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 lead exposure and mental disorders, assisted dying, depression treatment after positive screening in primary care, and chocolate and type 2 diabetes.
Program notes:
1:07 Health benefits of chocolate consumption
2:05 Flavonoids more so in dark
3:06 What is the biological plausibility?
3:42 Depression treatment after positive screens in primary care
4:45 38% received meds or referral at screening
5:46 Great that screening is taking place
6:46 Medical assistance in dying
7:46 Looked at twenty jurisdictions
8:46 Canada has employed for some time
9:46 Access in all jurisdictions
10:05 Lead exposure in childhood and mental disorders
11:05 Assuming lead psychopathology associations
12:05 Extrapolated a lot of data
13:06 End
Transcript:
Elizabeth: Is childhood lead exposure responsible for a huge uptick in mental conditions?
Rick: Chocolate intake and the risk of type 2 diabetes.
Elizabeth: How often does someone get treatment for depression after they have been screened for depression in a primary care setting?
Rick: And medical assistance in dying.
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 University Health Sciences Center in El Paso, where I'm also dean of the Paul L. Foster School of Medicine.
Elizabeth: We are going to start with a shoutout to Tom, our really wonderful guy who manages to monitor all of the social media relative to the podcast and has been doing so for quite a long time. He is our third and we need to celebrate him in the midst of this 20 years of recording.
Rick: Thank you, Elizabeth. Well, where do you want to start?
Elizabeth: I'm going to ask you to start, because you're such a chocolate addict, with, gosh, should we all start eating dark chocolate? That is in the British Medical Journal.
Rick: This was a study that investigated the association between chocolate consumption and the risk of type 2 diabetes mellitus in three three different cohorts in the United States: the Nurses' Health Study that was conducted from '86 to 2018, another Nurses' Health Study II from 1991 to 2021, and the Health Professionals Follow-Up Study from 1986 to 2020. There were almost 200,000 participants that did not have type 2 diabetes or cardiovascular disease or cancer. They asked them a simple question as a part of their dietary survey: Do you eat chocolate? How often do you do it? What kind of chocolate do you eat, dark chocolate or milk chocolate? They looked at total chocolate consumption.
Dark chocolate has a higher percentage of cocoa in it and it doesn't have much sugar. Milk chocolate has a lower percentage of cocoa, higher milk, and higher sugar. There are specific flavonoid subclasses that are present in chocolate, and dark chocolate happens to have more of these. These flavonoids are anti-inflammatory and antioxidant. They tend to dilate blood vessels. So there is potentially some benefit -- believe it or not -- associated with the ingestion of chocolate.
When they looked at these three specific populations, what they discovered is patients who consumed five or more servings per week of any chocolate showed a 10% lower risk of type 2 diabetes compared to those who never or rarely consume chocolate. It was limited to those that were actually dark chocolate consumers. They showed a 21% lower risk of type 2 diabetes, and there was no benefit for milk chocolate intake. Interestingly enough, Elizabeth, individuals that consumed milk chocolate did gain weight, but those that ate dark chocolate over the course of the 10-year follow-up did not have any increase in weight. It sounds like a great study to me.
Elizabeth: Of course, it does, being vested in this behavior. Now that we're entering the holiday season, it sounds like everybody ought to be gifting dark chocolate. Of course, we are so fond of biological plausibility. What's the plausibility? I would sure like to see the relationship between inflammatory markers and the consumption of dark chocolate.
Rick: Right. Well, as I mentioned, dark chocolate has the highest cocoa content -- it's about 50% to 80% -- and it's the richest chocolate in terms of flavonoids, known to decrease inflammation. They improve insulin sensitivity, they protect pancreatic beta cells from oxidative stress, they lower pro-inflammatory cytokines, and they improve endothelial function. By the way, this isn't the only study that's looked at this. There are a number of different studies and they are all concordant.
Elizabeth: And I know you're going to continue your habit.
Let's turn to JAMA Internal Medicine because I actually view this as a good news study. We are well aware, of course, that among the multitude of things that are being dropped onto the plate of primary care practices is screening for depression. We have talked about this a number of times -- the appropriate instruments and what's the yield. This study takes a look at as this practice is increasing, do these patients actually get prescribed antidepressant meds?
Their primary outcome in this population was an antidepressant or mental health referral that was ordered at screening and then their secondary outcomes were those two things, the antidepressant referrals or a follow-up visit within 8 weeks. A big cohort here, almost 61,000 folks. Of that number screened, just shy of 4,000 reported elevated depressive symptoms or suicidal ideation.
They represented quite a slice of the population, including many minority ethnicities. Of that number, about 38% received antidepressants or referrals and/or when they were screened (including 44% of those who had suicidal ideation). By 8 weeks, 70% had received the antidepressant or the referral or follow-up (including 75% of those folks who reported suicidal ideation).
When they broke this out, they did note, of course, that these minority ethnicities were less likely to receive this intervention and they also showed that estimated treatment decreased with increasing age. Those who reported suicidal ideation had greater estimated treatment overall than those who did not report this.
I think this is a good news study because it is showing that, yes, indeed, people who screen positive are receiving treatment. My hope is that this trend continues upward and that we overcome some of these other barriers that appear to show up in this study.
Rick: I think this is great that people are screening for depression and ultimately they end up with referrals for treatment, although it may take up to 8 weeks. It's still disturbing to me that about 20% of people with suicidal ideation aren't referred for treatment or referral even after 8 weeks. It's also a little disturbing that individuals that either were screened through the portal or were elderly were less likely to receive referrals even up to 8 weeks. In fact, that number for individuals over the age of 70 was less than 20%, Elizabeth.
Elizabeth: We know that the rates of depression, suicidal ideation, and frank suicide attempts are increasing among those folks rapidly.
Rick: Yeah. I was surprised that individuals that were screened via the portal weren't automatically referred. I mean, you would think one of the values of having all this electronically identified and recorded is you could automatically make a referral. We haven't closed that gap either. This should spur us to do even better.
Elizabeth: Turning to your next one and that's also in JAMA Internal Medicine.
Rick: Medical assistance in dying or the acronym would be called MAID. It's emerged as an option for end-of-life care to address issues in individuals who have severe conditions that result in severe pain, their burdensome transitions to the family as well, the stress for both the person undergoing it, and also for the family members and caregivers.
Medical assistance in dying can occur one of two ways: either through euthanasia -- that is, ending a patient's life by active drug administration; or physician-assisted suicide, where the physician provides drugs for the patient to end their own life, or it could be either. Access to MAID has increased substantially and is now available to nearly 300 million people worldwide.
What this has done is it has accelerated debates about access, equity, and appropriateness. The major concern is that making this available would increase its use and it would be inappropriately used. What these investigators did was they looked at medical assistance in dying from 20 different jurisdictions in which MAID was legalized, and that includes, by the way, 9 states in the United States. They looked at the number of deaths attributed to MAID and what the underlying causes were.
What they discovered was MAID accounted for only 1.4% of all deaths across the 20 jurisdictions and less than 0.5 deaths within the nine states in the United States. Rates of MAID were found to be highest in jurisdictions that allowed both euthanasia and physician-assisted suicide. The specific conditions most frequently associated with MAID were consistent regardless of whether it was in the United States or elsewhere, and that was ALS and advanced cancer. When they dug and looked into all of the data, it refuted the argument that increasing access to MAID resulted in either a groundswell of use in it, or that it would become normative and it would be inappropriately applied.
Elizabeth: I think this is very reassuring, especially in light of data that... again, shoutout to Tom and to Canada. Canada, of course, has employed this for quite a while and there is an activist I know about, a man who is disabled who had the experience of having his primary care doc actually suggest that he might want to entertain this option. He was so upset about this that he decided to make this important awareness that he was going to bring out -- and has since talked about the data and the increasing use of this option in Canada -- the concern that sometimes people are being kind of suggested that they might consider it. I would still advocate, as a chaplain, having seen so many people struggle with these kinds of things, that it should be an option.
Rick: Yeah. In fact, in Canada, now that you mentioned it, the incidence of MAID is about 2.2%. In the United States, it is less than 0.5%. While access to it in the five jurisdictions that were looked at in Australia, Belgium, Canada, Luxembourg, the Netherlands, New Zealand, and Switzerland, and in the nine jurisdictions in the U.S., although it has increased somewhat, it's been a relatively modest increase, it has been applied appropriately, and it's a relatively minor use across all deaths.
Elizabeth: That is reassuring. Finally, let's turn to the Journal of Child Psychology and Psychiatry, a journal we have never reported before.
This is a study that got quite a bit of attention. This examines the contribution of childhood lead exposure to psychopathology in the US population over the past 75 years. They looked at serial cross-sectional blood lead level data from the NHANES study with historic leaded gas data to estimate childhood BLLs [blood lead levels] from 1940 to 2015. Then they looked at the population mental health symptom elevations during that same time period, trying to synthesize those two data sets and see, "Gosh, can we account somehow for the increased prevalence of a lot of these different conditions with childhood exposure to lead?" -- which was largely from leaded gasoline, which as we know has since been phased out.
They make a very telling statement regarding the study. They say "Assuming that published lead-psychopathology associations are causal and not purely correlational," they estimated that this lead exposure had resulted in an overall 0.13 standard deviation increase in overall liability to mental illness in the population and an estimated 151 million excess mental disorders that are attributable to lead exposure.
They find this so-called internalizing symptoms, one category of mental disorders, a 0.64 standard deviation increase, a 0.42 standard deviation increase in ADHD symptoms, and conscientiousness decrease. They also note and attribute this exposure to lead. Are you convinced by this association?
Rick: Elizabeth, it makes a lot of assumptions. Blood lead levels weren't actually measured in all of the kids. It's just a small little window. They did a lot of extrapolations and extrapolated the amount of lead in the air. It's provocative, it makes sense, but I wouldn't put a whole lot of weight in it. But it's clear that lead isn't good. I do think it's important that we lower lead levels across the globe.
Elizabeth: The other part of this I wonder about is, what good does it do us to look retrospectively at this potential etiology of increasing mental disorders if there is really nothing we can do to change that?
Rick: Yeah. Removal of lead from gasoline was a more controversial issue and it wasn't thought that lead was a significant problem, especially in the air. But what's clear is that even small amounts of lead are neurotoxic and may result in poor neurologic outcomes.
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.