walking and 2,000 additional steps. They saw a drop in the development of cancer by about 11%. Going up to 9,000 steps, 16% and 13,000 steps would be a drop in 20%. Now, importantly, after 9,000 steps, what appears linear then starts to plateau. And I think that's really important because our patients do care about that. They want to know how many steps can they get. And historically, we've heard 10,000 steps, but there hasn't always been great precedent for that. So I think this really sets a precedent for it. We can say, okay, if you can't get 10,000 steps, let's aim for something still better than 5,000. So let's aim for that 7,000, 9,000 range. And that's an impressive decrease in cancer. If there was a pill that could do that, we'd all be going out asking our doctors for that pill. but you can do that without a pill, with exercise. In our second article, wearable device measured physical activity and the development of cardiovascular disease in cancer survivors, what did they find? This was a great article, really. So they looked at around just over 6,000 patients. Again, they also wore accelerometers and they were also followed for a week. These patients, they had a history of cancer, but no known cardiovascular disease. And what they looked at was the time that this person was getting either low intensity or moderate to vigorous intensity physical activity. How was that associated with both the development of cardiovascular disease or a second cancer associated with physical activity? And what they set as the baseline was zero to 75 minutes. That was going to be considered sedentary. And what they found was a linear relationship that anything above 75 minutes was good and that This dropped your rate of both cardiovascular disease and recurrence of cancer, as long as that cancer is associated with physical activity. So think like breast, thyroid, GI, skin cancers. I wrote down some numbers here. At 150 to 300 minutes a week, they saw a drop between 23% and up to 27% in a cardiovascular disease diagnosis, primarily referring to coronary artery disease in those. The So not necessarily surprising. Like the general population, more exercise is equating into less cardiovascular disease and also less diagnosis of cancer. But the clear reason I really like this study is a lot of people wear smartwatches and the smartwatches are excellent at recording not only things like step count, but the time that a person engages in exercise. And what the smartwatches will do is that they also will say, hey, it seems like you're walking pretty fast here. We're going to count that as exercise. And we can get a great idea for time that a person is engaging in this so that even if they aren't telling us that they're getting exercise, we can still see what their watch is recording. And so I think this study does a great job of that as well. And so when we put all of this together, and just prior to these two articles, we talked to Dr. Sturitz about the importance of diet and healthy diet leading to a greater chance, a significantly greater chance, of healthy aging, being without any significant disease at age 70 and even 75. And now, Bill, you just talked about exercise. What do you think this means for our patients? I think it means we need to do a much better job at focusing on lifestyle, right? Of course, we need to focus on a healthier diet. But I think looking at these two articles, I think it's clear that we need to really focus on exercise. And I think it's that Walking is something that most of us can do. And when we talk to our patients and they want to know how much walking, we can start with just let's aim for an additional 2000 steps a day on top of what they're already getting. And that seems doable for a lot of us. That's a wonderful way to translate this into actionable knowledge. Yeah, it's so impressive because exercise is in a way the everything pill. it improves. And I think most of us are familiar with the fact that it decreases the likelihood of diabetes, decreases the likelihood of cardiovascular disease. I think the fact that it decreases by over 20% the likelihood of cancer is not something that is in the forefront of our thinking when we talk to patients. Yet, cancer is in the forefront of everyone's thinking when they think about what is it that they are rate of developing. So this is incredibly important information. Yeah, I absolutely agree. We think of our patients coming in for a physical. We talk about things like, do they need mammography? Do they need colorectal cancer screening? Do they need lung cancer screening? I think this should be there too. How much exercise are we getting? And that exercise does translate into a decrease in risk of colon cancer, of breast cancer, of melanoma. I think this is really important. That's a great point. I've always found when I take the time to discuss exercise, patients are particularly thankful because they don't always get that input from us when they come to their regular visits. Dr. Bill Callahan, thank you so much for joining us and sharing your thoughts with us today. Thank you for having me, Neil. That concludes this month's NACE Journal Club. What can I say? Adverse effects of ICS in people with COPD Beneficial effects of diet on achieving healthy living to age 75. The incredibly powerful effects of exercise in decreasing the risk of cancer by up to 25%. That's information we can use when we take care of our patients. Check out NACE Online for upcoming DME programs with some of the best faculty in the country. Conversations in Primary Care 2025 is on May 10th where our faculty will give updates on atopic dermatitis, TLP1s, resistant hypertension, and the OPD. Till next month, I'm Dr. Neal Skolnick. Be well and keep learning.