Health Affects of Diabetes Remission; High-Deductible Plans for Cancer Patients

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 a possible cause for long COVID, screening for language disorders and delays in kids, costs of healthcare when someone with cancer gets switched to a high-deductible plan, and the health affects of diabetes remission.

Program notes:

0:33 Long COVID and the complement system

1:33 Top biomarkers identified

2:32 Which complement pathway involved?

3:35 Identify those at risk

3:50 Remission of type 2 diabetes and health outcomes

4:50 Reduced rate of chronic kidney disease and cardiovascular disease

5:50 1,200 to 1,800 kilocalories per day

6:50 DiRECT trial in U.K.

7:03 USPSTF screening for speech and language disorders

8:03 No studies evaluate screening

9:03 Different in different cultures

9:16 Out-of-pocket costs for patients with cancer and high-deductible plans

10:17 Over 2,700 in high-deductible group

11:15 Sacrificed non-cancer and primary care

12:25 End

Transcript:

Elizabeth: High-deductible plans and cancer care.

Rick: Should we be screening kids for speech and language disorders?

Elizabeth: What’s the impact of remission from type 2 diabetes on long-term health outcomes?

Rick: And insights into active long COVID.

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, we haven’t talked about COVID in so long — and that’s a blessed relief, of course — but let’s turn to our COVID material that’s in Science.

Rick: We’ve quibbled a little bit based upon studies about the percentage of individuals that develop COVID that will subsequently have long COVID symptoms. People would agree that at least 5% of individuals that have COVID develop long COVID symptoms. What causes that? Is there a persistent virus that’s circulating? Is there persistent inflammation or tissue damage?

What these investigators attempted to do was to answer this in a very rigorous and robust way. They followed 39 healthy controls and 113 COVID-19 patients for up to 1 year and then they attempted to identify biomarkers associated with long COVID. They measured over 6,500 proteins in the serum by proteomics, about 270 longitudinal blood samples, and then they used the top biomarkers and then examined these things experimentally.

Here is what they discovered. Among the 113 COVID-positive patients, they identified 40 that had long COVID. Compared to those that didn’t have long COVID or those who were healthy controls, they had dysregulation of what’s called the complement system.

Complement are those proteins that work with our antibodies and immune system. There were complexes that actually insert themselves into membranes of certain cells. The complement works to destroy those cells, and this dysregulation was likely responsible for the long COVID symptoms. They could measure tissue markers, and so there was injury. The inflammation led to increased thrombosis, which we’ve described before. This gives some mechanism for why long COVID symptoms may persist.

Elizabeth: I’m going to ask you to hearken back lo these many years ago to our respective educations and the fact, or what we were educated about, that there are two complement pathways — one extrinsic and one intrinsic. My question is, which of these pathways is it that becomes dysregulated? Then, of course, the big question is, what do we do about this?

Rick: It looks like there were a number of different complement pathways involved. There may be some specific treatments that can affect the complement system. It looks like during this time, by the way, there were reactivations of other viruses — for example, herpesvirus — so maybe the antiviral agents could play a role. They looked at a large number of proteins. It’s a relatively small number of patients — we’re talking about 40 patients — so you’d certainly want to look at this in a larger number.

Elizabeth: I agree and, of course, without our methods that we currently have available, it probably would have been impossible. They’re taking a really long time to get this data together. I’m still just really interested in this idea of dysregulation of the complement pathway or one of the complement pathways. I would be interested in looking at that more carefully in the sequelae that follow other viral infections.

Rick: That would be interesting if you want to identify those that are at risk. What I’d be interested in knowing is can we use the complement pathways or these other serum protein markers as a way of identifying early on who would be at risk.

Elizabeth: Let’s turn to Diabetologia. This article is taking a look at the impact of remission from type 2 diabetes on long-term health outcomes. This is from a study that’s been around here for a while and these are almost 12-year outcomes on average from a study that was called the Look AHEAD study.

They were looking to determine the association of attainment of diabetes remission in the context of a 12-year intensive lifestyle intervention with subsequent incidence of chronic kidney disease or cardiovascular disease. In it, they compared the incidence of cardiovascular disease and chronic kidney disease among 4,400+ people and 4,100+ people, respectively. This was based on achievement and duration of diabetes remission. This is an important factor.

They basically looked at participants with any evidence of remission during follow-up and found that they had a 33% lower rate of chronic kidney disease and a 40% lower rate of their composite cardiovascular disease measure compared with folks who did not have remission. They note that this association may be affected by post-baseline improvements in weight, fitness, hemoglobin A1C, and LDL [low-density lipoprotein] cholesterol.

It’s also noteworthy that very few of their participants were able to maintain their initial early remission of diabetes as they followed them over this 12-year period.

Rick: They changed their diet, they reduced their calories, and they had them exercise about 175 minutes per week. When they did that, if the diabetes was relatively early, if their hemoglobin A1C was relatively low, then in about 1 in 9 patients, the type 2 diabetes resolved. Now, when they followed them, by the way, over the next 10 years, that decreased to about 4%. But despite that, as you mentioned, there was a markedly reduced rate of chronic kidney disease and cardiovascular disease.

Elizabeth: Here is what the components of this intervention were. They reduced their total calorie intake to about 1,200 to 1,800 kilocalories per day based on their initial weight. They reduced total fat and saturated fat intake to less than 30% and 10%, respectively, of their caloric intake. They increased their physical activity to a level of 175 minutes per week with brisk walking and moderate-intensity activities. These are things, of course, that we’ve known for quite a while have been useful in helping people to achieve remission from type 2 diabetes, especially if it’s early on in the course of the condition.

Rick: I think a lot of people say, well, “I’ve got diabetes and, gosh, there is nothing to do about it.” The fact that you can actually change that and remit it, I think that will be news to many individuals. Even without sustained remission, changes in lifestyle significantly improved the risk of kidney disease and heart disease.

Elizabeth: I’m going to just note that maybe the general public wasn’t aware of this, but we’ve talked about this many times. There is a trial that’s being conducted right now in the U.K. that’s called the DiRECT trial where they are considering this kind of intervention as a primary care referral option for the U.K. National Health Service, so that’s pretty powerful.

Rick: Elizabeth, let’s turn to JAMA. This is the U.S. Preventive Services Task Force (USPSTF) evidence report. Shouldn’t we be screening for speech and language delay disorders in children 5 years or younger?

An estimated 8% of U.S. children age 3 to 17 have a communication disorder, and boys are almost twice as likely to be affected than girls, and African Americans disproportionately more affected than Hispanics or whites. Delayed means they go on to develop the normal language skills; it just takes a little bit longer. Disordered means they don’t develop the typical language skills. That could be either by difficulty understanding, called receptive language, or difficulty speaking, called expressive language.

What the USPSTF asked is should we be screening young kids? Because we know language disorders go on to affect how they do in school, their social interactions, and their behavior. Now, this was last examined back in 2015. Fast-forward 8 years, they looked at 38 different studies, 41 different articles, and what they determined was that none of these directly evaluated the benefits of screening versus no screening.

Now, by the way, this is just universal screening. This isn’t screening of children in whom the parents noticed there was some disorder. That’s a whole different group. Those individuals can be properly screened. There are treatments that can actually improve their communication disorder. But just routine screening across all children, we just don’t have any evidence that that’s going to be beneficial.

Elizabeth: Should we put resources into gathering that evidence to see whether it’s beneficial?

Rick: Well, in fact, that’s exactly what these authors suggested. I think this is an important thing to do.

Elizabeth: If parents are pretty good at catching that their child has some kind of a concern, then why is it that we need to study this more broadly? Are there a lot of kids who are falling through the cracks?

Rick: The presumption is that the parents are the best identifier of this. Should we be screening kids whose parents wouldn’t recognize communication disorders? We have different progression. It’s different in the African-American culture than it is in the Hispanic or white culture. I’m not sure parents are the best adjudicator of it. That’s why we need to address whether universal screening with good screening tools could be beneficial.

Elizabeth: Finally, let’s turn to JAMA Oncology. This is a look at out-of-pocket costs and outpatient visits among patients with cancer who are transitioned into high-deductible health plans. High-deductible health plans, of course, are associated with additional out-of-pocket medical costs.

This study took a look at data from 2003 to 2017 among adults age 18 to 64 years with cancer who were initially enrolled in low-deductible health plans, and then they continued to follow those whose employers then mandated they switch to a high-deductible health plan. They had 2 groups: those who had no option — they had to change to the high-deductible health plan — and the others who didn’t have that circumstance.

They matched these 2 groups on demographic variables including their age, sex, all the normal things, and their cancer types. They followed them up for 3 years after the baseline year. They had 45,000+ patients with cancer — 2,700+ in the high-deductible health plan group, and 43,000 in the control group. Their average age was disconcertingly young. It was only 53, just shy of 53 years. There were almost 60% females in both groups.

Those in the high-deductible health plans had an increase in annual out-of-pocket, medical expenditures, so 68%. They also found that in the high-deductible healthcare group, they also had fewer visits to their primary care physicians and fewer visits to non-cancer specialists.

It suggests that for the person with cancer who gets switched to one of these plans, they truncate their visits to other providers, which may have important implications if you’re a survivor. That’s who you’re relying on to scrutinize what your health is looking like and whether you need to have additional cancer treatment.

Rick: Yeah. It’s an unfortunate circumstance when someone has cancer and their employer switches them from a low-deductible to a high-deductible. Interestingly enough, they continue to receive their cancer care, but what they did sacrifice was visits to their primary care physicians and non-cancer specialists.

As you mentioned, once someone has received their treatment, these are the individuals that care for them. Individuals go on to have lung problems, heart problems, and neuropathy problems. If they’re receiving less care from the non-oncologist, it could affect their overall outcome.

Elizabeth: Unquestionably, and the reason this spoke to me was also because of this circumstance we’ve reported before about financial toxicity, which most people with cancer call the second most onerous burden relative to management of the disease.

Rick: I’m not sure there is an easy solution to this because when someone has limited resources you’re going to direct it towards the most compelling issue and that’s cancer, but we need to make sure that they receive comprehensive care afterwards.

Elizabeth: Absolutely. On that note then, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.

Rick: I’m Rick Lange. Y’all listen up and make healthy choices.