However, official word on skin protection varies

Ah, summer. Long days, warm temperatures, plentiful sunshine … and a heightened risk of skin cancer.

Melanoma is one of seven cancers whose incidence is on the rise (the others are HPV*-related mouth and throat cancers, esophageal cancer, pancreatic cancer, liver and bile duct cancer, thyroid cancer, and kidney and renal pelvic cancer.) 

Primary care clinicians may want to advise patients on safe sun exposure. However, the U.S. Preventive Services Task Force (USPSTF) does not give us much guidance on the topic.¹ It “concludes that the evidence is insufficient to recommend for or against routine counseling by primary care clinicians to prevent skin cancer … Counseling parents may increase the use of sunscreen for children, but there is little evidence to determine the effects of counseling on other preventive behaviors (such as wearing protective clothing, reducing excessive sun exposure, avoiding sun lamps/tanning beds, or practicing skin self-examination) and little evidence on potential harms.” This does not mean that counseling is never effective; it only means that the topic has not been studied enough for us to be able to draw conclusions about its effects.

Insufficient evidence prompts the USPSTF to shy away from endorsing a whole-body skin examination “by a primary care clinician or patient skin self-examination for the early detection of cutaneous melanoma, basal cell cancer, or squamous cell skin cancer in the adult general population.”

Nevertheless, malignant melanoma deserves consideration by primary care clinicians. It’s the fifth most common cancer in men and the sixth most common in women, although it doesn’t rank among the 10 most fatal cancers for either sex. Still, the American Cancer Society predicts that melanoma will kill 9,180 Americans this year — 6,060 males and 3,120 females. Physicians will diagnose as many as 76,250 new cases in 2012. Over a lifetime, one in every 55 women will develop the disease, and one in every 36 men. 

The American Academy of Dermatology recommends that you:

• Apply a broad-spectrum, water-resistant sunscreen with a Sun Protection Factor (SPF) of 30 or more to all exposed skin every two hours when outdoors, even on cloudy days, and after swimming or sweating.

• Use clothing, when possible, to protect skin from sun exposure: long-sleeved shirt, pants, a wide-brimmed hat, and sunglasses.

• Seek shade when appropriate.

• Recognize that water, snow and sand reflect and intensify the sun’s damaging rays of and increase the chances of sunburn.

• Get vitamin D through a healthy diet that may include vitamin supplements, not from seeking the sun.3

• Avoid tanning beds.  Studies have shown that people who used tanning beds have a much higher risk of developing melanoma.

• Check every inch of your body annually for moles or growths that are changing, growing or bleeding.

These guidelines are especially important for children, since most people get 80 percent of their sun exposure before the age of 18.

“If you choose to talk to patients about sunscreen, target your conversations to issues that will motivate them,” advises Martha Johns, MD, MPH, FACPM, HealthTeamWorks medical director for Guidelines and Implementation. “For example, preventing uncomfortable sunburns may be important even to teenagers. New parents want to protect their baby’s delicate skin. Many adults would like to prevent wrinkles and premature aging of the skin. And everyone in Colorado needs to be reminded of the stronger effects of the sun at high altitude.”   

 *Human papilloma virus

Source
1. United States Preventive Services Task Force. Counseling to prevent skin cancer. Recommendations and Rationale. www.uspreventiveservicestaskforce.org/3rduspstf/skcacoun/skcarr.htm

You laugh when it happens to the Marx Brothers or Inspector Clouseau. Little kids do it all the time and get right back up. But falling — especially for older adults — poses a significant risk of serious injury, disability and even death.

Falls are the leading cause of injury death among those 65 and older and the most frequent reason for nonfatal injuries and hospital admissions for trauma.^1,2 One out of three adults 65 or older falls each year, but less than half talk to their healthcare providers about it.² In 2008, more than 19,700 older adults died from injuries sustained in unintentional falls.³

Aging takes a toll on eyesight, hearing, strength and balance, increasing the likelihood of falls. Medications for depression, sleep problems, high blood pressure, diabetes and heart conditions can make patients unsteady on their feet. Poor health and lack of physical conditioning can also make seniors more vulnerable to falls.⁴

Help your senior patients avoid falls

Primary care providers can play an important role in preventing falls among older patients. Review their medication lists carefully, noting drugs that can cause dizziness. Ask your senior patients about:

• Dizziness, weakness or unsteadiness;

• Vision changes, cataracts, glaucoma and other eye problems, and whether they get annual check-ups from an eye specialist;

• Hearing changes;

• Foot pain, corns or bunions, ability to trim their toenails; and

• Feelings of mental confusion.

Encourage seniors to make their environment as safe as possible. You might suggest that they:

• Wear supportive shoes with nonskid soles;

• Keep their homes well lit so they can avoid obstacles;

• Use night lights in the bedroom, bathroom, hallways and stairways;

• Remove throw rugs or secure them to the floor with carpet tape, and tack down carpet edges;

• Keep pathways clear of electrical cords;

• Install grab bars in the bathtub, shower and toilet areas;

• Install handrails on both sides of stairways;

• Stay off stools and stepladders;

• Avoid waxing floors or use a nonskid wax; and

• Maintain sidewalks and walkways to keep surfaces smooth and even. 

After an assessment, you may suggest that patients unsteady on their feet use a cane or walker. Advise patients to sit on the side of the bed for a few moments when arising — during the night or in the morning — to allow blood pressure to adjust. Tell those who go to the bathroom frequently at night to consider using a bedside commode.⁵

Regular exercise, vigilant relatives help prevent falls

Physical strength and general well-being contribute to fall prevention. Encourage senior patients to get regular exercise, especially walking. Suggest exercises they can do to strengthen muscles used for walking and lifting. Advise a limit of one to two alcoholic beverages a day, and encourage smokers to quit.

Family members often accompany elderly patients to the visit, and you can enlist them in making the senior’s home safer from fall hazards, watching for changes in strength or balance and noting complaints about dizziness, weakness or unsteadiness. Vigilant relatives can help keep seniors safe from falls and take them to see you if concerns arise.
 

Sources

1. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web–based Injury Statistics Query and Reporting System (WISQARS) [online]. www.cdc.gov/HomeandRecreationalSafety/Falls/adultfalls.html.
2. Hornbrook MC, Stevens VJ, Wingfield DJ, Hollis JF, Greenlick MR, Ory MG. Preventing falls among community–dwelling older persons: results from a randomized trial. The Gerontologist 1994:34(1):16–23
3. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web–based Injury Statistics Query and Reporting System (WISQARS) [online].  
4. What causes falls in the elderly? How can I prevent a fall? American Academy of Family Physicians. Am Fam Physician. 2000 Apr 1;61(7):2173-2174. www.aafp.org/afp/2000/0401/p2173
5. Ibid.

The bad news: Eating large quantities of white rice increases the risk of developing type 2 diabetes. A recent article in The British Medical Journal presented this conclusion after its authors conducted a meta-analysis of prospective cohort studies on the topic. The researchers found that each daily serving was associated with an 11 percent increase in the risk of diabetes in the overall population.

Because white rice is a dietary staple of Asian countries such as China and Japan, the risk for those populations is greater than for Western countries whose citizens favor other grains. White rice in Asian countries composes the populations’ main dietary glycemic load; the study notes that glycemic load is consistently associated with increased risk of developing type 2 diabetes. The Chinese and Japanese typically eat three to four servings of white rice a day, while Westerners eat one to two servings a week.

Lifestyle changes in Asia contribute to diabetes risk

Rice consumption in Asian nations has always been high, but not so the risk of type 2 diabetes. “The recent transition in nutrition characterised by dramatically decreased physical activity levels and much improved security and variety of food has led to increased prevalence of obesity and insulin resistance in Asian countries,” the authors state. “Although rice has been a staple food in Asian populations for thousands of years, this transition may render Asian populations more susceptible to the adverse effects of high intakes of white rice, as well as other sources of refined carbohydrates such as pastries, white bread, and sugar sweetened beverages. In addition, the dose-response relations indicate that even for Western populations with typically low intake levels, relatively high white rice consumption may still modestly increase risk of diabetes.”

“Like many research findings, these results need to be put into context,” says Martha Johns, MD, MPH, FACPM, HealthTeamWorks medical director for Guidelines and Implementation. “As the researchers point out, modern cultural changes in Asian populations have led to increases in other refined carbohydrates, decreases in physical activity and increasing obesity, all of which are risk factors for diabetes. White rice is only one factor.” 

Brown rice may lower risk of diabetes

What about brown rice? The data are limited but seem to indicate that consumption of brown rice may “modestly” lower the risk of type 2 diabetes. “More studies with larger sample sizes and longer durations of follow-up are warranted to examine the effects of substituting brown rice for white rice on risk of diabetes,” the researchers say.

HealthTeamWorks has just updated its clinical guideline on type 2 diabetes. All HealthTeamWorks guidelines are available for free download.

The upshot of this study for white rice lovers: Enjoy, but in moderation. This is good advice for nearly all foods.

Source
Hu EA, Pan A, Malik V, Sun Q. White rice consumption and risk of type 2 diabetes: Meta-analysis and systematic review. BMJ 2012; 344 doi: 10.1136/bmj.e1454 (Published 15 March 2012)

Parents reluctant to have their children immunized against common diseases present a frequent, often daunting challenge to family physicians and pediatricians. “There are many reasons parents may want to avoid vaccinations for their kids,” says Robert Brayden, MD, professor of pediatrics at University of Colorado and board president of the Colorado Children’s Immunization Coalition. “Some are concerned about mercury [used in vaccines as a preservative] — they fear it can cause seizures or nervous system disorders. Some worry about aluminum, a vaccine adjuvant, stimulating an immune system response. Others believe vaccine manufacturers give physicians financial incentives to immunize patients.”                  

        Robert Brayden, MD (photo from childrenscolorado.org)

 For the record:

• Mercury is an ingredient in the preservative thimerosol, discontinued or used in only trace amounts in children’s vaccines since 2001. Extensive research has shown that vaccines containing thimerosol do not cause autism. The reduction or elimination of thimerosol in vaccines came as part of a general move to discontinue mercury in all products, although the type of mercury in thimerosol is not the same as the mercury that poses a health hazard in some seafood and other sources.¹                                                                        

• The levels of aluminum in vaccines are not dangerous to an infant’s or child’s health and actually stimulate a more prolonged immune response. Aluminum is a common element in the natural environment and appears in air, water, soil, food, breast milk and infant formula.²

• Physicians often lose money on vaccines. But recognizing their life-saving benefits, doctors encourage immunizations to keep children healthy and to safeguard the health of the general population.³

Brayden’s approach to hesitant parents begins with communication. “I encourage people to discuss their concerns and I truly listen.” Then he uses the example of a disease — tetanus, which is not transmitted person-to-person — and the vaccine that prevents it. Because the tetanus bacterium is found universally in soil, it threatens every human being. The disease it causes is characterized by jaw spasms (“lockjaw”), stiff neck, difficulty swallowing and stiff abdominal muscles. Tetanus can also cause fever, sweating, elevated blood pressure and rapid heart rate. The disease can be cured with weeks of intensive treatment, but 10 percent of its victims die.⁴ 

Martha Johns, MD, MPH, FACPM, HealthTeamWorks medical director for Guidelines and Implementation, agrees with Brayden that the clinician must start by listening to parents’ concerns. In addition to emphasizing vaccines’ ability to protect against a host of serious illnesses, she describes the importance of "herd immunity." "Herd immunity protects  unimmunized individuals from the contagious disease because a critical percentage of members of the community are immunized and the disease does not easily spread, reducing the probability of infection throughout a population," Johns says.

Brayden notes that vaccination has dramatically reduced the worldwide rate of tetanus. “If we had the health system of Somalia, we’d have 53 million cases of tetanus a year worldwide.” Because of vaccination, there were fewer than 10,000 reported cases in 2010.⁵ “If the world had the U.S. rate of tetanus immunization, there would be only 630 cases a year,” Brayden says.

He estimates that 3 percent of his patients don’t receive immunizations because of parents’ wishes, and that about 7 percent of children seeking to enroll in school have incomplete immunization records. (Colorado schools require that children show proof of vaccination against preventable diseases.)

Ultimately, “It’s important to keep one’s emotions out of this discussion,” Brayden says. “If a parent decides not to immunize, thinks you’re full of bunk, then people have to agree to disagree. I can’t make everybody see the benefit of vaccines. We can’t prevent every bad outcome. I just have to think I did the best I could.”

HealthTeamWorks has posted the 2012 immunization schedules for children and adolescents on our website. The schedules endorse those approved by the Advisory Committee on Immunization Practices, the American Academy of Pediatrics and the American Academy of Family Physicians.

Sources
1. Immunize Colorado. Fact or fiction – Thimerosol. www.immunizeforgood.com/fact-or-fiction/thimerosal, accessed March 1, 2012.
2. Immunize Colorado. Fact or fiction – Aluminum. www.immunizeforgood.com/fact-or-fiction/aluminum, accessed March 1, 2012.
3. Immunize Colorado. Fact or fiction – Vaccines are money-makers for docs? www.immunizeforgood.com/fact-or-fiction/vaccines-are-money-makers-for-docs, accessed March 1, 2012.
4. Immunization Action Coalition. www.vaccineinformation.org/tetanus/qandadis.asp, accessed March 1, 2012.
5. World Health Organization. Immunization surveillance, assessment and monitoring – Tetanus. www.who.int/immunization_monitoring/diseases/tetanus/en/index.html, accessed March 1, 2012.

Men’s health often gets less attention than women’s health, perhaps because men are 24 percent less likely than women to have seen a doctor within the past year.¹ Just over half of U.S. men (57 percent) visit a doctor, nurse practitioner or physician assistant for routine care, compared with 74 percent of women.² Regardless, men need certain preventive tests and screenings on a regular basis to ensure good health.

Prostate cancer: To screen or not to screen

Unique to men is screening for prostate cancer. Screening can detect cancers early and treatment may be more effective for early disease. Screening is done by digital rectal exam (DRE) or a blood test for prostate-specific antigen (PSA). In DRE, the clinician inserts a gloved, lubricated finger into the rectum to feel the prostate, estimate its size and feel for any abnormalities. 

The PSA test measures the level of PSA in the blood. Prostate cancer can cause an elevated PSA level, but many factors, such as age and race, can also affect it.

The most recent evidence suggests that PSA testing does not lower the risk for death from prostate cancer. A 13-year follow-up report published in the Journal of the National Cancer Institute concluded that there is no evidence of benefit from PSA screening. The test can, in fact, cause harm because of false-positive tests and overdiagnosis.³ This finding extends the trial's 10-year results, which also showed no mortality benefit.

The Centers for Disease Control and Prevention and other federal agencies follow the prostate cancer screening guidelines set forth by the U.S. Preventive Services Task Force, which state that there is not enough evidence to recommend or discourage routine screening for prostate cancer using PSA or DRE.⁴

Other preventive screening tests

Men — as well as women — should consider a number of other routine screening tests to maintain optimal health:⁵

Body mass index* — Your body mass index, or BMI, is a measure of your body fat based on your height and weight. It is used to screen for obesity. Find your BMI.

Cholesterol — Once you turn 35 (or once you turn 20 if you have risk factors like diabetes, history of heart disease, tobacco use, high blood pressure, or BMI of 30 or higher), have your cholesterol checked every five years. High blood cholesterol is one of the major risk factors for heart disease.

Blood pressure — Have your blood pressure checked every two years. High blood pressure increases your chance of getting heart or kidney disease and for having a stroke. If you have high blood pressure, you may need medication to control it.

Cardiovascular disease* — Beginning at age 45 and through age 79, ask your doctor if you should take aspirin every day to help lower your risk of a heart attack. How much aspirin you should take depends on your age, your health and your lifestyle.

Colorectal cancer* — Starting at age 50 and through age 75, get tested for colorectal cancer. You and your doctor can decide which test is best. How often you'll have the test depends on which test you choose. If you have a family history of colorectal cancer, you may need to be tested before you turn 50.

Other cancers — Ask your doctor if you should be tested for prostate, lung, oral, skin or other cancers.
Sexually transmitted diseases — Talk to your doctor to learn whether you should be tested for gonorrhea, syphilis, chlamydia or other sexually transmitted diseases.

HIV — Your doctor may recommend screening for HIV if you:

• Have sex with men.

• Had unprotected sex with multiple partners.

• Have used injected drugs.

• Pay for sex or have sex partners who do.

• Have past or current sex partners who are infected with HIV.

• Are being treated for sexually transmitted diseases.

• Had a blood transfusion between 1978 and 1985.

Depression* — If you have felt "down" or hopeless during the past two weeks or have had little interest in doing things you usually enjoy, talk to your doctor about depression. Depression is a treatable illness.

Abdominal aortic aneurysm — If you are 65 to 75 years old and have smoked 100 or more cigarettes in your lifetime, ask your doctor to screen you for an abdominal aortic aneurysm. This is an abnormally large or swollen blood vessel in your stomach that can burst without warning.

Diabetes* — If your sustained blood pressure is 135/80 or higher, ask your doctor to test you for diabetes. Diabetes, or high blood sugar, can cause problems with your heart, eyes, feet, kidneys, nerves and other body parts.

Tobacco use — If you smoke or use tobacco, talk to your doctor about quitting. Get tips online on how to quit or call the National Quitline at 1-800-QUITNOW.

Alcohol use — Moderate drinking levels for men are no more than 14 standard drinks on average per week and no more than four drinks on any occasion. Men older than 65 should drink half of what is recommended for younger men (seven drinks on average per week and no more than three on any occasion).

Remember, preventive medical tests benefit you AND your family and loved ones. 

*Denotes HealthTeamworks guideline
 

Sources

1. Agency for Healthcare Research and Quality. Healthcare Cost & Utilization Project and Medical Expenditure Panel Survey data.
2. Agency for Healthcare Research and Quality. Men Shy Away from Routine Medical Appointments. AHRQ News and Numbers, June 165, 2010. www.ahrq.gov/news/nn/nn061610.htm
3. Andriole GL, et al. Prostate cancer screening in the randomized prostate, lung, colorectal, and ovarian cancer screening trial: Mortality results after 13 years of follow-up. http://jnci.oxfordjournals.org/content/early/2012/01/06/jnci.djr500.abstract JNCI J Natl Cancer Inst (2012)doi: 10.1093/jnci/djr500First published online: Jan. 6, 2012
4. Chou R, Croswell JM, Dana T, et al. Screening for Prostate Cancer: A review of the evidence for the U.S. Preventive Services Task Force.  www.uspreventiveservicestaskforce.org/uspstf12/prostate/prostateart.htm. Oct. 2011.
5. U.S. Department of Health and Human Services. Agency for Healthcare Research and Quality. Get Preventive Medical Tests. www.ahrq.gov/healthymen/prevent.htm

Did you know that a daily dose of a certain B vitamin can reduce birth defects by 46 percent?¹ Folic acid helps the body make new cells. In a developing fetus, it can help prevent some major birth defects of the brain and spine by 50 percent to 70 percent.²

Everyone needs folic acid. However, women — particularly women who want to get pregnant — need at least 400 micrograms (mcg) daily to ensure proper development of a fetus. Many multivitamins contain 400 mgc of folic acid. Taking that amount of the vitamin before conception is essential for a fetus’ neural tube to develop fully. The neural tube is the initial, formative part of the spine and back. When the neural tube fails to form completely, the baby may be born without parts of the brain and skull (anencephaly) or with part of the spinal cord exposed (spina bifida).

Jan. 8-14 is National Folic Acid Awareness Week, part of National Birth Defects Prevention Month. HealthTeamWorks, along with the federal government, wants to ensure that people know the risks of insufficient folic acid intake on a developing fetus.

"Promoting protective factors, such as taking a daily multivitamin containing folic acid, eating well and exercising, and reducing risk factors such as smoking, alcohol use, obesity and poor mental health, is critical for the health of all women and any potential offspring," says Linda Archer, MSN, RN, CNS, Maternal Wellness Project specialist with the Colorado Department of Public Health and Environment.

Consuming folic acid daily before and during early pregnancy will help reduce the risk for neural tube defects. Healthcare providers should encourage every woman to consume 400 mcg of synthetic folic acid daily from fortified foods or supplements, or a combination of the two, in addition to getting folate that occurs naturally in certain foods. Good sources include: 

• Leafy green vegetables such as spinach, broccoli and lettuce;

• Okra;

• Asparagus;

• Fruits such as bananas, melons and lemons;

• Beans;

• Yeast;

• Mushrooms;

• Meat, including beef liver and kidneys; and

• Orange and tomato juice.³

In addition, since 1998, federal law has mandated that food manufacturers add folic acid to cold cereals, flour, breads, pasta, bakery items, cookies and crackers.⁴ Folic-acid fortified foods can help people increase their intake of the nutrient.

HealthTeamWorks’ clinical Guideline for Preconception and Interconception Care puts folic acid at the top of the list of factors that affect fetal health and development. Because 39 percent of pregnancies in Colorado are unplanned⁵ (50 percent nationwide⁶), and because folic acid intake is such a simple way to promote fetal health, we urge providers to counsel their female patients of child-bearing age about the importance of getting enough folic acid.

Anna Kelly, MD, who serves on the Healthy Women Healthy Babies Roundtable, participated in the committee that developed the HealthTeamWorks Guideline for Preconception and Interconception Care, says "While numerous individual preconception interventions are known to improve pregnancy outcomes, the HealthTeamWorks Preconception and Interconception Care guideline strives to summarize, simplify and prioritize interventions that have the strongest evidence. [It does so] in a manner that can serve as a foundation for provider- and consumer-focused preconception projects in Colorado and beyond."
 

Sources
1. Jan. 6, 2012, 60(51);1746. National Birth Defects Prevention Month and Folic Acid Awareness Week — January 2012. www.cdc.gov/mmwr/preview/mmwrhtml/mm6051a6.htm?s_cid=mm6051a6_e. Accessed Jan. 5, 2012.
2. Centers for Disease Control and Prevention. Facts about folic acid. www.cdc.gov/ncbddd/folicacid/about.html. Accessed Jan. 5, 2012.
3. WebMD. Folic acid. www.webmd.com/vitamins-supplements/ingredientmono-1017-FOLIC%20ACID.aspx?activeIngredientId=1017&activeIngredientName=FOLIC%20ACID. Accessed Jan. 5, 2012.
4. Ibid.
5. Colorado Department of Public Health and Environment, Health Statistics Section (2010). Colorado MCH Data Set 2010. Retrieved October 12, 2010 from www.cdphe.state.co.us/ps/mch/mchadmin/mchdatasets2010/profiles/colorado.pdf.
6. Finer LB, Henshaw SK. Disparities in Rates of Unintended Pregnancy in the United States, 1994 and 2001. Perspectives on Sexual Reproductive Health, 2006:38:90–96.