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March 3, 2015 Issue


Clinical Practice Points

Medical Knowledge

Effects of Exercise Amount and Intensity on Abdominal Obesity and Glucose Tolerance in Obese Adults. A Randomized Trial

Exercise benefits people who are obese or have diabetes, but the separate effects of exercise duration and intensity are not well-understood. In this study, participants assigned to higher or lower intensities of the same total amount of exercise had similar reductions in waist circumference and weight, although higher-intensity exercise led to greater increases in cardiovascular fitness and improved 2-hour glucose tolerance.

Use this study to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Ask your learners to define the metabolic syndrome. Do they know all of its components? What do we know of the risks associated with the metabolic syndrome?
  • Ask your learners what specific instructions they provide to patients when encouraging exercise? Do they know what to say? Do they really know what they’re talking about?
  • Patients are often encouraged to exercise as an important first step to ameliorating hyperglycemia. Should the results of this study alter how we advise our patients? What about patients who cannot, or will not, engage in high-intensity exercise? Use the accompanying editorial to help consider the answers.
  • Invite a member of your center’s weight loss or physical therapy program to tell your group how they make specific exercise recommendations. How do they differ according to patients’ underlying medical problems?


Medical Knowledge
Patient Care

Cigarette Smoking Prevalence Among Adults With HIV Compared With the General Adult Population in the United States. Cross-sectional Surveys

Smoking is associated with increased illness and death in adults with HIV. This study found that adults with HIV smoked more and were less likely to quit than adults in the general population, emphasizing the importance of tobacco screening and cessation strategies in routine HIV care.

Use this study to:

  • Ask your learners what preventive measures they should be performing in their HIV-positive patients. Do recommendations for health maintenance differ for those with and without HIV infection? How? Use the information in ACP Smart Medicine: Human Immunodeficiency Virus Disease.
  • In adults with HIV, cigarette smoking increases the risk for both HIV-related and non–HIV-related illnesses. Ask your learners which ones. The authors provide the answers in the paper’s introduction.
  • How do your learners communicate the importance of smoking cessation to their HIV-positive patients? Is the message different than with other patients? The authors note that recent data suggest the amount of life-years lost from HIV and cigarette smoking together is greater than that attributed to each individual condition, suggesting a synergistic effect.
  • Do your learners know how to counsel patients about smoking cessation, when to consider pharmacologic intervention to assist, and which agents to choose? Are there interactions between these agents and the drugs used to treat HIV infection? Use the information in In the Clinic: Smoking Cessation.


Medical Knowledge
Patient Care
Practice Based Learning and Improvement
In the Clinic:

Type 2 Diabetes

Diabetes is one of the most common illnesses encountered by internists. Currently, an estimated 29.1 million people in the United States have diabetes, and only 21.0 million of these cases have been diagnosed. The incidence of diabetes is increasing because of the aging and changing ethnic mix of the population and because of increasing obesity. Based on current trends, it is expected that the prevalence of diabetes will nearly double by 2050! Are your learners ready? Use this eminently practical review to ask and answer key questions in the care of patients with type 2 diabetes.

Use this review to:

  • Download the already prepared slides to help you get ready for a teaching session.
  • Ask whether we should screen for type 2 diabetes. Do we know whether screening alters outcomes? Which patients are likely to benefit from screening?
  • Ask what are the diagnostic criteria for type 2 diabetes. What should the evaluation of newly diagnosed diabetes include?
  • What are the goals of treatment, and how should they be monitored? What interventions should be considered and when?
  • Ask what measures U.S. stakeholders use to evaluate the quality of care provided to patients with type 2 diabetes.
  • Use the multiple-choice questions at the end to break up topics in your teaching, and log on to enter your answers and claim CME credit for yourself!

Our Health Care System


Professionalism
Systems-based Practice

Medicine and Public Issues: Major Concepts of Health Care Economics

This article, written for us physicians (i.e., not economists or health policy experts!) applies major economic concepts, such as supply, demand, monopoly, monopsony, adverse selection, and moral hazard, to central features of U.S. health care. These illustrations help explain some of the principal problems of health policy—high cost and the uninsured—and why solutions are difficult to obtain.

Use this paper to:

  • Ask your learners what are the drivers of “supply” in health care. How does scale matter? Who and what determines the available supply?
  • What is demand? How does the presence of insurance alter the demand? Why is demand hard to predict, and what are the implications for health care policy?

Humanism and Professionalism


Professionalism

On Being a Doctor: Healing the Enemy: The Personal Narrative of an Israeli Surgeon

In their essay, Drs. Gilbey and Spivey tell of their experience providing life-saving care to an “enemy soldier” and wonder, “Is it conceivable that he might return to his homeland and sometime in the future find himself aiming a deadly weapon at me, one of my colleagues, or my loved ones?” Yet the authors conclude hopefully that, “Is it not possible that, through our unplanned and unnatural relationship, we are laying the foundations for future peace?”

Use this essay to:

  • Listen to an audio recording, read by On Being a Doctor editor, Dr. Michael LaCombe.
  • Ask your learners how they would feel providing care to someone who might have tried, or might in the future try, to harm them or their families. Are they obliged as physicians to do so anyway?
  • When and where are the lines among politics, personal survival, and professional obligations to provide care?

mksap16

A 56-year-old woman is evaluated during a follow-up visit after presenting as a new patient 2 weeks ago. At that time, her blood pressure was found to be elevated (156/88 mm Hg) and follow-up laboratory tests were ordered. She has had no major illnesses. Her father had type 2 diabetes mellitus and died at age 52 years of a myocardial infarction. She is currently taking no medications.

On physical examination, blood pressure is 156/92 mm Hg in the left arm and 160/90 mm Hg in the right arm. Pulse rate is 86/min and respiration rate is 16/min. BMI is 34. Waist circumference is 39 in (99 cm). Results of a funduscopic examination are normal.

Laboratory studies:

Blood urea nitrogen 16 mg/dL (5.7 mmol/L)
Creatinine 0.9 mg/dL (79.6 µmol/L)
LDL cholesterol (fasting) 162 mg/dL (4.19 mmol/L)
HDL cholesterol (fasting) 32 mg/dL (0.83 mmol/L)
Triglycerides (fasting) 148 mg/dL (1.67 mmol/L)
Glucose (fasting) 98 mg/dL (5.4 mmol/L)
Urinalysis Trace protein, no glucose

In addition to hypertension and obesity, which of the following is the most likely diagnosis?

A. Hypertriglyceridemia
B. Impaired fasting glucose
C. Metabolic syndrome
D. No additional diagnoses

Answer
C. Metabolic syndrome

Key Point
Metabolic syndrome is diagnosed by the presence of three or more of five abnormalities: increased waist circumference, elevated systolic or diastolic blood pressure, decreased HDL cholesterol level, elevated triglyceride level, and elevated fasting plasma glucose level.

Educational Objective
Diagnose metabolic syndrome.

Given this patient's hypertension, lipid profile, and abdominal obesity, she meets the criteria for metabolic syndrome. The diagnosis of metabolic syndrome (Adult Treatment Panel III criteria) is made by the presence of three or more of the following five criteria: (1) waist circumference >40 in (102 cm) in men and >35 in (88 cm) in women; (2) systolic blood pressure ≥130 mm Hg or diastolic blood pressure ≥85 mm Hg; (3) HDL cholesterol level <40 mg/dL (1.04 mmol/L) in men and <50 mg/dL (1.30 mmol/L) in women; (4) triglyceride level ≥150 mg/dL (1.70 mmol/L); and (5) fasting plasma glucose level ≥110 mg/dL (6.1 mmol/L).

The clinical importance of identifying the metabolic syndrome is the increased risk for cardiovascular disease and type 2 diabetes mellitus in those with this diagnosis. Persons with the metabolic syndrome should receive aggressive intervention focused on lifestyle modification to decrease weight, increase physical activity, and implement a nonatherogenic diet, in addition to treating the significant metabolic abnormalities that define the syndrome. The metabolic syndrome is frequently identified in patients with polycystic ovary syndrome, and has also been associated with the development of other disorders, including fatty liver disease, obstructive sleep apnea, hyperuricemia, and gout.

The patient does not meet the criteria for hypertriglyceridemia, although American Heart Association guidelines recommend an optimal triglyceride level of below 100 mg/dL (1.13 mmol/L), and this would be an appropriate goal for this patient for lifestyle modifications.

Impaired fasting glucose (prediabetes) is defined as a fasting blood glucose level of 100 to 125 mg/dL (5.6-6.9 mmol/L). She does not have this diagnosis, and the diagnosis of the metabolic syndrome does not strictly require abnormalities in glucose metabolism.

Bibliography
Tota-Maharaj R, Defilippis AP, Blumenthal RS, Blaha MJ. A practical approach to the metabolic syndrome: review of current concepts and management. Curr Opin Cardiol. 2010;25(5):502-512. PMID: 20644468

This question is derived from MKSAP® 16, the Medical Knowledge Self-Assessment Program.


From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Program Director in Internal Medicine, Thomas Jefferson University.

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