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 tap water burn impact, inflammation in heart disease in people on statins, the worldwide cost of obesity, and active surveillance in prostate cancer.
Program notes:
0:33 World Obesity Atlas
1:35 $4 trillion dollar cost
2:33 Contributes to work absenteeism
3:33 Not a failure of will
3:50 Role of inflammation in cardiac events
4:50 Use anti-inflammatory agent
5:50 C-reactive protein may indicate
6:05 Tap water scalds
7:05 Multiple body surfaces involved
8:05 Water at 120º F
9:00 Active surveillance for low-risk prostate cancer
10:00 Minimizes side effects
11:00 Call to individuals
12:05 End
Transcript:
Elizabeth: A worldwide look at the economic impact of obesity.
Rick: Inflammation and cholesterol as predictors of cardiovascular events.
Elizabeth: How badly are people still getting burned by tap water?
Rick: And managing low-risk prostate cancer in the United States.
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: 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, if it's okay with you, I'd like to turn first to the World Obesity Atlas.
This is a rather daunting look at the worldwide burden of obesity that predicted the burden over the next several years until 2035. I didn't realize it was their fifth annual look at this. This organization works in conjunction with the WHO [World Health Organization], and they have taken different aspects of obesity on over these 5 years. In this case, they're looking at the economic impact of worldwide increasing obesity.
We have absolutely failed, of course, to even begin to get our arms around stabilizing the rate of obesity, and their look indicates that irrespective of income, really, of countries that percentage of people predicted to be obese by 2035 is just going to continue. With regard to the global economy in that year, over $4 trillion of potential income will be devoted to alleviating all of the multitude of problems that happen as a result of obesity.
They also note in here that the COVID-19 pandemic has increased the risk of weight gain in almost all the countries that they looked at around the world, including both overweight and obesity. They cite that 38% of the world's population has that condition or either of those two conditions in 2020. That number is predicted to increase to over 50% by 2035.
Rick: It is daunting. Those are percentages. The absolute numbers are by 2035 about 1.9 billion people will be overweight or obese. The steepest rise is expected to be among children and adolescents. They are going to go from 10% to 20% of kids will be obese. As you noted, it's not limited to high-income or developed countries. It's also affecting low-income countries as well.
Elizabeth: They, of course, point out that high BMI [body mass index] contributes to absenteeism from work, decreased productivity while you're there, and premature retirement or death. We're well aware of all of the health conditions that are either the direct result of obesity or exacerbated.
Rick: To their credit, the World Obesity Atlas also provides actions that countries around the world need to take, including a high level of political commitment and investment, leaving no one behind, investing in health workers, having community empowerment, better surveillance and data collection, increasing public financing for health, and then ensuring strong accountability mechanisms. Then they also provide countries scorecards to show how they are doing and what the effect of obesity will be on each country.
Elizabeth: Something we absolutely need to pay attention to, unquestionably. One of the things I liked about their interventions is that they emphasize the fact that we can't blame people for obesity. This is not some kind of failure of will.
Rick: No. It has to do with our environment, psychosocial issues, and some genetic issues as well. But it's going to be the major non-communicable disease problem throughout the entire world unless we begin to address it more seriously.
Elizabeth: Okay. Which of yours would you like to turn to?
Rick: Let's talk about this particular study that's from Lancet. It's an analysis of the role of inflammation and cholesterol in producing cardiovascular events like heart attacks, congestive heart failure, and strokes.
It was a really interesting study that they did. A lot of people now that are at high risk or known to have cardiovascular disease already take a statin to lower cholesterol, and we know that it decreases the risk of cardiovascular events. What's the incremental risk associated with this inflammation as measured by checking the C-reactive protein [CRP] or cholesterol on subsequent cardiovascular events?
What they found when they looked at over 31,000 patients, inflammation played a much bigger role than LDL cholesterol in people who are already on statins. When they compared the highest versus the lowest risk of inflammation, there is a 31% increased risk of having a cardiovascular event with increased inflammation. That's also about a 7% increase risk for just having a higher LDL.
What this suggests to the authors is once we treated with the statin we can't neglect the inflammation, and we need to address that using either one of more anti-inflammatory agents that are already on the market or some newer ones that are on the market. But just adding additional medicines to decrease LDL won't give us nearly the benefit as decreasing inflammation.
Elizabeth: I, for one, am of course happy that the identification of inflammation as a really important factor in the continuation of disease progression has been pointed out here, because it is a final common denominator. What specific interventions are they suggesting for the inflammatory component?
Rick: There are targeted anti-inflammatory therapies. Canakinumab [Ilaris] is one of them. There is another lower-cost agent called colchicine. Then there is a newer agent that we're going to be talking about over the next several weeks called bempedoic acid [Nexletol], and it also seems to decrease inflammation as well.
Although these agents have been shown to be effective in decreasing cardiovascular events, they really haven't been widely accepted yet. I guess that's the plea of the authors. It's if you have a low LDL, but your C-reactive protein is still high, let's give targeted therapies to address those particular individuals.
Elizabeth: I would also note that CRP is not the only inflammatory factor that might be important to assess.
Rick: Right. Targeting the inflammation itself may provide additional benefit.
Elizabeth: Right and there are others that might be important to also take a look at.
Let's turn to The BMJ. This is look at a problem that I didn't realize was nearly as big as it is, and that's the cost burden of hospital-treated tap water scald burns in the United States. This is a retrospective cross-sectional study where they looked at National Inpatient Sample and National Emergency Department Sample databases from Healthcare Cost and Utilization Project.
They identified 52,000-plus ED [emergency department] visits and 7,000-plus hospitalizations -- 110 hospital-based deaths attributed to tap water scald burns between 2016 and 2018. The average cost for these encounters was just shy of $600 per ED visit and just shy of $29,000 per hospitalization.
If you total it up, it's worth $207 million treating these inpatient visits and almost $30 million for these ED visits.
They also note that multiple body surfaces were involved in just over 35% of the inpatient visits and 16% of the ED visits. We know that the recommendation is, both from an energy cost standpoint as well as a scald potential perspective, that one should set their water heater at 120º Fahrenheit.
They note in here that depending on how old you are -- whether you're really young or really old -- how long you might be in contact with the water, and the temperature, of course, of the water are the three factors that indicate whether or not you're going to get a scald burn as a result of this exposure. There is another fix, a thermostatic mixing valve, which they've had in the U.K. for a while, which is a cost-effective approach to reducing this risk.
Rick: Yes, Elizabeth. If you had asked me what's the cause of most water burns, I would have said water that's basically boiling on the stove. The fact that's coming from the tap was really kind of surprising to me.
If the water is at 120º, which is what these thermostats can regulate to, it takes about 9 minutes to get a serious burn. If you heat the water up to 140º, a serious burn occurs in as little as 3 seconds. That's why bringing the temperature down in a way that's pretty reliable can decrease this substantially. There is no reason why we should be having 7,000 hospitalizations and 110 deaths due to tap water scald burns.
Elizabeth: Especially because many of those occur in children.
Rick: Yeah. There are two ways to address this. One is to require the use of thermostatic mixing valves, and there are some countries that do that. Canada does, and Australia. What you can do is, say if you put it in a new water heater, it also has to have a thermostatic mixing valve, so eventually over a period of time we'll get rid of excessively hot water that causes these scald water burns. For those people that are considering it, these thermostatic mixing valves retail for about $30.
Elizabeth: Well worth doing, I think. Let's turn to your final one -- that's in JAMA Network Open looking at active surveillance for low-risk prostate cancer in the U.S.
Rick: That active surveillance is endorsed by clinical guidelines as a preferred management for low-risk prostate cancer by a number of organizations. In fact, every organization now that talks about treating what's called low-risk prostate cancer involves active surveillance as opposed to doing things like prostate surgery or radiation therapy.
These low-risk prostate cancers are characterized by the fact that the individuals have a low PSA [prostate-specific antigen] -- a PSA less than 10, they have a biopsy that shows it's low-risk, a low Gleason score, and a clinical stage that indicates that it's confined; it hasn't made its way outside the prostate. In those circumstances, it's recommended that we do active surveillance -- i.e., we continue to measure the PSA, we continue to do imaging if we need it, or continue to do biopsy when indicated.
There is no difference in terms of long-term survival as opposed to treating the prostate cancer, but what it does, it minimizes the side effects. Despite those recommendations, the question is how often do we do that?
They used a database that includes over 1,945 urology practitioners at over 349 practices across really the entire United States, looking at 8.5 million unique patients. In that group, they found almost 21,000 patients who were diagnosed with low-risk prostate cancer between 2014 and 2021. Active surveillance, which started only at 27%, is now up to about 60%. That's good news, but the use of active surveillance varied according to the urology practice, from as little as 4% to as much as 78%, and at the individual practitioner level from 0% to 100%.
That means not everybody is getting the message.
The groups more likely to not do active surveillance are those where there was a high concentration of urologists in a particular area and they were competing for patients. They were more likely not to follow the guidelines -- a call to action and a call to individuals, because most of us know an individual at some time that will be diagnosed with prostate cancer. If it's low-risk, active surveillance is the recommendation.
Elizabeth: Exactly. I mean, I think this is just a clear indication of caveat emptor, that it's important as a patient that you become informed about what your treatment options are, and then actually ask, whoever it is you're seeing, "What about this? It seems like I've heard a lot about it. Am I a candidate for this strategy?"
Rick: Absolutely. Again, it would be different if you had a better outcome by doing something different, but you don't have a better outcome. In fact, you have a higher complication rate when you subject yourself to therapy that's really not going to prolong your survival.
Elizabeth: Okay. 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 making healthy choices.