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FDA Approves New Drug for Heart Failure

THURSDAY, July 9, 2015 (HealthDay News) — The U.S. Food and Drug Administration has approved the first in a new class of drugs that show promise for combating heart failure.

The approval of Entresto (sacubitril/varsatan) was sped up after a clinical trial found it significantly reduced the rate of death and hospitalization due to heart failure compared to another, often-prescribed treatment, the FDA said in a news release.

Heart failure, which is characterized by the heart’s inability to pump enough blood, affects some 5.1 million people in the United States. Heart attack, high blood pressure and other conditions that damage the heart are primary causes, the FDA said.

“Heart failure is a leading cause of death and disability in adults,” Dr. Norman Stockbridge, director of the division of cardiovascular and renal products in the FDA’s Center for Drug Evaluation and Research, said in the news release. “Treatment can help people with heart failure live longer and enjoy more active lives.”

Entresto is the first in a new class of drugs called angiotensin receptor neprilysin inhibitors, or ARNIs.

The new drug was evaluated in clinical trials involving more than 8,000 adults. It was shown to reduce the rate of cardiovascular death and hospitalization. Most trial participants also took standard heart failure medications, such as beta blockers and diuretics.

Common side effects of Entresto included low blood pressure, elevated blood potassium and impaired kidney function, according to the FDA.

A more serious adverse effect was angioedema, an allergic reaction characterized by swelling of the lips or face. Blacks and people with a history of angioedema are at higher risk of this reaction, the FDA said. People taking the drug should seek immediate medical help if they develop facial swelling or trouble breathing, the agency said.

Entresto should not be used with any ACE inhibitor drug, which would increase a user’s risk of angioedema. And women should discontinue Entresto as soon as possible if they become pregnant, the FDA warned.

The drug is made by Novartis Pharmaceuticals, based in East Hanover, N.J.

More information

For more on Entresto, visit the FDA.





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Uncontrolled Diabetes May Boost Dementia Risk

THURSDAY, July 9, 2015 (HealthDay News) — Diabetes patients with high rates of complications from the disease may face increased risk for dementia, a new study suggests.

“We found that as diabetes progresses and an individual experiences more complications from the disease, the risk of dementia rises as well,” wrote Dr. Wei-Che Chiu, of the National Taiwan University College of Public Health, in Taipei.

Better blood sugar control can help prevent the mental decline associated with diabetes, he and his colleagues said.

They examined data from more than 431,000 people in Taiwan who were older than 50 and newly diagnosed with diabetes.

Complications of diabetes include vision loss, kidney failure and nerve damage.

Over 12 years of follow-up, more than 6 percent of the patients were diagnosed with dementia. Those with a greater number of diabetes complications were at higher risk for mental decline than those with few or no complications.

The study was published online July 9 in the Journal of Clinical Endocrinology & Metabolism.

“The study demonstrates why it is so crucial for people with diabetes to work closely with health care providers on controlling their blood sugar. Managing the disease can help prevent the onset of dementia later in life,” Chiu said in a journal news release.

More than 29 million Americans have diabetes, according to the Endocrine Society. Of every 100 Americans with the disease, 21 have nerve damage, 27 have kidney damage and 29 to 33 have eye damage.

More information

The American Diabetes Association has more about diabetes complications.





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Testosterone Treatments Won’t Help Men With Ejaculatory Issues

THURSDAY, July 9, 2015 (HealthDay News) — Testosterone supplements won’t help men with low testosterone ease any problems they have with ejaculatory function, a new study suggests.

According to researchers led by Dr. Darius Paduch of NewYork-Presbyterian Hospital/Weill Cornell Medical Center in New York City, issues with ejaculation affect anywhere from 10 percent to 18 percent of men.

These conditions include an inability to ejaculate, low ejaculation volumes and force, and delayed time to ejaculation, the researchers said. They added that there is currently no U.S. Food and Drug Administration-approved treatment for ejaculatory dysfunction.

Could testosterone replacement therapy help men who face these problems, and who also have low levels of testosterone?

“This is the first clinical trial examining the treatment of a very common but poorly understood condition that affects men’s physical health as well as their interpersonal relationships,” Paduch said in a news release from the Journal of Clinical Endocrinology & Metabolism, which published the new findings on July 9.

The study included 66 men, aged 26 and older, with low testosterone levels and a history of ejaculatory dysfunction. The men were randomly selected to receive either a 2 percent testosterone solution applied to the skin, or a “dummy” placebo.

After 16 weeks, the men who received the testosterone therapy showed little improvement in ejaculatory function compared to those in the placebo group.

One expert in men’s sexual health wasn’t surprised.

“Testosterone levels have long been known not to affect ejaculatory function,” said Dr. Elizabeth Kavaler, a urology specialist at Lenox Hill Hospital in New York City.

“Orgasm is a function of the sympathetic nervous system, which does not respond to testosterone,” she explained. “Libido and sexual interest increase with testosterone, but not the ability to orgasm.”

As for Paduch, he said that “although the participants in this study did not experience any significant improvement in ejaculatory function, we hope our work will spur the development of additional clinical trials to find treatments for this condition.”

More information

The U.S. National Library of Medicine has more about sexual problems in men.





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Study Questions Safety of Chemicals Used in Plastic Consumer Products

THURSDAY, July 9, 2015 (HealthDay News) — Two supposedly safer chemicals used to replace a known harmful one in plastic and other consumer products pose similar health risks, a new study contends.

The compounds di-isononyl phthalate (DINP) and di-isodecyl phthalate (DIDP) — which belong to a class of chemicals known as phthalates — are associated with increased risk of high blood pressure and diabetes in children and teens, researchers from NYU Langone Medical Center in New York City found.

The two chemicals are used during manufacturing to strengthen plastic wrap, soap, cosmetics and containers for processed foods. They are replacements for another chemical — di-2-ethylhexylphlatate (DEHP) — which was previously found to have similar harmful effects on human health, the researchers said.

“Our research adds to growing concerns that environmental chemicals might be independent contributors to insulin resistance, elevated blood pressure and other metabolic disorders,” lead investigator Dr. Leonardo Trasande said in a medical center news release.

In a study published online July 9 in the journal Hypertension, the researchers said that for every 10-fold increase in the amount of DINP or DIDP consumed, there was a 1.1 millimeters of mercury (mm Hg) increase in blood pressure.

And in a study published in May in the Journal of Clinical Endocrinology & Metabolism, the researchers said they discovered a link between DINP and DIDP concentrations and increased insulin resistance, a precursor to diabetes.

The investigators said that one in three teens with the highest DINP levels had the highest insulin resistance, while for those with the lowest concentrations of the chemicals, only one in four had insulin resistance.

European regulators banned DEHP in 2004, and manufacturers in the United States began to replace DEHP with DINP and DIDP over the last decade, the study authors said.

“Alternatives to DIDP and DINP include wax paper and aluminum wrap; indeed, a dietary intervention that introduced fresh foods that were not canned or packaged in plastic reduced phthalate metabolites substantially,” Trasande said.

“Our study adds further concern for the need to test chemicals for toxicity prior to their broad and widespread use, which is not required under current federal law,” he added.

There are a number of “safe and simple” ways you can limit exposure to phthalates, Trasande said. Don’t microwave food in plastic containers or covered by plastic wrap. Wash plastic food containers by hand instead of putting them in the dishwasher, where harsh chemicals can increase the transfer of the chemicals into food.

Another way to protect yourself is by not using plastic containers with the numbers 3, 6 or 7 on the bottom, which indicates that they contain phthalates, Trasande said.

More information

The U.S. Consumer Product Safety Commission has more about phthalates.





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Back Pain and Depression Combo Lessens Pain Relief from Narcotic Painkillers

By Steven Reinberg
HealthDay Reporter

THURSDAY, July 9, 2015 (HealthDay News) — For people with chronic back pain who also have depression or anxiety, narcotic painkillers may not be the best therapy for their pain, a new study finds.

“A lot of patients have depression and anxiety on top of their back pain,” said lead researcher Dr. Ajay Wasan, a professor of anesthesiology and psychiatry at the University of Pittsburgh School of Medicine. Pain can make depression and anxiety worse and depression and anxiety can make pain worse, Wasan said. “It’s a two-way street.”

But, he added, people with depression or anxiety may get a lot less pain relief from narcotic painkillers and have a higher rate of misuse of their medications.

Wasan said misuse includes taking too many pills and running out of medication early, doctor shopping — getting prescriptions for the same drug from several doctors — and using marijuana or cocaine along with narcotic painkillers.

Doctors should know whether someone has depression or anxiety before prescribing a narcotic painkiller, Wasan said.

“That needs to be assessed and needs to be treated,” he said. “Treating these conditions improves pain by itself,” he added.

Wasan also thinks doctors should prescribe alternatives, such as non-narcotic pain medicines and physical rehabilitation.

The report was published July 9 online in the journal Anesthesiology.

The study included 55 people with chronic lower back pain and low to high levels of depression or anxiety. They were randomly assigned to receive morphine, oxycodone (Oxycontin) or a placebo for six months. Patients reported their pain levels and daily drug doses to the researchers.

People with high levels of depression and anxiety had less pain relief — about 21 percent pain improvement compared to 39 percent for the group with less depression and anxiety, the study found.

In addition, patients who had high levels of depression or anxiety showed far more painkiller abuse than those with lower levels of depression or anxiety — 39 percent versus 8 percent.

They also had more side effects from the narcotic medications, the study found. Side effects common to this class of medication include constipation, nausea, fatigue and confusion, according to the American Academy of Family Physicians.

Dr. Allyson Shrikhande, a physiatrist at Lenox Hill Hospital in New York City, said, “Using narcotics to treat chronic back pain in patients with a history of a psychiatric disorder may not be effective in decreasing the pain.”

In addition, patients with a history of anxiety or depression can have an increased risk of addiction to pain medication versus a person without a psychiatric history, she said.

“This is due to the effect of narcotic medications on the neurohormonal balance. It is important for physicians treating back pain to inquire about a patient’s psychiatric history prior to initiating treatment. A team approach is also vital, using experts such as psychiatrists and psychologists to assist in managing the patient,” Shrikhande said.

Dr. Scott Krakower is the assistant unit chief of psychiatry at Zucker Hillside Hospital in Glen Oaks, N.Y. He said, “Narcotic painkillers are a temporary ‘band-aid’ and often exacerbate the problem.”

With the rates of narcotic addiction on the rise, doctors should be mindful of other treatments available to patients for chronic back pain, he said. In addition, conditions such as depression and anxiety should themselves be treated, which in turn will make relieving back pain more effective, he added.

“This study reinforces the importance of screening for coexisting conditions and treating them effectively,” Krakower said. “If the anxiety and mood symptoms diminish, then there is a better chance of relieving pain in the long run.”

More information

For more on back pain, visit the U.S. National Institute of Arthritis and Musculoskeletal and Skin Diseases .





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Online ‘Symptom Checkers’ Often Miss Diagnosis, Study Finds

By Alan Mozes
HealthDay Reporter

THURSDAY, July 9, 2015 (HealthDay News) — Automated online “symptom checkers” that seem to offer patients a quick opportunity for self-diagnosis provide the right diagnosis in only about one-third of cases, a new analysis reveals.

The study team found that online checkers — which are typically free services offered by medical schools, insurance companies, and even government entities — are a more reliable and effective means to get a handle on symptoms than using web search engines such as Google.

The investigation also found that online medical checkers are about as accurate as primary care physician phone services that offer patients advice on whether or not a condition requires urgent care.

“The goal with these symptom checkers is to try and streamline the process by which people search the Internet for information on health problems,” explained study lead author Hannah Semigran, a research assistant in the department of health care policy at Harvard Medical School in Boston.

“And we found that they are a better alternative to previous attempts to conduct random searches. Symptom checkers are definitely a more organized and constructive way to go about that,” she added.

“We found that they are pretty good at effectively directing people with an (emergency) situation to seek some kind of appropriate care, and to do so quickly,” Semigran said. “But these tools are only a helpful piece of the information puzzle. And users should know that they definitely do not provide the final word on their diagnosis.”

Semigran and her colleagues reported their research online July 9 in the BMJ. Funding was provided by the U.S. National Institute of Allergy and Infectious Diseases.

To assess the pros and cons of symptom checkers, the study team made a list of symptoms from 45 medical scenarios typically presented to medical students for teaching purposes.

In 2014, those symptoms were input into 23 different English-language online symptom checkers. All were free, available to the public, and variously based in the United States, the United Kingdom, the Netherlands and Poland.

Some sites had multiple-choice symptom lists, while others allowed for users to enter their symptoms manually. These automated systems then generated a ballpark sense of what the user’s problem could be, and whether or not the person needed immediate in-person care.

Taken together, the online checkers accurately assessed symptoms on the first attempt in roughly one-third of cases. More than half the time, a correct diagnosis was listed among three top options. And that success rate rose to 58 percent among lists offering 20 options.

What’s more, the checkers were judged to be accurate 57 percent of the time when giving advice as to how to handle the symptoms and where to seek care; that figure jumped to 80 percent when faced with critical or urgent situations. The researchers pointed out that performance varied across the symptom checkers.

Prior research has suggested that random Internet searches only help patients get good advice 64 percent of the time when struggling to handle an urgent concern. Other studies have found triage phone lines to be similarly effective, providing in the range of 61 to 69 percent accuracy when diagnosing a range of conditions (compared with an in-person diagnosis rendered by a physician).

The study authors also found checkers to be relatively conservative when making judgment calls. At times that meant advising users to seek unwarranted medical care. “And sometimes the list of diagnoses options offered can be huge, which can be very confusing for users,” said Semigran.

She also said that incorrect information wasn’t uncommon. And she cautioned that not all symptom checkers are equally trustworthy.

“They definitely varied in terms of having qualified clinical content,” Semigran said. “Some clearly noted an association with a qualified panel of physicians, while others didn’t. So the safest approach is to figure out which entity actually owns the site you’re using. Is it a university? Is there a knowledgeable team behind it?”

Dr. David Hanauer, an associate professor in the department of pediatrics at the University of Michigan in Ann Arbor, suggested that symptom checkers pose a “very complicated” dilemma.

“A lot of physicians are hopeful about finding ways we can democratize the information that we have,” he said. “But the challenge is how we can really be sure that people can make the best decisions with the limited kind of information these services can offer.”

Hanauer explained that “sometimes patients can’t even describe the symptoms that they have. And it’s not always a ‘yes’ or ‘no’ answer. It’s how severe are the symptoms? Which started first, and which have gone away? A savvy clinician will know how to handle all of that, since so much of medicine is based on gut and instinct. A computer may not,” he noted.

“So I don’t want to sound like I’m putting people down for using these services,” Hanauer said. “But it’s a very tricky question.”

More information

Learn more about getting healthy at the American Heart Association.





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Only 1 in 10 Americans Eats Enough Fruits and Veggies: CDC

By Dennis Thompson
HealthDay Reporter

THURSDAY, July 9, 2015 (HealthDay News) — Only about one in every 10 Americans eats enough fruits and vegetables, a new government report shows.

Just 13 percent of U.S. residents consume one and a half to two cups of fruit every day as recommended by federal dietary guidelines, researchers from the U.S. Centers for Disease Control and Prevention found.

The news on the vegetable front was even worse. Less than 9 percent of Americans eat two to three cups of vegetables every day as recommended, the report showed.

Even residents of California, the state with the best consumption rate for these nutritious foods, fell woefully behind. Only close to 18 percent of Californians ate enough fruit every day, and only 13 percent ate enough vegetables.

Tennessee and Mississippi ranked among the lowest in terms of people eating enough fruits and veggies.

The authors of the study, published in the CDC’s July 10 issue of Morbidity and Mortality Weekly Report, called for widespread action to promote fruits and vegetables in the average diet.

“Substantial new efforts are needed to build consumer demand for fruits and vegetables through competitive pricing, placement, and promotion in child care, schools, grocery stores, communities and worksites,” they concluded.

This is the first time that researchers have been able to break down fruit and vegetable consumption on a state-by-state basis, said study author Latetia Moore, an epidemiologist with the CDC’s Obesity Prevention and Control Branch.

“Fruit and vegetable consumption has been consistently low over time,” she said. “This is just the first time we’ve been able to look at it on a state level.”

America likely needs a “culture shift” to get more people eating right, Moore added.

“There is a perception that fruits and vegetables are more expensive than other foods, and it’s not accurate,” she said. “We just have to get into the habit of replacing some of those foods we normally eat with fruits and vegetables.”

The findings are based on data gathered by the Behavioral Risk Factor Surveillance System, an ongoing CDC-sponsored survey that tracks the healthy and unhealthy actions that average Americans take.

Eating a good amount of colorful fruits and vegetables is important because they help lower a person’s risk of chronic illnesses such as obesity, heart disease and type 2 diabetes, said Jordana Turkel, a registered dietitian at Lenox Hill Hospital in New York City.

For example, fruits and vegetables are generally low in fat, which helps control cholesterol, Turkel said. They also contain a lot of fiber, which helps control spikes in blood sugar by slowing the digestive process.

“We are seeing now what is going to happen if this trend continues,” Turkel said. “Obesity is on the rise. The rates of type 2 diabetes and cardiovascular disease are on the rise. I think we are seeing the effects of all of this now.”

On average, Americans tend to eat fruit once a day and vegetables fewer than two times daily, the CDC researchers found.

State-by-state, the percentage of people who eat enough vegetables ranged from highs of 13 percent in California and 11 percent in Oregon to lows of 5.5 percent in Mississippi, 5.8 percent in Oklahoma and 6.2 percent in Tennessee.

People eating enough fruit ranged from highs of 17.7 percent in California and 15.5 percent in New York to lows of 7.5 percent in Tennessee, 7.7 percent in West Virginia and 8.2 percent in Oklahoma.

Turkel herself realized a few years back she wasn’t eating enough fruits and veggies. She began eating a piece of fruit every day as her afternoon snack.

People who want to boost their vegetable intake also can make a salad part of their daily diet, even if it is served as a side dish at lunch or dinner, Turkel said.

Fruit-and-vegetable smoothies are another option, although Turkel cautioned against putting too much fruit in a smoothie.

“Most dietitians have the same point of view when it comes to juicing — you shouldn’t juice unless you are sneaking in those green leafy vegetables and berries and different colorful fruits,” she said.

Also, people should make their own smoothies at home, Turkel said, and include all the fiber from the skin of fruits and berries.

Joy Dubost, a registered dietitian in Washington, D.C., called the findings “disappointing.”

“Dietitians and the public health community have more work to do in encouraging Americans to consume more fruits and vegetables,” said Dubost, a spokeswoman for the Academy of Nutrition and Dietetics. “These results are not good news, given the effort we’ve put out.”

Part of the problem might be that people find it daunting to eat the daily recommended amount of fruits and vegetables, Dubost said. Dietitians and health experts need to do a better job showing people how they can spread their intake across a full day of eating, she said.

Another stumbling block might be convenience, Dubost added. People may not want to go to the hassle of buying and preparing fruits and vegetables, even though time-saving options have become available, including bagged salads, precooked vegetables and microwaveable steam-in-the-bag frozen veggies.

Moore said part of the problem might be that people have a hard time grasping just how much fruit or vegetables are needed to meet daily requirements.

“It’s not that hard to eat the recommended amount of fruits and vegetables,” she said. “If you eat at least a banana and half an apple, you’re done for the day with fruit. For vegetables, if you have a side salad with lunch and a couple of vegetables with dinner, you’re done for the day. It’s not that hard to do, and it’s not that expensive to do.”

More information

For more on fruit and vegetable guidelines, visit the U.S. Department of Agriculture.





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Newly Enlisted Army Soldiers at Risk of Attempted Suicide: Study

By Alan Mozes
HealthDay Reporter

THURSDAY, July 9, 2015 (HealthDay News) — Among U.S. Army personnel, enlisted soldiers on their first tour of duty appear to be most at risk for attempted suicide, a new study finds.

Concerned by a spike in suicides and suicide attempts in the Army during the Iraq and Afghanistan wars, researchers set out to identify key risks for suicide attempts between 2004 and 2009.

“Those who were female, younger, early in their career, with a recent mental health problem, and never or previously deployed were at greatest risk,” said study lead author Dr. Robert Ursano, chair of psychiatry at the Center for the Study of Traumatic Stress at the Uniformed Services University of the Health Sciences in Bethesda, Md.

“By understanding who is at risk and when they are at risk, we can much better target treatments,” Ursano said.

The findings were published in the July 8 online issue of JAMA Psychiatry.

In 2014, as part of the Army’s Study to Assess Risk and Resilience in Servicemembers, investigators analyzed monthly records of suicide attempts collected by the Army and the U.S. Department of Defense.

The study team focused on records that registered suicide attempts, as opposed to completed suicides, among active-duty regular Army soldiers from 2004 through 2009. Neither former Army personnel nor those treated outside the Army’s health-care system were included in the tally.

During that time, nearly 9,800 Army personnel attempted suicide, according to the report.

Although enlisted soldiers make up roughly 84 percent of the active-duty Army pool, they made up nearly 99 percent of the attempts, the researchers found. By contrast, commissioned and warrant officers made up just 1.4 percent of the attempts.

Women, whether officers or enlisted, were more than twice as likely as men to attempt suicide, the study found.

Also, the risk for attempted suicide was 13 times higher among female enlisted soldiers than female officers. It was 16 times higher among enlisted soldiers entering the Army at age 25 and older compared to officers entering the Army at a similar age. Risk was also higher for whites; those with less than a high school education; those in the first four years of service; those who had never been deployed; and those diagnosed with a mental health condition in the prior month.

The risk for a suicide attempt among enlisted soldiers was highest in the second month of service, though risk dropped significantly the longer a soldier served, the investigators found.

Among officers, the risk for a suicide attempt remained steady over time, and was associated with being a woman, being 40 and up, entering the Army at 25 or older, and having a mental health diagnosis in the prior month.

Ursano suggested that the current effort offers an “unprecedented opportunity for understanding suicide as a disorder.”

He also said that the findings offer “great promise for dramatically changing our understanding and opportunities for intervention for suicide and mental health problems in (both the) Army and the nation.”

Mark Kaplan, a professor of social welfare with the Luskin School of Public Affairs at the University of California, Los Angeles, said the investigation addresses an important problem.

“But in addition to the pieces of the risk puzzle presented here, which focus mostly on personal psychology, it is also important to understand how the social organizational context of the Army affects these individual vulnerabilities,” Kaplan added. “We really don’t yet fully understand the connection between the two.”

He said those specific tipping factors can include job strain; the role of leadership; financial stress; the impact of multiple deployments; and the need to readjust back to family life and the role of firearms. The psychological demands and limited decision-making that characterize day-to-day life among people at the bottom of the Army ladder are also a consideration, he added.

“Going forward, it’ll be important to appreciate the complexity of the suicide,” he said, “to view it both as a personal as well as a social phenomenon.”

More information

The American Association of Suicidology talks about depression and suicide.





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Many Overweight or Obese Teens Don’t See the Problem

THURSDAY, July 9, 2015 (HealthDay News) — Many overweight and obese teens don’t believe they have a weight problem, a new study finds.

Researchers reviewed data on about 5,000 teens. They were between 13 and 15 years of age, and they all lived in the United Kingdom. The teens had been asked about their weight and if they thought they were too heavy, too light or about right.

Seventy-three percent of the teens had a weight within the normal range, 20 percent were overweight and 7 percent were obese. However, about 40 percent of those who were overweight or obese said they were about the right weight, and 0.4 percent even said they were too light, the findings showed.

More than 80 percent of the normal-weight teens correctly identified themselves as being the right weight, the study found. But, 7 percent felt they were too heavy, and 10 percent believed they were too light. Girls were more likely than boys to think they were too heavy, the research revealed.

The Cancer Research UK study was published July 9 in the International Journal of Obesity.

Being overweight or obese increases the risk of 10 types of cancer, including those of breast and colon cancers, the researchers said in a Cancer Research UK news release.

“This study was a cause for celebration and concern. Young people who think they’re overweight when they’re not can sometimes develop devastating eating disorders, so we’re delighted that most of the normal-weight teenagers had a realistic view of their body size,” said Jane Wardle, a professor at Cancer Research UK Health Behavior Research Center at University College London.

“But we need to find effective ways of helping too-heavy teenagers slim down and maintain a healthier weight, and it’s vitally important that we find out whether it helps if they are more aware of their weight status. There are no easy answers,” she added.

Julie Sharp is head of health information at Cancer Research UK. She explained that “overweight teenagers are more likely to become overweight adults at higher risk of cancer. So it’s important that young people who are too heavy have support to be more active and make healthy changes to their diet — being aware that they are above a healthy weight could be a first step. Making these changes as teenagers could help protect them from cancer as adults.”

More information

The American Academy of Pediatrics has more about obesity.





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No Change in Number of ‘Living Wills’ by U.S. Cancer Patients: Study

THURSDAY, July 9, 2015 (HealthDay News) — End-of-life care can be fraught with difficult decisions, but a new study finds that since 2000 there has been no increase in the number of Americans with cancer who compose “living wills” to help guide the process.

The study, led by Dr. Amol Narang of the Johns Hopkins School of Medicine in Baltimore, did find a rise in the percentage of cancer patients who had designated power of attorney to another person — from 52 percent of patients surveyed in 2000 to 74 percent in 2012.

However, there were no significant changes in the use of living wills — which help loved ones make decisions about care should the patient become incapacitated — or in the percentage of patients who had frank discussions about end-of-life care.

Still, Narang’s team said that by 2012 many patients had made some effort at “advance care planning,” with about 81 percent having completed at least one form of directive — power of attorney, a living will or end-of-life care discussions.

These efforts can be crucial when the patient becomes unable to decide important issues for themselves, the study authors said.

“Without written or verbal direction, surrogate decision makers may struggle to make care decisions consistent with patient preferences,” they wrote. “As such, policy and health system initiatives that support wider adoption of clinician-patient discussions of end- of-life care preferences are essential.”

The new study is published July 9 in the journal JAMA Oncology.

In the study, Narang’s group looked at data from nearly 2,000 family members — mainly partners, spouses and children — of cancer patients who had died between 2000 and 2012.

During that time, there was little change in hospitalization rates (as opposed to the use of hospice care) at the end of life, with 29 percent spending time in a hospital at the end of life in 2000, versus 27 percent in 2012.

The number of patients who had received “all care possible” rose from 7 percent to 58 percent, the study found. Efforts to limit or withhold treatment near the end of life were associated with living wills and end-of-life discussions, but not with power of attorney, the study authors noted.

They said that any end-of-life discussion “must also include surrogate decision makers,” and these conversations should seek to “educate surrogates on the goals, values and care preferences of their loved ones.”

One expert agreed.

“This shows that naming a person to make decisions for you is not the only answer — one must hold discussions to allow individuals to make decisions as one would want,” said Dr. Maria Carney. She is chief of the division of geriatrics & palliative care of medicine – internal medicine at Long Island Jewish Medical Center in New Hyde Park N.Y. and North Shore University Hospital in Manhasset, N.Y.

“These discussions need to occur, and even guidance on how to have these discussions may be needed,” Carney said.

Dr. Sean Morrison is co-director of the Patty and Jay Baker National Palliative Care Center at the Icahn School of Medicine at Mount Sinai in New York City. He believes that while advance directives can help ensure that patients receive the end-of-life care they desire, they are only “a very small part of the solution.”

Morrison believes that, beyond living wills and other advance care directives, “we need to redesign medical education so that all physicians receive training in having difficult conversations — something that in 2015 still does not occur.”

He also believes that hospice remains out of the reach of some terminally ill patients. “We need to redesign the health care system, such that those patients who decline ineffectual and burdensome treatments near the end of life have universal access to hospice and comfort-directed care that optimizes their quality of life,” Morrison said.

In a related study, also in the same issue of JAMA Oncology, researchers led by Dr. Jennifer Mack of the Dana-Farber Cancer Institute in Boston report that many American teens and young adults dying of cancer were often still receiving intensive care, even as they neared the end of their lives.

“Although adult patients who know they are dying usually do not want to receive aggressive care, which is associated with poorer quality of life near death, we do not know whether adolescents and young adults feel the same way,” Mack’s team wrote.

Her team looked at data on 663 patients, aged 15 to 39, in California who died of cancer between 2001 and 2010. The most common types of diagnoses were gastrointestinal, breast and genitourinary cancers, along with leukemia and lymphoma.

Eleven percent of the patients received chemotherapy within 14 days of death. In the last 30 days of life, 22 percent of patients were admitted to the intensive care, 22 percent had more than one emergency department visit and 62 percent were hospitalized.

Overall, 68 percent of the patients received at least one medically intensive end-of-life care measure.

Are these treatments desired by these young patients or their caregivers? The study authors say that remains unclear.

“High rates of intensive end-of-life measures in this population may not be a failure of communication or palliative care,” they wrote, “but might reflect very different values for end-of-life care in these young people compared with older adults.”

Carney said the study left other questions unanswered.

“What we don’t know is if patients and their families understood the severity of their illness and the prognosis at the time of these interventions,” she noted. “Could open discussions and care focused on palliation of symptoms have impacted care at the end of life to be less intensive care? Were resources such as pain management, home-based palliative services or hospice care offered to support patients and families?

More information

Find out more about living wills at the Harvard Medical School.





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