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 Texas Tech Health El Paso, look at the top medical stories of the week.
This week’s topics include caffeine’s impact on cardiovascular disease, antihistamines and atopic dermatitis, a community-designed diet for heart failure, and e-cigarettes after smoking cessation.
Program notes:
0:43 Caffeine and cardiovascular disease
1:43 J-shaped relationship with blood pressure
2:43 In those with existing cardiovascular disease
3:06 Antihistamines for atopic dermatitis
4:10 A small reduction in itching
5:10 First generation causes cognitive impairment
6:00 Prescription of a diet for heart failure
7:00 Usual advice 57% risk of hospitalization
8:00 Beneficial socially and lower symptom burden
8:32 Electronic cigarette use after smoking cessation and lung cancer
9:32 13,000 lung cancer deaths
10:32 Supplement with e-cigarettes
11:49 End
Transcript:
Elizabeth: Are antihistamines any good at all for atopic dermatitis?
Rick: What can we learn from a community-designed meal program for heart failure in the Navajo Indian Reservation?
Elizabeth: Should you use electronic cigarettes to help your smoking cessation efforts?
Rick: And a scientific statement from the American Heart Association on caffeine and cardiovascular disease.
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 Health El Paso.
Elizabeth: So I’m going to toss the ball to you, Rick, and to the journal Circulation. There’s lots and lots of talk about caffeine almost all the time, gosh, a ubiquitous drug it seems like. What does that do to our cardiovascular disease risk?
Rick: You’re right. It is ubiquitous, one of the most commonly consumed drugs in the world. It’s found in various natural-occurring substances like coffee, but it’s also ingested synthetically, energy drinks among that.
There’s been a number of different, primarily observational studies, but randomized controlled trials [too], that have looked at various aspects of caffeine and cardiovascular disease. Most of that’s been in the area of coffee consumption.
Besides caffeine, coffee has a lot of other chemicals or compounds. So what I want to know is, is it safe? And how many cups can I be safely drinking per day? There are acute effects and chronic effects. I’m more interested in the chronic effects. And that is, if I drink three or four or five cups every day over the course of years, how does it affect my risk of cardiovascular disease?
It looks like there’s a J-shaped relationship between consumption of naturally-occurring caffeinated products and blood pressure. Data on the relationship between caffeine and diabetes are not consistent, but it looks like habitual coffee consumption is associated with a lower risk of type 2 diabetes. There is no clear relationship between coffee and cholesterol, except for if people drink unfiltered coffee, it appears to increase their cholesterol and LDL cholesterol. Coffee is associated with a lower risk of coronary artery disease, heart failure, stroke, atrial fibrillation, and a slightly higher increased risk of premature ventricular contractions. So overall, I’m going to continue drinking my coffee on a daily basis.
Elizabeth: And I have to second that notion as a coffee addict, to myself, my requisite two cups every morning and a headache if I don’t consume them, by the way. What about in folks who have a baseline cardiovascular condition, however?
Rick: In those individuals, the results appear to extend to them as well. For individuals that have had coronary disease or heart failure, the ingestion of coffee does not increase their risk of subsequent cardiovascular problems, nor does it in atrial fibrillation.
I’m going to have one caveat. We talked about coffee, and I want to clearly distinguish that from high-energy drinks. The caffeine in those are clearly associated with increased risk of arrhythmias, cardiovascular disease, and mortality. Those are not safe, really, under any conditions.
Elizabeth: Let’s turn to the BMJ and let’s take a look at this issue of antihistamines for atopic dermatitis or eczema. This is a meta-analysis of the randomized trials that are out there. Can we reduce the itching and the other symptoms that are related to atopic dermatitis or eczema by using them? And it would seem that they would be a priori a good idea.
So they were looking at randomized trials assessing add-on oral H1 antihistamines, H2 blockers, mast cell stabilizers, or their combinations. They looked at, among their participant population, the atopic dermatitis severity, sleep disturbance, the atopic dermatitis-related quality of life, and harms. They had 47 trials enrolling 6,230 children and adults with primarily moderate to severe atopic dermatitis.
And what they showed is that, compared with placebo, a first- or second-generation H1 antihistamine only resulted in a small reduction in atopic dermatitis severity and itch severity, and that the first-generation agents probably increase cognitive impairment and may increase treatment discontinuation because of adverse events. So those first-generation agents really probably ought to not be used because they’re going to result in this cognitive impairment as well as other aspects of treatment that are not acceptable.
The other ones, hmm, should we use them or shouldn’t we use them? I think the authors kind of dropped the ball slightly, in that they say it’s got to be individually tailored. And in my estimation, it looks like yes, and even when we individually tailor it, it sure doesn’t look like there’s much in the way of benefit.
Rick: I’m going to even go further. It looked like there was a statistically significant difference, but so small it’s clinically undetectable. And that’s true for both the H1 and H2, that is the first- and second-generation histamine blockers. And you’re right, the first generation caused cognitive impairment. They make you sleepy and drowsy. And the other ones are non-drowsy, but they’re not effective. So the authors say, listen, we’re not going to recommend histamine blockers at all. And it suggests that the itching and inflammation that occurs in atopic dermatitis is not histamine related. It’s some other pathway that we haven’t even gotten our arms around.
Elizabeth: I was happy to see the authors say that this analysis addresses atopic dermatitis only and it’s not clear whether these findings can be extrapolated to contact dermatitis, which many, many people experience, and also hand eczema.
Rick: Totally agree. We’re talking about a specific condition, atopic dermatitis, not effective. We need to move on and do other things.
Elizabeth: Speaking of moving on then, let’s look at JAMA Internal Medicine. What about prescription of a diet?
Rick: They went to an Indigenous nation, the Navajo Nation, that typically has very high instances of cardiovascular disease, coronary disease, and heart failure. If food really is medicine, we’re going to see if we can alter their diet to decrease the risk that they’ll be visiting the emergency department or be hospitalized for heart failure.
They took individuals that had already, in the last 12 months, experienced symptoms of heart failure and had been hospitalized for it. We are going to take this group of individuals, 200, and we’re going to give them the routine advice, and the other half, we’re actually going to prescribe them a diet generated by people in the Navajo tribe. It was sourced from local food from local farmers. It was culturally sensitive, but still adhered to the American Heart Association DASH [Dietary Approaches to Stop Hypertension] and low-sodium diet. Some of these individuals don’t have microwaves, refrigerators, so these foods were all prepared [and] frozen. They were provided so each individual received two meals a day. And if you didn’t have a refrigerator or a microwave or a stove, they provided that as well. And they followed these individuals for about 3 months.
The individuals that received the usual advice, their risk of being hospitalized or visiting the emergency department was 57% versus 41% in the individuals that received the tailored food. If they look at heart failure hospitalizations specifically, they were reduced about 71%. I think the lessons we can learn are if you involve participants, if it’s food that they normally would eat, if it’s culturally sensitive, if you provide the means for them to ingest it and prepare it, it can be a significant health driver.
Elizabeth: And I guess our a priori hypothesis would be that it would be cost-effective since we know that a single day of hospitalization for something like heart failure can be very costly. My suspicion is that providing that food over a year is less expensive than just a single day of hospitalization if you’re being treated for heart failure.
Rick: Yep. And the comparison is, oh, let’s say you’re going to give a GLP-1 inhibitor. Well, that’s much more expensive and not readily available.
The other beneficial effects, not only did people go to the hospital less, but their symptoms were lower, their food insecurity was lower, their dietary intake went up, the financial strain was lower, their weight went down, their blood pressure went down. So there were many effects. Some of it related to the food, and some of it related to the socialization and the interaction they had. No bad side effects and a lot of beneficial health effects.
Elizabeth: Very interesting if this leads the way towards strategies that help to underpin this food-as-medicine movement, which we have been talking about for several years now.
Let’s finally turn to Nature Medicine. And this is a look at electronic cigarette use after smoking cessation. And what does that do to one’s lung cancer risk? This study was conducted in Korea. They have the Korean National Health Screening Program in 2018 data — 4.5 million plus adults with a conventional smoking history who are a part of that database with prior records from 2012 to 2014. They classified their participants as current smokers, short-term quitters, or long-term quitters. And they also looked at daily e-cigarette use at baseline. And then they looked at e-cigarette use after smoking cessation, lung cancer incidence, lung cancer-specific death in their follow-up. During that time, they had just shy of 36,000 lung cancers and just shy of 13,000 lung cancer-specific deaths occurring in their population.
So compared with folks who completely quit, e-cigarette use after smoking cessation was associated with a 56% higher risk of lung cancer incidence, a 200% increased risk of death from lung cancer. They weren’t looking at causality in this study, but they were sure looking at associations, and it sure looks like using e-cigarettes after you quit smoking is not good in the long haul.
Rick: Yes. The question is, do e-cigarettes cause lung cancer or promote it? And that’s a very difficult study because you’d have to take a group of individuals that is literally probably hundreds of thousands of individuals, expose them to e-cigarettes, and follow them over the course of 20 or 30 years.
The value of this particular study is they took people that were already at high risk that have stopped smoking, but some actually don’t stop smoking only, they supplement that with e-cigarettes. And now we know that those that use e-cigarettes, the benefits that you receive from smoking cessation, some of that’s attenuated. So this is a really elegant way to show that e-cigarette [use] does actually promote cancer, even in individuals that have stopped smoking and are at subsequent high risk of cancer.
Elizabeth: The authors also point out that we know already from other data, not from this, that e-cigarettes do render people more susceptible to respiratory infection and expose them to a host of other chemicals that are not good for their health, whether that’s specifically related to lung cancer or not.
Rick: Yeah. And you mentioned respiratory infections, but also COPD [chronic obstructive pulmonary disease] and asthma as well. So, unfortunately, they’re oftentimes sold as being a harmless substitute for cigarettes. But I think what we’ve discovered is they’re anything but harmless.
Elizabeth: And need to be abolished. Of course, that’s my editorial.
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.
