Weekend Warrior Benefits; Time-Restricted Eating and Metabolic Syndrome

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 time-restricted eating and metabolic syndrome, weekend warrior benefits, menopause hormone therapy in the U.S., and geriatric falls.

Program notes:

0:40 Time-restricted eating and metabolic syndrome

1:40 Personalized 8- to 10-hour window

2:40 Didn’t compare to other types of diets

3:45 Costs of geriatric falls versus firearm injury

4:45 Costs in 45+ years of age

5:46 Most firearm injuries in younger people

6:40 Weekend warrior benefits

7:40 Benefit whether it was daily or extended on weekends

8:40 Dose response seen

9:00 Menopausal hormone therapy (MHT)

10:00 About 3% of Hispanic women

11:00 When data came out in 2002

12:00 Overall shouldn’t have been abandoned

13:00 End

Transcript:

Elizabeth: Just how expensive are falls among older people?

Rick: Is time-restricted eating helpful in adults with metabolic syndrome?

Elizabeth: What’s the state of hormone use among menopausal women in the U.S.?

Rick: And does being a weekend warrior protect you against heart 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: 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, one of the things that’s been garnering a tremendous amount of media attention is this notion of time-restricted eating, and here is a population in Annals of Internal Medicine in whom we have some notion of how beneficial it might be.

Rick: This particular study looked at a specific patient population — those that have metabolic syndrome. This is a pretty common condition and is characterized by having at least three metabolic risk factors, such as a large waist, or elevated glucose, or elevated blood pressure, or elevated cholesterol levels. Having metabolic syndrome increases the risk for developing type 2 diabetes and also cardiovascular disease. Weight loss affects all of those. There are a lot of different ways to affect weight loss. One of those happens to be time-restricted eating. As you mentioned, it’s pretty popular.

They took 122 individuals that had metabolic syndrome and they all had elevated blood sugar. Many of these individuals were on a medication already. They were randomized to either standard nutritional counseling or they did the same nutritional counseling with a personalized 8- to 10-hour time-restricted eating intervention where they were asked to reduce their eating time window by at least 4 hours. They subsequently follow them and ask what happens to the hemoglobin A1C.

Individuals who had nutritional counseling had no significant change in their hemoglobin A1C; it changed from 5.86 to 5.84. Whereas those in the time-restricted eating, it fell from 5.87 to 5.75. Although this was a modest absolute difference, it was statistically significant. In addition, when they looked at the weights, those individuals who had standard nutritional counseling didn’t change their body weight, but those who were on time-restricted eating lowered their core weight by about 3 to 4 lbs. It does look like there are at least modest benefits with regard to metabolic syndrome.

Elizabeth: Maybe this is something that gets added to the armamentarium in terms of helping people achieve weight loss when they have metabolic syndrome, which is clearly the ultimate goal.

Rick: Yeah. Here are the limitations to this particular study. It didn’t compare to other types of diets. In previous podcasts that we have done, when you compare time-restricted eating to other more rigorous dietary interventions there really was no benefit for time-restricted eating. The second is this is a pretty modest benefit. Again, this was a relatively small study of 120 some patients with a relatively short duration. In a larger population for a longer duration, is it better than other dietary measures we have?

Elizabeth: I would also say, though, that almost everybody I talk to who is in this weight-loss business says that different strategies are successful for different people and that that’s also temporal, that one strategy might be helpful for a while and then it’s important to have other potential strategies to employ. This could be one of them.

Rick: Yeah. What happens is those individuals who do time-restricted eating also eat less calories and that’s the benefit. I agree with you, however, a particular individual needs to reduce their caloric intake is important.

Elizabeth: OK. Let’s turn to a BMJ journal, Trauma Surgery & Acute Care Open. This study looked at the enormous economic burden that’s represented by geriatric falls. They use as a comparator population those who experience firearm injury and death. This study looked at the Web-based Injury Statistics Query and Reporting System that’s part of the CDC. They looked at fatal firearm and falls in patients between the ages of 15 and 85 years old. Their primary outcome was medical costs and their secondary was combined costs, those of medical costs and value of their statistical life or years of life lost.

This medical cost was significantly higher relative to fatal falls in the 2015 to 2020 time period in all age groups. This combined cost was higher in fatal falls after 2019 and those who were 45 to 85 years of age. The percentage of fatal falls had a significant increase in all age ranges in the 2015 to 2019 period with a rise in the slope, so a dramatic increase, starting in 2019 for patients over 65 years of age. Finally, they find that the combined cost for fatal falls exceed that for fatal firearm injuries after 2019. This highlights the increasing socioeconomic burdens of an aging population.

Rick: I was fairly surprised. If you asked me in terms of total cost, I would have thought firearms cost a lot more and we need to pay a lot more attention. But this was really interesting. As you point out, from the time they look from 2015 to 2020, the cost of falls — both the total cost and the cost per patient — were significantly higher in those who had falls than those who had a firearm. This is particularly the combined cost in the 45-to-85-year-old population. That’s because most firearm injuries occur in younger patients as you highlighted, the increasing geriatric population, the increased fall risk associated with that patient population, especially those over the age of 85. What this tells me is if we’re going to reduce the cost of medical care altogether, not only do we need to address firearms, particularly in younger patients, but we also need to address falls in the older population.

Elizabeth: These numbers are revelatory. They cite that the average medical cost for a fatal fall was just shy of $77,000 while for a fatal firearm event, it was just shy of $45,000. That’s pretty impressive.

Rick: When you think about the fact that we have a larger aging population, not only is the per-patient cost higher, but the total medical cost is as well and that’s pretty substantial. There are a lot of ways to address this in the aging population.

Elizabeth: Let us move on then to your next one and that is weekend warriors, back in Annals of Internal Medicine.

Rick: Elizabeth, I was particularly happy this came out because we have talked before about the importance of exercise and the recommendations to be involved in 150 minutes of moderate to vigorous exercise per week. That amounts to about 30 minutes for 5 days of the week. But what if you do an hour over 2.5 days, is that equally beneficial?

That’s exactly what this study addressed. They looked at the associations between physical activity pattern and the incidence of 678 different diseases in almost 90,000 participants of the United Kingdom Biobank prospective cohort study. What they determined was that exercise was associated with a lower risk for over 200 different diseases. Now, the most prominent ones are those associated with cardiometabolic conditions: diabetes, obesity, sleep apnea, and hypertension. There was no difference between whether someone exercised regularly or whether they are a weekend warrior. Each of those was associated with the same benefits in all over 200 diseases. The benefit was approximately the same in both groups.

Elizabeth: Was this population matched for everything else outside of exercise?

Rick: Yep, and these were individuals that didn’t have these diseases to start with. The fact that exercise decreased the risk of 200 of those diseases is pretty remarkable. It decreased the risk by, gosh, as much as 50% in some of these conditions. But the fact that it didn’t matter whether you did it over 2 days or 3 days or 5 days, that’s really heartening to me. Because for many of us, we can’t possibly engage in physical activity 5 days per week on a regular basis, but we can do 150 minutes per week.

Elizabeth: I’m going to let you rest with that one and also prognosticate that we’re going to hear more about this, and we’ve also seen an awful lot about dose response relative to the benefits of exercise. I’m not convinced that this is the last word.

Rick: I think it is, maybe because I want it to be. But you’re right, there is a dose relationship, and they saw it here, too, by the way. The more you exercise, the more minutes per week, the lower the risk.

Elizabeth: Finally, let’s turn to JAMA Health Forum, and this is something that I think is very meaningful. The question is menopausal hormone therapy, and I’m guessing this is our new acronym. We used to call it HRT, hormone replacement therapy. Now we’re going to call it MHT, menopausal hormone therapy. What’s happened to that over the time period in post-menopausal women from 1999 to March of 2020 in the United States?

They look at NHANES [National Health and Nutrition Examination Survey] data in this and its 10 NHANES study cycles comprising 13,000+ U.S. post-menopausal women. What they showed was that over this time period the use of menopausal hormone therapy decreased among women of all age groups, from a composite of just shy of 27% to just shy of 5% in 2020. We see that there are definitely subgroups that have maintained a little bit higher use of this therapy and those that are very low, and that includes Hispanic women who now don’t use it very much at all, about 3% to 0.5% among non-Hispanic Black women.

They also note that there is a huge popularity in estrogen-only formulations that are accounting for more than 50% of the remaining menopausal hormone therapy for most study periods among these patients. I have to say that my opinion, of course, is that it is well known that this is a very effective way of dealing with both hot flashes — so vasomotor symptoms — as well as genitourinary, sleep difficulties, and cognitive problems. I think that based on the Women’s Health study, which seemed to aberrantly point out that there were increased risks of breast cancer, specifically a lot of women ran away from this, and I think that’s a mistake. We need to be looking at it again.

Rick: Elizabeth, as you mentioned, this is two decades of data from the National Health Nutrition Examination Survey, that’s NHANES as you mentioned. You’re right, when the data came out in 2002 that suggested that the hormone therapy’s health risk exceeded the benefits when they were used for chronic disease prevention, people started abandoning it.

A couple of things about that data. If you establish hormone therapy in older post-menopausal women, they have the highest risk of having complications from MHT. However, if you started it in healthy women, younger than age 60 or within 10 years of their final menstrual period, they actually received benefit and they weren’t at an increased risk. But by the time we had sorted that out, the news had already come out. Beep, beep, beep, beware hormone therapy could be detrimental. Now we need to have a more nuanced and I think a more informed opinion about how to prescribe it. As you mentioned, it’s the most effective therapy for vasomotor symptoms. There are women who need to be concerned about it, women who have had breast cancer, women who have cervical cancer, and women who smoke since it increases the risk of thromboembolic events. They need to talk to their physicians. But overall, we shouldn’t have abandoned it.

Elizabeth: Absolutely. The editorialist notes that educational attainment was positively associated with the use of menopausal hormone therapy and I am particularly disturbed by the fact that only 0.5% of non-Hispanic Black women are using it, although they disproportionately experience a lot of the troublesome symptomatology of menopause.

Rick: Yeah. Unfortunately, Black women are more likely to have menopausal symptoms earlier, and they’re more likely to be more severe, and they’re more likely to last longer. This is the patient population that could benefit most from MHT.

Elizabeth: OK. 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.

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