MDedge Endocrinology

Transgender people treated with gender-affirming hormone therapy show distinctive changes in blood pressure that begin soon after treatment initiation and do not subside over years of treatment, according to the largest and longest observational study to date to look at the issue.

“Many physicians may not be aware of the changes to blood pressure in trans patients who start hormone therapy,” senior author Michael S. Irwig, MD, director of transgender medicine at Beth Israel Deaconess Medical Center in Boston, told this news organization.

“The take-away message for physicians is to monitor blood pressure both before and after starting hormone therapy in transgender patients, as over a third of transgender individuals had stage 1 hypertension before starting hormone therapy, and many had their blood pressure increase after starting hormone therapy.”

Mean blood pressure increases in transgender males, decreases in females

In the study, published in Hypertension, Katherine Banks, MD, George Washington University, Washington, and colleagues, followed 470 transgender adult patients for up to 5 years.

The mean systolic blood pressure levels in transgender female patients (male at birth) significantly decreased compared with baseline within a few months of them starting gender-affirming hormone treatment.

Conversely, the systolic blood pressure levels in transgender males (females at birth) who were treated with testosterone increased over the same period.

There were no significant changes in the groups in terms of diastolic blood pressure, consistent with other studies.

“Our study is the first to describe the time course of the blood pressure effects of gender-affirming hormone therapy and to compare the rates of elevated blood pressure and stage 1 and stage 2 hypertension using blood pressure readings from gender-diverse individuals pre- and post–gender-affirming hormone therapy,” the authors note.

Gender-affirming hormone therapy – which has been prescribed to transgender patients for more than 25 years – typically involves a combination of estrogen and an anti-androgen for males transitioning to female, while the therapy for those transitioning to male generally only involves testosterone.

The therapy has previously been linked to various cardiac effects, with evidence showing transgender men have as much as a 5-times greater risk of heart attack versus cisgender women, the authors note.

Although the American Heart Association issued a 2020 Scientific Statement addressing the cardiovascular disease risk, evidence on the effects specifically on blood pressure in transgender patients has been inconsistent.

For the new study, Dr. Banks and colleagues enrolled 247 transgender females and 223 transgender males who were treated between 2007 and 2015 at two medical centers in Washington, D.C. Of the individuals, who had a mean age of 27.8, about 27% were non-White and 16% were Latinx.

They had blood pressure measurements taken at baseline and at follow-up clinical visits for up to 57 months following the initiation of gender-affirming hormone therapy.

Over the follow-up period, the transgender females had decreases in mean systolic blood pressure of 4.0 mm Hg within 2 to 4 months of starting hormone therapy (P < .0001) and mean declines of 6.0 mm Hg were further observed at 11 to 21 months compared with baseline.

In transgender males, the mean systolic blood pressure increased by 2.6 mm Hg at 2 to 4 months (P = .02), and by 2.9 mm Hg at 11 to 21 months after starting therapy.

Furthermore, “although the average increase in systolic blood pressure was 2.6 mm Hg in transgender men within 2 to 4 months, some patients had much higher increases,” Dr. Irwig noted.

As many as 40% of transgender men had stage 1 hypertension after 11 to 21 months of hormone therapy.

The blood pressure changes in transgender males and females were observed across all three racial ethnic groups of Whites, Blacks, and Latinx, and the changes remained consistent throughout the entire follow-up period of approximately 5 years while hormone therapy was continued.

In addition to the changes after therapy initiation, the researchers note that more than one-third of individuals in both groups had stage 1 hypertension even before starting hormone therapy.

The findings are a concern in light of “clear evidence linking hypertension and higher blood pressure with cardiovascular events such as stroke and heart attacks,” Dr. Irwig said.

Protective effects for transgender females?

Transgender females showed as much as a 47% decrease in the prevalence of stage 2 hypertension, from 19% to 10%, within 2 to 4 months of treatment with gender-affirming hormone therapy (P = .001), and the rate declined further to 8% at 11 to 21 months, suggesting a protective effect of the treatment.

“The rate of stage 2 hypertension did drop in transgender feminine individuals, which could be protective and lower their risk for cardiovascular events,” Dr. Irwig said.

“This was not a surprise, as lowering testosterone and the use of spironolactone can lower blood pressure,” he noted.

Exceptions in both groups

Of note, a sizable proportion of patients had blood pressure changes that were in fact the opposite of the patterns seen in the majority of their gender group.

Specifically, while 42% to 53% of the transgender females had systolic blood pressure readings of at least 5 mm Hg lower than their baseline readings, up to 32% had increases of at least 5 mm Hg compared to baseline readings.

Likewise, whereas 41% to 59% of transgender males had increases of at least 5 mm Hg compared with baseline, up to 35% had levels that were at least 5 mm Hg lower than baseline.

“It was a surprise that over a quarter of individuals had changes opposite to the mean changes,” Dr. Irwig said.

The differing blood pressure changes underscore that “more research is needed to determine which formulations of estrogen, testosterone, and antiandrogens are optimal regarding blood pressure and cardiovascular health, especially in older individuals,” the authors note.

Gender-affirming hormone therapy formulations differ

Various formulations for gender-affirming hormone regimens are available, including oral, transdermal, sublingual, and intramuscular preparations.

In the study, 77% to 91% of transgender males were on intramuscular testosterone injections, with the rest on transdermal formulations, and 92% of transgender female patients were started on oral estradiol, with mean doses generally increasing over time.  

The study’s results are consistent with evidence from other studies, with 7 of 8 involving transgender males showing mean increases in systolic blood pressure ranging from 1 to 14 mm Hg.

Previous research supports cardiovascular risk

As reported by this news organization, other emerging research on cardiovascular risks to transgender people include a recent study showing more than 10% of transgender males were found to have hematocrit levels that could put them at risk for blood clots.

And further research on transgender youth also shows concerning elevations in lipids and other cardiovascular risks.

The authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Transgender people treated with gender-affirming hormone therapy show distinctive changes in blood pressure that begin soon after treatment initiation and do not subside over years of treatment, according to the largest and longest observational study to date to look at the issue.

“Many physicians may not be aware of the changes to blood pressure in trans patients who start hormone therapy,” senior author Michael S. Irwig, MD, director of transgender medicine at Beth Israel Deaconess Medical Center in Boston, told this news organization.

“The take-away message for physicians is to monitor blood pressure both before and after starting hormone therapy in transgender patients, as over a third of transgender individuals had stage 1 hypertension before starting hormone therapy, and many had their blood pressure increase after starting hormone therapy.”

Mean blood pressure increases in transgender males, decreases in females

In the study, published in Hypertension, Katherine Banks, MD, George Washington University, Washington, and colleagues, followed 470 transgender adult patients for up to 5 years.

The mean systolic blood pressure levels in transgender female patients (male at birth) significantly decreased compared with baseline within a few months of them starting gender-affirming hormone treatment.

Conversely, the systolic blood pressure levels in transgender males (females at birth) who were treated with testosterone increased over the same period.

There were no significant changes in the groups in terms of diastolic blood pressure, consistent with other studies.

“Our study is the first to describe the time course of the blood pressure effects of gender-affirming hormone therapy and to compare the rates of elevated blood pressure and stage 1 and stage 2 hypertension using blood pressure readings from gender-diverse individuals pre- and post–gender-affirming hormone therapy,” the authors note.

Gender-affirming hormone therapy – which has been prescribed to transgender patients for more than 25 years – typically involves a combination of estrogen and an anti-androgen for males transitioning to female, while the therapy for those transitioning to male generally only involves testosterone.

The therapy has previously been linked to various cardiac effects, with evidence showing transgender men have as much as a 5-times greater risk of heart attack versus cisgender women, the authors note.

Although the American Heart Association issued a 2020 Scientific Statement addressing the cardiovascular disease risk, evidence on the effects specifically on blood pressure in transgender patients has been inconsistent.

For the new study, Dr. Banks and colleagues enrolled 247 transgender females and 223 transgender males who were treated between 2007 and 2015 at two medical centers in Washington, D.C. Of the individuals, who had a mean age of 27.8, about 27% were non-White and 16% were Latinx.

They had blood pressure measurements taken at baseline and at follow-up clinical visits for up to 57 months following the initiation of gender-affirming hormone therapy.

Over the follow-up period, the transgender females had decreases in mean systolic blood pressure of 4.0 mm Hg within 2 to 4 months of starting hormone therapy (P < .0001) and mean declines of 6.0 mm Hg were further observed at 11 to 21 months compared with baseline.

In transgender males, the mean systolic blood pressure increased by 2.6 mm Hg at 2 to 4 months (P = .02), and by 2.9 mm Hg at 11 to 21 months after starting therapy.

Furthermore, “although the average increase in systolic blood pressure was 2.6 mm Hg in transgender men within 2 to 4 months, some patients had much higher increases,” Dr. Irwig noted.

As many as 40% of transgender men had stage 1 hypertension after 11 to 21 months of hormone therapy.

The blood pressure changes in transgender males and females were observed across all three racial ethnic groups of Whites, Blacks, and Latinx, and the changes remained consistent throughout the entire follow-up period of approximately 5 years while hormone therapy was continued.

In addition to the changes after therapy initiation, the researchers note that more than one-third of individuals in both groups had stage 1 hypertension even before starting hormone therapy.

The findings are a concern in light of “clear evidence linking hypertension and higher blood pressure with cardiovascular events such as stroke and heart attacks,” Dr. Irwig said.

Protective effects for transgender females?

Transgender females showed as much as a 47% decrease in the prevalence of stage 2 hypertension, from 19% to 10%, within 2 to 4 months of treatment with gender-affirming hormone therapy (P = .001), and the rate declined further to 8% at 11 to 21 months, suggesting a protective effect of the treatment.

“The rate of stage 2 hypertension did drop in transgender feminine individuals, which could be protective and lower their risk for cardiovascular events,” Dr. Irwig said.

“This was not a surprise, as lowering testosterone and the use of spironolactone can lower blood pressure,” he noted.

Exceptions in both groups

Of note, a sizable proportion of patients had blood pressure changes that were in fact the opposite of the patterns seen in the majority of their gender group.

Specifically, while 42% to 53% of the transgender females had systolic blood pressure readings of at least 5 mm Hg lower than their baseline readings, up to 32% had increases of at least 5 mm Hg compared to baseline readings.

Likewise, whereas 41% to 59% of transgender males had increases of at least 5 mm Hg compared with baseline, up to 35% had levels that were at least 5 mm Hg lower than baseline.

“It was a surprise that over a quarter of individuals had changes opposite to the mean changes,” Dr. Irwig said.

The differing blood pressure changes underscore that “more research is needed to determine which formulations of estrogen, testosterone, and antiandrogens are optimal regarding blood pressure and cardiovascular health, especially in older individuals,” the authors note.

Gender-affirming hormone therapy formulations differ

Various formulations for gender-affirming hormone regimens are available, including oral, transdermal, sublingual, and intramuscular preparations.

In the study, 77% to 91% of transgender males were on intramuscular testosterone injections, with the rest on transdermal formulations, and 92% of transgender female patients were started on oral estradiol, with mean doses generally increasing over time.  

The study’s results are consistent with evidence from other studies, with 7 of 8 involving transgender males showing mean increases in systolic blood pressure ranging from 1 to 14 mm Hg.

Previous research supports cardiovascular risk

As reported by this news organization, other emerging research on cardiovascular risks to transgender people include a recent study showing more than 10% of transgender males were found to have hematocrit levels that could put them at risk for blood clots.

And further research on transgender youth also shows concerning elevations in lipids and other cardiovascular risks.

The authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Transgender people treated with gender-affirming hormone therapy show distinctive changes in blood pressure that begin soon after treatment initiation and do not subside over years of treatment, according to the largest and longest observational study to date to look at the issue.

“Many physicians may not be aware of the changes to blood pressure in trans patients who start hormone therapy,” senior author Michael S. Irwig, MD, director of transgender medicine at Beth Israel Deaconess Medical Center in Boston, told this news organization.

“The take-away message for physicians is to monitor blood pressure both before and after starting hormone therapy in transgender patients, as over a third of transgender individuals had stage 1 hypertension before starting hormone therapy, and many had their blood pressure increase after starting hormone therapy.”

Mean blood pressure increases in transgender males, decreases in females

In the study, published in Hypertension, Katherine Banks, MD, George Washington University, Washington, and colleagues, followed 470 transgender adult patients for up to 5 years.

The mean systolic blood pressure levels in transgender female patients (male at birth) significantly decreased compared with baseline within a few months of them starting gender-affirming hormone treatment.

Conversely, the systolic blood pressure levels in transgender males (females at birth) who were treated with testosterone increased over the same period.

There were no significant changes in the groups in terms of diastolic blood pressure, consistent with other studies.

“Our study is the first to describe the time course of the blood pressure effects of gender-affirming hormone therapy and to compare the rates of elevated blood pressure and stage 1 and stage 2 hypertension using blood pressure readings from gender-diverse individuals pre- and post–gender-affirming hormone therapy,” the authors note.

Gender-affirming hormone therapy – which has been prescribed to transgender patients for more than 25 years – typically involves a combination of estrogen and an anti-androgen for males transitioning to female, while the therapy for those transitioning to male generally only involves testosterone.

The therapy has previously been linked to various cardiac effects, with evidence showing transgender men have as much as a 5-times greater risk of heart attack versus cisgender women, the authors note.

Although the American Heart Association issued a 2020 Scientific Statement addressing the cardiovascular disease risk, evidence on the effects specifically on blood pressure in transgender patients has been inconsistent.

For the new study, Dr. Banks and colleagues enrolled 247 transgender females and 223 transgender males who were treated between 2007 and 2015 at two medical centers in Washington, D.C. Of the individuals, who had a mean age of 27.8, about 27% were non-White and 16% were Latinx.

They had blood pressure measurements taken at baseline and at follow-up clinical visits for up to 57 months following the initiation of gender-affirming hormone therapy.

Over the follow-up period, the transgender females had decreases in mean systolic blood pressure of 4.0 mm Hg within 2 to 4 months of starting hormone therapy (P < .0001) and mean declines of 6.0 mm Hg were further observed at 11 to 21 months compared with baseline.

In transgender males, the mean systolic blood pressure increased by 2.6 mm Hg at 2 to 4 months (P = .02), and by 2.9 mm Hg at 11 to 21 months after starting therapy.

Furthermore, “although the average increase in systolic blood pressure was 2.6 mm Hg in transgender men within 2 to 4 months, some patients had much higher increases,” Dr. Irwig noted.

As many as 40% of transgender men had stage 1 hypertension after 11 to 21 months of hormone therapy.

The blood pressure changes in transgender males and females were observed across all three racial ethnic groups of Whites, Blacks, and Latinx, and the changes remained consistent throughout the entire follow-up period of approximately 5 years while hormone therapy was continued.

In addition to the changes after therapy initiation, the researchers note that more than one-third of individuals in both groups had stage 1 hypertension even before starting hormone therapy.

The findings are a concern in light of “clear evidence linking hypertension and higher blood pressure with cardiovascular events such as stroke and heart attacks,” Dr. Irwig said.

Protective effects for transgender females?

Transgender females showed as much as a 47% decrease in the prevalence of stage 2 hypertension, from 19% to 10%, within 2 to 4 months of treatment with gender-affirming hormone therapy (P = .001), and the rate declined further to 8% at 11 to 21 months, suggesting a protective effect of the treatment.

“The rate of stage 2 hypertension did drop in transgender feminine individuals, which could be protective and lower their risk for cardiovascular events,” Dr. Irwig said.

“This was not a surprise, as lowering testosterone and the use of spironolactone can lower blood pressure,” he noted.

Exceptions in both groups

Of note, a sizable proportion of patients had blood pressure changes that were in fact the opposite of the patterns seen in the majority of their gender group.

Specifically, while 42% to 53% of the transgender females had systolic blood pressure readings of at least 5 mm Hg lower than their baseline readings, up to 32% had increases of at least 5 mm Hg compared to baseline readings.

Likewise, whereas 41% to 59% of transgender males had increases of at least 5 mm Hg compared with baseline, up to 35% had levels that were at least 5 mm Hg lower than baseline.

“It was a surprise that over a quarter of individuals had changes opposite to the mean changes,” Dr. Irwig said.

The differing blood pressure changes underscore that “more research is needed to determine which formulations of estrogen, testosterone, and antiandrogens are optimal regarding blood pressure and cardiovascular health, especially in older individuals,” the authors note.

Gender-affirming hormone therapy formulations differ

Various formulations for gender-affirming hormone regimens are available, including oral, transdermal, sublingual, and intramuscular preparations.

In the study, 77% to 91% of transgender males were on intramuscular testosterone injections, with the rest on transdermal formulations, and 92% of transgender female patients were started on oral estradiol, with mean doses generally increasing over time.  

The study’s results are consistent with evidence from other studies, with 7 of 8 involving transgender males showing mean increases in systolic blood pressure ranging from 1 to 14 mm Hg.

Previous research supports cardiovascular risk

As reported by this news organization, other emerging research on cardiovascular risks to transgender people include a recent study showing more than 10% of transgender males were found to have hematocrit levels that could put them at risk for blood clots.

And further research on transgender youth also shows concerning elevations in lipids and other cardiovascular risks.

The authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

In a U.K. cohort of more than 260,000 mostly middle-aged adults in primary care with overweight or obesity, body mass index remained relatively stable over a decade.

However, compared to overweight individuals, those with severe (class 3) obesity were more socioeconomically disadvantaged and had triple the risk for incident heart failure or all-cause or cardiovascular disease (CVD)–related mortality in a study published online April 15 in BMC Public Health.

“This is the first study to evaluate the long-term impact of overweight and obese individuals’ BMI trajectory on cardiovascular endpoints, heart failure, and mortality outcomes,” wrote Barbara Iyen, PhD, University of Nottingham, England, and colleagues.

The findings emphasize “the high cardiovascular toll exacted by continuing failure to tackle obesity, particularly among more socioeconomically deprived populations,” they warned.

“We have found that despite widespread efforts to prevent and manage obesity, the majority of adults who are overweight or obese in the general population continue to remain so in the long term,” Dr. Iyen said in a statement from her university.

“More effective policies and weight-management interventions are needed urgently to address this increasing burden and associated adverse health outcomes,” she stressed.

Invited to comment, Sadiya S. Khan, MD, Northwestern University, Chicago, said in an interview: “This research adds to the growing body of evidence [that] earlier and more intensive interventions for weight loss are necessary to promote cardiovascular health and reduce morbidity and mortality.

“Adjunctive pharmacotherapy and bariatric surgery are both options that should be considered in addition to intensive lifestyle interventions in overweight and obesity groups,” she added.

“I would always advocate for earlier prevention efforts focused on weight loss, because years lived with obesity are associated with future CVD, so every year counts,” Dr. Khan said.
 

Does BMI remain elevated, predict worse heart health?

Although obesity is a well-recognized risk factor for CVD, long-term changes in BMI and the impact of BMI on the risk for heart failure, CVD, and mortality have not been quantified among adults with overweight and obesity, Dr. Iyen and colleagues explained.

The researchers examined data from the UK Clinical Practice Research Datalink and secondary care and mortality records to determine BMI trajectories among adults with overweight or obesity and to quantify the risk for heart failure, CVD (defined as coronary heart disease, stroke, transient ischemic attack, or peripheral vascular disease, CVD-related mortality, and all-cause mortality.

They identified 264,230 adults with overweight or obesity who were seen in 790 primary care practices in the United Kingdom from 1999 to 2018 and who did not initially have heart failure or CVD and for whom baseline BMI measurements and at least one other BMI measurement 2, 5, 8, and 10 years later was available.

The researchers divided the cohort into four groups on the basis of initial BMI: overweight (36% of patients; mean BMI, 28.7 kg/m²); class 1 obesity (40%; mean BMI, 33.7 kg/m²); class 2 obesity (19%; mean BMI, 39.9 kg/m²), and class 3 obesity (5%; mean BMI, 49.1 kg/m²).

The mean age of the individuals was 50 years, and 64% were White. Race/ethnicity data were unavailable for 31%. Asian Indian, Asian, and Black patients comprised 5% of the cohort.
 

“Strong significant gradient in heart failure risk”

Compared to the overweight (reference) group, the severe-obesity group comprised a higher percentage of women (74% vs. 70%), and the prevalence of comorbidities and socioeconomic deprivation was higher.

BMI remained relatively stable in each BMI group. The mean BMI increase was 1.06 kg/m² during a median follow-up of 10.9 years.

There were 30,400 incident cases of CVD, 7,662 incident cases of heart failure, and 24,022 deaths, of which 2,827 (11.8%) were from CVD.

The risk for heart failure and CVD-related or all-cause mortality increased with increasing obesity severity.

Compared with overweight individuals, those with class 3 obesity were at significantly increased risk for heart failure (hazard ratio [HR], 3.26), all-cause mortality (HR, 2.72), and CVD-related mortality (HR, 3.31) after adjustment for age, sex, and comorbidities (hypertension, type 2 diabetes, atrial fibrillation, and chronic kidney disease).

The risk for stroke/TIA or coronary heart disease was similar among those with severe obesity and the other individuals. The risk for PVD was significantly lower (HR, 0.73).

The reduced risk for PVD in the most severely obese group is similar to findings in the Framingham heart study, the authors noted, and may be due to underdiagnosis or differences in the underlying mechanism.
 

Compelling evidence of poor health outcomes associated with obesity

Study limitations include the fact that the findings may not be generalizable to other race/ethnicity groups, the lack of information on diet and exercise, and the fact that BMI was used as a surrogate of adiposity. As such, it does not account for an age-related decrease in heavier-than-fat muscle mass and differences between sexes and ethnic groups.

The finding of stable obesity over time accords with two smaller studies that included Canadian and American adults.

The current study did not uncover an obesity paradox, unlike some studies that included patients with preexisting CVD or a history of acute coronary events. Those studies reported better clinical outcomes among patients with overweight or obesity.

The current study included individuals who did not initially have CVD. Those with more severe obesity were younger than individuals with overweight at the time of the occurrence of incident CVD (age 64 vs. 66) and at the age of death (age 67 vs. age 75), which “provides compelling evidence of poor health outcomes associated with obesity,” the authors emphasized.

“Further research is ... needed to explore whether interventions to change BMI trajectories would have an impact on future CVD outcomes,” they concluded.

Dr. Iyen’s clinical academic lectureship is fully funded by the National Institute for Health Research (NIHR). The views expressed are those of the authors and are not necessarily those of the National Health Service, the NIHR, or the Department of Health and Social Care. Dr. Khan has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

In a U.K. cohort of more than 260,000 mostly middle-aged adults in primary care with overweight or obesity, body mass index remained relatively stable over a decade.

However, compared to overweight individuals, those with severe (class 3) obesity were more socioeconomically disadvantaged and had triple the risk for incident heart failure or all-cause or cardiovascular disease (CVD)–related mortality in a study published online April 15 in BMC Public Health.

“This is the first study to evaluate the long-term impact of overweight and obese individuals’ BMI trajectory on cardiovascular endpoints, heart failure, and mortality outcomes,” wrote Barbara Iyen, PhD, University of Nottingham, England, and colleagues.

The findings emphasize “the high cardiovascular toll exacted by continuing failure to tackle obesity, particularly among more socioeconomically deprived populations,” they warned.

“We have found that despite widespread efforts to prevent and manage obesity, the majority of adults who are overweight or obese in the general population continue to remain so in the long term,” Dr. Iyen said in a statement from her university.

“More effective policies and weight-management interventions are needed urgently to address this increasing burden and associated adverse health outcomes,” she stressed.

Invited to comment, Sadiya S. Khan, MD, Northwestern University, Chicago, said in an interview: “This research adds to the growing body of evidence [that] earlier and more intensive interventions for weight loss are necessary to promote cardiovascular health and reduce morbidity and mortality.

“Adjunctive pharmacotherapy and bariatric surgery are both options that should be considered in addition to intensive lifestyle interventions in overweight and obesity groups,” she added.

“I would always advocate for earlier prevention efforts focused on weight loss, because years lived with obesity are associated with future CVD, so every year counts,” Dr. Khan said.
 

Does BMI remain elevated, predict worse heart health?

Although obesity is a well-recognized risk factor for CVD, long-term changes in BMI and the impact of BMI on the risk for heart failure, CVD, and mortality have not been quantified among adults with overweight and obesity, Dr. Iyen and colleagues explained.

The researchers examined data from the UK Clinical Practice Research Datalink and secondary care and mortality records to determine BMI trajectories among adults with overweight or obesity and to quantify the risk for heart failure, CVD (defined as coronary heart disease, stroke, transient ischemic attack, or peripheral vascular disease, CVD-related mortality, and all-cause mortality.

They identified 264,230 adults with overweight or obesity who were seen in 790 primary care practices in the United Kingdom from 1999 to 2018 and who did not initially have heart failure or CVD and for whom baseline BMI measurements and at least one other BMI measurement 2, 5, 8, and 10 years later was available.

The researchers divided the cohort into four groups on the basis of initial BMI: overweight (36% of patients; mean BMI, 28.7 kg/m²); class 1 obesity (40%; mean BMI, 33.7 kg/m²); class 2 obesity (19%; mean BMI, 39.9 kg/m²), and class 3 obesity (5%; mean BMI, 49.1 kg/m²).

The mean age of the individuals was 50 years, and 64% were White. Race/ethnicity data were unavailable for 31%. Asian Indian, Asian, and Black patients comprised 5% of the cohort.
 

“Strong significant gradient in heart failure risk”

Compared to the overweight (reference) group, the severe-obesity group comprised a higher percentage of women (74% vs. 70%), and the prevalence of comorbidities and socioeconomic deprivation was higher.

BMI remained relatively stable in each BMI group. The mean BMI increase was 1.06 kg/m² during a median follow-up of 10.9 years.

There were 30,400 incident cases of CVD, 7,662 incident cases of heart failure, and 24,022 deaths, of which 2,827 (11.8%) were from CVD.

The risk for heart failure and CVD-related or all-cause mortality increased with increasing obesity severity.

Compared with overweight individuals, those with class 3 obesity were at significantly increased risk for heart failure (hazard ratio [HR], 3.26), all-cause mortality (HR, 2.72), and CVD-related mortality (HR, 3.31) after adjustment for age, sex, and comorbidities (hypertension, type 2 diabetes, atrial fibrillation, and chronic kidney disease).

The risk for stroke/TIA or coronary heart disease was similar among those with severe obesity and the other individuals. The risk for PVD was significantly lower (HR, 0.73).

The reduced risk for PVD in the most severely obese group is similar to findings in the Framingham heart study, the authors noted, and may be due to underdiagnosis or differences in the underlying mechanism.
 

Compelling evidence of poor health outcomes associated with obesity

Study limitations include the fact that the findings may not be generalizable to other race/ethnicity groups, the lack of information on diet and exercise, and the fact that BMI was used as a surrogate of adiposity. As such, it does not account for an age-related decrease in heavier-than-fat muscle mass and differences between sexes and ethnic groups.

The finding of stable obesity over time accords with two smaller studies that included Canadian and American adults.

The current study did not uncover an obesity paradox, unlike some studies that included patients with preexisting CVD or a history of acute coronary events. Those studies reported better clinical outcomes among patients with overweight or obesity.

The current study included individuals who did not initially have CVD. Those with more severe obesity were younger than individuals with overweight at the time of the occurrence of incident CVD (age 64 vs. 66) and at the age of death (age 67 vs. age 75), which “provides compelling evidence of poor health outcomes associated with obesity,” the authors emphasized.

“Further research is ... needed to explore whether interventions to change BMI trajectories would have an impact on future CVD outcomes,” they concluded.

Dr. Iyen’s clinical academic lectureship is fully funded by the National Institute for Health Research (NIHR). The views expressed are those of the authors and are not necessarily those of the National Health Service, the NIHR, or the Department of Health and Social Care. Dr. Khan has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

In a U.K. cohort of more than 260,000 mostly middle-aged adults in primary care with overweight or obesity, body mass index remained relatively stable over a decade.

However, compared to overweight individuals, those with severe (class 3) obesity were more socioeconomically disadvantaged and had triple the risk for incident heart failure or all-cause or cardiovascular disease (CVD)–related mortality in a study published online April 15 in BMC Public Health.

“This is the first study to evaluate the long-term impact of overweight and obese individuals’ BMI trajectory on cardiovascular endpoints, heart failure, and mortality outcomes,” wrote Barbara Iyen, PhD, University of Nottingham, England, and colleagues.

The findings emphasize “the high cardiovascular toll exacted by continuing failure to tackle obesity, particularly among more socioeconomically deprived populations,” they warned.

“We have found that despite widespread efforts to prevent and manage obesity, the majority of adults who are overweight or obese in the general population continue to remain so in the long term,” Dr. Iyen said in a statement from her university.

“More effective policies and weight-management interventions are needed urgently to address this increasing burden and associated adverse health outcomes,” she stressed.

Invited to comment, Sadiya S. Khan, MD, Northwestern University, Chicago, said in an interview: “This research adds to the growing body of evidence [that] earlier and more intensive interventions for weight loss are necessary to promote cardiovascular health and reduce morbidity and mortality.

“Adjunctive pharmacotherapy and bariatric surgery are both options that should be considered in addition to intensive lifestyle interventions in overweight and obesity groups,” she added.

“I would always advocate for earlier prevention efforts focused on weight loss, because years lived with obesity are associated with future CVD, so every year counts,” Dr. Khan said.
 

Does BMI remain elevated, predict worse heart health?

Although obesity is a well-recognized risk factor for CVD, long-term changes in BMI and the impact of BMI on the risk for heart failure, CVD, and mortality have not been quantified among adults with overweight and obesity, Dr. Iyen and colleagues explained.

The researchers examined data from the UK Clinical Practice Research Datalink and secondary care and mortality records to determine BMI trajectories among adults with overweight or obesity and to quantify the risk for heart failure, CVD (defined as coronary heart disease, stroke, transient ischemic attack, or peripheral vascular disease, CVD-related mortality, and all-cause mortality.

They identified 264,230 adults with overweight or obesity who were seen in 790 primary care practices in the United Kingdom from 1999 to 2018 and who did not initially have heart failure or CVD and for whom baseline BMI measurements and at least one other BMI measurement 2, 5, 8, and 10 years later was available.

The researchers divided the cohort into four groups on the basis of initial BMI: overweight (36% of patients; mean BMI, 28.7 kg/m²); class 1 obesity (40%; mean BMI, 33.7 kg/m²); class 2 obesity (19%; mean BMI, 39.9 kg/m²), and class 3 obesity (5%; mean BMI, 49.1 kg/m²).

The mean age of the individuals was 50 years, and 64% were White. Race/ethnicity data were unavailable for 31%. Asian Indian, Asian, and Black patients comprised 5% of the cohort.
 

“Strong significant gradient in heart failure risk”

Compared to the overweight (reference) group, the severe-obesity group comprised a higher percentage of women (74% vs. 70%), and the prevalence of comorbidities and socioeconomic deprivation was higher.

BMI remained relatively stable in each BMI group. The mean BMI increase was 1.06 kg/m² during a median follow-up of 10.9 years.

There were 30,400 incident cases of CVD, 7,662 incident cases of heart failure, and 24,022 deaths, of which 2,827 (11.8%) were from CVD.

The risk for heart failure and CVD-related or all-cause mortality increased with increasing obesity severity.

Compared with overweight individuals, those with class 3 obesity were at significantly increased risk for heart failure (hazard ratio [HR], 3.26), all-cause mortality (HR, 2.72), and CVD-related mortality (HR, 3.31) after adjustment for age, sex, and comorbidities (hypertension, type 2 diabetes, atrial fibrillation, and chronic kidney disease).

The risk for stroke/TIA or coronary heart disease was similar among those with severe obesity and the other individuals. The risk for PVD was significantly lower (HR, 0.73).

The reduced risk for PVD in the most severely obese group is similar to findings in the Framingham heart study, the authors noted, and may be due to underdiagnosis or differences in the underlying mechanism.
 

Compelling evidence of poor health outcomes associated with obesity

Study limitations include the fact that the findings may not be generalizable to other race/ethnicity groups, the lack of information on diet and exercise, and the fact that BMI was used as a surrogate of adiposity. As such, it does not account for an age-related decrease in heavier-than-fat muscle mass and differences between sexes and ethnic groups.

The finding of stable obesity over time accords with two smaller studies that included Canadian and American adults.

The current study did not uncover an obesity paradox, unlike some studies that included patients with preexisting CVD or a history of acute coronary events. Those studies reported better clinical outcomes among patients with overweight or obesity.

The current study included individuals who did not initially have CVD. Those with more severe obesity were younger than individuals with overweight at the time of the occurrence of incident CVD (age 64 vs. 66) and at the age of death (age 67 vs. age 75), which “provides compelling evidence of poor health outcomes associated with obesity,” the authors emphasized.

“Further research is ... needed to explore whether interventions to change BMI trajectories would have an impact on future CVD outcomes,” they concluded.

Dr. Iyen’s clinical academic lectureship is fully funded by the National Institute for Health Research (NIHR). The views expressed are those of the authors and are not necessarily those of the National Health Service, the NIHR, or the Department of Health and Social Care. Dr. Khan has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The Food and Drug Administration has approved a new estrogen for the first time in more than 50 years.

The novel combined oral contraceptive, marketed as Nextstellis, contains 3 mg drospirenone (DRSP) and 14.2 mg of estetrol (E4) in tablet form. Estetrol is an estrogen that is naturally produced during pregnancy, but will now be produced from a plant source; it has not previously been used in oral contraceptives.

Approval of the unique estetrol/drospirenone combination was based on data from a pair of phase 3 clinical trials including 3,725 women. Overall, Nextstellis was safe and effective while meeting its primary endpoint of pregnancy prevention, according to a company press release. Participants also reported favorable results on secondary endpoints including cycle control, bleeding profile, safety, and tolerability.

Although many women take short-acting contraceptives containing estrogen and progestin, concerns persist about side effects, said Mitchell Creinin, MD, of the University of California, in the press release. In addition to providing effective contraception, the drug showed minimal impact on specific markers of concern, including triglycerides, cholesterol, and glucose, as well as weight and endocrine markers, Dr. Creinin said.

Nextstellis was developed by the Belgian biotech company Mithra Pharmaceuticals, and the drug is licensed for distribution in Australia and the United States by Mayne Pharma, with an expected launch at the end of June 2021.

The Food and Drug Administration has approved a new estrogen for the first time in more than 50 years.

The novel combined oral contraceptive, marketed as Nextstellis, contains 3 mg drospirenone (DRSP) and 14.2 mg of estetrol (E4) in tablet form. Estetrol is an estrogen that is naturally produced during pregnancy, but will now be produced from a plant source; it has not previously been used in oral contraceptives.

Approval of the unique estetrol/drospirenone combination was based on data from a pair of phase 3 clinical trials including 3,725 women. Overall, Nextstellis was safe and effective while meeting its primary endpoint of pregnancy prevention, according to a company press release. Participants also reported favorable results on secondary endpoints including cycle control, bleeding profile, safety, and tolerability.

Although many women take short-acting contraceptives containing estrogen and progestin, concerns persist about side effects, said Mitchell Creinin, MD, of the University of California, in the press release. In addition to providing effective contraception, the drug showed minimal impact on specific markers of concern, including triglycerides, cholesterol, and glucose, as well as weight and endocrine markers, Dr. Creinin said.

Nextstellis was developed by the Belgian biotech company Mithra Pharmaceuticals, and the drug is licensed for distribution in Australia and the United States by Mayne Pharma, with an expected launch at the end of June 2021.

The Food and Drug Administration has approved a new estrogen for the first time in more than 50 years.

The novel combined oral contraceptive, marketed as Nextstellis, contains 3 mg drospirenone (DRSP) and 14.2 mg of estetrol (E4) in tablet form. Estetrol is an estrogen that is naturally produced during pregnancy, but will now be produced from a plant source; it has not previously been used in oral contraceptives.

Approval of the unique estetrol/drospirenone combination was based on data from a pair of phase 3 clinical trials including 3,725 women. Overall, Nextstellis was safe and effective while meeting its primary endpoint of pregnancy prevention, according to a company press release. Participants also reported favorable results on secondary endpoints including cycle control, bleeding profile, safety, and tolerability.

Although many women take short-acting contraceptives containing estrogen and progestin, concerns persist about side effects, said Mitchell Creinin, MD, of the University of California, in the press release. In addition to providing effective contraception, the drug showed minimal impact on specific markers of concern, including triglycerides, cholesterol, and glucose, as well as weight and endocrine markers, Dr. Creinin said.

Nextstellis was developed by the Belgian biotech company Mithra Pharmaceuticals, and the drug is licensed for distribution in Australia and the United States by Mayne Pharma, with an expected launch at the end of June 2021.

The scientific evidence for airborne transmission of the SARS-CoV-2 virus from different researchers all point in the same direction – that infectious aerosols are the principal means of person-to-person transmission, according to experts.

Not that it’s without controversy.

The science backing aerosol transmission “is clear-cut, but it is not accepted in many circles,” Trisha Greenhalgh, PhD, said in an interview.

“In particular, some in the evidence-based medicine movement and some infectious diseases clinicians are remarkably resistant to the evidence,” added Dr. Greenhalgh, professor of primary care health sciences at the University of Oxford (England).

“It’s very hard to see why, since the evidence all stacks up,” Dr. Greenhalgh said.

“The scientific evidence on spread from both near-field and far-field aerosols has been clear since early on in the pandemic, but there was resistance to acknowledging this in some circles, including the medical journals,” Joseph G. Allen, DSc, MPH, told this news organization when asked to comment.

“This is the week the dam broke. Three new commentaries came out … in top medical journals – BMJ, The Lancet, JAMA – all making the same point that aerosols are the dominant mode of transmission,” added Dr. Allen, associate professor of exposure assessment science at the Harvard T.H. Chan School of Public Health in Boston.

Dr. Greenhalgh and colleagues point to an increase in COVID-19 cases in the aftermath of so-called “super-spreader” events, spread of SARS-CoV-2 to people across different hotel rooms, and the relatively lower transmission detected after outdoor events.
 

Top 10 reasons

They outlined 10 scientific reasons backing airborne transmission in a commentary published online April 15 in The Lancet:

• The dominance of airborne transmission is supported by long-range transmission observed at super-spreader events.
• Long-range transmission has been reported among rooms at COVID-19 quarantine hotels, settings where infected people never spent time in the same room.
• Asymptomatic individuals account for an estimated 33%-59% of SARS-CoV-2 transmission, and could be spreading the virus through speaking, which produces thousands of aerosol particles and few large droplets.
• Transmission outdoors and in well-ventilated indoor spaces is lower than in enclosed spaces.
• Nosocomial infections are reported in health care settings where protective measures address large droplets but not aerosols.
• Viable SARS-CoV-2 has been detected in the air of hospital rooms and in the car of an infected person.
• Investigators found SARS-CoV-2 in hospital air filters and building ducts.
• It’s not just humans – infected animals can infect animals in other cages connected only through an air duct.
• No strong evidence refutes airborne transmission, and contact tracing supports secondary transmission in crowded, poorly ventilated indoor spaces.
• Only limited evidence supports other means of SARS-CoV-2 transmission, including through fomites or large droplets.

“We thought we’d summarize [the evidence] to clarify the arguments for and against. We looked hard for evidence against but found none,” Dr. Greenhalgh said.

“Although other routes can contribute, we believe that the airborne route is likely to be dominant,” the authors note.

The evidence on airborne transmission was there very early on but the Centers for Disease Control and Prevention, World Health Organization, and others repeated the message that the primary concern was droplets and fomites.
 

Response to a review

The top 10 list is also part rebuttal of a systematic review funded by the WHO and published last month that points to inconclusive evidence for airborne transmission. The researchers involved with that review state that “the lack of recoverable viral culture samples of SARS-CoV-2 prevents firm conclusions to be drawn about airborne transmission.”

However, Dr. Greenhalgh and colleagues note that “this conclusion, and the wide circulation of the review’s findings, is concerning because of the public health implications.”

The current authors also argue that enough evidence already exists on airborne transmission. “Policy should change. We don’t need more research on this topic; we need different policy,” Dr. Greenhalgh said. “We need ventilation front and center, air filtration when necessary, and better-fitting masks worn whenever indoors.”

Dr. Allen agreed that guidance hasn’t always kept pace with the science. “With all of the new evidence accumulated on airborne transmission since last winter, there is still widespread confusion in the public about modes of transmission,” he said. Dr. Allen also serves as commissioner of The Lancet COVID-19 Commission and is chair of the commission’s Task Force on Safe Work, Safe Schools, and Safe Travel.

“It was only just last week that CDC pulled back on guidance on ‘deep cleaning’ and in its place correctly said that the risk from touching surfaces is low,” he added. “The science has been clear on this for over a year, but official guidance was only recently updated.”

As a result, many companies and organizations continued to focus on “hygiene theatre,” Dr. Allen said, “wasting resources on overcleaning surfaces. Unbelievably, many schools still close for an entire day each week for deep cleaning and some still quarantine library books. The message that shared air is the problem, not shared surfaces, is a message that still needs to be reinforced.”

The National Institute for Health Research, Economic and Social Research Council, and Wellcome support Dr. Greenhalgh’s research. Dr. Greenhalgh and Dr. Allen had no relevant financial relationships to disclose.

A version of this article first appeared on Medscape.com.

The scientific evidence for airborne transmission of the SARS-CoV-2 virus from different researchers all point in the same direction – that infectious aerosols are the principal means of person-to-person transmission, according to experts.

Not that it’s without controversy.

The science backing aerosol transmission “is clear-cut, but it is not accepted in many circles,” Trisha Greenhalgh, PhD, said in an interview.

“In particular, some in the evidence-based medicine movement and some infectious diseases clinicians are remarkably resistant to the evidence,” added Dr. Greenhalgh, professor of primary care health sciences at the University of Oxford (England).

“It’s very hard to see why, since the evidence all stacks up,” Dr. Greenhalgh said.

“The scientific evidence on spread from both near-field and far-field aerosols has been clear since early on in the pandemic, but there was resistance to acknowledging this in some circles, including the medical journals,” Joseph G. Allen, DSc, MPH, told this news organization when asked to comment.

“This is the week the dam broke. Three new commentaries came out … in top medical journals – BMJ, The Lancet, JAMA – all making the same point that aerosols are the dominant mode of transmission,” added Dr. Allen, associate professor of exposure assessment science at the Harvard T.H. Chan School of Public Health in Boston.

Dr. Greenhalgh and colleagues point to an increase in COVID-19 cases in the aftermath of so-called “super-spreader” events, spread of SARS-CoV-2 to people across different hotel rooms, and the relatively lower transmission detected after outdoor events.
 

Top 10 reasons

They outlined 10 scientific reasons backing airborne transmission in a commentary published online April 15 in The Lancet:

• The dominance of airborne transmission is supported by long-range transmission observed at super-spreader events.
• Long-range transmission has been reported among rooms at COVID-19 quarantine hotels, settings where infected people never spent time in the same room.
• Asymptomatic individuals account for an estimated 33%-59% of SARS-CoV-2 transmission, and could be spreading the virus through speaking, which produces thousands of aerosol particles and few large droplets.
• Transmission outdoors and in well-ventilated indoor spaces is lower than in enclosed spaces.
• Nosocomial infections are reported in health care settings where protective measures address large droplets but not aerosols.
• Viable SARS-CoV-2 has been detected in the air of hospital rooms and in the car of an infected person.
• Investigators found SARS-CoV-2 in hospital air filters and building ducts.
• It’s not just humans – infected animals can infect animals in other cages connected only through an air duct.
• No strong evidence refutes airborne transmission, and contact tracing supports secondary transmission in crowded, poorly ventilated indoor spaces.
• Only limited evidence supports other means of SARS-CoV-2 transmission, including through fomites or large droplets.

“We thought we’d summarize [the evidence] to clarify the arguments for and against. We looked hard for evidence against but found none,” Dr. Greenhalgh said.

“Although other routes can contribute, we believe that the airborne route is likely to be dominant,” the authors note.

The evidence on airborne transmission was there very early on but the Centers for Disease Control and Prevention, World Health Organization, and others repeated the message that the primary concern was droplets and fomites.
 

Response to a review

The top 10 list is also part rebuttal of a systematic review funded by the WHO and published last month that points to inconclusive evidence for airborne transmission. The researchers involved with that review state that “the lack of recoverable viral culture samples of SARS-CoV-2 prevents firm conclusions to be drawn about airborne transmission.”

However, Dr. Greenhalgh and colleagues note that “this conclusion, and the wide circulation of the review’s findings, is concerning because of the public health implications.”

The current authors also argue that enough evidence already exists on airborne transmission. “Policy should change. We don’t need more research on this topic; we need different policy,” Dr. Greenhalgh said. “We need ventilation front and center, air filtration when necessary, and better-fitting masks worn whenever indoors.”

Dr. Allen agreed that guidance hasn’t always kept pace with the science. “With all of the new evidence accumulated on airborne transmission since last winter, there is still widespread confusion in the public about modes of transmission,” he said. Dr. Allen also serves as commissioner of The Lancet COVID-19 Commission and is chair of the commission’s Task Force on Safe Work, Safe Schools, and Safe Travel.

“It was only just last week that CDC pulled back on guidance on ‘deep cleaning’ and in its place correctly said that the risk from touching surfaces is low,” he added. “The science has been clear on this for over a year, but official guidance was only recently updated.”

As a result, many companies and organizations continued to focus on “hygiene theatre,” Dr. Allen said, “wasting resources on overcleaning surfaces. Unbelievably, many schools still close for an entire day each week for deep cleaning and some still quarantine library books. The message that shared air is the problem, not shared surfaces, is a message that still needs to be reinforced.”

The National Institute for Health Research, Economic and Social Research Council, and Wellcome support Dr. Greenhalgh’s research. Dr. Greenhalgh and Dr. Allen had no relevant financial relationships to disclose.

A version of this article first appeared on Medscape.com.

The scientific evidence for airborne transmission of the SARS-CoV-2 virus from different researchers all point in the same direction – that infectious aerosols are the principal means of person-to-person transmission, according to experts.

Not that it’s without controversy.

The science backing aerosol transmission “is clear-cut, but it is not accepted in many circles,” Trisha Greenhalgh, PhD, said in an interview.

“In particular, some in the evidence-based medicine movement and some infectious diseases clinicians are remarkably resistant to the evidence,” added Dr. Greenhalgh, professor of primary care health sciences at the University of Oxford (England).

“It’s very hard to see why, since the evidence all stacks up,” Dr. Greenhalgh said.

“The scientific evidence on spread from both near-field and far-field aerosols has been clear since early on in the pandemic, but there was resistance to acknowledging this in some circles, including the medical journals,” Joseph G. Allen, DSc, MPH, told this news organization when asked to comment.

“This is the week the dam broke. Three new commentaries came out … in top medical journals – BMJ, The Lancet, JAMA – all making the same point that aerosols are the dominant mode of transmission,” added Dr. Allen, associate professor of exposure assessment science at the Harvard T.H. Chan School of Public Health in Boston.

Dr. Greenhalgh and colleagues point to an increase in COVID-19 cases in the aftermath of so-called “super-spreader” events, spread of SARS-CoV-2 to people across different hotel rooms, and the relatively lower transmission detected after outdoor events.
 

Top 10 reasons

They outlined 10 scientific reasons backing airborne transmission in a commentary published online April 15 in The Lancet:

• The dominance of airborne transmission is supported by long-range transmission observed at super-spreader events.
• Long-range transmission has been reported among rooms at COVID-19 quarantine hotels, settings where infected people never spent time in the same room.
• Asymptomatic individuals account for an estimated 33%-59% of SARS-CoV-2 transmission, and could be spreading the virus through speaking, which produces thousands of aerosol particles and few large droplets.
• Transmission outdoors and in well-ventilated indoor spaces is lower than in enclosed spaces.
• Nosocomial infections are reported in health care settings where protective measures address large droplets but not aerosols.
• Viable SARS-CoV-2 has been detected in the air of hospital rooms and in the car of an infected person.
• Investigators found SARS-CoV-2 in hospital air filters and building ducts.
• It’s not just humans – infected animals can infect animals in other cages connected only through an air duct.
• No strong evidence refutes airborne transmission, and contact tracing supports secondary transmission in crowded, poorly ventilated indoor spaces.
• Only limited evidence supports other means of SARS-CoV-2 transmission, including through fomites or large droplets.

“We thought we’d summarize [the evidence] to clarify the arguments for and against. We looked hard for evidence against but found none,” Dr. Greenhalgh said.

“Although other routes can contribute, we believe that the airborne route is likely to be dominant,” the authors note.

The evidence on airborne transmission was there very early on but the Centers for Disease Control and Prevention, World Health Organization, and others repeated the message that the primary concern was droplets and fomites.
 

Response to a review

The top 10 list is also part rebuttal of a systematic review funded by the WHO and published last month that points to inconclusive evidence for airborne transmission. The researchers involved with that review state that “the lack of recoverable viral culture samples of SARS-CoV-2 prevents firm conclusions to be drawn about airborne transmission.”

However, Dr. Greenhalgh and colleagues note that “this conclusion, and the wide circulation of the review’s findings, is concerning because of the public health implications.”

The current authors also argue that enough evidence already exists on airborne transmission. “Policy should change. We don’t need more research on this topic; we need different policy,” Dr. Greenhalgh said. “We need ventilation front and center, air filtration when necessary, and better-fitting masks worn whenever indoors.”

Dr. Allen agreed that guidance hasn’t always kept pace with the science. “With all of the new evidence accumulated on airborne transmission since last winter, there is still widespread confusion in the public about modes of transmission,” he said. Dr. Allen also serves as commissioner of The Lancet COVID-19 Commission and is chair of the commission’s Task Force on Safe Work, Safe Schools, and Safe Travel.

“It was only just last week that CDC pulled back on guidance on ‘deep cleaning’ and in its place correctly said that the risk from touching surfaces is low,” he added. “The science has been clear on this for over a year, but official guidance was only recently updated.”

As a result, many companies and organizations continued to focus on “hygiene theatre,” Dr. Allen said, “wasting resources on overcleaning surfaces. Unbelievably, many schools still close for an entire day each week for deep cleaning and some still quarantine library books. The message that shared air is the problem, not shared surfaces, is a message that still needs to be reinforced.”

The National Institute for Health Research, Economic and Social Research Council, and Wellcome support Dr. Greenhalgh’s research. Dr. Greenhalgh and Dr. Allen had no relevant financial relationships to disclose.

A version of this article first appeared on Medscape.com.

Physician compensation plummeted in the opening weeks of the COVID-19 pandemic in March and April 2020, but earnings had rebounded for many physicians by the end of the year, according to the Medscape Physician Compensation Report 2021: The Recovery Begins.

Almost 18,000 physicians in more than 29 specialties told Medscape about their income, hours worked, greatest challenges, and the unexpected impact of COVID-19 on their compensation.
 

How many physicians avoided massive losses

When the pandemic started around March 2020, “a great many physicians saw reductions in volume at first,” says Robert Pearl, MD, former CEO of the Permanente Medical Group and a professor at Stanford (Calif.) University.

Medscape’s survey report shows that a staggering 44% saw a 1%-25% reduction in patient volume, and 9% saw a 26%-50% decline. “That is indeed breathtaking,” Dr. Pearl says.

Several key factors saved many practices from hemorrhaging money, says Michael Belkin, JD, divisional vice president at Merritt Hawkins and Associates in Dallas. “Many physicians used the federal Paycheck Protection Program [PPP] to help keep themselves afloat,” he says. “A large percentage reduced their staff, which reduced their expenses, and many got some of their volume back by transitioning to telemedicine.”

In a 2020 survey for the Physicians Foundation, conducted by Merritt Hawkins, 48% of physicians said their practice had received PPP support, and most of those said the support was enough to allow them to stay open without reducing staff. Only 6% of practices that received PPP support did not stay open.
 

Telemedicine helped many practices

Early in the pandemic, Medicare reimbursements for telemedicine were equal with those for face-to-face visits. “Since telemedicine takes a third less time than an inpatient visit, doctors could see more patients,” Dr. Pearl says.

The switch was almost instantaneous in some practices. Within 3 days, a 200-provider multispecialty practice in Wilmington, N.C., went from not using telehealth to its being used by all physicians, the Medical Group Management Association reported. By late April, the practice was already back up to about 70% of normal overall production.

However, telemedicine could not help every specialty equally. “Generally, allergists can’t do their allergy testing virtually, and patients with mild problems probably put off visits,” Dr. Pearl says. Allergists experienced a large percentage decline in compensation, according to Medscape’s survey. For some, income fell from $301,000 the prior year to $274,000 this year.
 

Primary care struggled

Primary care physicians posted lower compensation than they did the prior year, but most rebounded to some degree. A study released in June 2020 projected that, even with telemedicine, primary care physicians would lose an average of $67,774 for the year.

However, Medscape’s survey found that internists’ average compensation declined from $251,000 in the prior year to $248,000, and average family physicians’ compensation actually rose from $234,000.

Pediatricians had a harder slog. Their average compensation sank from $232,000 to $221,000, according to the report. Even with telemedicine, parents of young children were not contacting the doctor. In May 2020, visits by children aged 3-5 years were down by 56%.
 

Many proceduralists recovered

Procedure-oriented specialties were particularly hard-hit at first, because many hospitals and some states banned all elective surgeries at the beginning of the pandemic.

“In March and April, ophthalmology practices were virtually at a standstill,” says John B. Pinto, an ophthalmology practice management consultant in San Diego. “But by the fourth quarter, operations were back to normal. Practices were fully open, and patients were coming back in.”

Medscape’s survey shows that, by year’s end, compensation was about the same as the year before for orthopedic surgeons ($511,000 in both the 2020 and 2021 reports); cardiologists actually did better ($438,000 in our 2020 report and $459,000 in 2021); and ophthalmologists’ compensation was about the same ($378,000 in our prior report and $379,000 in 2021).

Some other proceduralists, however, did not do as well. Otolaryngologists’ compensation fell to $417,000, the second-biggest percentage drop. “This may be because otolaryngologists’ chief procedures are tonsillectomies, sinus surgery, and nasal surgery, which can be put off,” Dr. Pearl says.

Anesthesiologists, who depend on surgical volume, also did not earn as much in 2020. Their compensation declined from $398,000 in our 2020 report to $378,000 in Medscape’s 2021 report.

“Not only has 70% of our revenue disappeared, but our physicians are still working every day,” an independent anesthesiology practice in Alabama told the MGMA early in the pandemic.
 

Plastic surgeons now the top earners

The biggest increase in compensation by far was made by plastic surgeons, whose income rose 9.8% over the year before, to $526,000. This put them at the top of the list

Dr. Pearl adds that plastic surgeons can perform their procedures in their offices, rather than in a hospital, where elective surgeries were often canceled.

Mr. Belkin says specialties other than plastic surgery had been offering more boutique cosmetic care even before the pandemic. In 2020, nonsurgical cosmetic procedures such as neurotoxin therapy, dermal filler procedures, chemical peels, and hair removal earned $3.1 billion in revenue, according to a survey by the Aesthetic Society.
 

Other specialties that earned more even during COVID

In Medscape’s survey, several specialties actually earned more during the pandemic than in 2019. Some specialties, such as critical care and public health, were integral in managing COVID patients and the pandemic.

However, some specialties involved in COVID care did not see an increase. Compensation for infectious disease specialists (at $245,000) and emergency medicine specialists (at $354,000) remained basically unchanged from the prior year, and for pulmonologists, it was slightly down.

Emergency departments reported decreases in volume of 40% or more early in the pandemic, according to the American College of Emergency Physicians. It was reported that patients were avoiding EDs for fear of contracting COVID, and car accidents were down because people ventured out less.

In this year’s report, psychiatrists saw a modest rise in compensation, to $275,000. “There has been an increase in mental health visits in the pandemic,” Dr. Pearl says. In 2020, about 4 in 10 adults in the United States reported symptoms of anxiety or depressive disorder, up from 1 in 10 adults the prior year. In addition, psychiatrists were third on the list of Merritt Hawkins’ most requested recruiting engagements.

Oncologists saw a rise in compensation, from $377,000 to $403,000. “Volume likely did not fall because cancer patients would go through with their chemotherapy in spite of the pandemic,” Dr. Pearl says. “The increase in income might have to do with the usual inflation in the cost of chemotherapy drugs.” Dr. Pinto saw the same trend for retinal surgeons, whose care also cannot be delayed.

Medscape’s survey also reports increases in compensation for rheumatologists, endocrinologists, and neurologists, but it reports small declines among dermatologists, radiologists, and gastroenterologists.
 

Gender-based pay gap remains in place

The gender-based pay gap in this year’s report is similar to that seen in Medscape’s report for the prior year. Men earned 27% more than women in 2021, compared with 25% more the year before. Some physicians commented that more women physicians maintained flexible or shorter work schedules to help with children who could not go into school.

“Having to be a full-time physician, full-time mom, and full-time teacher during our surge was unbelievable,” a primary care pediatrician in group practice and mother of two reported in November. “I felt pulled in all directions and didn’t do anything well.”

In addition, “men dominate some specialties that seem to have seen a smaller drop in volume in the pandemic, such as emergency medicine, infectious disease, pulmonology, and oncology,” says Halee Fischer-Wright, MD, CEO of MGMA.
 

Employed physicians shared their employers’ pain

Employed physicians, who typically work at hospitals, shared the financial pains of their institutions, particularly in the early stages of the pandemic. In April, hospital admissions were 34.1% below prepandemic levels, according to a study published in Health Affairs. That figure had risen by June, but it was still 8.3% below prepandemic volume.

By the end of the year, many hospitals and hospital systems were in the black, thanks in large part to generous federal subsidies, but actual operations still lost money for the year. Altogether, 42% of them posted an operational loss in 2020, up from the 23% in 2019, according to a survey by Moody’s Investors Service.

Medscape’s report shows that many employed physicians lost pay in 2020, and for many, pay had not returned to pre-COVID levels. Only 28% of primary care physicians and 32% of specialists who lost pay have seen it restored, according to the report. In addition, 15% of surveyed physicians did not receive an annual raise.

Many employed doctors are paid on the basis of relative value units (RVUs), which is a measure of the value of their work. In many cases, there was not enough work to reach RVU thresholds. Would hospitals and other employers lower RVU targets to meet the problem? “I haven’t seen our clients make concessions to providers along those lines,” Mr. Belkin says.
 

Physicians had to work longer hours

The Medscape report also found that in 2020, physicians saw fewer patients because each visit took longer.

“With the threat of COVID, in-person visits take more time than before,” Mr. Belkin says. “Physicians and staff have to prepare the exam room after each visit, and doctors must spend more time answering patients’ questions about COVID.”

“The new protocols to keep everyone safe add time between patients, and physicians have to answer patients’ questions about the pandemic and vaccines,” Dr. Fischer-Wright says. “You might see a 20% increase in time spent just on these non–revenue-generating COVID activities.”
 

Physicians still like their specialty

Although 2020 was a challenging year for physicians, the percentage of those who were satisfied with their specialty choice generally did not slip from the year before. It actually rose for several specialties – most notably, rheumatology, pulmonology, physical medicine and rehabilitation, and nephrology.

One specialty saw a decline in satisfaction with their specialty choice, and that was public health and preventive medicine, which plummeted 16 percentage points to 67% – putting it at the bottom of the list.

Even before the pandemic, many public health departments were chronically underfunded. This problem was possibly exacerbated by the pressures to keep up with COVID reporting and testing responsibilities.
 

Conclusion

Although 2020 was a wild ride for many physicians, many came out of it with only minor reductions in overall compensation, and some saw increases. Still, some specialties and many individuals experienced terrible financial stress and had to make changes in their lives and their spending in order to stay afloat.

“The biggest inhibitor to getting back to normal had to do with doctors who did not want to return because they did not want to risk getting COVID,” Dr. Pinto reports. But he notes that by February 2021 most doctors were completely vaccinated and could feel safe again.

A version of this article first appeared on Medscape.com.

Physician compensation plummeted in the opening weeks of the COVID-19 pandemic in March and April 2020, but earnings had rebounded for many physicians by the end of the year, according to the Medscape Physician Compensation Report 2021: The Recovery Begins.

Almost 18,000 physicians in more than 29 specialties told Medscape about their income, hours worked, greatest challenges, and the unexpected impact of COVID-19 on their compensation.
 

How many physicians avoided massive losses

When the pandemic started around March 2020, “a great many physicians saw reductions in volume at first,” says Robert Pearl, MD, former CEO of the Permanente Medical Group and a professor at Stanford (Calif.) University.

Medscape’s survey report shows that a staggering 44% saw a 1%-25% reduction in patient volume, and 9% saw a 26%-50% decline. “That is indeed breathtaking,” Dr. Pearl says.

Several key factors saved many practices from hemorrhaging money, says Michael Belkin, JD, divisional vice president at Merritt Hawkins and Associates in Dallas. “Many physicians used the federal Paycheck Protection Program [PPP] to help keep themselves afloat,” he says. “A large percentage reduced their staff, which reduced their expenses, and many got some of their volume back by transitioning to telemedicine.”

In a 2020 survey for the Physicians Foundation, conducted by Merritt Hawkins, 48% of physicians said their practice had received PPP support, and most of those said the support was enough to allow them to stay open without reducing staff. Only 6% of practices that received PPP support did not stay open.
 

Telemedicine helped many practices

Early in the pandemic, Medicare reimbursements for telemedicine were equal with those for face-to-face visits. “Since telemedicine takes a third less time than an inpatient visit, doctors could see more patients,” Dr. Pearl says.

The switch was almost instantaneous in some practices. Within 3 days, a 200-provider multispecialty practice in Wilmington, N.C., went from not using telehealth to its being used by all physicians, the Medical Group Management Association reported. By late April, the practice was already back up to about 70% of normal overall production.

However, telemedicine could not help every specialty equally. “Generally, allergists can’t do their allergy testing virtually, and patients with mild problems probably put off visits,” Dr. Pearl says. Allergists experienced a large percentage decline in compensation, according to Medscape’s survey. For some, income fell from $301,000 the prior year to $274,000 this year.
 

Primary care struggled

Primary care physicians posted lower compensation than they did the prior year, but most rebounded to some degree. A study released in June 2020 projected that, even with telemedicine, primary care physicians would lose an average of $67,774 for the year.

However, Medscape’s survey found that internists’ average compensation declined from $251,000 in the prior year to $248,000, and average family physicians’ compensation actually rose from $234,000.

Pediatricians had a harder slog. Their average compensation sank from $232,000 to $221,000, according to the report. Even with telemedicine, parents of young children were not contacting the doctor. In May 2020, visits by children aged 3-5 years were down by 56%.
 

Many proceduralists recovered

Procedure-oriented specialties were particularly hard-hit at first, because many hospitals and some states banned all elective surgeries at the beginning of the pandemic.

“In March and April, ophthalmology practices were virtually at a standstill,” says John B. Pinto, an ophthalmology practice management consultant in San Diego. “But by the fourth quarter, operations were back to normal. Practices were fully open, and patients were coming back in.”

Medscape’s survey shows that, by year’s end, compensation was about the same as the year before for orthopedic surgeons ($511,000 in both the 2020 and 2021 reports); cardiologists actually did better ($438,000 in our 2020 report and $459,000 in 2021); and ophthalmologists’ compensation was about the same ($378,000 in our prior report and $379,000 in 2021).

Some other proceduralists, however, did not do as well. Otolaryngologists’ compensation fell to $417,000, the second-biggest percentage drop. “This may be because otolaryngologists’ chief procedures are tonsillectomies, sinus surgery, and nasal surgery, which can be put off,” Dr. Pearl says.

Anesthesiologists, who depend on surgical volume, also did not earn as much in 2020. Their compensation declined from $398,000 in our 2020 report to $378,000 in Medscape’s 2021 report.

“Not only has 70% of our revenue disappeared, but our physicians are still working every day,” an independent anesthesiology practice in Alabama told the MGMA early in the pandemic.
 

Plastic surgeons now the top earners

The biggest increase in compensation by far was made by plastic surgeons, whose income rose 9.8% over the year before, to $526,000. This put them at the top of the list

Dr. Pearl adds that plastic surgeons can perform their procedures in their offices, rather than in a hospital, where elective surgeries were often canceled.

Mr. Belkin says specialties other than plastic surgery had been offering more boutique cosmetic care even before the pandemic. In 2020, nonsurgical cosmetic procedures such as neurotoxin therapy, dermal filler procedures, chemical peels, and hair removal earned $3.1 billion in revenue, according to a survey by the Aesthetic Society.
 

Other specialties that earned more even during COVID

In Medscape’s survey, several specialties actually earned more during the pandemic than in 2019. Some specialties, such as critical care and public health, were integral in managing COVID patients and the pandemic.

However, some specialties involved in COVID care did not see an increase. Compensation for infectious disease specialists (at $245,000) and emergency medicine specialists (at $354,000) remained basically unchanged from the prior year, and for pulmonologists, it was slightly down.

Emergency departments reported decreases in volume of 40% or more early in the pandemic, according to the American College of Emergency Physicians. It was reported that patients were avoiding EDs for fear of contracting COVID, and car accidents were down because people ventured out less.

In this year’s report, psychiatrists saw a modest rise in compensation, to $275,000. “There has been an increase in mental health visits in the pandemic,” Dr. Pearl says. In 2020, about 4 in 10 adults in the United States reported symptoms of anxiety or depressive disorder, up from 1 in 10 adults the prior year. In addition, psychiatrists were third on the list of Merritt Hawkins’ most requested recruiting engagements.

Oncologists saw a rise in compensation, from $377,000 to $403,000. “Volume likely did not fall because cancer patients would go through with their chemotherapy in spite of the pandemic,” Dr. Pearl says. “The increase in income might have to do with the usual inflation in the cost of chemotherapy drugs.” Dr. Pinto saw the same trend for retinal surgeons, whose care also cannot be delayed.

Medscape’s survey also reports increases in compensation for rheumatologists, endocrinologists, and neurologists, but it reports small declines among dermatologists, radiologists, and gastroenterologists.
 

Gender-based pay gap remains in place

The gender-based pay gap in this year’s report is similar to that seen in Medscape’s report for the prior year. Men earned 27% more than women in 2021, compared with 25% more the year before. Some physicians commented that more women physicians maintained flexible or shorter work schedules to help with children who could not go into school.

“Having to be a full-time physician, full-time mom, and full-time teacher during our surge was unbelievable,” a primary care pediatrician in group practice and mother of two reported in November. “I felt pulled in all directions and didn’t do anything well.”

In addition, “men dominate some specialties that seem to have seen a smaller drop in volume in the pandemic, such as emergency medicine, infectious disease, pulmonology, and oncology,” says Halee Fischer-Wright, MD, CEO of MGMA.
 

Employed physicians shared their employers’ pain

Employed physicians, who typically work at hospitals, shared the financial pains of their institutions, particularly in the early stages of the pandemic. In April, hospital admissions were 34.1% below prepandemic levels, according to a study published in Health Affairs. That figure had risen by June, but it was still 8.3% below prepandemic volume.

By the end of the year, many hospitals and hospital systems were in the black, thanks in large part to generous federal subsidies, but actual operations still lost money for the year. Altogether, 42% of them posted an operational loss in 2020, up from the 23% in 2019, according to a survey by Moody’s Investors Service.

Medscape’s report shows that many employed physicians lost pay in 2020, and for many, pay had not returned to pre-COVID levels. Only 28% of primary care physicians and 32% of specialists who lost pay have seen it restored, according to the report. In addition, 15% of surveyed physicians did not receive an annual raise.

Many employed doctors are paid on the basis of relative value units (RVUs), which is a measure of the value of their work. In many cases, there was not enough work to reach RVU thresholds. Would hospitals and other employers lower RVU targets to meet the problem? “I haven’t seen our clients make concessions to providers along those lines,” Mr. Belkin says.
 

Physicians had to work longer hours

The Medscape report also found that in 2020, physicians saw fewer patients because each visit took longer.

“With the threat of COVID, in-person visits take more time than before,” Mr. Belkin says. “Physicians and staff have to prepare the exam room after each visit, and doctors must spend more time answering patients’ questions about COVID.”

“The new protocols to keep everyone safe add time between patients, and physicians have to answer patients’ questions about the pandemic and vaccines,” Dr. Fischer-Wright says. “You might see a 20% increase in time spent just on these non–revenue-generating COVID activities.”
 

Physicians still like their specialty

Although 2020 was a challenging year for physicians, the percentage of those who were satisfied with their specialty choice generally did not slip from the year before. It actually rose for several specialties – most notably, rheumatology, pulmonology, physical medicine and rehabilitation, and nephrology.

One specialty saw a decline in satisfaction with their specialty choice, and that was public health and preventive medicine, which plummeted 16 percentage points to 67% – putting it at the bottom of the list.

Even before the pandemic, many public health departments were chronically underfunded. This problem was possibly exacerbated by the pressures to keep up with COVID reporting and testing responsibilities.
 

Conclusion

Although 2020 was a wild ride for many physicians, many came out of it with only minor reductions in overall compensation, and some saw increases. Still, some specialties and many individuals experienced terrible financial stress and had to make changes in their lives and their spending in order to stay afloat.

“The biggest inhibitor to getting back to normal had to do with doctors who did not want to return because they did not want to risk getting COVID,” Dr. Pinto reports. But he notes that by February 2021 most doctors were completely vaccinated and could feel safe again.

A version of this article first appeared on Medscape.com.

Physician compensation plummeted in the opening weeks of the COVID-19 pandemic in March and April 2020, but earnings had rebounded for many physicians by the end of the year, according to the Medscape Physician Compensation Report 2021: The Recovery Begins.

Almost 18,000 physicians in more than 29 specialties told Medscape about their income, hours worked, greatest challenges, and the unexpected impact of COVID-19 on their compensation.
 

How many physicians avoided massive losses

When the pandemic started around March 2020, “a great many physicians saw reductions in volume at first,” says Robert Pearl, MD, former CEO of the Permanente Medical Group and a professor at Stanford (Calif.) University.

Medscape’s survey report shows that a staggering 44% saw a 1%-25% reduction in patient volume, and 9% saw a 26%-50% decline. “That is indeed breathtaking,” Dr. Pearl says.

Several key factors saved many practices from hemorrhaging money, says Michael Belkin, JD, divisional vice president at Merritt Hawkins and Associates in Dallas. “Many physicians used the federal Paycheck Protection Program [PPP] to help keep themselves afloat,” he says. “A large percentage reduced their staff, which reduced their expenses, and many got some of their volume back by transitioning to telemedicine.”

In a 2020 survey for the Physicians Foundation, conducted by Merritt Hawkins, 48% of physicians said their practice had received PPP support, and most of those said the support was enough to allow them to stay open without reducing staff. Only 6% of practices that received PPP support did not stay open.
 

Telemedicine helped many practices

Early in the pandemic, Medicare reimbursements for telemedicine were equal with those for face-to-face visits. “Since telemedicine takes a third less time than an inpatient visit, doctors could see more patients,” Dr. Pearl says.

The switch was almost instantaneous in some practices. Within 3 days, a 200-provider multispecialty practice in Wilmington, N.C., went from not using telehealth to its being used by all physicians, the Medical Group Management Association reported. By late April, the practice was already back up to about 70% of normal overall production.

However, telemedicine could not help every specialty equally. “Generally, allergists can’t do their allergy testing virtually, and patients with mild problems probably put off visits,” Dr. Pearl says. Allergists experienced a large percentage decline in compensation, according to Medscape’s survey. For some, income fell from $301,000 the prior year to $274,000 this year.
 

Primary care struggled

Primary care physicians posted lower compensation than they did the prior year, but most rebounded to some degree. A study released in June 2020 projected that, even with telemedicine, primary care physicians would lose an average of $67,774 for the year.

However, Medscape’s survey found that internists’ average compensation declined from $251,000 in the prior year to $248,000, and average family physicians’ compensation actually rose from $234,000.

Pediatricians had a harder slog. Their average compensation sank from $232,000 to $221,000, according to the report. Even with telemedicine, parents of young children were not contacting the doctor. In May 2020, visits by children aged 3-5 years were down by 56%.
 

Many proceduralists recovered

Procedure-oriented specialties were particularly hard-hit at first, because many hospitals and some states banned all elective surgeries at the beginning of the pandemic.

“In March and April, ophthalmology practices were virtually at a standstill,” says John B. Pinto, an ophthalmology practice management consultant in San Diego. “But by the fourth quarter, operations were back to normal. Practices were fully open, and patients were coming back in.”

Medscape’s survey shows that, by year’s end, compensation was about the same as the year before for orthopedic surgeons ($511,000 in both the 2020 and 2021 reports); cardiologists actually did better ($438,000 in our 2020 report and $459,000 in 2021); and ophthalmologists’ compensation was about the same ($378,000 in our prior report and $379,000 in 2021).

Some other proceduralists, however, did not do as well. Otolaryngologists’ compensation fell to $417,000, the second-biggest percentage drop. “This may be because otolaryngologists’ chief procedures are tonsillectomies, sinus surgery, and nasal surgery, which can be put off,” Dr. Pearl says.

Anesthesiologists, who depend on surgical volume, also did not earn as much in 2020. Their compensation declined from $398,000 in our 2020 report to $378,000 in Medscape’s 2021 report.

“Not only has 70% of our revenue disappeared, but our physicians are still working every day,” an independent anesthesiology practice in Alabama told the MGMA early in the pandemic.
 

Plastic surgeons now the top earners

The biggest increase in compensation by far was made by plastic surgeons, whose income rose 9.8% over the year before, to $526,000. This put them at the top of the list

Dr. Pearl adds that plastic surgeons can perform their procedures in their offices, rather than in a hospital, where elective surgeries were often canceled.

Mr. Belkin says specialties other than plastic surgery had been offering more boutique cosmetic care even before the pandemic. In 2020, nonsurgical cosmetic procedures such as neurotoxin therapy, dermal filler procedures, chemical peels, and hair removal earned $3.1 billion in revenue, according to a survey by the Aesthetic Society.
 

Other specialties that earned more even during COVID

In Medscape’s survey, several specialties actually earned more during the pandemic than in 2019. Some specialties, such as critical care and public health, were integral in managing COVID patients and the pandemic.

However, some specialties involved in COVID care did not see an increase. Compensation for infectious disease specialists (at $245,000) and emergency medicine specialists (at $354,000) remained basically unchanged from the prior year, and for pulmonologists, it was slightly down.

Emergency departments reported decreases in volume of 40% or more early in the pandemic, according to the American College of Emergency Physicians. It was reported that patients were avoiding EDs for fear of contracting COVID, and car accidents were down because people ventured out less.

In this year’s report, psychiatrists saw a modest rise in compensation, to $275,000. “There has been an increase in mental health visits in the pandemic,” Dr. Pearl says. In 2020, about 4 in 10 adults in the United States reported symptoms of anxiety or depressive disorder, up from 1 in 10 adults the prior year. In addition, psychiatrists were third on the list of Merritt Hawkins’ most requested recruiting engagements.

Oncologists saw a rise in compensation, from $377,000 to $403,000. “Volume likely did not fall because cancer patients would go through with their chemotherapy in spite of the pandemic,” Dr. Pearl says. “The increase in income might have to do with the usual inflation in the cost of chemotherapy drugs.” Dr. Pinto saw the same trend for retinal surgeons, whose care also cannot be delayed.

Medscape’s survey also reports increases in compensation for rheumatologists, endocrinologists, and neurologists, but it reports small declines among dermatologists, radiologists, and gastroenterologists.
 

Gender-based pay gap remains in place

The gender-based pay gap in this year’s report is similar to that seen in Medscape’s report for the prior year. Men earned 27% more than women in 2021, compared with 25% more the year before. Some physicians commented that more women physicians maintained flexible or shorter work schedules to help with children who could not go into school.

“Having to be a full-time physician, full-time mom, and full-time teacher during our surge was unbelievable,” a primary care pediatrician in group practice and mother of two reported in November. “I felt pulled in all directions and didn’t do anything well.”

In addition, “men dominate some specialties that seem to have seen a smaller drop in volume in the pandemic, such as emergency medicine, infectious disease, pulmonology, and oncology,” says Halee Fischer-Wright, MD, CEO of MGMA.
 

Employed physicians shared their employers’ pain

Employed physicians, who typically work at hospitals, shared the financial pains of their institutions, particularly in the early stages of the pandemic. In April, hospital admissions were 34.1% below prepandemic levels, according to a study published in Health Affairs. That figure had risen by June, but it was still 8.3% below prepandemic volume.

By the end of the year, many hospitals and hospital systems were in the black, thanks in large part to generous federal subsidies, but actual operations still lost money for the year. Altogether, 42% of them posted an operational loss in 2020, up from the 23% in 2019, according to a survey by Moody’s Investors Service.

Medscape’s report shows that many employed physicians lost pay in 2020, and for many, pay had not returned to pre-COVID levels. Only 28% of primary care physicians and 32% of specialists who lost pay have seen it restored, according to the report. In addition, 15% of surveyed physicians did not receive an annual raise.

Many employed doctors are paid on the basis of relative value units (RVUs), which is a measure of the value of their work. In many cases, there was not enough work to reach RVU thresholds. Would hospitals and other employers lower RVU targets to meet the problem? “I haven’t seen our clients make concessions to providers along those lines,” Mr. Belkin says.
 

Physicians had to work longer hours

The Medscape report also found that in 2020, physicians saw fewer patients because each visit took longer.

“With the threat of COVID, in-person visits take more time than before,” Mr. Belkin says. “Physicians and staff have to prepare the exam room after each visit, and doctors must spend more time answering patients’ questions about COVID.”

“The new protocols to keep everyone safe add time between patients, and physicians have to answer patients’ questions about the pandemic and vaccines,” Dr. Fischer-Wright says. “You might see a 20% increase in time spent just on these non–revenue-generating COVID activities.”
 

Physicians still like their specialty

Although 2020 was a challenging year for physicians, the percentage of those who were satisfied with their specialty choice generally did not slip from the year before. It actually rose for several specialties – most notably, rheumatology, pulmonology, physical medicine and rehabilitation, and nephrology.

One specialty saw a decline in satisfaction with their specialty choice, and that was public health and preventive medicine, which plummeted 16 percentage points to 67% – putting it at the bottom of the list.

Even before the pandemic, many public health departments were chronically underfunded. This problem was possibly exacerbated by the pressures to keep up with COVID reporting and testing responsibilities.
 

Conclusion

Although 2020 was a wild ride for many physicians, many came out of it with only minor reductions in overall compensation, and some saw increases. Still, some specialties and many individuals experienced terrible financial stress and had to make changes in their lives and their spending in order to stay afloat.

“The biggest inhibitor to getting back to normal had to do with doctors who did not want to return because they did not want to risk getting COVID,” Dr. Pinto reports. But he notes that by February 2021 most doctors were completely vaccinated and could feel safe again.

A version of this article first appeared on Medscape.com.

In April, federal rules implementing the bipartisan federal 21st Century Cures Act went into effect that allow patients to see their clinical notes. While some clinicians consider it an unwelcome intrusion, advocates say it will improve communication and compliance.

Patient access to notes is not new. In many states, patients already have the ability to request copies of their charts, or to access truncated information via clinic websites. The difference is that most patients will now be able to click on a patient portal – such as MyChart, or other similar apps – and gain instantaneous, unfettered access to everything in their records.

Clinicians have traditionally thought of medical notes as private journal entries; but in the last few decades they have become an important component of the documentation necessary for billing, as well as evidence in the event of litigation. Now, with the implementation of the Cures Act, medical notes have evolved into a tool to communicate with the patient, rather than just among health care providers, lawyers, and billing departments.

Supporters contend that this change will make a big difference, because patients will be able to see exactly what their doctors have written, rather than just a list of confusing test results and diagnosis lists in “medicalese.”

OpenNotes, a think tank that has promoted the sharing of clinical notes with patients for years, calls the Cures Act legislation a “new world” where shared notes are valuable tools to improve communication between patients and physicians while strengthening their relationship. They cite evidence indicating that “when health professionals offer patients and families ready access to clinical notes, the quality and safety of care improves.”

Not all doctors are as enthusiastic. Many are concerned that patients might misinterpret what they see in their doctors’ notes, including complex descriptions of clinical assessments and decisions.

Others worry about patients having immediate access to their records, perhaps even before their physicians. The American Academy of Dermatology is working with the American Medical Association and other groups to gather real-world instances where the release of lab results, reports, or notes directly to patients before their physician could review the information with them caused emotional harm or other adverse consequences.

Undoubtedly, there are scenarios where unrestricted display of clinical notes could be problematic. One example is the issue of adolescents and reproductive health. Since parents now have access to their children’s records, some teenagers might hesitate to confide in their physicians and deny themselves important medical care.

The new rules permit blocking access to records if there is clear evidence that doing so “will substantially reduce the risk of harm” to patients or third parties. Psychotherapy counseling notes, for example, are completely exempt from the new requirements.

There are also state-level laws that can supersede the new federal law and block access to notes. For example, California law forbids providers from posting cancer test results without discussing them with the patient first.

Research indicates that shared notes have benefits that should outweigh the concerns of most physicians. One study showed that about 70% of patients said reviewing their notes helped them understand why medications were prescribed, which improved their compliance. This was particularly true for patients whose primary language is not English. A British study found that patients felt empowered by shared notes, and thought they improved their relationship with their physicians.

Other advantages of sharing notes include the ability of family members to review what happened at visits, which can be particularly important when dementia or other disabilities are involved. Patients will also be able to share their medical records with physicians outside of their health network, thus avoiding unnecessary or repetitious workups.

OpenNotes contends that when patients review their doctors’ notes, they gain “a newfound, deeper respect for what physicians have to understand to do their jobs.” Other predicted advantages include improved medical record accuracy and less miscommunication. In a study published in 2019 that evaluated experiences of patients who read ambulatory visit notes, only 5% were more worried after reading the notes and 3% were confused.

Alleviating worry among clinicians may be a bigger problem; but as a general principle, you should avoid judgmental language, and never write anything in a chart that you wouldn’t want your patients or their family members – or lawyers – to see.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

In April, federal rules implementing the bipartisan federal 21st Century Cures Act went into effect that allow patients to see their clinical notes. While some clinicians consider it an unwelcome intrusion, advocates say it will improve communication and compliance.

Patient access to notes is not new. In many states, patients already have the ability to request copies of their charts, or to access truncated information via clinic websites. The difference is that most patients will now be able to click on a patient portal – such as MyChart, or other similar apps – and gain instantaneous, unfettered access to everything in their records.

Clinicians have traditionally thought of medical notes as private journal entries; but in the last few decades they have become an important component of the documentation necessary for billing, as well as evidence in the event of litigation. Now, with the implementation of the Cures Act, medical notes have evolved into a tool to communicate with the patient, rather than just among health care providers, lawyers, and billing departments.

Supporters contend that this change will make a big difference, because patients will be able to see exactly what their doctors have written, rather than just a list of confusing test results and diagnosis lists in “medicalese.”

OpenNotes, a think tank that has promoted the sharing of clinical notes with patients for years, calls the Cures Act legislation a “new world” where shared notes are valuable tools to improve communication between patients and physicians while strengthening their relationship. They cite evidence indicating that “when health professionals offer patients and families ready access to clinical notes, the quality and safety of care improves.”

Not all doctors are as enthusiastic. Many are concerned that patients might misinterpret what they see in their doctors’ notes, including complex descriptions of clinical assessments and decisions.

Others worry about patients having immediate access to their records, perhaps even before their physicians. The American Academy of Dermatology is working with the American Medical Association and other groups to gather real-world instances where the release of lab results, reports, or notes directly to patients before their physician could review the information with them caused emotional harm or other adverse consequences.

Undoubtedly, there are scenarios where unrestricted display of clinical notes could be problematic. One example is the issue of adolescents and reproductive health. Since parents now have access to their children’s records, some teenagers might hesitate to confide in their physicians and deny themselves important medical care.

The new rules permit blocking access to records if there is clear evidence that doing so “will substantially reduce the risk of harm” to patients or third parties. Psychotherapy counseling notes, for example, are completely exempt from the new requirements.

There are also state-level laws that can supersede the new federal law and block access to notes. For example, California law forbids providers from posting cancer test results without discussing them with the patient first.

Research indicates that shared notes have benefits that should outweigh the concerns of most physicians. One study showed that about 70% of patients said reviewing their notes helped them understand why medications were prescribed, which improved their compliance. This was particularly true for patients whose primary language is not English. A British study found that patients felt empowered by shared notes, and thought they improved their relationship with their physicians.

Other advantages of sharing notes include the ability of family members to review what happened at visits, which can be particularly important when dementia or other disabilities are involved. Patients will also be able to share their medical records with physicians outside of their health network, thus avoiding unnecessary or repetitious workups.

OpenNotes contends that when patients review their doctors’ notes, they gain “a newfound, deeper respect for what physicians have to understand to do their jobs.” Other predicted advantages include improved medical record accuracy and less miscommunication. In a study published in 2019 that evaluated experiences of patients who read ambulatory visit notes, only 5% were more worried after reading the notes and 3% were confused.

Alleviating worry among clinicians may be a bigger problem; but as a general principle, you should avoid judgmental language, and never write anything in a chart that you wouldn’t want your patients or their family members – or lawyers – to see.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

In April, federal rules implementing the bipartisan federal 21st Century Cures Act went into effect that allow patients to see their clinical notes. While some clinicians consider it an unwelcome intrusion, advocates say it will improve communication and compliance.

Patient access to notes is not new. In many states, patients already have the ability to request copies of their charts, or to access truncated information via clinic websites. The difference is that most patients will now be able to click on a patient portal – such as MyChart, or other similar apps – and gain instantaneous, unfettered access to everything in their records.

Clinicians have traditionally thought of medical notes as private journal entries; but in the last few decades they have become an important component of the documentation necessary for billing, as well as evidence in the event of litigation. Now, with the implementation of the Cures Act, medical notes have evolved into a tool to communicate with the patient, rather than just among health care providers, lawyers, and billing departments.

Supporters contend that this change will make a big difference, because patients will be able to see exactly what their doctors have written, rather than just a list of confusing test results and diagnosis lists in “medicalese.”

OpenNotes, a think tank that has promoted the sharing of clinical notes with patients for years, calls the Cures Act legislation a “new world” where shared notes are valuable tools to improve communication between patients and physicians while strengthening their relationship. They cite evidence indicating that “when health professionals offer patients and families ready access to clinical notes, the quality and safety of care improves.”

Not all doctors are as enthusiastic. Many are concerned that patients might misinterpret what they see in their doctors’ notes, including complex descriptions of clinical assessments and decisions.

Others worry about patients having immediate access to their records, perhaps even before their physicians. The American Academy of Dermatology is working with the American Medical Association and other groups to gather real-world instances where the release of lab results, reports, or notes directly to patients before their physician could review the information with them caused emotional harm or other adverse consequences.

Undoubtedly, there are scenarios where unrestricted display of clinical notes could be problematic. One example is the issue of adolescents and reproductive health. Since parents now have access to their children’s records, some teenagers might hesitate to confide in their physicians and deny themselves important medical care.

The new rules permit blocking access to records if there is clear evidence that doing so “will substantially reduce the risk of harm” to patients or third parties. Psychotherapy counseling notes, for example, are completely exempt from the new requirements.

There are also state-level laws that can supersede the new federal law and block access to notes. For example, California law forbids providers from posting cancer test results without discussing them with the patient first.

Research indicates that shared notes have benefits that should outweigh the concerns of most physicians. One study showed that about 70% of patients said reviewing their notes helped them understand why medications were prescribed, which improved their compliance. This was particularly true for patients whose primary language is not English. A British study found that patients felt empowered by shared notes, and thought they improved their relationship with their physicians.

Other advantages of sharing notes include the ability of family members to review what happened at visits, which can be particularly important when dementia or other disabilities are involved. Patients will also be able to share their medical records with physicians outside of their health network, thus avoiding unnecessary or repetitious workups.

OpenNotes contends that when patients review their doctors’ notes, they gain “a newfound, deeper respect for what physicians have to understand to do their jobs.” Other predicted advantages include improved medical record accuracy and less miscommunication. In a study published in 2019 that evaluated experiences of patients who read ambulatory visit notes, only 5% were more worried after reading the notes and 3% were confused.

Alleviating worry among clinicians may be a bigger problem; but as a general principle, you should avoid judgmental language, and never write anything in a chart that you wouldn’t want your patients or their family members – or lawyers – to see.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

Among U.S. patients who regularly undergo hemodialysis, 20% had some degree of hesitancy about receiving a COVID-19 vaccine in a survey of 1,515 patients conducted during January and February 2021.
 

The most frequently cited concern associated with hesitancy over vaccination against the SARS-CoV-2 virus was with regard to possible adverse effects. This was cited by more than half of the patients who were concerned about being vaccinated.

Hesitancy rates were highest among people aged 44 years or younger, women, people who identified as non-Hispanic Black or non-Hispanic other (generally Native American or Pacific Islander), those with less than some college education, and those without a history of influenza vaccination, Pablo Garcia, MD, reported at the National Kidney Foundation (NKF) 2021 Spring Clinical Meetings.
 

Hesitancy or access?

Overall, however, the findings suggest that the main barrier to COVID-19 vaccine uptake is “access rather than hesitancy,” explained Dr. Garcia, a nephrologist at Stanford (Calif.) University. He predicts that this barrier will soon resolve, in part because of a Centers for Disease Control and Prevention program launched in March 2021 that is supplying COVID-19 vaccine to U.S. dialysis centers to administer to their patients.

“This will facilitate access to the vaccine” for patients who regularly receive hemodialysis, Dr. Garcia said during his presentation.

“Administering vaccines in dialysis clinics will help. Patients are already accustomed to receiving influenza vaccine in the clinic,” said Joseph A. Vassalotti, MD, a nephrologist at Mount Sinai Hospital, New York, and chief medical officer for the NKF.

Dr. Vassalotti cited the importance of protecting the vulnerable population of people who regularly receive hemodialysis. Among those patients, there was a 37% spike in all-cause mortality during peak weeks of the pandemic compared with similar periods during 2017-2019.
 

Any level of vaccine hesitancy is concerning

In an interview, he said, “Vaccination is the key to reducing this burden, so any level of vaccine hesitancy is concerning” with regard to patients who regularly undergo dialysis.

Hesitancy among patients who undergo dialysis appears to be less than in the general U.S. population, according to a series of surveys conducted from April through December 2020. In that series, hesitancy rates approached 50% in a sample of more than 8,000 people.

Hesitancy among people overall may have recently increased, at least for the short term, because of concerns over rare thrombotic events among people who receive certain types of COVID-19 vaccine, Dr. Vassalotti noted.

Dr. Garcia and associates conducted their survey from Jan. 8 to Feb. 11, 2021, among patients who regularly received hemodialysis at any of 150 randomly selected dialysis clinics that treat 30 or more patients and are managed by U.S. Renal Care. The study enrolled patients in 22 states. Most of the patients were aged 45-79 years; 30% were non-Hispanic White; 30% were Black, and 24% were Hispanic. The survey included 24 questions and took about 10 minutes to complete.

In reply to the statement, “If COVID-19 vaccine was proven safe and effective for the general population I would seek to get it,” 20% gave a reply of definitely not, probably not, or unsure; 79% answered either probably or definitely yes.

Another question asked about willingness to receive a vaccine if it was shown to be safe and effective for people receiving dialysis. In answer to that question, 19% said definitely not, probably not, or unsure.
 

Possible adverse effects an issue

Asked the reason why they were hesitant to receive the vaccine, 53% cited possible adverse effects; 19% cited general unease about vaccines; 19% said they did not think the COVID-19 vaccines would work; 17% said they did not think they needed a COVID-19 vaccine; and 15% said they had read or heard that COVID-19 vaccines were dangerous.

A set of questions asked survey respondents about their primary source of information about COVID-19 vaccines. About three-quarters cited television news; about 35% cited members of their dialysis clinic staff; about 30% cited friends and family; 20% cited social media; 20% cited their nephrologists; and roughly 15% cited newspapers.

The results suggest that potentially effective interventions to promote vaccine uptake include showing informational videos to patients during dialysis sessions and encouraging the staff at dialysis centers to proactively educate patients about COVID-19 vaccines and to promote uptake, suggest Dr. Garcia and Dr. Vassalotti.

Dr. Vassalotti noted that in a recent single-center survey of 90 U.S. patients undergoing hemodialysis that included 75 (85%) Black persons, the prevalence of hesitancy about COVID-19 vaccines was 50%. Hesitancy was often linked with gaps in patient education.

“We need broad educational measures, as well as targeting specific demographic groups” among whom the level of hesitancy is high, said Dr. Vassalotti.

He noted that patients who undergo dialysis are receptive to messages from dialysis clinic staff members and that this offers an “opportunity to understand misconceptions that underlie hesitancy and address them on an individual basis.”

The NKF has prepared a fact sheet for educating patients with kidney disease about the efficacy and safety of COVID-19 vaccines, Dr. Vassalotti noted.

Dr. Garcia has disclosed no relevant financial relationships. Dr. Vassalotti is an adviser and consultant to Renalytix AI and is a consultant to Janssen.

A version of this article first appeared on Medscape.com.

Among U.S. patients who regularly undergo hemodialysis, 20% had some degree of hesitancy about receiving a COVID-19 vaccine in a survey of 1,515 patients conducted during January and February 2021.
 

The most frequently cited concern associated with hesitancy over vaccination against the SARS-CoV-2 virus was with regard to possible adverse effects. This was cited by more than half of the patients who were concerned about being vaccinated.

Hesitancy rates were highest among people aged 44 years or younger, women, people who identified as non-Hispanic Black or non-Hispanic other (generally Native American or Pacific Islander), those with less than some college education, and those without a history of influenza vaccination, Pablo Garcia, MD, reported at the National Kidney Foundation (NKF) 2021 Spring Clinical Meetings.
 

Hesitancy or access?

Overall, however, the findings suggest that the main barrier to COVID-19 vaccine uptake is “access rather than hesitancy,” explained Dr. Garcia, a nephrologist at Stanford (Calif.) University. He predicts that this barrier will soon resolve, in part because of a Centers for Disease Control and Prevention program launched in March 2021 that is supplying COVID-19 vaccine to U.S. dialysis centers to administer to their patients.

“This will facilitate access to the vaccine” for patients who regularly receive hemodialysis, Dr. Garcia said during his presentation.

“Administering vaccines in dialysis clinics will help. Patients are already accustomed to receiving influenza vaccine in the clinic,” said Joseph A. Vassalotti, MD, a nephrologist at Mount Sinai Hospital, New York, and chief medical officer for the NKF.

Dr. Vassalotti cited the importance of protecting the vulnerable population of people who regularly receive hemodialysis. Among those patients, there was a 37% spike in all-cause mortality during peak weeks of the pandemic compared with similar periods during 2017-2019.
 

Any level of vaccine hesitancy is concerning

In an interview, he said, “Vaccination is the key to reducing this burden, so any level of vaccine hesitancy is concerning” with regard to patients who regularly undergo dialysis.

Hesitancy among patients who undergo dialysis appears to be less than in the general U.S. population, according to a series of surveys conducted from April through December 2020. In that series, hesitancy rates approached 50% in a sample of more than 8,000 people.

Hesitancy among people overall may have recently increased, at least for the short term, because of concerns over rare thrombotic events among people who receive certain types of COVID-19 vaccine, Dr. Vassalotti noted.

Dr. Garcia and associates conducted their survey from Jan. 8 to Feb. 11, 2021, among patients who regularly received hemodialysis at any of 150 randomly selected dialysis clinics that treat 30 or more patients and are managed by U.S. Renal Care. The study enrolled patients in 22 states. Most of the patients were aged 45-79 years; 30% were non-Hispanic White; 30% were Black, and 24% were Hispanic. The survey included 24 questions and took about 10 minutes to complete.

In reply to the statement, “If COVID-19 vaccine was proven safe and effective for the general population I would seek to get it,” 20% gave a reply of definitely not, probably not, or unsure; 79% answered either probably or definitely yes.

Another question asked about willingness to receive a vaccine if it was shown to be safe and effective for people receiving dialysis. In answer to that question, 19% said definitely not, probably not, or unsure.
 

Possible adverse effects an issue

Asked the reason why they were hesitant to receive the vaccine, 53% cited possible adverse effects; 19% cited general unease about vaccines; 19% said they did not think the COVID-19 vaccines would work; 17% said they did not think they needed a COVID-19 vaccine; and 15% said they had read or heard that COVID-19 vaccines were dangerous.

A set of questions asked survey respondents about their primary source of information about COVID-19 vaccines. About three-quarters cited television news; about 35% cited members of their dialysis clinic staff; about 30% cited friends and family; 20% cited social media; 20% cited their nephrologists; and roughly 15% cited newspapers.

The results suggest that potentially effective interventions to promote vaccine uptake include showing informational videos to patients during dialysis sessions and encouraging the staff at dialysis centers to proactively educate patients about COVID-19 vaccines and to promote uptake, suggest Dr. Garcia and Dr. Vassalotti.

Dr. Vassalotti noted that in a recent single-center survey of 90 U.S. patients undergoing hemodialysis that included 75 (85%) Black persons, the prevalence of hesitancy about COVID-19 vaccines was 50%. Hesitancy was often linked with gaps in patient education.

“We need broad educational measures, as well as targeting specific demographic groups” among whom the level of hesitancy is high, said Dr. Vassalotti.

He noted that patients who undergo dialysis are receptive to messages from dialysis clinic staff members and that this offers an “opportunity to understand misconceptions that underlie hesitancy and address them on an individual basis.”

The NKF has prepared a fact sheet for educating patients with kidney disease about the efficacy and safety of COVID-19 vaccines, Dr. Vassalotti noted.

Dr. Garcia has disclosed no relevant financial relationships. Dr. Vassalotti is an adviser and consultant to Renalytix AI and is a consultant to Janssen.

A version of this article first appeared on Medscape.com.

Among U.S. patients who regularly undergo hemodialysis, 20% had some degree of hesitancy about receiving a COVID-19 vaccine in a survey of 1,515 patients conducted during January and February 2021.
 

The most frequently cited concern associated with hesitancy over vaccination against the SARS-CoV-2 virus was with regard to possible adverse effects. This was cited by more than half of the patients who were concerned about being vaccinated.

Hesitancy rates were highest among people aged 44 years or younger, women, people who identified as non-Hispanic Black or non-Hispanic other (generally Native American or Pacific Islander), those with less than some college education, and those without a history of influenza vaccination, Pablo Garcia, MD, reported at the National Kidney Foundation (NKF) 2021 Spring Clinical Meetings.
 

Hesitancy or access?

Overall, however, the findings suggest that the main barrier to COVID-19 vaccine uptake is “access rather than hesitancy,” explained Dr. Garcia, a nephrologist at Stanford (Calif.) University. He predicts that this barrier will soon resolve, in part because of a Centers for Disease Control and Prevention program launched in March 2021 that is supplying COVID-19 vaccine to U.S. dialysis centers to administer to their patients.

“This will facilitate access to the vaccine” for patients who regularly receive hemodialysis, Dr. Garcia said during his presentation.

“Administering vaccines in dialysis clinics will help. Patients are already accustomed to receiving influenza vaccine in the clinic,” said Joseph A. Vassalotti, MD, a nephrologist at Mount Sinai Hospital, New York, and chief medical officer for the NKF.

Dr. Vassalotti cited the importance of protecting the vulnerable population of people who regularly receive hemodialysis. Among those patients, there was a 37% spike in all-cause mortality during peak weeks of the pandemic compared with similar periods during 2017-2019.
 

Any level of vaccine hesitancy is concerning

In an interview, he said, “Vaccination is the key to reducing this burden, so any level of vaccine hesitancy is concerning” with regard to patients who regularly undergo dialysis.

Hesitancy among patients who undergo dialysis appears to be less than in the general U.S. population, according to a series of surveys conducted from April through December 2020. In that series, hesitancy rates approached 50% in a sample of more than 8,000 people.

Hesitancy among people overall may have recently increased, at least for the short term, because of concerns over rare thrombotic events among people who receive certain types of COVID-19 vaccine, Dr. Vassalotti noted.

Dr. Garcia and associates conducted their survey from Jan. 8 to Feb. 11, 2021, among patients who regularly received hemodialysis at any of 150 randomly selected dialysis clinics that treat 30 or more patients and are managed by U.S. Renal Care. The study enrolled patients in 22 states. Most of the patients were aged 45-79 years; 30% were non-Hispanic White; 30% were Black, and 24% were Hispanic. The survey included 24 questions and took about 10 minutes to complete.

In reply to the statement, “If COVID-19 vaccine was proven safe and effective for the general population I would seek to get it,” 20% gave a reply of definitely not, probably not, or unsure; 79% answered either probably or definitely yes.

Another question asked about willingness to receive a vaccine if it was shown to be safe and effective for people receiving dialysis. In answer to that question, 19% said definitely not, probably not, or unsure.
 

Possible adverse effects an issue

Asked the reason why they were hesitant to receive the vaccine, 53% cited possible adverse effects; 19% cited general unease about vaccines; 19% said they did not think the COVID-19 vaccines would work; 17% said they did not think they needed a COVID-19 vaccine; and 15% said they had read or heard that COVID-19 vaccines were dangerous.

A set of questions asked survey respondents about their primary source of information about COVID-19 vaccines. About three-quarters cited television news; about 35% cited members of their dialysis clinic staff; about 30% cited friends and family; 20% cited social media; 20% cited their nephrologists; and roughly 15% cited newspapers.

The results suggest that potentially effective interventions to promote vaccine uptake include showing informational videos to patients during dialysis sessions and encouraging the staff at dialysis centers to proactively educate patients about COVID-19 vaccines and to promote uptake, suggest Dr. Garcia and Dr. Vassalotti.

Dr. Vassalotti noted that in a recent single-center survey of 90 U.S. patients undergoing hemodialysis that included 75 (85%) Black persons, the prevalence of hesitancy about COVID-19 vaccines was 50%. Hesitancy was often linked with gaps in patient education.

“We need broad educational measures, as well as targeting specific demographic groups” among whom the level of hesitancy is high, said Dr. Vassalotti.

He noted that patients who undergo dialysis are receptive to messages from dialysis clinic staff members and that this offers an “opportunity to understand misconceptions that underlie hesitancy and address them on an individual basis.”

The NKF has prepared a fact sheet for educating patients with kidney disease about the efficacy and safety of COVID-19 vaccines, Dr. Vassalotti noted.

Dr. Garcia has disclosed no relevant financial relationships. Dr. Vassalotti is an adviser and consultant to Renalytix AI and is a consultant to Janssen.

A version of this article first appeared on Medscape.com.

Patients with heart failure get pneumonia at a rate almost three times greater than expected and, once they do get pneumonia, have about a fourfold greater risk of death, investigators for a retrospective analysis of 13,000 patients from two landmark randomized HF trials have found.

Catherine Hackett/MDedge News

The investigators also found that HF patients with preserved ejection fraction (HFpEF) are at the highest risk of developing pneumonia. The findings underscore the importance of patients with HF getting a pneumonia vaccination, they found.

The analysis showed that 6.3% of patients in the PARADIGM-HF trial and 10.6% of those in the PARAGON-HF trial developed pneumonia, reported the study authors, led by John J.V. McMurray, MD, of the British Heart Foundation Cardiovascular Research Center at the University of Glasgow in Scotland (J Am Coll Cardiol. 2021;77:1961-73).

“The main reason for doing this study was the fact that many heart failure patients are not vaccinated, as they should be, against pneumonia – both pneumococcus and influenza vaccination,” Dr. McMurray said in an interview. “We wanted to document the frequency and consequences of pneumonia in patients with heart failure to help highlight this deficiency in care.”

Dr. McMurray said he believes this is the first study to document the incidence of pneumonia and pneumonia-related outcomes according to the two major ejection fraction phenotypes.
 

PARADIGM-HF and PARAGON-HF

The post hoc analysis consisted of 8,399 patients with HF with reduced ejection fraction (HFrEF) in PARADIGM-HF (Eur J Heart Fail. 2013 Sep;15[9]:1062-73) and 4,796 patients with HFpEF in PARAGON-HF (N Engl J Med. 2014 Sep 11;371[11]:993-1004). The analysis focused on the 528 and 510 patients in each study, respectively, who developed pneumonia. Those rates translated to an incidence rate of 29 per 1,000 patient-years (95% confidence interval, 27-31) in PARADIGM-HF and 39 per 1,000 patient-years (95% CI, 36-42) in PARAGON-HF.

After pneumonia, the risk of death in patients increased substantially. In PARADIGM-HF, the adjusted hazard ratio for the risk of death from any cause after pneumonia was 4.34 (95% CI, 3.73-5.05). In PARAGON-HF, it was 3.76 (95% CI, 3.09-4.58). HF patients who contracted pneumonia also tended to have HF longer than their counterparts who didn’t develop pneumonia, but the frequency of previous hospitalization for HF didn’t vary between the pneumonia and no-pneumonia groups.

Patients who developed pneumonia tended to be older (average age of 66.9 years vs. 64.6 years, P < .001) and male (83.9% vs. 77.8%, P < .001). The mean age of patients in PARADIGM-HF was almost a decade younger than those in PARAGON-HF, 64 vs. 73 years.

Pneumonia patients also had worse Kansas City Cardiomyopathy Questionnaire scores (76 vs. 80 on average), but no difference in New York Heart Association functional class. “In general, patients who developed pneumonia had more symptoms and signs and HF than those who did not develop pneumonia,” Dr. McMurray and colleagues wrote.

Pneumonia patients also had higher rates of chronic obstructive pulmonary disease (26% vs. 12%), diabetes (43% vs. 34%), and atrial fibrillation (46% vs. 36%).

Another reason for conducting the study, Dr. McMurray said, “was the prior findings in patients with coronary disease and acute myocardial infarction that the risk associated with an episode of pneumonia [e.g., in subsequent vascular events and deaths] persisted long after the acute event. We wanted to see if this was also the case for heart failure, and indeed it was.”

For example, the adjusted HR for cardiovascular death or hospitalization in the first month following an episode of pneumonia was 9.48 (range of 6.85-13.12, P < .001), leveling off to 1.59 after 3 months or more.
 

Vaccination crucial in HF patients

Dr. McMurray noted that this study emphasizes the importance of pneumonia vaccination for patients with HF. “Given that we have so few treatments to offer patients with HFpEF, this makes the potential value of vaccination in these patients all the greater,” he said.

The COVID-19 pandemic, Dr. McMurray said, is a “good reminder of the dangers of a respiratory infection and the importance of vaccination in these patients. COVID-19 has interesting parallels in being a systemic disease and one with postacute, persisting effects.”

The persistent risk for adverse cardiovascular events 3 months and later after pneumonia is a novel finding of the study, wrote Donna Mancini, MD, and Gregory Gibson, MD, in an invited commentary (J Am Coll Cardiol. 2021;77:1974-6). Both are with the Icahn School of Medicine at Mt. Sinai in New York. The post hoc study also “serves as an important reminder” of pneumonia risk in patients with HF, especially during the pandemic, they wrote.

“Although vaccination alone appears unlikely to be a panacea, it is a readily accessible tool for mitigating disease severity and improving outcomes,” Dr. Mancini and Dr. Gibson wrote. “After all, an ounce of prevention is worth a pound of cure.”

Novartis provided funding for the PARADIGM-HF and PARAGON-HF trials, and Dr. McMurray and coauthors disclosed financial relationships with Novartis. Dr. Mancini and Dr. Gibson have no relevant financial relationships to disclose.

Patients with heart failure get pneumonia at a rate almost three times greater than expected and, once they do get pneumonia, have about a fourfold greater risk of death, investigators for a retrospective analysis of 13,000 patients from two landmark randomized HF trials have found.

Catherine Hackett/MDedge News

The investigators also found that HF patients with preserved ejection fraction (HFpEF) are at the highest risk of developing pneumonia. The findings underscore the importance of patients with HF getting a pneumonia vaccination, they found.

The analysis showed that 6.3% of patients in the PARADIGM-HF trial and 10.6% of those in the PARAGON-HF trial developed pneumonia, reported the study authors, led by John J.V. McMurray, MD, of the British Heart Foundation Cardiovascular Research Center at the University of Glasgow in Scotland (J Am Coll Cardiol. 2021;77:1961-73).

“The main reason for doing this study was the fact that many heart failure patients are not vaccinated, as they should be, against pneumonia – both pneumococcus and influenza vaccination,” Dr. McMurray said in an interview. “We wanted to document the frequency and consequences of pneumonia in patients with heart failure to help highlight this deficiency in care.”

Dr. McMurray said he believes this is the first study to document the incidence of pneumonia and pneumonia-related outcomes according to the two major ejection fraction phenotypes.
 

PARADIGM-HF and PARAGON-HF

The post hoc analysis consisted of 8,399 patients with HF with reduced ejection fraction (HFrEF) in PARADIGM-HF (Eur J Heart Fail. 2013 Sep;15[9]:1062-73) and 4,796 patients with HFpEF in PARAGON-HF (N Engl J Med. 2014 Sep 11;371[11]:993-1004). The analysis focused on the 528 and 510 patients in each study, respectively, who developed pneumonia. Those rates translated to an incidence rate of 29 per 1,000 patient-years (95% confidence interval, 27-31) in PARADIGM-HF and 39 per 1,000 patient-years (95% CI, 36-42) in PARAGON-HF.

After pneumonia, the risk of death in patients increased substantially. In PARADIGM-HF, the adjusted hazard ratio for the risk of death from any cause after pneumonia was 4.34 (95% CI, 3.73-5.05). In PARAGON-HF, it was 3.76 (95% CI, 3.09-4.58). HF patients who contracted pneumonia also tended to have HF longer than their counterparts who didn’t develop pneumonia, but the frequency of previous hospitalization for HF didn’t vary between the pneumonia and no-pneumonia groups.

Patients who developed pneumonia tended to be older (average age of 66.9 years vs. 64.6 years, P < .001) and male (83.9% vs. 77.8%, P < .001). The mean age of patients in PARADIGM-HF was almost a decade younger than those in PARAGON-HF, 64 vs. 73 years.

Pneumonia patients also had worse Kansas City Cardiomyopathy Questionnaire scores (76 vs. 80 on average), but no difference in New York Heart Association functional class. “In general, patients who developed pneumonia had more symptoms and signs and HF than those who did not develop pneumonia,” Dr. McMurray and colleagues wrote.

Pneumonia patients also had higher rates of chronic obstructive pulmonary disease (26% vs. 12%), diabetes (43% vs. 34%), and atrial fibrillation (46% vs. 36%).

Another reason for conducting the study, Dr. McMurray said, “was the prior findings in patients with coronary disease and acute myocardial infarction that the risk associated with an episode of pneumonia [e.g., in subsequent vascular events and deaths] persisted long after the acute event. We wanted to see if this was also the case for heart failure, and indeed it was.”

For example, the adjusted HR for cardiovascular death or hospitalization in the first month following an episode of pneumonia was 9.48 (range of 6.85-13.12, P < .001), leveling off to 1.59 after 3 months or more.
 

Vaccination crucial in HF patients

Dr. McMurray noted that this study emphasizes the importance of pneumonia vaccination for patients with HF. “Given that we have so few treatments to offer patients with HFpEF, this makes the potential value of vaccination in these patients all the greater,” he said.

The COVID-19 pandemic, Dr. McMurray said, is a “good reminder of the dangers of a respiratory infection and the importance of vaccination in these patients. COVID-19 has interesting parallels in being a systemic disease and one with postacute, persisting effects.”

The persistent risk for adverse cardiovascular events 3 months and later after pneumonia is a novel finding of the study, wrote Donna Mancini, MD, and Gregory Gibson, MD, in an invited commentary (J Am Coll Cardiol. 2021;77:1974-6). Both are with the Icahn School of Medicine at Mt. Sinai in New York. The post hoc study also “serves as an important reminder” of pneumonia risk in patients with HF, especially during the pandemic, they wrote.

“Although vaccination alone appears unlikely to be a panacea, it is a readily accessible tool for mitigating disease severity and improving outcomes,” Dr. Mancini and Dr. Gibson wrote. “After all, an ounce of prevention is worth a pound of cure.”

Novartis provided funding for the PARADIGM-HF and PARAGON-HF trials, and Dr. McMurray and coauthors disclosed financial relationships with Novartis. Dr. Mancini and Dr. Gibson have no relevant financial relationships to disclose.

Patients with heart failure get pneumonia at a rate almost three times greater than expected and, once they do get pneumonia, have about a fourfold greater risk of death, investigators for a retrospective analysis of 13,000 patients from two landmark randomized HF trials have found.

Catherine Hackett/MDedge News

The investigators also found that HF patients with preserved ejection fraction (HFpEF) are at the highest risk of developing pneumonia. The findings underscore the importance of patients with HF getting a pneumonia vaccination, they found.

The analysis showed that 6.3% of patients in the PARADIGM-HF trial and 10.6% of those in the PARAGON-HF trial developed pneumonia, reported the study authors, led by John J.V. McMurray, MD, of the British Heart Foundation Cardiovascular Research Center at the University of Glasgow in Scotland (J Am Coll Cardiol. 2021;77:1961-73).

“The main reason for doing this study was the fact that many heart failure patients are not vaccinated, as they should be, against pneumonia – both pneumococcus and influenza vaccination,” Dr. McMurray said in an interview. “We wanted to document the frequency and consequences of pneumonia in patients with heart failure to help highlight this deficiency in care.”

Dr. McMurray said he believes this is the first study to document the incidence of pneumonia and pneumonia-related outcomes according to the two major ejection fraction phenotypes.
 

PARADIGM-HF and PARAGON-HF

The post hoc analysis consisted of 8,399 patients with HF with reduced ejection fraction (HFrEF) in PARADIGM-HF (Eur J Heart Fail. 2013 Sep;15[9]:1062-73) and 4,796 patients with HFpEF in PARAGON-HF (N Engl J Med. 2014 Sep 11;371[11]:993-1004). The analysis focused on the 528 and 510 patients in each study, respectively, who developed pneumonia. Those rates translated to an incidence rate of 29 per 1,000 patient-years (95% confidence interval, 27-31) in PARADIGM-HF and 39 per 1,000 patient-years (95% CI, 36-42) in PARAGON-HF.

After pneumonia, the risk of death in patients increased substantially. In PARADIGM-HF, the adjusted hazard ratio for the risk of death from any cause after pneumonia was 4.34 (95% CI, 3.73-5.05). In PARAGON-HF, it was 3.76 (95% CI, 3.09-4.58). HF patients who contracted pneumonia also tended to have HF longer than their counterparts who didn’t develop pneumonia, but the frequency of previous hospitalization for HF didn’t vary between the pneumonia and no-pneumonia groups.

Patients who developed pneumonia tended to be older (average age of 66.9 years vs. 64.6 years, P < .001) and male (83.9% vs. 77.8%, P < .001). The mean age of patients in PARADIGM-HF was almost a decade younger than those in PARAGON-HF, 64 vs. 73 years.

Pneumonia patients also had worse Kansas City Cardiomyopathy Questionnaire scores (76 vs. 80 on average), but no difference in New York Heart Association functional class. “In general, patients who developed pneumonia had more symptoms and signs and HF than those who did not develop pneumonia,” Dr. McMurray and colleagues wrote.

Pneumonia patients also had higher rates of chronic obstructive pulmonary disease (26% vs. 12%), diabetes (43% vs. 34%), and atrial fibrillation (46% vs. 36%).

Another reason for conducting the study, Dr. McMurray said, “was the prior findings in patients with coronary disease and acute myocardial infarction that the risk associated with an episode of pneumonia [e.g., in subsequent vascular events and deaths] persisted long after the acute event. We wanted to see if this was also the case for heart failure, and indeed it was.”

For example, the adjusted HR for cardiovascular death or hospitalization in the first month following an episode of pneumonia was 9.48 (range of 6.85-13.12, P < .001), leveling off to 1.59 after 3 months or more.
 

Vaccination crucial in HF patients

Dr. McMurray noted that this study emphasizes the importance of pneumonia vaccination for patients with HF. “Given that we have so few treatments to offer patients with HFpEF, this makes the potential value of vaccination in these patients all the greater,” he said.

The COVID-19 pandemic, Dr. McMurray said, is a “good reminder of the dangers of a respiratory infection and the importance of vaccination in these patients. COVID-19 has interesting parallels in being a systemic disease and one with postacute, persisting effects.”

The persistent risk for adverse cardiovascular events 3 months and later after pneumonia is a novel finding of the study, wrote Donna Mancini, MD, and Gregory Gibson, MD, in an invited commentary (J Am Coll Cardiol. 2021;77:1974-6). Both are with the Icahn School of Medicine at Mt. Sinai in New York. The post hoc study also “serves as an important reminder” of pneumonia risk in patients with HF, especially during the pandemic, they wrote.

“Although vaccination alone appears unlikely to be a panacea, it is a readily accessible tool for mitigating disease severity and improving outcomes,” Dr. Mancini and Dr. Gibson wrote. “After all, an ounce of prevention is worth a pound of cure.”

Novartis provided funding for the PARADIGM-HF and PARAGON-HF trials, and Dr. McMurray and coauthors disclosed financial relationships with Novartis. Dr. Mancini and Dr. Gibson have no relevant financial relationships to disclose.

Low-fat diets appear to decrease testosterone levels in men, but further randomized, controlled trials are needed to confirm this effect, the authors of a meta-analysis of six small intervention studies concluded.

A total of 206 healthy men with normal testosterone received a high-fat diet followed by a low-fat diet (or vice versa), and their mean total testosterone levels were 10%-15% lower (but still in the normal range) during the low-fat diet.

The study by registered nutritionist Joseph Whittaker, MSc, University of Worcester (England), and statistician Kexin Wu, MSc, University of Warwick, Coventry, England, was published online in the Journal of Steroid Biochemistry and Molecular Biology.

“I think our results are consistent and fairly strong, but they are not strong enough to give blanket recommendations,” Mr. Whittaker said in an interview.

However, “if somebody has low testosterone, particularly borderline, they could try increasing their fat intake, maybe on a Mediterranean diet,” he said, and see if that works to increase their testosterone by 60 ng/dL, the weighted mean difference in total testosterone levels between the low-fat versus high-fat diet interventions in this meta-analysis.

“A Mediterranean diet is a good way to increase ‘healthy fats,’ mono- and polyunsaturated fatty acids, which will likely decrease cardiovascular disease risk, and boost testosterone at the same time,” Mr. Whittaker noted.

Olive oil has been shown to boost testosterone more than butter, and it also reduces CVD, he continued. Nuts are high in “healthy fats” and consistently decrease CVD and mortality and may boost testosterone. Other sources of “good fat” in a healthy diet include avocado, and red meat and poultry in moderation.

“It is controversial, but our results also indicate that foods with saturated fatty acids may boost testosterone,” he added, noting however that such foods are also associated with an increase in cholesterol.
 

Is waning testosterone explained by leaner diet?

Men need healthy testosterone levels for good physical performance, mental health, and sexual health, and low levels are associated with a higher risk of heart disease, diabetes, and Alzheimer’s disease, according to a statement about this research issued by the University of Worcester.

Although testosterone levels do decline with advancing age, there has also been an additional age-independent and persistent decline in testosterone levels that began roughly after nutrition guidelines began recommending a lower-fat diet in 1965.

Fat consumption dropped from 45% of the diet in 1965 to 35% of the diet in 1991, and stayed around that lower level through to 2011.

However, it is not clear if this decrease in dietary fat intake might explain part of the concurrent decline in men’s testosterone levels.

Mr. Whittaker and Mr. Wu conducted a systematic literature review and identified six crossover intervention studies that compared testosterone levels during low-fat versus high-fat diets – Dorgan 1996, Wang 2005, Hamalainen 1984, Hill 1980, Reed 1987, and Hill 1979 – and then they combined these studies in a meta-analysis.

Five studies each enrolled 6-43 healthy men from North America, the United Kingdom, and Scandinavia, and the sixth study (Hill 1980) enrolled 34 healthy men from North America and 39 farm laborers from South Africa.

Overall, on average, the men were aged 34-54 years and slightly overweight (a mean body mass index of roughly 27 kg/m²) with normal testosterone (i.e., >300 ng/dL, based on the 2018 American Urological Association guidelines criteria).

Most men received a high-fat diet (40% of calories from fat) first, followed by a low-fat diet (on average 20% of calories from fat; range, 7%-25%), but the subgroup of men from South Africa received the low-fat diet first.

To put this into context, U.K. guidelines recommend a fat intake of less than 35% of daily calories, and U.S. guidelines recommend a fat intake of 20%-35% of daily calories.

The low-and high-fat interventions ranged from 2 to 10 weeks.  
 

Lowest testosterone levels with low-fat vegetarian diets

Overall, on average, the men’s total testosterone was 475 mg/dL when they were consuming a low-fat diet and 532 mg/dL when they were consuming a high-fat diet.

However, the South African men had higher testosterone levels when they consumed a low-fat diet. This suggests that “men with European ancestry may experience a greater decrease in testosterone in response to a low-fat diet,” the researchers wrote.

The decrease in total testosterone in the low-fat versus high-fat diet was largest (26%) in the two studies of men who consumed a vegetarian diet (Hill 1979 and Hill 1980). These diets may have been low in zinc, since a marginal zinc deficiency has been shown to decrease total testosterone, Mr. Whittaker and Mr. Wu speculated.

The meta-analysis also showed that levels of free testosterone, urinary testosterone, and dihydrotestosterone declined during the low-fat diet, whereas levels of luteinizing hormone or sex hormone binding globulin were similar with both diets.
 

Men with low testosterone and overweight, obesity

What nutritional advice should practitioners give to men who have low testosterone and overweight/obesity?

“If you are very overweight, losing weight is going to dramatically improve your testosterone,” Mr. Whittaker said.

However, proponents of various diets are often in stark disagreement about the merits of a low-fat versus low-carbohydrate diet to lose weight.

“In general,” he continued, “the literature shows low-carb (high-fat) diets are better for weight loss [although many will disagree with that statement].”

Although nutrition guidelines have stressed the importance of limiting fat intake, fat in the diet is also associated with lower triglyceride levels and blood pressure and higher HDL cholesterol levels, and now in this study, higher testosterone levels.
 

More research needed

The researchers acknowledge study limitations: The meta-analysis included just a few small studies with heterogeneous designs and findings, and there was possible bias from confounding variables.

“Ideally, we would like to see a few more studies to confirm our results,” Mr. Whittaker said in the statement. “However, these studies may never come; normally researchers want to find new results, not replicate old ones. In the meantime, men with low testosterone would be wise to avoid low-fat diets.”

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Low-fat diets appear to decrease testosterone levels in men, but further randomized, controlled trials are needed to confirm this effect, the authors of a meta-analysis of six small intervention studies concluded.

A total of 206 healthy men with normal testosterone received a high-fat diet followed by a low-fat diet (or vice versa), and their mean total testosterone levels were 10%-15% lower (but still in the normal range) during the low-fat diet.

The study by registered nutritionist Joseph Whittaker, MSc, University of Worcester (England), and statistician Kexin Wu, MSc, University of Warwick, Coventry, England, was published online in the Journal of Steroid Biochemistry and Molecular Biology.

“I think our results are consistent and fairly strong, but they are not strong enough to give blanket recommendations,” Mr. Whittaker said in an interview.

However, “if somebody has low testosterone, particularly borderline, they could try increasing their fat intake, maybe on a Mediterranean diet,” he said, and see if that works to increase their testosterone by 60 ng/dL, the weighted mean difference in total testosterone levels between the low-fat versus high-fat diet interventions in this meta-analysis.

“A Mediterranean diet is a good way to increase ‘healthy fats,’ mono- and polyunsaturated fatty acids, which will likely decrease cardiovascular disease risk, and boost testosterone at the same time,” Mr. Whittaker noted.

Olive oil has been shown to boost testosterone more than butter, and it also reduces CVD, he continued. Nuts are high in “healthy fats” and consistently decrease CVD and mortality and may boost testosterone. Other sources of “good fat” in a healthy diet include avocado, and red meat and poultry in moderation.

“It is controversial, but our results also indicate that foods with saturated fatty acids may boost testosterone,” he added, noting however that such foods are also associated with an increase in cholesterol.
 

Is waning testosterone explained by leaner diet?

Men need healthy testosterone levels for good physical performance, mental health, and sexual health, and low levels are associated with a higher risk of heart disease, diabetes, and Alzheimer’s disease, according to a statement about this research issued by the University of Worcester.

Although testosterone levels do decline with advancing age, there has also been an additional age-independent and persistent decline in testosterone levels that began roughly after nutrition guidelines began recommending a lower-fat diet in 1965.

Fat consumption dropped from 45% of the diet in 1965 to 35% of the diet in 1991, and stayed around that lower level through to 2011.

However, it is not clear if this decrease in dietary fat intake might explain part of the concurrent decline in men’s testosterone levels.

Mr. Whittaker and Mr. Wu conducted a systematic literature review and identified six crossover intervention studies that compared testosterone levels during low-fat versus high-fat diets – Dorgan 1996, Wang 2005, Hamalainen 1984, Hill 1980, Reed 1987, and Hill 1979 – and then they combined these studies in a meta-analysis.

Five studies each enrolled 6-43 healthy men from North America, the United Kingdom, and Scandinavia, and the sixth study (Hill 1980) enrolled 34 healthy men from North America and 39 farm laborers from South Africa.

Overall, on average, the men were aged 34-54 years and slightly overweight (a mean body mass index of roughly 27 kg/m²) with normal testosterone (i.e., >300 ng/dL, based on the 2018 American Urological Association guidelines criteria).

Most men received a high-fat diet (40% of calories from fat) first, followed by a low-fat diet (on average 20% of calories from fat; range, 7%-25%), but the subgroup of men from South Africa received the low-fat diet first.

To put this into context, U.K. guidelines recommend a fat intake of less than 35% of daily calories, and U.S. guidelines recommend a fat intake of 20%-35% of daily calories.

The low-and high-fat interventions ranged from 2 to 10 weeks.  
 

Lowest testosterone levels with low-fat vegetarian diets

Overall, on average, the men’s total testosterone was 475 mg/dL when they were consuming a low-fat diet and 532 mg/dL when they were consuming a high-fat diet.

However, the South African men had higher testosterone levels when they consumed a low-fat diet. This suggests that “men with European ancestry may experience a greater decrease in testosterone in response to a low-fat diet,” the researchers wrote.

The decrease in total testosterone in the low-fat versus high-fat diet was largest (26%) in the two studies of men who consumed a vegetarian diet (Hill 1979 and Hill 1980). These diets may have been low in zinc, since a marginal zinc deficiency has been shown to decrease total testosterone, Mr. Whittaker and Mr. Wu speculated.

The meta-analysis also showed that levels of free testosterone, urinary testosterone, and dihydrotestosterone declined during the low-fat diet, whereas levels of luteinizing hormone or sex hormone binding globulin were similar with both diets.
 

Men with low testosterone and overweight, obesity

What nutritional advice should practitioners give to men who have low testosterone and overweight/obesity?

“If you are very overweight, losing weight is going to dramatically improve your testosterone,” Mr. Whittaker said.

However, proponents of various diets are often in stark disagreement about the merits of a low-fat versus low-carbohydrate diet to lose weight.

“In general,” he continued, “the literature shows low-carb (high-fat) diets are better for weight loss [although many will disagree with that statement].”

Although nutrition guidelines have stressed the importance of limiting fat intake, fat in the diet is also associated with lower triglyceride levels and blood pressure and higher HDL cholesterol levels, and now in this study, higher testosterone levels.
 

More research needed

The researchers acknowledge study limitations: The meta-analysis included just a few small studies with heterogeneous designs and findings, and there was possible bias from confounding variables.

“Ideally, we would like to see a few more studies to confirm our results,” Mr. Whittaker said in the statement. “However, these studies may never come; normally researchers want to find new results, not replicate old ones. In the meantime, men with low testosterone would be wise to avoid low-fat diets.”

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Low-fat diets appear to decrease testosterone levels in men, but further randomized, controlled trials are needed to confirm this effect, the authors of a meta-analysis of six small intervention studies concluded.

A total of 206 healthy men with normal testosterone received a high-fat diet followed by a low-fat diet (or vice versa), and their mean total testosterone levels were 10%-15% lower (but still in the normal range) during the low-fat diet.

The study by registered nutritionist Joseph Whittaker, MSc, University of Worcester (England), and statistician Kexin Wu, MSc, University of Warwick, Coventry, England, was published online in the Journal of Steroid Biochemistry and Molecular Biology.

“I think our results are consistent and fairly strong, but they are not strong enough to give blanket recommendations,” Mr. Whittaker said in an interview.

However, “if somebody has low testosterone, particularly borderline, they could try increasing their fat intake, maybe on a Mediterranean diet,” he said, and see if that works to increase their testosterone by 60 ng/dL, the weighted mean difference in total testosterone levels between the low-fat versus high-fat diet interventions in this meta-analysis.

“A Mediterranean diet is a good way to increase ‘healthy fats,’ mono- and polyunsaturated fatty acids, which will likely decrease cardiovascular disease risk, and boost testosterone at the same time,” Mr. Whittaker noted.

Olive oil has been shown to boost testosterone more than butter, and it also reduces CVD, he continued. Nuts are high in “healthy fats” and consistently decrease CVD and mortality and may boost testosterone. Other sources of “good fat” in a healthy diet include avocado, and red meat and poultry in moderation.

“It is controversial, but our results also indicate that foods with saturated fatty acids may boost testosterone,” he added, noting however that such foods are also associated with an increase in cholesterol.
 

Is waning testosterone explained by leaner diet?

Men need healthy testosterone levels for good physical performance, mental health, and sexual health, and low levels are associated with a higher risk of heart disease, diabetes, and Alzheimer’s disease, according to a statement about this research issued by the University of Worcester.

Although testosterone levels do decline with advancing age, there has also been an additional age-independent and persistent decline in testosterone levels that began roughly after nutrition guidelines began recommending a lower-fat diet in 1965.

Fat consumption dropped from 45% of the diet in 1965 to 35% of the diet in 1991, and stayed around that lower level through to 2011.

However, it is not clear if this decrease in dietary fat intake might explain part of the concurrent decline in men’s testosterone levels.

Mr. Whittaker and Mr. Wu conducted a systematic literature review and identified six crossover intervention studies that compared testosterone levels during low-fat versus high-fat diets – Dorgan 1996, Wang 2005, Hamalainen 1984, Hill 1980, Reed 1987, and Hill 1979 – and then they combined these studies in a meta-analysis.

Five studies each enrolled 6-43 healthy men from North America, the United Kingdom, and Scandinavia, and the sixth study (Hill 1980) enrolled 34 healthy men from North America and 39 farm laborers from South Africa.

Overall, on average, the men were aged 34-54 years and slightly overweight (a mean body mass index of roughly 27 kg/m²) with normal testosterone (i.e., >300 ng/dL, based on the 2018 American Urological Association guidelines criteria).

Most men received a high-fat diet (40% of calories from fat) first, followed by a low-fat diet (on average 20% of calories from fat; range, 7%-25%), but the subgroup of men from South Africa received the low-fat diet first.

To put this into context, U.K. guidelines recommend a fat intake of less than 35% of daily calories, and U.S. guidelines recommend a fat intake of 20%-35% of daily calories.

The low-and high-fat interventions ranged from 2 to 10 weeks.  
 

Lowest testosterone levels with low-fat vegetarian diets

Overall, on average, the men’s total testosterone was 475 mg/dL when they were consuming a low-fat diet and 532 mg/dL when they were consuming a high-fat diet.

However, the South African men had higher testosterone levels when they consumed a low-fat diet. This suggests that “men with European ancestry may experience a greater decrease in testosterone in response to a low-fat diet,” the researchers wrote.

The decrease in total testosterone in the low-fat versus high-fat diet was largest (26%) in the two studies of men who consumed a vegetarian diet (Hill 1979 and Hill 1980). These diets may have been low in zinc, since a marginal zinc deficiency has been shown to decrease total testosterone, Mr. Whittaker and Mr. Wu speculated.

The meta-analysis also showed that levels of free testosterone, urinary testosterone, and dihydrotestosterone declined during the low-fat diet, whereas levels of luteinizing hormone or sex hormone binding globulin were similar with both diets.
 

Men with low testosterone and overweight, obesity

What nutritional advice should practitioners give to men who have low testosterone and overweight/obesity?

“If you are very overweight, losing weight is going to dramatically improve your testosterone,” Mr. Whittaker said.

However, proponents of various diets are often in stark disagreement about the merits of a low-fat versus low-carbohydrate diet to lose weight.

“In general,” he continued, “the literature shows low-carb (high-fat) diets are better for weight loss [although many will disagree with that statement].”

Although nutrition guidelines have stressed the importance of limiting fat intake, fat in the diet is also associated with lower triglyceride levels and blood pressure and higher HDL cholesterol levels, and now in this study, higher testosterone levels.
 

More research needed

The researchers acknowledge study limitations: The meta-analysis included just a few small studies with heterogeneous designs and findings, and there was possible bias from confounding variables.

“Ideally, we would like to see a few more studies to confirm our results,” Mr. Whittaker said in the statement. “However, these studies may never come; normally researchers want to find new results, not replicate old ones. In the meantime, men with low testosterone would be wise to avoid low-fat diets.”

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Dr. Ben-a-bo?

Nope.

Ben-nabi?

Nope.

Ben-NO-bo?

Also no.

My surname is tricky to pronounce for some people. I sometimes exaggerate to help patients get it right: “Beh-NAAH-bee-oh.” Almost daily someone will reply: “Oh, you’re Italian!” Well, no actually, my friend Enzo who was born in Sicily and lives in Milan, he’s Italian. I’m just a Rhode Islander who knows some Italian words from his grandmother. Most times though, I just answer: ‘Yep, I’m Italian.” It’s faster.

We use names as a shortcut to identify people. In clinic, it can help to find things in common quickly, similar to asking where you’re from. (East Coast patients seem to love that I’m from New England and if they’re Italian and from New York, well then, we’re paisans right from the start.)

However, using names to guess how someone identifies can be risky. In some instances, it could even be seen as microaggressive, particularly if you got it wrong.

Like most of you I’ll bet, I’m pretty good at pronouncing names – we practice thousands of times! Other than accepting a compliment for getting a tricky one right, such as Radivojevic (I think it’s Ra-di-VOI-ye-vich), I hadn’t thought much about names until I heard a great podcast on the topic. I thought I’d share a couple tips.

First, if you’re not particularly good at names or if you struggle with certain types of names, it’s better to ask than to butcher it. Like learning the wrong way to hit a golf ball, you may never be able to do it properly once you’ve done it wrong. (Trust me, I know from both.)

If I’m feeling confident, I’ll give it a try. But if unsure, I ask the patient to pronounce it for me, then I repeat it to confirm I’ve gotten it correct. Then I say it once or twice more during the visit. Lastly, for the knotty tongue-twisting ones, I write it phonetically in their chart.

It is important because mispronouncing names can alienate patients. It might make them feel like we don’t “know” them or that we don’t care about them. Making an effort to pronounce every patients’ name correctly I believe is a simple act we can all do to move us closer to mitigating racial biases and eliminating ethnic disparities in care. Just think how much harder it might be to convince skeptical patients to take their lisinopril if you can’t even get their names right.

Worse perhaps than getting the pronunciation wrong is to turn the name into an issue. Saying: “Oh, that’s hard to pronounce” could be felt as a subtly racist remark – it’s not hard for them to pronounce of course, only for you. Also, guessing a patient’s nationality from the name is risky. Asking “are you Russian?” to someone from Ukraine or “is that Chinese?” to someone from Vietnam can quickly turn a nice office visit down a road named “Awkward.” It can give the impression that they “all look the same” to you, exactly the type of exclusion we’re trying to eliminate in medicine.

Saying a patient’s name perfectly is rewarding and a super-efficient way to connect. It can make salient the truth that you care about the patient and about his or her story, even if the name happens to be Mrs. Xiomara Winyuwongse Khosrowshahi Sundararajan Ngoc. Go ahead, give it a try.

Want more on how properly pronounce names correctly? You might like this episode of NPR’s Life Kit.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]

Dr. Ben-a-bo?

Nope.

Ben-nabi?

Nope.

Ben-NO-bo?

Also no.

My surname is tricky to pronounce for some people. I sometimes exaggerate to help patients get it right: “Beh-NAAH-bee-oh.” Almost daily someone will reply: “Oh, you’re Italian!” Well, no actually, my friend Enzo who was born in Sicily and lives in Milan, he’s Italian. I’m just a Rhode Islander who knows some Italian words from his grandmother. Most times though, I just answer: ‘Yep, I’m Italian.” It’s faster.

We use names as a shortcut to identify people. In clinic, it can help to find things in common quickly, similar to asking where you’re from. (East Coast patients seem to love that I’m from New England and if they’re Italian and from New York, well then, we’re paisans right from the start.)

However, using names to guess how someone identifies can be risky. In some instances, it could even be seen as microaggressive, particularly if you got it wrong.

Like most of you I’ll bet, I’m pretty good at pronouncing names – we practice thousands of times! Other than accepting a compliment for getting a tricky one right, such as Radivojevic (I think it’s Ra-di-VOI-ye-vich), I hadn’t thought much about names until I heard a great podcast on the topic. I thought I’d share a couple tips.

First, if you’re not particularly good at names or if you struggle with certain types of names, it’s better to ask than to butcher it. Like learning the wrong way to hit a golf ball, you may never be able to do it properly once you’ve done it wrong. (Trust me, I know from both.)

If I’m feeling confident, I’ll give it a try. But if unsure, I ask the patient to pronounce it for me, then I repeat it to confirm I’ve gotten it correct. Then I say it once or twice more during the visit. Lastly, for the knotty tongue-twisting ones, I write it phonetically in their chart.

It is important because mispronouncing names can alienate patients. It might make them feel like we don’t “know” them or that we don’t care about them. Making an effort to pronounce every patients’ name correctly I believe is a simple act we can all do to move us closer to mitigating racial biases and eliminating ethnic disparities in care. Just think how much harder it might be to convince skeptical patients to take their lisinopril if you can’t even get their names right.

Worse perhaps than getting the pronunciation wrong is to turn the name into an issue. Saying: “Oh, that’s hard to pronounce” could be felt as a subtly racist remark – it’s not hard for them to pronounce of course, only for you. Also, guessing a patient’s nationality from the name is risky. Asking “are you Russian?” to someone from Ukraine or “is that Chinese?” to someone from Vietnam can quickly turn a nice office visit down a road named “Awkward.” It can give the impression that they “all look the same” to you, exactly the type of exclusion we’re trying to eliminate in medicine.

Saying a patient’s name perfectly is rewarding and a super-efficient way to connect. It can make salient the truth that you care about the patient and about his or her story, even if the name happens to be Mrs. Xiomara Winyuwongse Khosrowshahi Sundararajan Ngoc. Go ahead, give it a try.

Want more on how properly pronounce names correctly? You might like this episode of NPR’s Life Kit.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]

Dr. Ben-a-bo?

Nope.

Ben-nabi?

Nope.

Ben-NO-bo?

Also no.

My surname is tricky to pronounce for some people. I sometimes exaggerate to help patients get it right: “Beh-NAAH-bee-oh.” Almost daily someone will reply: “Oh, you’re Italian!” Well, no actually, my friend Enzo who was born in Sicily and lives in Milan, he’s Italian. I’m just a Rhode Islander who knows some Italian words from his grandmother. Most times though, I just answer: ‘Yep, I’m Italian.” It’s faster.

We use names as a shortcut to identify people. In clinic, it can help to find things in common quickly, similar to asking where you’re from. (East Coast patients seem to love that I’m from New England and if they’re Italian and from New York, well then, we’re paisans right from the start.)

However, using names to guess how someone identifies can be risky. In some instances, it could even be seen as microaggressive, particularly if you got it wrong.

Like most of you I’ll bet, I’m pretty good at pronouncing names – we practice thousands of times! Other than accepting a compliment for getting a tricky one right, such as Radivojevic (I think it’s Ra-di-VOI-ye-vich), I hadn’t thought much about names until I heard a great podcast on the topic. I thought I’d share a couple tips.

First, if you’re not particularly good at names or if you struggle with certain types of names, it’s better to ask than to butcher it. Like learning the wrong way to hit a golf ball, you may never be able to do it properly once you’ve done it wrong. (Trust me, I know from both.)

If I’m feeling confident, I’ll give it a try. But if unsure, I ask the patient to pronounce it for me, then I repeat it to confirm I’ve gotten it correct. Then I say it once or twice more during the visit. Lastly, for the knotty tongue-twisting ones, I write it phonetically in their chart.

It is important because mispronouncing names can alienate patients. It might make them feel like we don’t “know” them or that we don’t care about them. Making an effort to pronounce every patients’ name correctly I believe is a simple act we can all do to move us closer to mitigating racial biases and eliminating ethnic disparities in care. Just think how much harder it might be to convince skeptical patients to take their lisinopril if you can’t even get their names right.

Worse perhaps than getting the pronunciation wrong is to turn the name into an issue. Saying: “Oh, that’s hard to pronounce” could be felt as a subtly racist remark – it’s not hard for them to pronounce of course, only for you. Also, guessing a patient’s nationality from the name is risky. Asking “are you Russian?” to someone from Ukraine or “is that Chinese?” to someone from Vietnam can quickly turn a nice office visit down a road named “Awkward.” It can give the impression that they “all look the same” to you, exactly the type of exclusion we’re trying to eliminate in medicine.

Saying a patient’s name perfectly is rewarding and a super-efficient way to connect. It can make salient the truth that you care about the patient and about his or her story, even if the name happens to be Mrs. Xiomara Winyuwongse Khosrowshahi Sundararajan Ngoc. Go ahead, give it a try.

Want more on how properly pronounce names correctly? You might like this episode of NPR’s Life Kit.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected]