Food Labels and Childhood Obesity; Prehabilitation in Older Adults

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 socioeconomic status (SES) and brain development in kids, lifestyle changes and multimorbidity, food labeling and childhood obesity, and prehabilitation in older adults.

Program notes:

0:40 Prehabilitation in older adults

1:40 Both pre- and postoperative

2:40 Pulmonary and cardiovascular benefits?

3:16 Food labeling and advertising law changes and childhood excess weight

4:15 300,000 kids 4 to 6 years of age

5:15 Interrupt cascade of excess weight

6:15 Very early age

7:00 Prediabetes prevention, lifestyle changes, and multimorbidity

8:00 Looked at 15 most common Medicare claims

8:50 SES and brain changes

9:50 Map hundreds of non-imaging variables to the brain

10:50 Negatively associated with maps of higher order cognition

11:50 Single-parent home?

12:52 End

Transcript:

Elizabeth: Food labeling, advertising laws, and early childhood obesity.

Rick: Can prehabilitation reduce complications in older adults undergoing spinal fusion?

Elizabeth: What does socioeconomic status have to do with childhood brain development?

Rick: And in adults with prediabetes, does lifestyle and metformin reduce the risk of multimorbidity?

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: Rick, I am just so interested in this notion of prehabilitation. So I’m hoping that you are willing to talk about the Annals of Internal Medicine study taking a look at that.

Rick: We’re talking specifically about older adults that undergo spinal fusion. And the volume of that procedure has increased from approximately 800,000 to more than 1.1 million over the last decade in the United States. And about three-fourths of those are lumbar and cervical fusion. And if you’re over the age of 75, there’s an increased risk of having complications after that. As a result of that, there has been recently the adoption of what’s called enhanced recovery after surgery to promote early rehabilitation. Those have been shown in frail and older individuals to decrease postoperative complications. What would happen if we actually started this beforehand, prehabilitation?

That’s what the study addressed. It was conducted in three tertiary hospitals in China. These were adults aged 75 or older undergoing spinal fusion therapy. And they were all exposed to the early recovery after surgery. But half the adults were also exposed to preoperative, multimodal prehabilitation or re-prehabilitation program that integrated supervised group sessions, a multicomponent exercise tailored to the individual, optimized nutrition, and doing psychological intervention. And those that only did rehabilitation enhanced recovery, 91% of them experienced at least one complication. For those that did prehabilitation, that was 75%.

Elizabeth: Let’s talk about what were the nature of the postoperative complications they experienced.

Rick: That could be prolonged hospital stay, respiratory issues, cardiovascular issues, infections, need to go to a skilled nursing home, a lot of different things.

Elizabeth: I think I would be interested in a larger and longer study, or not necessarily longer, but certainly larger, that would specifically look at the impact on respiratory complications and cardiovascular complications. Because I would think those would be the low-hanging fruit with regard to the prehabilitation strategy.

Rick: You would think so. And remember, this is just a 4-week program. Keep in mind also, these are older individuals. They have back or neck pain, which is why they’re having spinal fusion, so many of them are unable to exercise. How can you rule this out? Because it’s a pretty intensive program. It’s individualized, and as a result, it’s unlikely to be embraced by many hospitals.

Elizabeth: Still, it’s very encouraging, and it sounds like trying to develop mechanisms for streamlining it or enabling a lot of it to be delivered online, or whatever those other strategies might be, would be helpful.

Rick: Right. Prehabilitation can be helpful, and the next question is, how can we optimize that?

Elizabeth: Let’s turn to The Lancet, and let’s take a look at something that also has some benefits: the notion that multipronged food labeling and advertising law changes can impact on trajectories of early childhood excess weight. And this was conducted in Chile.

In 2016, the Chilean food labeling and advertising law was enacted, and this features black octagonal front-of-package warning labels, and also marketing and school restrictions relative to foods that are purveyed to children. It was among the first sets of multiple healthy food policies globally. How has this impacted on the trajectory of childhood obesity development? And interestingly, Chile experiences quite a lot of that. In fact, the highest rate of it in the world.

This was a cohort difference-in-differences approach, where they took a look at over 300,000 school-aged children, age 4 to 6 years, across public and publicly subsidized schools nationally. They used a nutritional map to find cohorts by the year students entered prekindergarten, and looked at unexposed versus exposed groups during prekindergarten, kindergarten, and first grade.

And what they showed was that children who were exposed to this intervention, this multipronged intervention, during both kindergarten and first grade had the largest effects on their trajectory of their probability of developing excess weight. The girls had a 2.85% lower probability, while the boys had a 2.4% lower probability. They observed significant effects after just 6 months of exposure. While those are modest, the authors put forward the idea that if they can incept this early, they’re going to interrupt that whole cascade of things that propel people into excess weight and all of the health complications of that.

Rick: This is an extension of the food labeling and advertising law in Chile. And as you mentioned, in Chile, 51% of the school children under the age of 14 are overweight.

Here’s what this law did. It had three core components. There’s mandatory front-of-package warning labels. If the food had a high content of sugar, saturated fat, sodium, or energy density, it had a black label. That was the first thing. They put restrictions on the sale of regulated products in schools. And the third thing they did was a comprehensive limits on the regulated food marketing directed at kids.

Prior to this study, they could show that, in fact, the consumption of these high-end foods went down. They drove the manufacturers to decrease manufacturing of these, and they could show that the nutritional content of food went up in schools and the kids ate better. And this is a study that says, OK, it did decrease excessive weight and obesity in both girls and boys, as you mentioned, at a very early age. This is prekindergarten, kindergarten, and first grade.

Elizabeth: One of the things, though, in drilling down further in the data, if you look at who benefited most, was dependent upon the mom’s education and also on the nature of the school that the child attended. There are target groups that we probably need to figure out how to reach even more effectively.

Rick: You’re right. Because as you mentioned, among the girls, there were no significant effects for those whose mothers did not complete high school, and in some urban/rural differences as well.

Elizabeth: Still a step in the right direction, and I think a global approach that’s well worth adopting globally.

Rick: It is. Let’s turn to prediabetes and let’s look at this study in JAMA.

It’s actually a follow-up. There were individuals who participated in the 3-year Diabetes Prevention Program 25 or 30 years ago, randomized to either placebo, lifestyle changes (better nutrition and exercising for 150 minutes per week), or the initiation of metformin. The lifestyle intervention could decrease your risk of developing diabetes by almost 60%. Using metformin also decreased the risk of developing diabetes as well.

Let’s look back and say, OK, now these three different treatment arms, do those affect the subsequent attainment of comorbidities? They followed about half this cohort — this is over 1,100 adults. Thirty years later, about 85% experienced two or more comorbidities. Those that experienced three or more, the risk of multimorbidity was lower among lifestyle compared with placebo. It went down about 21%. However, there’s no difference between participants in the metformin group and the placebo group.

Elizabeth: Let’s talk about which multimorbidities we’re referring to.

Rick: They looked at 15 common chronic conditions: hypertension, heart failure, coronary artery disease, cardiac arrhythmias, high cholesterol, stroke, arthritis, asthma, cancer, chronic kidney disease, [chronic obstructive pulmonary disease], dementia, Alzheimer’s, depression, diabetes, and osteoporosis. So the 15 most common chronic conditions in the Medicare claims database.

Elizabeth: We have been singing this song a really long time about how important diet and exercise and sleep and good nutritional choices are in staving off a multitude of chronic diseases. And this provides more evidence of that.

Rick: Yep. Not only do lifestyle changes delay the onset of diabetes, but it reduces the risk of these 15 chronic conditions as well, especially when combined together. I don’t know what else to say. Better lifestyle, longer life, better life.

Elizabeth: OK. That’s a great summation.

Finally, let’s turn to Science, a paper that you and I both found to be extremely dense. And since we both consider ourselves to be nerds, it was powerful to be confronted with a paper that was really such a dense look at this particular issue.

As I said, in Science, what they were doing was looking at brain-wide association studies. And these are things that link individual differences in behavioral traits or living conditions to variability in our brain function and structure. So they most of the time are using MRI to assess these different things. And they map these networks based on spontaneous neural fluctuations and cortical thickness.

Previous studies have taken a look at these brain-wide association studies for a number of characteristics. In this case, they’re looking at datasets with many thousands of participants. They were able to simultaneously map hundreds of non-imaging variables to the brain and compare them both to each other and with well-established neurobiological reference patterns or non-brain-wide association studies. They examined 649 non-imaging variables in a large sample of 9- to 10-year-olds.

And what they showed was that socioeconomic measures had the strongest and most repeatable brain-wide associations, with the single strongest brain association with the SES determined by a child’s zip code. These associations were concentrated in the primary motor and sensory regions of the brain with spatial similarity to arousal and stress patterns. And that’s also a really important factor to enter into this SES determination.

They looked at the neurotransmitter norepinephrine receptor density, sleep duration, stimulant medication effects. They were all positively associated and negatively correlated with task functional MRI maps of higher-order cognition. So basically what they’re showing is that this SES in a child and young life is impacting on both the anatomy of the brain as well as the function of the brain.

Rick: They hypothesized that insufficient sleep and greater stress — which are known to occur in individuals in lower socioeconomic status, those in poverty — are the cause of these fluctuations. This is a dense study. Of all the things they looked at, the socioeconomic measures had the strongest, the most replicable brain-wide associations.

Elizabeth: It points to something that I think we’ve known on many levels for a long time, which is that children are such a precious resource and we really need to figure out how to support children regardless of what their parents are honestly able to provide.

Rick: Yeah. And, you know, Elizabeth, I was thinking about this. For some of these kids, they come from single-parent homes and the parent oftentimes is not at home; they’re trying to make a living and support the child. Even when that’s not the case, oftentimes parents don’t realize the importance of sleep in a child in decreasing inflammation, and how that affects them later in life. So there are a number of different ways in which these things, that is insufficient sleep and greater stress, are manifest in kids and subsequently manifest later in life.

Elizabeth: I am hoping that this informs policy relative to the support of children as they grow.

Rick: Yeah. Again, it talks about the extreme importance of the environment the child lives in for later neurologic development. I agree.

Elizabeth: 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.