Steps, Intensity, and Mortality; Artificial Sweeteners and CVD

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 benefits of walking at different intensities, food analysis and mortality, screening for prediabetes and type 2 diabetes in youth, and use of artificial sweeteners and cardiovascular disease.

Program notes:

0:44 Screening for type 2 diabetes in children

1:44 Don’t know the benefits

2:44 During the pandemic increasing

3:44 How well does that treat it?

4:30 Categorizing foods and mortality

5:30 Cardiovascular and all cause mortality

6:30 Higher mortality from both

7:30 Increased inflammation and CVD

8:35 Artificial sweeteners and CVD

9:35 Frequently found in ultra-processed foods

10:23 Steps, intensity, and mortality

11:23 Cancer and diagnosis

12:54 End

Transcript:

Elizabeth: Daily step counts and intensity with cancer and cardiovascular disease incidence and mortality, and all-cause mortality.

Rick: Do artificial sweeteners change the risk of cardiovascular disease?

Elizabeth: Nutritionally profiling food or reporting ultra-processing, which of those impacts mortality?

Rick: And do data support screening children and adolescents for prediabetes and type 2 diabetes?

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, I hope you’ll agree that we should turn to JAMA and take a look at this notion of, “Should we be screening children for diabetes?” We are certainly seeing a huge increase in the incidence of type 2 diabetes among this group. What are we learning from the USPSTF?

Rick: Great. As you mentioned, this is the United States Preventive Services Task Force Recommendation Statement. They commissioned a review of all the evidence looking about screening for prediabetes and type 2 diabetes in asymptomatic kids, nonpregnant children and adolescents younger than 18 years of age. It basically centers around these questions. I’m going to ask you the question and you tell me whether the answer is yes or no. Is there a direct evidence that screening for prediabetes and type 2 diabetes in asymptomatic kids improves their health outcomes? Yes or no?

Elizabeth: No.

Rick: Not enough data. You’re right. Do we know enough about the harms and benefits of screening in this population?

Elizabeth: No.

Rick: No, you’re right. If we initiate treatment early on, once you’ve detected it, does that improve their outcomes?

Elizabeth: We don’t know.

Rick: Absolutely, don’t know. Can we prevent progression to type 2 diabetes in people with prediabetes in that population?

Elizabeth: Don’t know that either.

Rick: We don’t know that either. In fact, we don’t know very much at all about this population. That is the opinion of the USPSTF.

This is really unusual, because every other time we have reported out over the last two decades they provide recommendations based upon the existing data and they oftentimes update that. But their conclusion here was, “Gosh, here is a population that’s growing by millions because a large proportion of children and adolescents have both diabetes and prediabetes — in fact, that incidence has increased 95% over the last couple of decades — and yet we still don’t know enough about whether screening this group really improves their outcome or not.” This particular recommendation was, “Let’s get some data.”

Elizabeth: I’m pretty unsatisfied with this. I will reveal that a study that was partially done at Hopkins, but also around the country, reported in the last 2 years, so just during the pandemic, the incidence of type 2 diabetes among adolescents increased 77%. Many of these kids are hospitalized with severe metabolic complications of type 2 diabetes. It just seems like, “Look, how can we defend it?” We don’t have enough data here.

Rick: I think your point is very well taken. I would say not only in children in general, but high-risk groups, particularly American Indians, Blacks, and Hispanic groups have a particularly high incidence. This is a chance for us to align studies with unanswered questions that we just talked about.

Elizabeth: Right. I don’t think, though, that that argues for any kind of a delay in treating a kid who is obese, sedentary, and has risk factors.

Rick: When you say treat them, you mean with lifestyle changes or you mean putting them on a medication?

Elizabeth: Lifestyle changes are the beginning of any treatment plan for type 2 diabetes.

Rick: I would agree with that. But the real question is let’s say we institute those, how well does that prevent type 2 diabetes and when should that be initiated by the way? Those are questions we don’t know. Are we better off adding a medication to it or not? We both, after decades of recording, talk about the importance of healthy lifestyles: diet, exercise, physical activity, but, again, many of these questions go unanswered in this particular population.

Elizabeth: Well, you did bring up one issue, which is when you put them on a medication does that mean they are going to be taking it for the remainder of their lifetime? I think another unanswered question here is if we see a significant weight loss and improvement in physical activity, can this condition be reversed in this population, which we have seen in many adults?

Rick: The authors here are talking about what we see in adults oftentimes doesn’t apply to children, and that’s why we need to dig in.

Elizabeth: Well, since we are talking about lifestyle things, let’s turn to the BMJ. This is a rather strange study that takes a look at ways of categorizing foods and what are the impacts of those different foods with mortality, something called the Moli-sani prospective cohort study, which is conducted in Italy.

It turns out that there is a couple of ways that in Europe they label foods. One of them is with regard to nutritional content of foods, so called FSAm-NPS dietary index. This gives rise to something that’s known as the Nutri-Score, which they can label foods with. Then there is also another classification that’s called the NOVA classification, which is an index of how ultra-processed a food is, so how poorly nutritional is it really? Then they looked at what are the risks relative to all-cause and cardiovascular mortality relative to these two ways of assessing foods.

They make a statement that I think is really interesting and is totally unequivocal at the beginning of this paper. They say poor diets are responsible for more deaths than any other risk factor globally, and are the leading cause of obesity and non-communicable diseases. Before I go on on the data, what do you think of that statement?

Rick: That’s a pretty powerful statement, but again it indicates the importance of diet and, as you said, both nutrition and processing as well. Tell us what the data show about each of those.

Elizabeth: Okay. They have almost 23,000 participants. During their time period of follow-up, which was 12 years, they had a total of 2,205 deaths. The upshot of the whole thing is, sure enough, if you have a not-great diet you are going to die both from all-cause and cardiovascular mortality faster than you are if you have a better diet.

What about the intersection of these two things? They say that the association of the FSAm-NPS dietary index with all-cause and cardiovascular mortality was attenuated by 22% and 15% respectively, whereas mortality risks associated with ultra-processed foods were not altered by their joint indices.

Rick: In part, the mortality risk associated with nutritionally unbalanced food is due to the fact that it’s processed. Conversely, however, the fact that processed food increased mortality has nothing to do with the nutritional content at all. That means these are two complementary different dimensions.

Europe is about to embark upon a program that on the front of the package it’s going to tell you the nutritional content. It’s going to use different color-coding schemes, but it doesn’t tell you anything at all about the processing. What these authors are suggesting is, “Hey, we really need to look at both,” because the processing puts in things — chemicals — that even if it’s nutritionally of value you don’t want to be having some of these additives. They can increase inflammation, they’re associated with increased cardiovascular disease and associated with increased metabolic disorders. Therefore knowing both of those things ends up being important with regard to looking at overall diet.

Elizabeth: Right. Exactly, and they are both important. We really need to assess both of them. They drilled down and they looked at different aspects of blood counts, C-reactive protein, and so forth that were relative to both of these ways of looking at food. They did find some disparities between them.

Rick: In essence, what happens with the low-nutritional diet, it changes the glycemic index and how you process sugar. With the ultra-processed foods, there was an increased risk in altered kidney function, and higher inflammation as well. It does give some biologic plausibility to why each of those different compositions in nutrition and the processing ends up being important.

Elizabeth: Exactly. So, are you then in favor of some metric that’s going to establish a measure of both of these things with regard to food labeling?

Rick: I am, Elizabeth, but it has to be simple.

Elizabeth: Let’s move on to your next one. That’s also in the BMJ.

Rick: It is. It’s a look at artificial sweeteners and the risk of cardiovascular disease. It’s done based upon a prospective study done in France. Even though we use artificial sweeteners to replace sugar in beverages, we also do that in tabletop sweeteners and dairy products. There has been some concern that they may not overall be healthy.

What this study did was they had over 103,000 participants where they looked at the dietary intake of artificial sweeteners by doing repetitive 24-hour dietary records over the course of several years. They looked at total artificial sweetener intake and they found that it was associated with an increased risk of cardiovascular disease. It increased it by about 10%.

They looked at both heart disease and cerebrovascular disease. They looked at individual sweeteners and, for example, aspartame increased the risk of cerebrovascular disease whereas sucralose was associated with an increased risk of coronary heart disease. It is an observational study; therefore, it can’t really talk about causation.

Elizabeth: Gosh, we just talked about ultra-processed foods and these things are frequently found in ultra-processed foods. I’m wondering if there really isn’t some aspect of biological plausibility here.

Rick: It’s very hard to sort these things out. It may be that people that use artificial sweeteners have a worse diet, are older, have other risk factors, and all those things together characterize a person, not one particular thing.

Elizabeth: As we know, the only thing that’s ultimately going to answer this is going to be a prospective study where we feed these things to different groups of people and try to control for all the other risk factors. I just don’t see that happening. Maybe training oneself not to need a sweetener at all might be the best strategy.

Rick: Yep. In fact, we have talked before about best dietary habits. Interestingly enough, those people that use the artificial sweeteners were less likely to have diets that were healthy.

Elizabeth: Finally, let’s turn to JAMA Internal Medicine. This is a prospective association of daily step counts and intensity with cancer, cardiovascular disease incidence and mortality and all-cause mortality.

I would like to just mention that last week there was also a study that took a look at daily step counts and the association with the development of Alzheimer’s disease that got a tremendous amount of attention. The upshot of this whole thing — and it’s no surprise to anybody — is, of course, it’s really good to get out there and do those steps.

This is a study taking a look at the U.K. Biobank from 2013 to 2015 with a median follow-up of 7 years using a wrist accelerometer, measured daily step count, and cadence-based step intensity measurements. These included three categories: incidental steps, purposeful steps, and peak-30 cadence. Their outcomes were all-cause mortality, primary and secondary cardiovascular disease or cancer mortality, and incidence diagnosis.

What they found was that, sure enough, doing those 10,000 steps a day may be associated with a lower risk of mortality, cancer, cardiovascular disease incidence, and that those steps performed at the higher cadence may be associated with additional risk reduction.

Rick: I appreciate you mentioning again, this is an association study. They tried to correct for a number of different things, age and sex, in one model. Then they tried to add race, education, socioeconomic status, and smoking.

There are several things it didn’t address, like the presence of hypertension or previous cardiovascular disease. The other issue is, they just didn’t accelerate it and they just measured steps one time. We would like to have data that’s a little bit longer because you can imagine where you said, “We are going to do this study, we’ll put an accelerometer and measure your steps.” Most of us are going to want to get out there and look really good. But the question is, is that sustained?

Nevertheless, it suggests that the more you walk, the better off you are. That sounds pretty logical to me. If you walk, you do better than if you don’t walk. That also sounds like pretty common-sense advice to me as well.

Elizabeth: And step it up sometimes.

Rick: That’s a great thing. Step it up. I like that. In Texas, we just do the two-step, but you’re talking about doing the 10,000 step.

Elizabeth: Indeed, I am. 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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