CHEST

CHEST was recently informed of the death of former CHEST President, James E. Dalen, MD, MPH, Master FCCP. He served as CHEST President from 1985 to 1986.

Dr. Dalen was a graduate of Washington State University. (His undergraduate education was temporarily interrupted when he served as a Corpsman in the Navy and Marines.) He held a master’s degree from the University of Michigan, an MD from the University of Washington, an MPH from Harvard University, and an honorary Doctor of Science degree from the University of Massachusetts. He was internationally recognized as a medical visionary and esteemed cardiologist.

Dr. Dalen’s academic career spanned 3 medical schools. During the time he spent at each, he achieved great things and nurtured great ideas that helped transform medicine. From 1967 to 1975, he was on the faculty of Harvard Medical School (and the Peter Bent Brigham Hospital). From 1975 to 1988, he was a faculty member at the University of Massachusetts Medical School where he served as Chairman of Cardiovascular Medicine from 1975 to 1977 and as Chairman of Medicine from 1977 to 1988. From 1986 to 1987, he served as Interim Chancellor of the University of Massachusetts at the Worcester Campus. Dr. Dalen left Massachusetts in 1988 to become the Dean of the University of Arizona College of Medicine.

During his tenure as Dean and Vice-President at the University of Arizona, Dr. Dalen oversaw the establishment of the Zuckerman College of Public Health, the Arizona Center for Integrative Medicine, and the Arizona Telemedicine Program. Successful fundraising under his leadership led to the establishment of new research facilities, including the Children’s Research Center, the Sarver Heart Center, the Arizona Arthritis Center, and a major expansion of the Arizona Cancer Center. While at the University of Arizona College of Medicine, Dr. Dalen recognized the importance of integrative medicine and the need to promote integrative medicine in the academic environment. With the active participation of Dr. Andrew Weil, this led to the creation of the Academic Consortium for Integrative Medicine and Health and the Arizona Center for Integrative Medicine.

Dr. Dalen received many teaching awards. In 1987, he received the Distinguished Public Service Award from the University of Massachusetts. In 1988, he was named the University of Washington Distinguished Medical Alumnus of the Year and received the Alumni Achievement Award from Washington State University. In 2000, he received the College Medal from CHEST and was named a Master Fellow. In 2010, he was awarded the Harvard School of Public Health’s highest honor for its alumni: the 2010 Alumni Award of Merit. In 2012, he was named a Master Fellow of the American College of Physicians and was awarded an honorary Doctor of Science degree by the University of Massachusetts in 2013. In 2015, he received the Bravewell Distinguished Service Award from the Academic Consortium for Integrative Medicine and Health for his role as one of the founders of the consortium and as one of the founders of the Arizona Center for Integrative Medicine at the University of Arizona.

In his spare time, he enjoyed reading, gardening, sailing, art, and music and was a lifelong student with a passion for the pursuit of knowledge. Dr. Dalen enjoyed watching basketball, particularly the Arizona Wildcats. His favorite place to spend time was by the ocean in Coronado, California. Dr. Dalen was an advocate for public health, social justice, and health care reform throughout his life and career. He mentored thousands of medical students and championed access to health care for populations who were underserved. He touched many lives as a leading physician and caring friend.

Dr. Dalen is survived by his devoted wife, Priscilla M. Dalen (Dunton); loving children, James E. Dalen, Jr, and Angela M. Snodgrass (Dalen); daughter-in-law, Suzan M. Dalen; son-in-law, Daniel N. Snodgrass; and many step-grandchildren. We remember our colleague and extend our sincere condolences.

CHEST

CHEST was recently informed of the death of former CHEST President, James E. Dalen, MD, MPH, Master FCCP. He served as CHEST President from 1985 to 1986.

Dr. Dalen was a graduate of Washington State University. (His undergraduate education was temporarily interrupted when he served as a Corpsman in the Navy and Marines.) He held a master’s degree from the University of Michigan, an MD from the University of Washington, an MPH from Harvard University, and an honorary Doctor of Science degree from the University of Massachusetts. He was internationally recognized as a medical visionary and esteemed cardiologist.

Dr. Dalen’s academic career spanned 3 medical schools. During the time he spent at each, he achieved great things and nurtured great ideas that helped transform medicine. From 1967 to 1975, he was on the faculty of Harvard Medical School (and the Peter Bent Brigham Hospital). From 1975 to 1988, he was a faculty member at the University of Massachusetts Medical School where he served as Chairman of Cardiovascular Medicine from 1975 to 1977 and as Chairman of Medicine from 1977 to 1988. From 1986 to 1987, he served as Interim Chancellor of the University of Massachusetts at the Worcester Campus. Dr. Dalen left Massachusetts in 1988 to become the Dean of the University of Arizona College of Medicine.

During his tenure as Dean and Vice-President at the University of Arizona, Dr. Dalen oversaw the establishment of the Zuckerman College of Public Health, the Arizona Center for Integrative Medicine, and the Arizona Telemedicine Program. Successful fundraising under his leadership led to the establishment of new research facilities, including the Children’s Research Center, the Sarver Heart Center, the Arizona Arthritis Center, and a major expansion of the Arizona Cancer Center. While at the University of Arizona College of Medicine, Dr. Dalen recognized the importance of integrative medicine and the need to promote integrative medicine in the academic environment. With the active participation of Dr. Andrew Weil, this led to the creation of the Academic Consortium for Integrative Medicine and Health and the Arizona Center for Integrative Medicine.

Dr. Dalen received many teaching awards. In 1987, he received the Distinguished Public Service Award from the University of Massachusetts. In 1988, he was named the University of Washington Distinguished Medical Alumnus of the Year and received the Alumni Achievement Award from Washington State University. In 2000, he received the College Medal from CHEST and was named a Master Fellow. In 2010, he was awarded the Harvard School of Public Health’s highest honor for its alumni: the 2010 Alumni Award of Merit. In 2012, he was named a Master Fellow of the American College of Physicians and was awarded an honorary Doctor of Science degree by the University of Massachusetts in 2013. In 2015, he received the Bravewell Distinguished Service Award from the Academic Consortium for Integrative Medicine and Health for his role as one of the founders of the consortium and as one of the founders of the Arizona Center for Integrative Medicine at the University of Arizona.

In his spare time, he enjoyed reading, gardening, sailing, art, and music and was a lifelong student with a passion for the pursuit of knowledge. Dr. Dalen enjoyed watching basketball, particularly the Arizona Wildcats. His favorite place to spend time was by the ocean in Coronado, California. Dr. Dalen was an advocate for public health, social justice, and health care reform throughout his life and career. He mentored thousands of medical students and championed access to health care for populations who were underserved. He touched many lives as a leading physician and caring friend.

Dr. Dalen is survived by his devoted wife, Priscilla M. Dalen (Dunton); loving children, James E. Dalen, Jr, and Angela M. Snodgrass (Dalen); daughter-in-law, Suzan M. Dalen; son-in-law, Daniel N. Snodgrass; and many step-grandchildren. We remember our colleague and extend our sincere condolences.

CHEST

CHEST was recently informed of the death of former CHEST President, James E. Dalen, MD, MPH, Master FCCP. He served as CHEST President from 1985 to 1986.

Dr. Dalen was a graduate of Washington State University. (His undergraduate education was temporarily interrupted when he served as a Corpsman in the Navy and Marines.) He held a master’s degree from the University of Michigan, an MD from the University of Washington, an MPH from Harvard University, and an honorary Doctor of Science degree from the University of Massachusetts. He was internationally recognized as a medical visionary and esteemed cardiologist.

Dr. Dalen’s academic career spanned 3 medical schools. During the time he spent at each, he achieved great things and nurtured great ideas that helped transform medicine. From 1967 to 1975, he was on the faculty of Harvard Medical School (and the Peter Bent Brigham Hospital). From 1975 to 1988, he was a faculty member at the University of Massachusetts Medical School where he served as Chairman of Cardiovascular Medicine from 1975 to 1977 and as Chairman of Medicine from 1977 to 1988. From 1986 to 1987, he served as Interim Chancellor of the University of Massachusetts at the Worcester Campus. Dr. Dalen left Massachusetts in 1988 to become the Dean of the University of Arizona College of Medicine.

During his tenure as Dean and Vice-President at the University of Arizona, Dr. Dalen oversaw the establishment of the Zuckerman College of Public Health, the Arizona Center for Integrative Medicine, and the Arizona Telemedicine Program. Successful fundraising under his leadership led to the establishment of new research facilities, including the Children’s Research Center, the Sarver Heart Center, the Arizona Arthritis Center, and a major expansion of the Arizona Cancer Center. While at the University of Arizona College of Medicine, Dr. Dalen recognized the importance of integrative medicine and the need to promote integrative medicine in the academic environment. With the active participation of Dr. Andrew Weil, this led to the creation of the Academic Consortium for Integrative Medicine and Health and the Arizona Center for Integrative Medicine.

Dr. Dalen received many teaching awards. In 1987, he received the Distinguished Public Service Award from the University of Massachusetts. In 1988, he was named the University of Washington Distinguished Medical Alumnus of the Year and received the Alumni Achievement Award from Washington State University. In 2000, he received the College Medal from CHEST and was named a Master Fellow. In 2010, he was awarded the Harvard School of Public Health’s highest honor for its alumni: the 2010 Alumni Award of Merit. In 2012, he was named a Master Fellow of the American College of Physicians and was awarded an honorary Doctor of Science degree by the University of Massachusetts in 2013. In 2015, he received the Bravewell Distinguished Service Award from the Academic Consortium for Integrative Medicine and Health for his role as one of the founders of the consortium and as one of the founders of the Arizona Center for Integrative Medicine at the University of Arizona.

In his spare time, he enjoyed reading, gardening, sailing, art, and music and was a lifelong student with a passion for the pursuit of knowledge. Dr. Dalen enjoyed watching basketball, particularly the Arizona Wildcats. His favorite place to spend time was by the ocean in Coronado, California. Dr. Dalen was an advocate for public health, social justice, and health care reform throughout his life and career. He mentored thousands of medical students and championed access to health care for populations who were underserved. He touched many lives as a leading physician and caring friend.

Dr. Dalen is survived by his devoted wife, Priscilla M. Dalen (Dunton); loving children, James E. Dalen, Jr, and Angela M. Snodgrass (Dalen); daughter-in-law, Suzan M. Dalen; son-in-law, Daniel N. Snodgrass; and many step-grandchildren. We remember our colleague and extend our sincere condolences.

Increasingly recognized as a multifactorial disease, obesity demands an approach that involves multiple healthcare professionals. For psychologist Andréa Levy, coordinator and founder of the nongovernmental organization Obesity Brazil, addressing the patient’s “psychological weight” is crucial.

In an interview with this news organization, Ms. Levy, who was one of the speakers at the International Congress on Obesity in 2024, emphasized the importance of integrating emotional and behavioral aspects into treatment, because these factors often influence eating habits and weight gain.

She also highlighted the essential collaboration between endocrinologists, nutritionists, psychiatrists, and psychologists, who must work together to provide comprehensive and effective care to patients.
 

How do psychological factors affect the treatment of obesity?

Psychological factors are important triggers for weight gain. As the degree of obesity increases, so does the predisposition to mental health problems such as anxiety, mood disorders, personality disorders, and eating disorders. Understanding these factors is important because accurate psychodiagnosis is essential for effective disease treatment.

Without a proper diagnosis, the treatment may be incomplete and omit relevant factors. For example, a person with undiagnosed depression who is starting treatment for weight loss may feel discouraged and low on energy. He or she may wrongly attribute these symptoms to the diet or surgery. Similarly, someone undergoing bariatric surgery may confuse malnutrition symptoms with depression, resulting in inadequate treatment with antidepressants and possible iatrogenic complications.

Furthermore, psychotherapy and psychological follow-up are essential to help the individual organize better and understand the treatment and the disease itself. This is especially important in stigmatized diseases and those subject to prejudice such as obesity, where understanding and acceptance are often challenging, which affects treatment adherence.

Is the collaboration between psychologist and psychiatrist always necessary?

Often, it is necessary to have the support of both a psychologist and a psychiatrist. The process generally begins with a good psychodiagnosis. Initially, there may not be a case that requires treatment, but it is important to perform this evaluation to rule out any issues.

The follow-up, unlike weekly psychotherapy, can be monthly or at an interval agreed on with the patient. It is crucial to help him or her navigate the various stages of obesity treatment. For example, the patient may be going through a period of mourning or separation, or a happier moment, such as the beginning of a relationship or the birth of a child in the family. These moments affect eating habits and need to be well managed.

Depending on the degree of the pathology, such as depression, severe binge-eating disorder, or personality disorders, the psychologist works in conjunction with the psychiatrist. When we talk about obesity, we are possibly also talking about a psychiatric population because it is a disease that, besides being highly recurrent, involves many other factors, such as the gaze of others, difficulty with dressing, body pains, mobility, and relationships. Therefore, having this disease alone is already a trigger for disorders such as depression.
 

What is the main evidence regarding the psychological follow-up of patients with obesity?

Several studies have investigated the relationship between obesity and mental health. Research indicates that the greater the obesity, the higher the likelihood of a positive diagnosis for a psychiatric disorder. Additionally, there is evidence of the benefits of psychological treatment for patients with obesity.

A study published in the Journal of Clinical Endocrinology and Metabolism addressed the impact of cognitive-behavioral therapy (CBT), which helps patients manage goals and treat maladaptive behaviors such as binge-eating disorders. CBT has a modest effect on weight loss, but its integration as part of a lifestyle modification amplifies the results of this loss.

Recent research also shows that weight loss through bariatric surgery offers significant psychological benefits. In the past, it was believed that this procedure could cause depression and other severe psychiatric disorders, but it is now more than proven that weight loss, when done properly and without misconduct or malnutrition, improves psychological and psychiatric issues.
 

How does psychological follow-up affect the use of medication during obesity treatment?

Many people who take medications, such as corticosteroids for chronic pain or psychiatric medications, may experience weight gain. It is essential to discuss these issues with the psychiatrist because if the patient already has a predisposition to weight gain, medication X should be chosen instead of medication Y, or the dosage should be adjusted. The psychiatrist needs to understand obesity to medicate correctly. Other types of medication, such as chemotherapeutics, may also cause weight gain, often resulting in more abdominal obesity.

There is also lipedema, a hormone-dependent disease that is different from obesity. In this disease, the person gains weight mainly in the legs and arms. In this case, bariatric surgery may result in weight loss only in specific areas, causing disproportionality and difficulty in understanding for the patient. Therefore, when treating obesity, it is important to analyze the patient from all angles: psychological, physiologic, and physical, considering the diversity of the body, its functioning, and hormonal reactions.

Although psychologists do not prescribe medications, they often explain their functioning to the patient. For example, if a patient is taking a glucagon-like peptide 1 analog and experiences initial nausea, he or she may stop using the treatment because the wrong dose had been started. In this case, the psychologist can explain how the medication works and encourage the patient to discuss adjustments with the doctor, avoiding premature discontinuation.
 

How has the mental health follow-up of patients with obesity evolved over the years?

I started working with people with obesity 25 years ago, when I myself underwent bariatric surgery. At that time, surgeons were used to “solving” the problem and sending the person home. Often, the patient did not even return for surgical follow-up because, in theory, the problem was solved.

Over time, I believe that surgeons learned to talk to the patient, understanding that there is a whole process that even involves creating a bond with the individual who underwent the surgical procedure. Within this process, the importance of the mental health of patients was recognized, and how common it is to confuse a degree of malnutrition with a mental disorder.

Even though I am not a nutritionist, I need to know the difference between a case of malnutrition and depression. So, it is a whole set of factors that needs to be worked on like an orchestra. It is not necessary for this work to be done in the same physical space, but dialogue is important.

Of course, there are things that the patient will only share with the psychologist or with the surgeon, but there are also pieces of information that need to be shared for positive management. I have had patients who were afraid to go back to the nutritionist because they did not lose weight. If they are afraid, it is because the professional is guiding them incorrectly.
 

What tips would you give to clinicians regarding the psychological approach to people with obesity?

Accessibility is crucial. When someone tells me they are dealing with obesity and depression, I usually ask, “Did you know you have two chronic diseases?” It is essential to explain these concepts because the patient may often think they are free after a successful diet and weight loss, which is not true because of the high relapse associated with obesity. Depression and anxiety follow similar patterns. If the same person wears prescription glasses, I interact by saying, “Did you know you have three chronic diseases?” This question often causes surprise. “I hadn’t thought of that.”

It is essential to use accessible language for the patient to understand the functioning of the disease. More important than choosing a treatment approach is understanding the pathophysiology of obesity and its psychological impact. This avoids a one-size-fits-all approach for all patients.

For example, the impact on someone who developed obesity in childhood after suffering physical, moral, or sexual abuse will probably be deeper than on someone in a healthy family who gained weight after becoming sedentary. Each life story requires a personalized approach.

Sometimes, a patient with mild obesity (grade 1) may not seem to need specific interventions at first glance, but it is crucial to listen to his or her story. Similarly, patients with severe obesity (grades 3 or 4) who resist surgery are entitled to other treatment options, and this is perfectly valid. Therefore, it is always important to ask, “Who is this person? What does obesity represent in their story?” Then propose the most appropriate treatment.

Ms. Levy reported having no relevant financial relationships.
 

This story was translated from the Medscape Portuguese edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

Increasingly recognized as a multifactorial disease, obesity demands an approach that involves multiple healthcare professionals. For psychologist Andréa Levy, coordinator and founder of the nongovernmental organization Obesity Brazil, addressing the patient’s “psychological weight” is crucial.

In an interview with this news organization, Ms. Levy, who was one of the speakers at the International Congress on Obesity in 2024, emphasized the importance of integrating emotional and behavioral aspects into treatment, because these factors often influence eating habits and weight gain.

She also highlighted the essential collaboration between endocrinologists, nutritionists, psychiatrists, and psychologists, who must work together to provide comprehensive and effective care to patients.
 

How do psychological factors affect the treatment of obesity?

Psychological factors are important triggers for weight gain. As the degree of obesity increases, so does the predisposition to mental health problems such as anxiety, mood disorders, personality disorders, and eating disorders. Understanding these factors is important because accurate psychodiagnosis is essential for effective disease treatment.

Without a proper diagnosis, the treatment may be incomplete and omit relevant factors. For example, a person with undiagnosed depression who is starting treatment for weight loss may feel discouraged and low on energy. He or she may wrongly attribute these symptoms to the diet or surgery. Similarly, someone undergoing bariatric surgery may confuse malnutrition symptoms with depression, resulting in inadequate treatment with antidepressants and possible iatrogenic complications.

Furthermore, psychotherapy and psychological follow-up are essential to help the individual organize better and understand the treatment and the disease itself. This is especially important in stigmatized diseases and those subject to prejudice such as obesity, where understanding and acceptance are often challenging, which affects treatment adherence.

Is the collaboration between psychologist and psychiatrist always necessary?

Often, it is necessary to have the support of both a psychologist and a psychiatrist. The process generally begins with a good psychodiagnosis. Initially, there may not be a case that requires treatment, but it is important to perform this evaluation to rule out any issues.

The follow-up, unlike weekly psychotherapy, can be monthly or at an interval agreed on with the patient. It is crucial to help him or her navigate the various stages of obesity treatment. For example, the patient may be going through a period of mourning or separation, or a happier moment, such as the beginning of a relationship or the birth of a child in the family. These moments affect eating habits and need to be well managed.

Depending on the degree of the pathology, such as depression, severe binge-eating disorder, or personality disorders, the psychologist works in conjunction with the psychiatrist. When we talk about obesity, we are possibly also talking about a psychiatric population because it is a disease that, besides being highly recurrent, involves many other factors, such as the gaze of others, difficulty with dressing, body pains, mobility, and relationships. Therefore, having this disease alone is already a trigger for disorders such as depression.
 

What is the main evidence regarding the psychological follow-up of patients with obesity?

Several studies have investigated the relationship between obesity and mental health. Research indicates that the greater the obesity, the higher the likelihood of a positive diagnosis for a psychiatric disorder. Additionally, there is evidence of the benefits of psychological treatment for patients with obesity.

A study published in the Journal of Clinical Endocrinology and Metabolism addressed the impact of cognitive-behavioral therapy (CBT), which helps patients manage goals and treat maladaptive behaviors such as binge-eating disorders. CBT has a modest effect on weight loss, but its integration as part of a lifestyle modification amplifies the results of this loss.

Recent research also shows that weight loss through bariatric surgery offers significant psychological benefits. In the past, it was believed that this procedure could cause depression and other severe psychiatric disorders, but it is now more than proven that weight loss, when done properly and without misconduct or malnutrition, improves psychological and psychiatric issues.
 

How does psychological follow-up affect the use of medication during obesity treatment?

Many people who take medications, such as corticosteroids for chronic pain or psychiatric medications, may experience weight gain. It is essential to discuss these issues with the psychiatrist because if the patient already has a predisposition to weight gain, medication X should be chosen instead of medication Y, or the dosage should be adjusted. The psychiatrist needs to understand obesity to medicate correctly. Other types of medication, such as chemotherapeutics, may also cause weight gain, often resulting in more abdominal obesity.

There is also lipedema, a hormone-dependent disease that is different from obesity. In this disease, the person gains weight mainly in the legs and arms. In this case, bariatric surgery may result in weight loss only in specific areas, causing disproportionality and difficulty in understanding for the patient. Therefore, when treating obesity, it is important to analyze the patient from all angles: psychological, physiologic, and physical, considering the diversity of the body, its functioning, and hormonal reactions.

Although psychologists do not prescribe medications, they often explain their functioning to the patient. For example, if a patient is taking a glucagon-like peptide 1 analog and experiences initial nausea, he or she may stop using the treatment because the wrong dose had been started. In this case, the psychologist can explain how the medication works and encourage the patient to discuss adjustments with the doctor, avoiding premature discontinuation.
 

How has the mental health follow-up of patients with obesity evolved over the years?

I started working with people with obesity 25 years ago, when I myself underwent bariatric surgery. At that time, surgeons were used to “solving” the problem and sending the person home. Often, the patient did not even return for surgical follow-up because, in theory, the problem was solved.

Over time, I believe that surgeons learned to talk to the patient, understanding that there is a whole process that even involves creating a bond with the individual who underwent the surgical procedure. Within this process, the importance of the mental health of patients was recognized, and how common it is to confuse a degree of malnutrition with a mental disorder.

Even though I am not a nutritionist, I need to know the difference between a case of malnutrition and depression. So, it is a whole set of factors that needs to be worked on like an orchestra. It is not necessary for this work to be done in the same physical space, but dialogue is important.

Of course, there are things that the patient will only share with the psychologist or with the surgeon, but there are also pieces of information that need to be shared for positive management. I have had patients who were afraid to go back to the nutritionist because they did not lose weight. If they are afraid, it is because the professional is guiding them incorrectly.
 

What tips would you give to clinicians regarding the psychological approach to people with obesity?

Accessibility is crucial. When someone tells me they are dealing with obesity and depression, I usually ask, “Did you know you have two chronic diseases?” It is essential to explain these concepts because the patient may often think they are free after a successful diet and weight loss, which is not true because of the high relapse associated with obesity. Depression and anxiety follow similar patterns. If the same person wears prescription glasses, I interact by saying, “Did you know you have three chronic diseases?” This question often causes surprise. “I hadn’t thought of that.”

It is essential to use accessible language for the patient to understand the functioning of the disease. More important than choosing a treatment approach is understanding the pathophysiology of obesity and its psychological impact. This avoids a one-size-fits-all approach for all patients.

For example, the impact on someone who developed obesity in childhood after suffering physical, moral, or sexual abuse will probably be deeper than on someone in a healthy family who gained weight after becoming sedentary. Each life story requires a personalized approach.

Sometimes, a patient with mild obesity (grade 1) may not seem to need specific interventions at first glance, but it is crucial to listen to his or her story. Similarly, patients with severe obesity (grades 3 or 4) who resist surgery are entitled to other treatment options, and this is perfectly valid. Therefore, it is always important to ask, “Who is this person? What does obesity represent in their story?” Then propose the most appropriate treatment.

Ms. Levy reported having no relevant financial relationships.
 

This story was translated from the Medscape Portuguese edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

Increasingly recognized as a multifactorial disease, obesity demands an approach that involves multiple healthcare professionals. For psychologist Andréa Levy, coordinator and founder of the nongovernmental organization Obesity Brazil, addressing the patient’s “psychological weight” is crucial.

In an interview with this news organization, Ms. Levy, who was one of the speakers at the International Congress on Obesity in 2024, emphasized the importance of integrating emotional and behavioral aspects into treatment, because these factors often influence eating habits and weight gain.

She also highlighted the essential collaboration between endocrinologists, nutritionists, psychiatrists, and psychologists, who must work together to provide comprehensive and effective care to patients.
 

How do psychological factors affect the treatment of obesity?

Psychological factors are important triggers for weight gain. As the degree of obesity increases, so does the predisposition to mental health problems such as anxiety, mood disorders, personality disorders, and eating disorders. Understanding these factors is important because accurate psychodiagnosis is essential for effective disease treatment.

Without a proper diagnosis, the treatment may be incomplete and omit relevant factors. For example, a person with undiagnosed depression who is starting treatment for weight loss may feel discouraged and low on energy. He or she may wrongly attribute these symptoms to the diet or surgery. Similarly, someone undergoing bariatric surgery may confuse malnutrition symptoms with depression, resulting in inadequate treatment with antidepressants and possible iatrogenic complications.

Furthermore, psychotherapy and psychological follow-up are essential to help the individual organize better and understand the treatment and the disease itself. This is especially important in stigmatized diseases and those subject to prejudice such as obesity, where understanding and acceptance are often challenging, which affects treatment adherence.

Is the collaboration between psychologist and psychiatrist always necessary?

Often, it is necessary to have the support of both a psychologist and a psychiatrist. The process generally begins with a good psychodiagnosis. Initially, there may not be a case that requires treatment, but it is important to perform this evaluation to rule out any issues.

The follow-up, unlike weekly psychotherapy, can be monthly or at an interval agreed on with the patient. It is crucial to help him or her navigate the various stages of obesity treatment. For example, the patient may be going through a period of mourning or separation, or a happier moment, such as the beginning of a relationship or the birth of a child in the family. These moments affect eating habits and need to be well managed.

Depending on the degree of the pathology, such as depression, severe binge-eating disorder, or personality disorders, the psychologist works in conjunction with the psychiatrist. When we talk about obesity, we are possibly also talking about a psychiatric population because it is a disease that, besides being highly recurrent, involves many other factors, such as the gaze of others, difficulty with dressing, body pains, mobility, and relationships. Therefore, having this disease alone is already a trigger for disorders such as depression.
 

What is the main evidence regarding the psychological follow-up of patients with obesity?

Several studies have investigated the relationship between obesity and mental health. Research indicates that the greater the obesity, the higher the likelihood of a positive diagnosis for a psychiatric disorder. Additionally, there is evidence of the benefits of psychological treatment for patients with obesity.

A study published in the Journal of Clinical Endocrinology and Metabolism addressed the impact of cognitive-behavioral therapy (CBT), which helps patients manage goals and treat maladaptive behaviors such as binge-eating disorders. CBT has a modest effect on weight loss, but its integration as part of a lifestyle modification amplifies the results of this loss.

Recent research also shows that weight loss through bariatric surgery offers significant psychological benefits. In the past, it was believed that this procedure could cause depression and other severe psychiatric disorders, but it is now more than proven that weight loss, when done properly and without misconduct or malnutrition, improves psychological and psychiatric issues.
 

How does psychological follow-up affect the use of medication during obesity treatment?

Many people who take medications, such as corticosteroids for chronic pain or psychiatric medications, may experience weight gain. It is essential to discuss these issues with the psychiatrist because if the patient already has a predisposition to weight gain, medication X should be chosen instead of medication Y, or the dosage should be adjusted. The psychiatrist needs to understand obesity to medicate correctly. Other types of medication, such as chemotherapeutics, may also cause weight gain, often resulting in more abdominal obesity.

There is also lipedema, a hormone-dependent disease that is different from obesity. In this disease, the person gains weight mainly in the legs and arms. In this case, bariatric surgery may result in weight loss only in specific areas, causing disproportionality and difficulty in understanding for the patient. Therefore, when treating obesity, it is important to analyze the patient from all angles: psychological, physiologic, and physical, considering the diversity of the body, its functioning, and hormonal reactions.

Although psychologists do not prescribe medications, they often explain their functioning to the patient. For example, if a patient is taking a glucagon-like peptide 1 analog and experiences initial nausea, he or she may stop using the treatment because the wrong dose had been started. In this case, the psychologist can explain how the medication works and encourage the patient to discuss adjustments with the doctor, avoiding premature discontinuation.
 

How has the mental health follow-up of patients with obesity evolved over the years?

I started working with people with obesity 25 years ago, when I myself underwent bariatric surgery. At that time, surgeons were used to “solving” the problem and sending the person home. Often, the patient did not even return for surgical follow-up because, in theory, the problem was solved.

Over time, I believe that surgeons learned to talk to the patient, understanding that there is a whole process that even involves creating a bond with the individual who underwent the surgical procedure. Within this process, the importance of the mental health of patients was recognized, and how common it is to confuse a degree of malnutrition with a mental disorder.

Even though I am not a nutritionist, I need to know the difference between a case of malnutrition and depression. So, it is a whole set of factors that needs to be worked on like an orchestra. It is not necessary for this work to be done in the same physical space, but dialogue is important.

Of course, there are things that the patient will only share with the psychologist or with the surgeon, but there are also pieces of information that need to be shared for positive management. I have had patients who were afraid to go back to the nutritionist because they did not lose weight. If they are afraid, it is because the professional is guiding them incorrectly.
 

What tips would you give to clinicians regarding the psychological approach to people with obesity?

Accessibility is crucial. When someone tells me they are dealing with obesity and depression, I usually ask, “Did you know you have two chronic diseases?” It is essential to explain these concepts because the patient may often think they are free after a successful diet and weight loss, which is not true because of the high relapse associated with obesity. Depression and anxiety follow similar patterns. If the same person wears prescription glasses, I interact by saying, “Did you know you have three chronic diseases?” This question often causes surprise. “I hadn’t thought of that.”

It is essential to use accessible language for the patient to understand the functioning of the disease. More important than choosing a treatment approach is understanding the pathophysiology of obesity and its psychological impact. This avoids a one-size-fits-all approach for all patients.

For example, the impact on someone who developed obesity in childhood after suffering physical, moral, or sexual abuse will probably be deeper than on someone in a healthy family who gained weight after becoming sedentary. Each life story requires a personalized approach.

Sometimes, a patient with mild obesity (grade 1) may not seem to need specific interventions at first glance, but it is crucial to listen to his or her story. Similarly, patients with severe obesity (grades 3 or 4) who resist surgery are entitled to other treatment options, and this is perfectly valid. Therefore, it is always important to ask, “Who is this person? What does obesity represent in their story?” Then propose the most appropriate treatment.

Ms. Levy reported having no relevant financial relationships.
 

This story was translated from the Medscape Portuguese edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

TOPLINE:

Elevated blood levels of estradiol are associated with an increased risk for corneal ectasia, characterized by thinning and outward bulging of the tissue, in premenopausal women.

METHODOLOGY:

• Researchers conducted an observational case-control study of premenopausal women with naturally occurring corneal ectasia, named keratoconus (n = 36), or those who developed ectasia after refractive surgery (n = 29) from an eye clinic in Israel between 2019 and 2022, and healthy women from hospital staff (n = 31).
• The median age of the participants was 29, 33, and 31 years, respectively.
• Levels of estradiol in the study participants were measured on the second day of their menstrual cycles.

TAKEAWAY:

• The mean levels of estradiol were 38.0 pg/mL in patients with keratoconus, 43.4 pg/mL in those who developed ectasia after surgery, and 28.6 pg/mL in the healthy controls (all P = .001).
• Increased levels of estradiol were associated with corneal ectasia (adjusted odds ratio, 2.44; P < .001).
• Age and use of oral contraceptives were not associated with the risk for corneal ectasia.

IN PRACTICE:

“Our results could have an impact on patient selection for refractive surgery and on better management of patients with keratoconus,” the authors wrote.

SOURCE:

The study was led by Nir Stanescu, MD, of the Department of Ophthalmology at Assuta Samson Hospital, in Ashdod, Israel. It was published online in the European Journal of Ophthalmology.

LIMITATIONS:

The sample size of the study was relatively small. Causality could not be established due to cross-sectional design. The control group consisting of hospital staff may have led to selection bias. The study did not account for factors such as body mass index, diet, smoking status, alcohol consumption, and exercise, which may affect the circulating levels of estradiol.

DISCLOSURES:

The study did not receive any financial support. The authors declared no conflicts of interests.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Elevated blood levels of estradiol are associated with an increased risk for corneal ectasia, characterized by thinning and outward bulging of the tissue, in premenopausal women.

METHODOLOGY:

• Researchers conducted an observational case-control study of premenopausal women with naturally occurring corneal ectasia, named keratoconus (n = 36), or those who developed ectasia after refractive surgery (n = 29) from an eye clinic in Israel between 2019 and 2022, and healthy women from hospital staff (n = 31).
• The median age of the participants was 29, 33, and 31 years, respectively.
• Levels of estradiol in the study participants were measured on the second day of their menstrual cycles.

TAKEAWAY:

• The mean levels of estradiol were 38.0 pg/mL in patients with keratoconus, 43.4 pg/mL in those who developed ectasia after surgery, and 28.6 pg/mL in the healthy controls (all P = .001).
• Increased levels of estradiol were associated with corneal ectasia (adjusted odds ratio, 2.44; P < .001).
• Age and use of oral contraceptives were not associated with the risk for corneal ectasia.

IN PRACTICE:

“Our results could have an impact on patient selection for refractive surgery and on better management of patients with keratoconus,” the authors wrote.

SOURCE:

The study was led by Nir Stanescu, MD, of the Department of Ophthalmology at Assuta Samson Hospital, in Ashdod, Israel. It was published online in the European Journal of Ophthalmology.

LIMITATIONS:

The sample size of the study was relatively small. Causality could not be established due to cross-sectional design. The control group consisting of hospital staff may have led to selection bias. The study did not account for factors such as body mass index, diet, smoking status, alcohol consumption, and exercise, which may affect the circulating levels of estradiol.

DISCLOSURES:

The study did not receive any financial support. The authors declared no conflicts of interests.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

TOPLINE:

Elevated blood levels of estradiol are associated with an increased risk for corneal ectasia, characterized by thinning and outward bulging of the tissue, in premenopausal women.

METHODOLOGY:

• Researchers conducted an observational case-control study of premenopausal women with naturally occurring corneal ectasia, named keratoconus (n = 36), or those who developed ectasia after refractive surgery (n = 29) from an eye clinic in Israel between 2019 and 2022, and healthy women from hospital staff (n = 31).
• The median age of the participants was 29, 33, and 31 years, respectively.
• Levels of estradiol in the study participants were measured on the second day of their menstrual cycles.

TAKEAWAY:

• The mean levels of estradiol were 38.0 pg/mL in patients with keratoconus, 43.4 pg/mL in those who developed ectasia after surgery, and 28.6 pg/mL in the healthy controls (all P = .001).
• Increased levels of estradiol were associated with corneal ectasia (adjusted odds ratio, 2.44; P < .001).
• Age and use of oral contraceptives were not associated with the risk for corneal ectasia.

IN PRACTICE:

“Our results could have an impact on patient selection for refractive surgery and on better management of patients with keratoconus,” the authors wrote.

SOURCE:

The study was led by Nir Stanescu, MD, of the Department of Ophthalmology at Assuta Samson Hospital, in Ashdod, Israel. It was published online in the European Journal of Ophthalmology.

LIMITATIONS:

The sample size of the study was relatively small. Causality could not be established due to cross-sectional design. The control group consisting of hospital staff may have led to selection bias. The study did not account for factors such as body mass index, diet, smoking status, alcohol consumption, and exercise, which may affect the circulating levels of estradiol.

DISCLOSURES:

The study did not receive any financial support. The authors declared no conflicts of interests.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.

A recent survey by the Pew Research Center has found that among adults younger than 50, the percentage who say they are unlikely to have children rose from 37% to 47%. With this trend freshly etched in my consciousness, I stumbled across an interview with Anastasia Berg, an assistant professor of philosophy at the University of California, Irvine. Professor Berg and Rachel Wiseman have just published What Are Children For? On Ambivalence and Choice. How could a pediatrician with time on his hands ignore a provocative title like that?

I was immediately drawn to Professor Berg’s observations about the “concerns, anxieties, and lines of reasoning people encounter when considering whether or not they should have children.” Prior to the 1960s, motherhood seemed to just be a natural progression from marriage. That’s the way my wife and I approached it when we had our first child while I was in my last year of medical school in 1971. There was no discussion of the pros and cons, except maybe that financially waiting until the eve of my first professional paycheck seemed to make sense.

However, as Professor Berg points out, from the 1960s up until well into the 1980s, as feminist thought gained a higher profile, there were anti-motherhood factions. There were others who wanted to see motherhood reformed and adapted so it “could once again be a legitimate source of meaning and value in life.” However, both camps agreed that the choice to have children was a decision that “women should make completely on their own.”

Now, well into the new millennium, we are looking at a completely different landscape. In the past, having children was woven into the fabric of human life in which we had a past, a present, and a role in creating the future. Professor Berg observes that currently, having children is often considered a project, not unlike our other projects such as “career choice or travel plans.” What are the pluses and minuses?

The Pew Survey found that 60% of adults younger than 50 who don’t have children said that not having children made it less difficult to be successful and have an active social life. Many felt that being a parent would improve the chances of having someone to care for you as you aged.

When my wife and I considered the financial costs of motherhood more than 50 years ago, our calculation was primarily about the timing. The decision to have a second child focused our concern around our ability to balance our attention between two siblings. A third child just sorta happened without any discussion.

Professor Berg echoes the Pew findings when she observes that currently woman are considering the cost in terms of their identities. Will motherhood transform me? Will there be a cost not only to my career but also to all the associations, interests, and activities I have accumulated? These costs are likely to be greater the longer the decision to have a child is put off. She adds that viewing motherhood as a transformation can make the decision to have children scarier than it needs to be. My wife and I, at age 26 and 27, were still in the early stages of building our identities. My wife had a 2-year college degree and no career plans on the horizon. Having a child was one of those things that was built into who we became.

But to compare our experiences in the 1970s to the realities of the first quarter of the 21st century ignores the concerns facing today’s adults who are facing the cloud of uncertainty hanging over all of us. Despite their claims to fix the situation, both sides of the political spectrum are leveraging fear to gain our support. Even climate change skeptics must have some concern in the spate of natural disasters we are experiencing. Not to mention the pandemic. Anxiety in this country is at an all time high. Optimism doesn’t seem to fit into today’s journalists’ lexicon, as they chose to focus on conflict instead of cooperation. It’s hard to question any adult who harbors serious doubts on taking on the challenge of parenthood and bringing a child into a world that feels unsettled.

However, based on her research and her own experience as a parent, Professor Berg offers some advice. She encourages people to think and discuss the decision to have children earlier in their life trajectory, before they have made decisions that may eventually limit their options. Second, she discourages making a list of pros and cons. Finally, she advises taking a long view and ask yourself whether you “choose to take a direct part in ushering in the next generation.”

Sounds like advice that will optimize the chances of making the good decision about having a child. I’m just thankful to have lived at time and in a situation when having child was just the thing most married couples did.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

A recent survey by the Pew Research Center has found that among adults younger than 50, the percentage who say they are unlikely to have children rose from 37% to 47%. With this trend freshly etched in my consciousness, I stumbled across an interview with Anastasia Berg, an assistant professor of philosophy at the University of California, Irvine. Professor Berg and Rachel Wiseman have just published What Are Children For? On Ambivalence and Choice. How could a pediatrician with time on his hands ignore a provocative title like that?

I was immediately drawn to Professor Berg’s observations about the “concerns, anxieties, and lines of reasoning people encounter when considering whether or not they should have children.” Prior to the 1960s, motherhood seemed to just be a natural progression from marriage. That’s the way my wife and I approached it when we had our first child while I was in my last year of medical school in 1971. There was no discussion of the pros and cons, except maybe that financially waiting until the eve of my first professional paycheck seemed to make sense.

However, as Professor Berg points out, from the 1960s up until well into the 1980s, as feminist thought gained a higher profile, there were anti-motherhood factions. There were others who wanted to see motherhood reformed and adapted so it “could once again be a legitimate source of meaning and value in life.” However, both camps agreed that the choice to have children was a decision that “women should make completely on their own.”

Now, well into the new millennium, we are looking at a completely different landscape. In the past, having children was woven into the fabric of human life in which we had a past, a present, and a role in creating the future. Professor Berg observes that currently, having children is often considered a project, not unlike our other projects such as “career choice or travel plans.” What are the pluses and minuses?

The Pew Survey found that 60% of adults younger than 50 who don’t have children said that not having children made it less difficult to be successful and have an active social life. Many felt that being a parent would improve the chances of having someone to care for you as you aged.

When my wife and I considered the financial costs of motherhood more than 50 years ago, our calculation was primarily about the timing. The decision to have a second child focused our concern around our ability to balance our attention between two siblings. A third child just sorta happened without any discussion.

Professor Berg echoes the Pew findings when she observes that currently woman are considering the cost in terms of their identities. Will motherhood transform me? Will there be a cost not only to my career but also to all the associations, interests, and activities I have accumulated? These costs are likely to be greater the longer the decision to have a child is put off. She adds that viewing motherhood as a transformation can make the decision to have children scarier than it needs to be. My wife and I, at age 26 and 27, were still in the early stages of building our identities. My wife had a 2-year college degree and no career plans on the horizon. Having a child was one of those things that was built into who we became.

But to compare our experiences in the 1970s to the realities of the first quarter of the 21st century ignores the concerns facing today’s adults who are facing the cloud of uncertainty hanging over all of us. Despite their claims to fix the situation, both sides of the political spectrum are leveraging fear to gain our support. Even climate change skeptics must have some concern in the spate of natural disasters we are experiencing. Not to mention the pandemic. Anxiety in this country is at an all time high. Optimism doesn’t seem to fit into today’s journalists’ lexicon, as they chose to focus on conflict instead of cooperation. It’s hard to question any adult who harbors serious doubts on taking on the challenge of parenthood and bringing a child into a world that feels unsettled.

However, based on her research and her own experience as a parent, Professor Berg offers some advice. She encourages people to think and discuss the decision to have children earlier in their life trajectory, before they have made decisions that may eventually limit their options. Second, she discourages making a list of pros and cons. Finally, she advises taking a long view and ask yourself whether you “choose to take a direct part in ushering in the next generation.”

Sounds like advice that will optimize the chances of making the good decision about having a child. I’m just thankful to have lived at time and in a situation when having child was just the thing most married couples did.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

A recent survey by the Pew Research Center has found that among adults younger than 50, the percentage who say they are unlikely to have children rose from 37% to 47%. With this trend freshly etched in my consciousness, I stumbled across an interview with Anastasia Berg, an assistant professor of philosophy at the University of California, Irvine. Professor Berg and Rachel Wiseman have just published What Are Children For? On Ambivalence and Choice. How could a pediatrician with time on his hands ignore a provocative title like that?

I was immediately drawn to Professor Berg’s observations about the “concerns, anxieties, and lines of reasoning people encounter when considering whether or not they should have children.” Prior to the 1960s, motherhood seemed to just be a natural progression from marriage. That’s the way my wife and I approached it when we had our first child while I was in my last year of medical school in 1971. There was no discussion of the pros and cons, except maybe that financially waiting until the eve of my first professional paycheck seemed to make sense.

However, as Professor Berg points out, from the 1960s up until well into the 1980s, as feminist thought gained a higher profile, there were anti-motherhood factions. There were others who wanted to see motherhood reformed and adapted so it “could once again be a legitimate source of meaning and value in life.” However, both camps agreed that the choice to have children was a decision that “women should make completely on their own.”

Now, well into the new millennium, we are looking at a completely different landscape. In the past, having children was woven into the fabric of human life in which we had a past, a present, and a role in creating the future. Professor Berg observes that currently, having children is often considered a project, not unlike our other projects such as “career choice or travel plans.” What are the pluses and minuses?

The Pew Survey found that 60% of adults younger than 50 who don’t have children said that not having children made it less difficult to be successful and have an active social life. Many felt that being a parent would improve the chances of having someone to care for you as you aged.

When my wife and I considered the financial costs of motherhood more than 50 years ago, our calculation was primarily about the timing. The decision to have a second child focused our concern around our ability to balance our attention between two siblings. A third child just sorta happened without any discussion.

Professor Berg echoes the Pew findings when she observes that currently woman are considering the cost in terms of their identities. Will motherhood transform me? Will there be a cost not only to my career but also to all the associations, interests, and activities I have accumulated? These costs are likely to be greater the longer the decision to have a child is put off. She adds that viewing motherhood as a transformation can make the decision to have children scarier than it needs to be. My wife and I, at age 26 and 27, were still in the early stages of building our identities. My wife had a 2-year college degree and no career plans on the horizon. Having a child was one of those things that was built into who we became.

But to compare our experiences in the 1970s to the realities of the first quarter of the 21st century ignores the concerns facing today’s adults who are facing the cloud of uncertainty hanging over all of us. Despite their claims to fix the situation, both sides of the political spectrum are leveraging fear to gain our support. Even climate change skeptics must have some concern in the spate of natural disasters we are experiencing. Not to mention the pandemic. Anxiety in this country is at an all time high. Optimism doesn’t seem to fit into today’s journalists’ lexicon, as they chose to focus on conflict instead of cooperation. It’s hard to question any adult who harbors serious doubts on taking on the challenge of parenthood and bringing a child into a world that feels unsettled.

However, based on her research and her own experience as a parent, Professor Berg offers some advice. She encourages people to think and discuss the decision to have children earlier in their life trajectory, before they have made decisions that may eventually limit their options. Second, she discourages making a list of pros and cons. Finally, she advises taking a long view and ask yourself whether you “choose to take a direct part in ushering in the next generation.”

Sounds like advice that will optimize the chances of making the good decision about having a child. I’m just thankful to have lived at time and in a situation when having child was just the thing most married couples did.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

I need a hobby. Any suggestions?

Due to the annual summertime slowdown, I find myself with less to do and catch up on during weekends. My kids are grown. Nowadays, when I have free time, I have no idea what to do with myself.

That’s not to say I don’t do things to relax. Jigsaw puzzles, reading P.G. Wodehouse ... but there’s only so long I can sit there, maybe 30 minutes, before I get bored. Then I go back to my desk, check email, log in to see if any prescription refills need to be addressed ...

I look online for ideas. No, I don’t want to collect things. Or start gardening. Or learn an instrument. Or paint. Or take up photography. The last thing I want is a hobby that involves a significant financial outlay for stuff I may be selling on eBay in 3 months.

Dr. Block has a solo neurology practice in Scottsdale, Arizona.

I need a hobby. Any suggestions?

Due to the annual summertime slowdown, I find myself with less to do and catch up on during weekends. My kids are grown. Nowadays, when I have free time, I have no idea what to do with myself.

That’s not to say I don’t do things to relax. Jigsaw puzzles, reading P.G. Wodehouse ... but there’s only so long I can sit there, maybe 30 minutes, before I get bored. Then I go back to my desk, check email, log in to see if any prescription refills need to be addressed ...

I look online for ideas. No, I don’t want to collect things. Or start gardening. Or learn an instrument. Or paint. Or take up photography. The last thing I want is a hobby that involves a significant financial outlay for stuff I may be selling on eBay in 3 months.

Dr. Block has a solo neurology practice in Scottsdale, Arizona.

I need a hobby. Any suggestions?

Due to the annual summertime slowdown, I find myself with less to do and catch up on during weekends. My kids are grown. Nowadays, when I have free time, I have no idea what to do with myself.

That’s not to say I don’t do things to relax. Jigsaw puzzles, reading P.G. Wodehouse ... but there’s only so long I can sit there, maybe 30 minutes, before I get bored. Then I go back to my desk, check email, log in to see if any prescription refills need to be addressed ...

I look online for ideas. No, I don’t want to collect things. Or start gardening. Or learn an instrument. Or paint. Or take up photography. The last thing I want is a hobby that involves a significant financial outlay for stuff I may be selling on eBay in 3 months.

Dr. Block has a solo neurology practice in Scottsdale, Arizona.

Introduction

Abdominal bloating is a common condition affecting up to 3.5% of people globally (4.6% in women and 2.4% in men),¹ with 13.9% of the US population reporting bloating in the past 7 days.² The prevalence of bloating and distention exceeds 50% when linked to disorders of gut-brain interaction (DGBIs) such as irritable bowel syndrome (IBS), constipation, gastroparesis, and functional dyspepsia (FD).^3,4 According to the Rome IV criteria, functional bloating and distention (FABD) patients are characterized by recurrent symptoms of abdominal fullness or pressure (bloating), or a visible increase in abdominal girth (distention) occurring at least 1 day per week for 3 consecutive months with an onset of 6 months and without predominant pain or altered bowel habits.⁵

Prolonged abdominal bloating and distention (ABD) can significantly impact quality of life and work productivity and can lead to increased medical consultations.² Multiple pathophysiological mechanisms are involved in ABD that complicate the clinical management.⁴ There is an unmet need to understand the underlying mechanisms that lead to the development of ABD such as, food intolerance, abnormal viscerosomatic reflex, visceral hypersensitivity, and gut microbial dysbiosis. Recent advancements and acceptance of a multidisciplinary management of ABD have shifted the paradigm from merely treating symptoms to subtyping the condition and identifying overlaps with other DGBIs in order to individualize treatment that addresses the underlying pathophysiological mechanism. The recent American Gastroenterological Association (AGA) clinical update provided insights into the best practice advice for evaluating and managing ABD based on a review of current literature and on expert opinion of coauthors.⁶ This article aims to deliberate a practical approach to diagnostic strategies and treatment options based on etiology to refine clinical care of patients with ABD.

University of Nevada, Reno

Pathophysiological Mechanisms

ABD can result from various pathophysiological mechanisms. This section highlights the major causes (illustrated in Figure 1).

Food intolerances

Understanding food intolerances is crucial for diagnosing and managing patients with ABD. Disaccharidase deficiency is common (e.g., lactase deficiency is found in 35%-40% of adults).⁷ It can be undiagnosed in patients presenting with IBS symptoms, given the overlap in presentation with a prevalence of 9% of pan-disaccharidase deficiency. Sucrase-deficient patients must often adjust sugar and carbohydrate/starch intake to relieve symptoms.⁷ Deficiencies in lactase and sucrase activity, along with the consumption of some artificial sweeteners (e.g., sugar alcohols and sorbitol) and fructans can lead to bloating and distention. These substances increase osmotic load, fluid retention, microbial fermentation, and visceral hypersensitivity, leading to gas production and abdominal distention. One prospective study of symptomatic patients with various DGBIs (n = 1372) reported a prevalence of lactose intolerance and malabsorption at 51% and 32%, respectively.⁸ Furthermore, fructose intolerance and malabsorption prevalence were 60% and 45%, respectively.⁸ Notably, lactase deficiency does not always cause ABD, as not all individuals with lactase deficiency experience these symptoms after consuming lactose. Patients with celiac disease (CD), non-celiac gluten sensitivity (NCGS), and gluten intolerance can also experience bloating and distention, with or without changes in bowel habits.⁹ In some patients with self-reported NCGS, symptoms may be due to fructans in gluten-rich foods rather than gluten itself, thus recommending the elimination of fructans may help improve symptoms.⁹

Visceral hypersensitivity

Visceral hypersensitivity is explained by an increased perception of gut mechano-chemical stimulation, which typically manifests in an aggravated feeling of pain, nausea, distension, and ABD.¹⁰ In the gut, food particles and gut bacteria and their derived molecules interact with neuroimmune and enteroendocrine cells causing visceral sensitivity by the proximity of gut’s neurons to immune cells activated by them and leading to inflammatory reactions (Figure 1).

Dr. Singh and Dr. Moshiree

Pelvic floor dysfunction

Patients with anorectal motor dysfunction often experience difficulty in effectively evacuating both gas and stool, leading to ABD.¹² Impaired ability to expel gas and stool results in prolonged balloon expulsion times, which correlates with symptoms of distention in patients with constipation.

Atrium Health

Abdominophrenic dyssynergia

Abdominophrenic dyssynergia is characterized as a paradoxical viscerosomatic reflex response to minimal gaseous distention in individuals with FABD.¹³ In this condition, the diaphragm contracts (descends), and the anterior abdominal wall muscles relax in response to the presence of gas. This response is opposite to the normal physiological response to increased intraluminal gas, where the diaphragm relaxes and the anterior abdominal muscles contract to increase the craniocaudal capacity of the abdominal cavity without causing abdominal protrusion.¹³ Patients with FABD exhibit significant abdominal wall protrusion and diaphragmatic descent even with relatively small increases in intraluminal gas.¹¹ Understanding the role of abdominophrenic dyssynergia in abdominal bloating and distention is essential for effective diagnosis and management of the patients.

Gut dysmotility

Gut dysmotility is a crucial factor that can contribute to FABD. Gut dysmotility affects the movement of contents through the GI tract, accumulating gas and stool, directly contributing to bloating and distention. A prospective study involving over 2000 patients with functional constipation and constipation predominant-IBS (IBS-C) found that more than 90% of these patients reported symptoms of bloating.¹⁴ Furthermore, in IBS-C patients, those with prolonged colonic transit exhibited greater abdominal distention compared to those with normal gut transit times. In patients with gastroparesis, delayed gastric emptying resulting in prolonged retention of stomach contents is the main factor in the generation of bloating symptoms.⁴

Small intestinal bacterial overgrowth (SIBO)

SIBO is overrepresented in various conditions, including IBS, FD, diabetes, gastrointestinal (GI) surgery patients and obesity, and can play an important role in generating ABD. Excess bacteria in the small intestine ferment carbohydrates, producing gas that stretches and distends the small intestine, leading to these symptoms. Additionally, altered sensation and abnormal viscerosomatic reflexes may contribute to SIBO-related bloating.⁴ One recent study noted decreased duodenal phylogenetic diversity in individuals who developed postprandial bloating.¹⁵ Increased methane levels caused by intestinal methanogen overgrowth, primarily the archaea Methanobrevibacter smithii, is possibly responsible for ABD in patients with IBS-C.¹⁶ Testing for SIBO in patients with ABD is generally only recommended if there are clear risk factors or severe symptoms warranting a test-and-treat approach.

Practical Diagnosis

Diagnosing ABD typically does not require extensive laboratory testing, imaging, or endoscopy unless there are alarm features or significant changes in symptoms. Here is the AGA clinical update on best practice advice⁶ for when to conduct further testing:

Diagnostic tests should be considered if patients exhibit:

• Recent onset or worsening of dyspepsia or abdominal pain
• Vomiting
• GI bleeding
• Unintentional weight loss exceeding 10% of body weight
• Chronic diarrhea
• Family history of GI malignancy, celiac disease, or inflammatory bowel disease

Physical examination

If visible abdominal distention is present, a thorough abdominal examination can help identify potential issues:

• Tympany to percussion suggests bowel dilation.
• Abnormal bowel sounds may indicate obstruction or ileus.
• A succussion splash could indicate the presence of ascites and obstruction.
• Any abnormalities discovered during the physical exam should prompt further investigation with imaging, such as a computed tomography (CT) scan or ultrasound, to evaluate for ascites, masses, or increased bowel gas due to ileus, obstruction, or pseudo-obstruction.

Radiologic imaging, laboratory testing and endoscopy

• An abdominal x-ray may reveal an increased stool burden, suggesting the need for further evaluation of slow transit constipation or a pelvic floor disorder, particularly in patients with functional constipation, IBS-mixed, or IBS-C.
• Hyperglycemia, weight gain, and bloating can be a presenting sign of ovarian cancer therefore all women should continue pelvic exams as dictated by the gynecologic societies. The need for an annual pelvic exam should be discussed with health care professionals especially in those with family history of ovarian cancer.
• An upper endoscopy may be warranted for patients over 40 years old with dyspeptic symptoms and abdominal bloating or distention, especially in regions with a high prevalence of Helicobacter pylori.
• Chronic pancreatitis, indicated by bloating and pain, may necessitate fecal elastase testing to assess pancreatic function.

The expert review in the AGA clinical update provides step-by-step advice regarding the best practices⁶ for diagnosis and identifying who to test for ABD.
 

Treatment Options

The following sections highlight recent best practice advice on therapeutic approaches for treating ABD.

Dietary interventions

Specific foods may trigger bloating and abdominal distention, especially in patients with overlapping DGBIs. However, only a few studies have evaluated dietary restriction specifically for patients with primary ABD. Restricting non-absorbable sugars led to symptomatic improvement in 81% of patients with FABD who had documented sugar malabsorption.¹⁷ Two studies have shown that IBS patients treated with a low-fermentable, oligo-, di-, and monosaccharides (FODMAP) diet noted improvement in ABD and that restricting fructans initially may be the most optimal.¹⁸ A recent study showed that the Mediterranean diet improved IBS symptoms, including abdominal pain and bloating.¹⁹ It should be noted restrictive diets are efficacious but come with short- and long-term challenges. If empiric treatment and/or therapeutic testing do not resolve symptoms, a referral to a dietitian can be useful. Dietitians can provide tailored dietary advice, ensuring patients avoid trigger foods while maintaining a balanced and nutritious diet.

Prokinetics and laxatives

Prokinetic agents are used to treat symptoms of FD, gastroparesis, chronic idiopathic constipation (CIC), and IBS. A meta-analysis of 13 trials found all constipation medications superior to placebo for treating abdominal bloating in patients with IBS-C.²⁰

Probiotics

Treatment with probiotics is recommended for bloating or distention. One double-blind placebo-controlled trial with two separate probiotics, Bifidobacterium lactis and Lactobacillus acidophilus, showed improvements in global GI symptoms of patients with DGBI at 8 weeks versus placebo, with improvements in bloating symptoms.²¹

Antibiotics

The most commonly studied antibiotic for treating bloating is rifaximin.²² Global symptomatic improvement in IBS patients treated with antibiotics has correlated with the normalization of hydrogen levels in lactulose hydrogen breath tests.²² Patients with non-constipation IBS randomized to rifaximin 550 mg three times daily for 14 days had a greater proportion of relief of IBS-related bloating compared to placebo for at least 2 of the first 4 weeks after treatment.²² Future research warrants use of narrow-spectrum antibiotics study for FABD as the use of broad-spectrum antibiotics may deplete commensals forever, resulting in metabolic disorders.

Biofeedback therapy

Anorectal biofeedback therapy may help with ABD, particularly in patients with IBS-C and chronic constipation. One study noted that post-biofeedback therapy, myoelectric activity of the intercostals and diaphragm decreased, and internal oblique myoelectric activity increased.²³ This study also showed ascent of the diaphragm and decreased girth, improving distention.

Central neuromodulators

As bloating results from multiple disturbed mechanisms, including altered gut-brain interaction, these symptoms can be amplified by psychological states such as anxiety, depression, or somatization. Central neuromodulators reduce the perception of visceral signals, re-regulate brain-gut control mechanisms, and improve psychological comorbidities.⁶ A large study of FD patients demonstrated that both amitriptyline (50 mg daily) and escitalopram (10 mg daily) significantly improved postprandial bloating compared to placebo.²⁴ Antidepressants that activate noradrenergic and serotonergic pathways, including tricyclic antidepressants (e.g., amitriptyline) and serotonin-norepinephrine reuptake inhibitors (e.g., duloxetine and venlafaxine), show the greatest benefit in reducing visceral sensations.⁶

Brain-gut behavioral therapies

A recent multidisciplinary consensus report supports a myriad of potential brain-gut behavioral therapies (BGBTs) for treating DGBI.²⁵ These therapies, including hypnotherapy, cognitive behavioral therapy (CBT), and other modalities, may be combined with central neuromodulators and other GI treatments in a safe, noninvasive, and complementary fashion. BGBTs do not need to be symptom-specific, as they improve overall quality of life, anxiety, stress, and the burden associated with DGBIs. To date, none of the BGBTs have focused exclusively on FABD; however, prescription-based psychological therapies are now FDA-approved for use on smart apps, improving global symptoms that include bloating in IBS and FD.

Recent AGA clinical update best practices should be considered for the clinical care of patients with ABD.⁶

Conclusion and Future Perspectives

ABD are highly prevalent and significantly impact patients with various GI and metabolic disorders. Although our understanding of these symptoms is still evolving, evidence increasingly points to the dysregulation of the gut-brain axis and supports the application of the biopsychosocial model in treatment. This model addresses diet, motility, visceral sensitivity, pelvic floor disorders and psychosocial factors, providing a comprehensive approach to patient care.

Physician-scientists around the globe face numerous challenges when evaluating patients with these symptoms. However, the recent AGA clinical update on the best practice guidelines offers step-by-step diagnostic tests and treatment options to assist physicians in making informed decisions. A multidisciplinary approach and a patient-centered model are essential for effectively managing treatment in patients with ABD. More comprehensive, large-scale, and longitudinal studies using metabolomics, capsule technologies for discovery of dysbiosis, mass spectrometry, and imaging data are needed to identify the exact contributors to disease pathogenesis, particularly those that can be targeted with pharmacologic agents. Collaborative work between gastroenterologists, dietitians, gut-brain behavioral therapists, endocrinologists, is crucial for clinical care of patients with ABD.

Careful attention to the patient’s primary symptoms and physical examination, combined with advancements in targeted diagnostics like the analysis of microbial markers, metabolites, and molecular signals, can significantly enhance patient clinical outcomes. Additionally, education and effective communication using a patient-centered care model are essential for guiding practical evaluation and individualized treatment.

Dr. Singh is assistant professor (research) at the University of Nevada, Reno, School of Medicine. Dr. Moshiree is director of motility at Atrium Health, and clinical professor of medicine, Wake Forest Medical University, Charlotte, North Carolina.

References

1. Ballou S et al. Prevalence and associated factors of bloating: Results from the Rome Foundation Global Epidemiology Study. Gastroenterology. 2023 June. doi: 10.1053/j.gastro.2023.05.049.

2. Oh JE et al. Abdominal bloating in the United States: Results of a survey of 88,795 Americans examining prevalence and healthcare seeking. Clin Gastroenterol Hepatol. 2023 Aug. doi: 10.1016/j.cgh.2022.10.031.

3. Drossman DA et al. Neuromodulators for functional gastrointestinal disorders (disorders of gut-brain interaction): A Rome Foundation Working Team Report. Gastroenterology. 2018 Mar. doi: 10.1053/j.gastro.2017.11.279.

4. Lacy BE et al. Management of chronic abdominal distension and bloating. Clin Gastroenterol Hepatol. 2021 Feb. doi: 10.1016/j.cgh.2020.03.056.

5. Mearin F et al. Bowel disorders. Gastroenterology. 2016 Feb. doi: 10.1053/j.gastro.2016.02.031.

6. Moshiree B et al. AGA Clinical Practice Update on evaluation and management of belching, abdominal bloating, and distention: expert review. Gastroenterology. 2023 Sep. doi: 10.1053/j.gastro.2023.04.039.

7. Viswanathan L and Rao SS. Intestinal disaccharidase deficiency in adults: evaluation and treatment. Curr Gastroenterol Rep 2023 May. doi: 10.1007/s11894-023-00870-z.

8. Wilder-Smith CH et al. Fructose and lactose intolerance and malabsorption testing: the relationship with symptoms in functional gastrointestinal disorders. Aliment Pharmacol Ther. 2013 Jun. doi: 10.1111/apt.12306.

9. Skodje GI et al. Fructan, rather than gluten, induces symptoms in patients with self-reported non-celiac gluten sensitivity. Gastroenterology. 2018 Feb. doi: 10.1053/j.gastro.2017.10.040.

10. Singh R et al. Current treatment options and therapeutic insights for gastrointestinal dysmotility and functional gastrointestinal disorders. Front Pharmacol. 2022 Jan. doi: 10.3389/fphar.2022.808195.

11. Accarino A et al. Abdominal distention results from caudo-ventral redistribution of contents. Gastroenterology 2009 May. doi: 10.1053/j.gastro.2009.01.067.

12. Shim L et al. Prolonged balloon expulsion is predictive of abdominal distension in bloating. Am J Gastroenterol. 2010 Apr. doi: 10.1038/ajg.2010.54.

13. Villoria A et al. Abdomino-phrenic dyssynergia in patients with abdominal bloating and distension. Am J Gastroenterol. 2011 May. doi: 10.1038/ajg.2010.408.

14. Neri L and Iovino P. Laxative Inadequate Relief Survey Group. Bloating is associated with worse quality of life, treatment satisfaction, and treatment responsiveness among patients with constipation-predominant irritable bowel syndrome and functional constipation. Neurogastroenterol Motil. 2016 Apr. doi: 10.1111/nmo.12758.

15. Saffouri GB et al. Small intestinal microbial dysbiosis underlies symptoms associated with functional gastrointestinal disorders. Nat Commun. 2019 May. doi: 10.1038/s41467-019-09964-7.

16. Villanueva-Millan MJ et al. Methanogens and hydrogen sulfide producing bacteria guide distinct gut microbe profiles and irritable bowel syndrome subtypes. Am J Gastroenterol. 2022 Dec. doi: 10.14309/ajg.0000000000001997.

17. Fernández-Bañares F et al. Sugar malabsorption in functional abdominal bloating: a pilot study on the long-term effect of dietary treatment. Clin Nutr. 2006 Oct. doi: 10.1016/j.clnu.2005.11.010.

18. Böhn L et al. Diet low in FODMAPs reduces symptoms of irritable bowel syndrome as well as traditional dietary advice: a randomized controlled trial. Gastroenterology. 2015 Nov. doi: 10.1053/j.gastro.2015.07.054.

19. Staudacher HM et al. Clinical trial: A Mediterranean diet is feasible and improves gastrointestinal and psychological symptoms in irritable bowel syndrome. Aliment Pharmacol Ther. 2024 Feb. doi: 10.1111/apt.17791.

20. Nelson AD et al. Systematic review and network meta-analysis: efficacy of licensed drugs for abdominal bloating in irritable bowel syndrome with constipation. Aliment Pharmacol Ther. 2021 Jul. doi: 10.1111/apt.16437.

21. Ringel-Kulka T et al. Probiotic bacteria Lactobacillus acidophilus NCFM and Bifidobacterium lactis Bi-07 versus placebo for the symptoms of bloating in patients with functional bowel disorders: a double-blind study. J Clin Gastroenterol. 2011 Jul. doi: 10.1097/MCG.0b013e31820ca4d6.

22. Pimentel M et al. Rifaximin therapy for patients with irritable bowel syndrome without constipation. N Engl J Med. 2011 Jan. doi: 10.1056/NEJMoa1004409.

23. Iovino P et al. Pelvic floor biofeedback is an effective treatment for severe bloating in disorders of gut-brain interaction with outlet dysfunction. Neurogastroenterol Motil 2022 May. doi: 10.1111/nmo.14264.

24. Talley NJ et al. Effect of amitriptyline and escitalopram on functional dyspepsia: A multicenter, randomized controlled study. Gastroenterology. 2015 Aug. doi: 10.1053/j.gastro.2015.04.020.

25. Keefer L et al. A Rome Working Team Report on brain-gut behavior therapies for disorders of gut-brain interaction. Gastroenterology. 2022 Jan. doi: 10.1053/j.gastro.2021.09.015.

Introduction

Abdominal bloating is a common condition affecting up to 3.5% of people globally (4.6% in women and 2.4% in men),¹ with 13.9% of the US population reporting bloating in the past 7 days.² The prevalence of bloating and distention exceeds 50% when linked to disorders of gut-brain interaction (DGBIs) such as irritable bowel syndrome (IBS), constipation, gastroparesis, and functional dyspepsia (FD).^3,4 According to the Rome IV criteria, functional bloating and distention (FABD) patients are characterized by recurrent symptoms of abdominal fullness or pressure (bloating), or a visible increase in abdominal girth (distention) occurring at least 1 day per week for 3 consecutive months with an onset of 6 months and without predominant pain or altered bowel habits.⁵

Prolonged abdominal bloating and distention (ABD) can significantly impact quality of life and work productivity and can lead to increased medical consultations.² Multiple pathophysiological mechanisms are involved in ABD that complicate the clinical management.⁴ There is an unmet need to understand the underlying mechanisms that lead to the development of ABD such as, food intolerance, abnormal viscerosomatic reflex, visceral hypersensitivity, and gut microbial dysbiosis. Recent advancements and acceptance of a multidisciplinary management of ABD have shifted the paradigm from merely treating symptoms to subtyping the condition and identifying overlaps with other DGBIs in order to individualize treatment that addresses the underlying pathophysiological mechanism. The recent American Gastroenterological Association (AGA) clinical update provided insights into the best practice advice for evaluating and managing ABD based on a review of current literature and on expert opinion of coauthors.⁶ This article aims to deliberate a practical approach to diagnostic strategies and treatment options based on etiology to refine clinical care of patients with ABD.

University of Nevada, Reno

Pathophysiological Mechanisms

ABD can result from various pathophysiological mechanisms. This section highlights the major causes (illustrated in Figure 1).

Food intolerances

Understanding food intolerances is crucial for diagnosing and managing patients with ABD. Disaccharidase deficiency is common (e.g., lactase deficiency is found in 35%-40% of adults).⁷ It can be undiagnosed in patients presenting with IBS symptoms, given the overlap in presentation with a prevalence of 9% of pan-disaccharidase deficiency. Sucrase-deficient patients must often adjust sugar and carbohydrate/starch intake to relieve symptoms.⁷ Deficiencies in lactase and sucrase activity, along with the consumption of some artificial sweeteners (e.g., sugar alcohols and sorbitol) and fructans can lead to bloating and distention. These substances increase osmotic load, fluid retention, microbial fermentation, and visceral hypersensitivity, leading to gas production and abdominal distention. One prospective study of symptomatic patients with various DGBIs (n = 1372) reported a prevalence of lactose intolerance and malabsorption at 51% and 32%, respectively.⁸ Furthermore, fructose intolerance and malabsorption prevalence were 60% and 45%, respectively.⁸ Notably, lactase deficiency does not always cause ABD, as not all individuals with lactase deficiency experience these symptoms after consuming lactose. Patients with celiac disease (CD), non-celiac gluten sensitivity (NCGS), and gluten intolerance can also experience bloating and distention, with or without changes in bowel habits.⁹ In some patients with self-reported NCGS, symptoms may be due to fructans in gluten-rich foods rather than gluten itself, thus recommending the elimination of fructans may help improve symptoms.⁹

Visceral hypersensitivity

Visceral hypersensitivity is explained by an increased perception of gut mechano-chemical stimulation, which typically manifests in an aggravated feeling of pain, nausea, distension, and ABD.¹⁰ In the gut, food particles and gut bacteria and their derived molecules interact with neuroimmune and enteroendocrine cells causing visceral sensitivity by the proximity of gut’s neurons to immune cells activated by them and leading to inflammatory reactions (Figure 1).

Dr. Singh and Dr. Moshiree

Pelvic floor dysfunction

Patients with anorectal motor dysfunction often experience difficulty in effectively evacuating both gas and stool, leading to ABD.¹² Impaired ability to expel gas and stool results in prolonged balloon expulsion times, which correlates with symptoms of distention in patients with constipation.

Atrium Health

Abdominophrenic dyssynergia

Abdominophrenic dyssynergia is characterized as a paradoxical viscerosomatic reflex response to minimal gaseous distention in individuals with FABD.¹³ In this condition, the diaphragm contracts (descends), and the anterior abdominal wall muscles relax in response to the presence of gas. This response is opposite to the normal physiological response to increased intraluminal gas, where the diaphragm relaxes and the anterior abdominal muscles contract to increase the craniocaudal capacity of the abdominal cavity without causing abdominal protrusion.¹³ Patients with FABD exhibit significant abdominal wall protrusion and diaphragmatic descent even with relatively small increases in intraluminal gas.¹¹ Understanding the role of abdominophrenic dyssynergia in abdominal bloating and distention is essential for effective diagnosis and management of the patients.

Gut dysmotility

Gut dysmotility is a crucial factor that can contribute to FABD. Gut dysmotility affects the movement of contents through the GI tract, accumulating gas and stool, directly contributing to bloating and distention. A prospective study involving over 2000 patients with functional constipation and constipation predominant-IBS (IBS-C) found that more than 90% of these patients reported symptoms of bloating.¹⁴ Furthermore, in IBS-C patients, those with prolonged colonic transit exhibited greater abdominal distention compared to those with normal gut transit times. In patients with gastroparesis, delayed gastric emptying resulting in prolonged retention of stomach contents is the main factor in the generation of bloating symptoms.⁴

Small intestinal bacterial overgrowth (SIBO)

SIBO is overrepresented in various conditions, including IBS, FD, diabetes, gastrointestinal (GI) surgery patients and obesity, and can play an important role in generating ABD. Excess bacteria in the small intestine ferment carbohydrates, producing gas that stretches and distends the small intestine, leading to these symptoms. Additionally, altered sensation and abnormal viscerosomatic reflexes may contribute to SIBO-related bloating.⁴ One recent study noted decreased duodenal phylogenetic diversity in individuals who developed postprandial bloating.¹⁵ Increased methane levels caused by intestinal methanogen overgrowth, primarily the archaea Methanobrevibacter smithii, is possibly responsible for ABD in patients with IBS-C.¹⁶ Testing for SIBO in patients with ABD is generally only recommended if there are clear risk factors or severe symptoms warranting a test-and-treat approach.

Practical Diagnosis

Diagnosing ABD typically does not require extensive laboratory testing, imaging, or endoscopy unless there are alarm features or significant changes in symptoms. Here is the AGA clinical update on best practice advice⁶ for when to conduct further testing:

Diagnostic tests should be considered if patients exhibit:

• Recent onset or worsening of dyspepsia or abdominal pain
• Vomiting
• GI bleeding
• Unintentional weight loss exceeding 10% of body weight
• Chronic diarrhea
• Family history of GI malignancy, celiac disease, or inflammatory bowel disease

Physical examination

If visible abdominal distention is present, a thorough abdominal examination can help identify potential issues:

• Tympany to percussion suggests bowel dilation.
• Abnormal bowel sounds may indicate obstruction or ileus.
• A succussion splash could indicate the presence of ascites and obstruction.
• Any abnormalities discovered during the physical exam should prompt further investigation with imaging, such as a computed tomography (CT) scan or ultrasound, to evaluate for ascites, masses, or increased bowel gas due to ileus, obstruction, or pseudo-obstruction.

Radiologic imaging, laboratory testing and endoscopy

• An abdominal x-ray may reveal an increased stool burden, suggesting the need for further evaluation of slow transit constipation or a pelvic floor disorder, particularly in patients with functional constipation, IBS-mixed, or IBS-C.
• Hyperglycemia, weight gain, and bloating can be a presenting sign of ovarian cancer therefore all women should continue pelvic exams as dictated by the gynecologic societies. The need for an annual pelvic exam should be discussed with health care professionals especially in those with family history of ovarian cancer.
• An upper endoscopy may be warranted for patients over 40 years old with dyspeptic symptoms and abdominal bloating or distention, especially in regions with a high prevalence of Helicobacter pylori.
• Chronic pancreatitis, indicated by bloating and pain, may necessitate fecal elastase testing to assess pancreatic function.

The expert review in the AGA clinical update provides step-by-step advice regarding the best practices⁶ for diagnosis and identifying who to test for ABD.
 

Treatment Options

The following sections highlight recent best practice advice on therapeutic approaches for treating ABD.

Dietary interventions

Specific foods may trigger bloating and abdominal distention, especially in patients with overlapping DGBIs. However, only a few studies have evaluated dietary restriction specifically for patients with primary ABD. Restricting non-absorbable sugars led to symptomatic improvement in 81% of patients with FABD who had documented sugar malabsorption.¹⁷ Two studies have shown that IBS patients treated with a low-fermentable, oligo-, di-, and monosaccharides (FODMAP) diet noted improvement in ABD and that restricting fructans initially may be the most optimal.¹⁸ A recent study showed that the Mediterranean diet improved IBS symptoms, including abdominal pain and bloating.¹⁹ It should be noted restrictive diets are efficacious but come with short- and long-term challenges. If empiric treatment and/or therapeutic testing do not resolve symptoms, a referral to a dietitian can be useful. Dietitians can provide tailored dietary advice, ensuring patients avoid trigger foods while maintaining a balanced and nutritious diet.

Prokinetics and laxatives

Prokinetic agents are used to treat symptoms of FD, gastroparesis, chronic idiopathic constipation (CIC), and IBS. A meta-analysis of 13 trials found all constipation medications superior to placebo for treating abdominal bloating in patients with IBS-C.²⁰

Probiotics

Treatment with probiotics is recommended for bloating or distention. One double-blind placebo-controlled trial with two separate probiotics, Bifidobacterium lactis and Lactobacillus acidophilus, showed improvements in global GI symptoms of patients with DGBI at 8 weeks versus placebo, with improvements in bloating symptoms.²¹

Antibiotics

The most commonly studied antibiotic for treating bloating is rifaximin.²² Global symptomatic improvement in IBS patients treated with antibiotics has correlated with the normalization of hydrogen levels in lactulose hydrogen breath tests.²² Patients with non-constipation IBS randomized to rifaximin 550 mg three times daily for 14 days had a greater proportion of relief of IBS-related bloating compared to placebo for at least 2 of the first 4 weeks after treatment.²² Future research warrants use of narrow-spectrum antibiotics study for FABD as the use of broad-spectrum antibiotics may deplete commensals forever, resulting in metabolic disorders.

Biofeedback therapy

Anorectal biofeedback therapy may help with ABD, particularly in patients with IBS-C and chronic constipation. One study noted that post-biofeedback therapy, myoelectric activity of the intercostals and diaphragm decreased, and internal oblique myoelectric activity increased.²³ This study also showed ascent of the diaphragm and decreased girth, improving distention.

Central neuromodulators

As bloating results from multiple disturbed mechanisms, including altered gut-brain interaction, these symptoms can be amplified by psychological states such as anxiety, depression, or somatization. Central neuromodulators reduce the perception of visceral signals, re-regulate brain-gut control mechanisms, and improve psychological comorbidities.⁶ A large study of FD patients demonstrated that both amitriptyline (50 mg daily) and escitalopram (10 mg daily) significantly improved postprandial bloating compared to placebo.²⁴ Antidepressants that activate noradrenergic and serotonergic pathways, including tricyclic antidepressants (e.g., amitriptyline) and serotonin-norepinephrine reuptake inhibitors (e.g., duloxetine and venlafaxine), show the greatest benefit in reducing visceral sensations.⁶

Brain-gut behavioral therapies

A recent multidisciplinary consensus report supports a myriad of potential brain-gut behavioral therapies (BGBTs) for treating DGBI.²⁵ These therapies, including hypnotherapy, cognitive behavioral therapy (CBT), and other modalities, may be combined with central neuromodulators and other GI treatments in a safe, noninvasive, and complementary fashion. BGBTs do not need to be symptom-specific, as they improve overall quality of life, anxiety, stress, and the burden associated with DGBIs. To date, none of the BGBTs have focused exclusively on FABD; however, prescription-based psychological therapies are now FDA-approved for use on smart apps, improving global symptoms that include bloating in IBS and FD.

Recent AGA clinical update best practices should be considered for the clinical care of patients with ABD.⁶

Conclusion and Future Perspectives

ABD are highly prevalent and significantly impact patients with various GI and metabolic disorders. Although our understanding of these symptoms is still evolving, evidence increasingly points to the dysregulation of the gut-brain axis and supports the application of the biopsychosocial model in treatment. This model addresses diet, motility, visceral sensitivity, pelvic floor disorders and psychosocial factors, providing a comprehensive approach to patient care.

Physician-scientists around the globe face numerous challenges when evaluating patients with these symptoms. However, the recent AGA clinical update on the best practice guidelines offers step-by-step diagnostic tests and treatment options to assist physicians in making informed decisions. A multidisciplinary approach and a patient-centered model are essential for effectively managing treatment in patients with ABD. More comprehensive, large-scale, and longitudinal studies using metabolomics, capsule technologies for discovery of dysbiosis, mass spectrometry, and imaging data are needed to identify the exact contributors to disease pathogenesis, particularly those that can be targeted with pharmacologic agents. Collaborative work between gastroenterologists, dietitians, gut-brain behavioral therapists, endocrinologists, is crucial for clinical care of patients with ABD.

Careful attention to the patient’s primary symptoms and physical examination, combined with advancements in targeted diagnostics like the analysis of microbial markers, metabolites, and molecular signals, can significantly enhance patient clinical outcomes. Additionally, education and effective communication using a patient-centered care model are essential for guiding practical evaluation and individualized treatment.

Dr. Singh is assistant professor (research) at the University of Nevada, Reno, School of Medicine. Dr. Moshiree is director of motility at Atrium Health, and clinical professor of medicine, Wake Forest Medical University, Charlotte, North Carolina.

References

1. Ballou S et al. Prevalence and associated factors of bloating: Results from the Rome Foundation Global Epidemiology Study. Gastroenterology. 2023 June. doi: 10.1053/j.gastro.2023.05.049.

2. Oh JE et al. Abdominal bloating in the United States: Results of a survey of 88,795 Americans examining prevalence and healthcare seeking. Clin Gastroenterol Hepatol. 2023 Aug. doi: 10.1016/j.cgh.2022.10.031.

3. Drossman DA et al. Neuromodulators for functional gastrointestinal disorders (disorders of gut-brain interaction): A Rome Foundation Working Team Report. Gastroenterology. 2018 Mar. doi: 10.1053/j.gastro.2017.11.279.

4. Lacy BE et al. Management of chronic abdominal distension and bloating. Clin Gastroenterol Hepatol. 2021 Feb. doi: 10.1016/j.cgh.2020.03.056.

5. Mearin F et al. Bowel disorders. Gastroenterology. 2016 Feb. doi: 10.1053/j.gastro.2016.02.031.

6. Moshiree B et al. AGA Clinical Practice Update on evaluation and management of belching, abdominal bloating, and distention: expert review. Gastroenterology. 2023 Sep. doi: 10.1053/j.gastro.2023.04.039.

7. Viswanathan L and Rao SS. Intestinal disaccharidase deficiency in adults: evaluation and treatment. Curr Gastroenterol Rep 2023 May. doi: 10.1007/s11894-023-00870-z.

8. Wilder-Smith CH et al. Fructose and lactose intolerance and malabsorption testing: the relationship with symptoms in functional gastrointestinal disorders. Aliment Pharmacol Ther. 2013 Jun. doi: 10.1111/apt.12306.

9. Skodje GI et al. Fructan, rather than gluten, induces symptoms in patients with self-reported non-celiac gluten sensitivity. Gastroenterology. 2018 Feb. doi: 10.1053/j.gastro.2017.10.040.

10. Singh R et al. Current treatment options and therapeutic insights for gastrointestinal dysmotility and functional gastrointestinal disorders. Front Pharmacol. 2022 Jan. doi: 10.3389/fphar.2022.808195.

11. Accarino A et al. Abdominal distention results from caudo-ventral redistribution of contents. Gastroenterology 2009 May. doi: 10.1053/j.gastro.2009.01.067.

12. Shim L et al. Prolonged balloon expulsion is predictive of abdominal distension in bloating. Am J Gastroenterol. 2010 Apr. doi: 10.1038/ajg.2010.54.

13. Villoria A et al. Abdomino-phrenic dyssynergia in patients with abdominal bloating and distension. Am J Gastroenterol. 2011 May. doi: 10.1038/ajg.2010.408.

14. Neri L and Iovino P. Laxative Inadequate Relief Survey Group. Bloating is associated with worse quality of life, treatment satisfaction, and treatment responsiveness among patients with constipation-predominant irritable bowel syndrome and functional constipation. Neurogastroenterol Motil. 2016 Apr. doi: 10.1111/nmo.12758.

15. Saffouri GB et al. Small intestinal microbial dysbiosis underlies symptoms associated with functional gastrointestinal disorders. Nat Commun. 2019 May. doi: 10.1038/s41467-019-09964-7.

16. Villanueva-Millan MJ et al. Methanogens and hydrogen sulfide producing bacteria guide distinct gut microbe profiles and irritable bowel syndrome subtypes. Am J Gastroenterol. 2022 Dec. doi: 10.14309/ajg.0000000000001997.

17. Fernández-Bañares F et al. Sugar malabsorption in functional abdominal bloating: a pilot study on the long-term effect of dietary treatment. Clin Nutr. 2006 Oct. doi: 10.1016/j.clnu.2005.11.010.

18. Böhn L et al. Diet low in FODMAPs reduces symptoms of irritable bowel syndrome as well as traditional dietary advice: a randomized controlled trial. Gastroenterology. 2015 Nov. doi: 10.1053/j.gastro.2015.07.054.

19. Staudacher HM et al. Clinical trial: A Mediterranean diet is feasible and improves gastrointestinal and psychological symptoms in irritable bowel syndrome. Aliment Pharmacol Ther. 2024 Feb. doi: 10.1111/apt.17791.

20. Nelson AD et al. Systematic review and network meta-analysis: efficacy of licensed drugs for abdominal bloating in irritable bowel syndrome with constipation. Aliment Pharmacol Ther. 2021 Jul. doi: 10.1111/apt.16437.

21. Ringel-Kulka T et al. Probiotic bacteria Lactobacillus acidophilus NCFM and Bifidobacterium lactis Bi-07 versus placebo for the symptoms of bloating in patients with functional bowel disorders: a double-blind study. J Clin Gastroenterol. 2011 Jul. doi: 10.1097/MCG.0b013e31820ca4d6.

22. Pimentel M et al. Rifaximin therapy for patients with irritable bowel syndrome without constipation. N Engl J Med. 2011 Jan. doi: 10.1056/NEJMoa1004409.

23. Iovino P et al. Pelvic floor biofeedback is an effective treatment for severe bloating in disorders of gut-brain interaction with outlet dysfunction. Neurogastroenterol Motil 2022 May. doi: 10.1111/nmo.14264.

24. Talley NJ et al. Effect of amitriptyline and escitalopram on functional dyspepsia: A multicenter, randomized controlled study. Gastroenterology. 2015 Aug. doi: 10.1053/j.gastro.2015.04.020.

25. Keefer L et al. A Rome Working Team Report on brain-gut behavior therapies for disorders of gut-brain interaction. Gastroenterology. 2022 Jan. doi: 10.1053/j.gastro.2021.09.015.

Introduction

Abdominal bloating is a common condition affecting up to 3.5% of people globally (4.6% in women and 2.4% in men),¹ with 13.9% of the US population reporting bloating in the past 7 days.² The prevalence of bloating and distention exceeds 50% when linked to disorders of gut-brain interaction (DGBIs) such as irritable bowel syndrome (IBS), constipation, gastroparesis, and functional dyspepsia (FD).^3,4 According to the Rome IV criteria, functional bloating and distention (FABD) patients are characterized by recurrent symptoms of abdominal fullness or pressure (bloating), or a visible increase in abdominal girth (distention) occurring at least 1 day per week for 3 consecutive months with an onset of 6 months and without predominant pain or altered bowel habits.⁵

Prolonged abdominal bloating and distention (ABD) can significantly impact quality of life and work productivity and can lead to increased medical consultations.² Multiple pathophysiological mechanisms are involved in ABD that complicate the clinical management.⁴ There is an unmet need to understand the underlying mechanisms that lead to the development of ABD such as, food intolerance, abnormal viscerosomatic reflex, visceral hypersensitivity, and gut microbial dysbiosis. Recent advancements and acceptance of a multidisciplinary management of ABD have shifted the paradigm from merely treating symptoms to subtyping the condition and identifying overlaps with other DGBIs in order to individualize treatment that addresses the underlying pathophysiological mechanism. The recent American Gastroenterological Association (AGA) clinical update provided insights into the best practice advice for evaluating and managing ABD based on a review of current literature and on expert opinion of coauthors.⁶ This article aims to deliberate a practical approach to diagnostic strategies and treatment options based on etiology to refine clinical care of patients with ABD.

University of Nevada, Reno

Pathophysiological Mechanisms

ABD can result from various pathophysiological mechanisms. This section highlights the major causes (illustrated in Figure 1).

Food intolerances

Understanding food intolerances is crucial for diagnosing and managing patients with ABD. Disaccharidase deficiency is common (e.g., lactase deficiency is found in 35%-40% of adults).⁷ It can be undiagnosed in patients presenting with IBS symptoms, given the overlap in presentation with a prevalence of 9% of pan-disaccharidase deficiency. Sucrase-deficient patients must often adjust sugar and carbohydrate/starch intake to relieve symptoms.⁷ Deficiencies in lactase and sucrase activity, along with the consumption of some artificial sweeteners (e.g., sugar alcohols and sorbitol) and fructans can lead to bloating and distention. These substances increase osmotic load, fluid retention, microbial fermentation, and visceral hypersensitivity, leading to gas production and abdominal distention. One prospective study of symptomatic patients with various DGBIs (n = 1372) reported a prevalence of lactose intolerance and malabsorption at 51% and 32%, respectively.⁸ Furthermore, fructose intolerance and malabsorption prevalence were 60% and 45%, respectively.⁸ Notably, lactase deficiency does not always cause ABD, as not all individuals with lactase deficiency experience these symptoms after consuming lactose. Patients with celiac disease (CD), non-celiac gluten sensitivity (NCGS), and gluten intolerance can also experience bloating and distention, with or without changes in bowel habits.⁹ In some patients with self-reported NCGS, symptoms may be due to fructans in gluten-rich foods rather than gluten itself, thus recommending the elimination of fructans may help improve symptoms.⁹

Visceral hypersensitivity

Visceral hypersensitivity is explained by an increased perception of gut mechano-chemical stimulation, which typically manifests in an aggravated feeling of pain, nausea, distension, and ABD.¹⁰ In the gut, food particles and gut bacteria and their derived molecules interact with neuroimmune and enteroendocrine cells causing visceral sensitivity by the proximity of gut’s neurons to immune cells activated by them and leading to inflammatory reactions (Figure 1).

Dr. Singh and Dr. Moshiree

Pelvic floor dysfunction

Patients with anorectal motor dysfunction often experience difficulty in effectively evacuating both gas and stool, leading to ABD.¹² Impaired ability to expel gas and stool results in prolonged balloon expulsion times, which correlates with symptoms of distention in patients with constipation.

Atrium Health

Abdominophrenic dyssynergia

Abdominophrenic dyssynergia is characterized as a paradoxical viscerosomatic reflex response to minimal gaseous distention in individuals with FABD.¹³ In this condition, the diaphragm contracts (descends), and the anterior abdominal wall muscles relax in response to the presence of gas. This response is opposite to the normal physiological response to increased intraluminal gas, where the diaphragm relaxes and the anterior abdominal muscles contract to increase the craniocaudal capacity of the abdominal cavity without causing abdominal protrusion.¹³ Patients with FABD exhibit significant abdominal wall protrusion and diaphragmatic descent even with relatively small increases in intraluminal gas.¹¹ Understanding the role of abdominophrenic dyssynergia in abdominal bloating and distention is essential for effective diagnosis and management of the patients.

Gut dysmotility

Gut dysmotility is a crucial factor that can contribute to FABD. Gut dysmotility affects the movement of contents through the GI tract, accumulating gas and stool, directly contributing to bloating and distention. A prospective study involving over 2000 patients with functional constipation and constipation predominant-IBS (IBS-C) found that more than 90% of these patients reported symptoms of bloating.¹⁴ Furthermore, in IBS-C patients, those with prolonged colonic transit exhibited greater abdominal distention compared to those with normal gut transit times. In patients with gastroparesis, delayed gastric emptying resulting in prolonged retention of stomach contents is the main factor in the generation of bloating symptoms.⁴

Small intestinal bacterial overgrowth (SIBO)

SIBO is overrepresented in various conditions, including IBS, FD, diabetes, gastrointestinal (GI) surgery patients and obesity, and can play an important role in generating ABD. Excess bacteria in the small intestine ferment carbohydrates, producing gas that stretches and distends the small intestine, leading to these symptoms. Additionally, altered sensation and abnormal viscerosomatic reflexes may contribute to SIBO-related bloating.⁴ One recent study noted decreased duodenal phylogenetic diversity in individuals who developed postprandial bloating.¹⁵ Increased methane levels caused by intestinal methanogen overgrowth, primarily the archaea Methanobrevibacter smithii, is possibly responsible for ABD in patients with IBS-C.¹⁶ Testing for SIBO in patients with ABD is generally only recommended if there are clear risk factors or severe symptoms warranting a test-and-treat approach.

Practical Diagnosis

Diagnosing ABD typically does not require extensive laboratory testing, imaging, or endoscopy unless there are alarm features or significant changes in symptoms. Here is the AGA clinical update on best practice advice⁶ for when to conduct further testing:

Diagnostic tests should be considered if patients exhibit:

• Recent onset or worsening of dyspepsia or abdominal pain
• Vomiting
• GI bleeding
• Unintentional weight loss exceeding 10% of body weight
• Chronic diarrhea
• Family history of GI malignancy, celiac disease, or inflammatory bowel disease

Physical examination

If visible abdominal distention is present, a thorough abdominal examination can help identify potential issues:

• Tympany to percussion suggests bowel dilation.
• Abnormal bowel sounds may indicate obstruction or ileus.
• A succussion splash could indicate the presence of ascites and obstruction.
• Any abnormalities discovered during the physical exam should prompt further investigation with imaging, such as a computed tomography (CT) scan or ultrasound, to evaluate for ascites, masses, or increased bowel gas due to ileus, obstruction, or pseudo-obstruction.

Radiologic imaging, laboratory testing and endoscopy

• An abdominal x-ray may reveal an increased stool burden, suggesting the need for further evaluation of slow transit constipation or a pelvic floor disorder, particularly in patients with functional constipation, IBS-mixed, or IBS-C.
• Hyperglycemia, weight gain, and bloating can be a presenting sign of ovarian cancer therefore all women should continue pelvic exams as dictated by the gynecologic societies. The need for an annual pelvic exam should be discussed with health care professionals especially in those with family history of ovarian cancer.
• An upper endoscopy may be warranted for patients over 40 years old with dyspeptic symptoms and abdominal bloating or distention, especially in regions with a high prevalence of Helicobacter pylori.
• Chronic pancreatitis, indicated by bloating and pain, may necessitate fecal elastase testing to assess pancreatic function.

The expert review in the AGA clinical update provides step-by-step advice regarding the best practices⁶ for diagnosis and identifying who to test for ABD.
 

Treatment Options

The following sections highlight recent best practice advice on therapeutic approaches for treating ABD.

Dietary interventions

Specific foods may trigger bloating and abdominal distention, especially in patients with overlapping DGBIs. However, only a few studies have evaluated dietary restriction specifically for patients with primary ABD. Restricting non-absorbable sugars led to symptomatic improvement in 81% of patients with FABD who had documented sugar malabsorption.¹⁷ Two studies have shown that IBS patients treated with a low-fermentable, oligo-, di-, and monosaccharides (FODMAP) diet noted improvement in ABD and that restricting fructans initially may be the most optimal.¹⁸ A recent study showed that the Mediterranean diet improved IBS symptoms, including abdominal pain and bloating.¹⁹ It should be noted restrictive diets are efficacious but come with short- and long-term challenges. If empiric treatment and/or therapeutic testing do not resolve symptoms, a referral to a dietitian can be useful. Dietitians can provide tailored dietary advice, ensuring patients avoid trigger foods while maintaining a balanced and nutritious diet.

Prokinetics and laxatives

Prokinetic agents are used to treat symptoms of FD, gastroparesis, chronic idiopathic constipation (CIC), and IBS. A meta-analysis of 13 trials found all constipation medications superior to placebo for treating abdominal bloating in patients with IBS-C.²⁰

Probiotics

Treatment with probiotics is recommended for bloating or distention. One double-blind placebo-controlled trial with two separate probiotics, Bifidobacterium lactis and Lactobacillus acidophilus, showed improvements in global GI symptoms of patients with DGBI at 8 weeks versus placebo, with improvements in bloating symptoms.²¹

Antibiotics

The most commonly studied antibiotic for treating bloating is rifaximin.²² Global symptomatic improvement in IBS patients treated with antibiotics has correlated with the normalization of hydrogen levels in lactulose hydrogen breath tests.²² Patients with non-constipation IBS randomized to rifaximin 550 mg three times daily for 14 days had a greater proportion of relief of IBS-related bloating compared to placebo for at least 2 of the first 4 weeks after treatment.²² Future research warrants use of narrow-spectrum antibiotics study for FABD as the use of broad-spectrum antibiotics may deplete commensals forever, resulting in metabolic disorders.

Biofeedback therapy

Anorectal biofeedback therapy may help with ABD, particularly in patients with IBS-C and chronic constipation. One study noted that post-biofeedback therapy, myoelectric activity of the intercostals and diaphragm decreased, and internal oblique myoelectric activity increased.²³ This study also showed ascent of the diaphragm and decreased girth, improving distention.

Central neuromodulators

As bloating results from multiple disturbed mechanisms, including altered gut-brain interaction, these symptoms can be amplified by psychological states such as anxiety, depression, or somatization. Central neuromodulators reduce the perception of visceral signals, re-regulate brain-gut control mechanisms, and improve psychological comorbidities.⁶ A large study of FD patients demonstrated that both amitriptyline (50 mg daily) and escitalopram (10 mg daily) significantly improved postprandial bloating compared to placebo.²⁴ Antidepressants that activate noradrenergic and serotonergic pathways, including tricyclic antidepressants (e.g., amitriptyline) and serotonin-norepinephrine reuptake inhibitors (e.g., duloxetine and venlafaxine), show the greatest benefit in reducing visceral sensations.⁶

Brain-gut behavioral therapies

A recent multidisciplinary consensus report supports a myriad of potential brain-gut behavioral therapies (BGBTs) for treating DGBI.²⁵ These therapies, including hypnotherapy, cognitive behavioral therapy (CBT), and other modalities, may be combined with central neuromodulators and other GI treatments in a safe, noninvasive, and complementary fashion. BGBTs do not need to be symptom-specific, as they improve overall quality of life, anxiety, stress, and the burden associated with DGBIs. To date, none of the BGBTs have focused exclusively on FABD; however, prescription-based psychological therapies are now FDA-approved for use on smart apps, improving global symptoms that include bloating in IBS and FD.

Recent AGA clinical update best practices should be considered for the clinical care of patients with ABD.⁶

Conclusion and Future Perspectives

ABD are highly prevalent and significantly impact patients with various GI and metabolic disorders. Although our understanding of these symptoms is still evolving, evidence increasingly points to the dysregulation of the gut-brain axis and supports the application of the biopsychosocial model in treatment. This model addresses diet, motility, visceral sensitivity, pelvic floor disorders and psychosocial factors, providing a comprehensive approach to patient care.

Physician-scientists around the globe face numerous challenges when evaluating patients with these symptoms. However, the recent AGA clinical update on the best practice guidelines offers step-by-step diagnostic tests and treatment options to assist physicians in making informed decisions. A multidisciplinary approach and a patient-centered model are essential for effectively managing treatment in patients with ABD. More comprehensive, large-scale, and longitudinal studies using metabolomics, capsule technologies for discovery of dysbiosis, mass spectrometry, and imaging data are needed to identify the exact contributors to disease pathogenesis, particularly those that can be targeted with pharmacologic agents. Collaborative work between gastroenterologists, dietitians, gut-brain behavioral therapists, endocrinologists, is crucial for clinical care of patients with ABD.

Careful attention to the patient’s primary symptoms and physical examination, combined with advancements in targeted diagnostics like the analysis of microbial markers, metabolites, and molecular signals, can significantly enhance patient clinical outcomes. Additionally, education and effective communication using a patient-centered care model are essential for guiding practical evaluation and individualized treatment.

Dr. Singh is assistant professor (research) at the University of Nevada, Reno, School of Medicine. Dr. Moshiree is director of motility at Atrium Health, and clinical professor of medicine, Wake Forest Medical University, Charlotte, North Carolina.

References

1. Ballou S et al. Prevalence and associated factors of bloating: Results from the Rome Foundation Global Epidemiology Study. Gastroenterology. 2023 June. doi: 10.1053/j.gastro.2023.05.049.

2. Oh JE et al. Abdominal bloating in the United States: Results of a survey of 88,795 Americans examining prevalence and healthcare seeking. Clin Gastroenterol Hepatol. 2023 Aug. doi: 10.1016/j.cgh.2022.10.031.

3. Drossman DA et al. Neuromodulators for functional gastrointestinal disorders (disorders of gut-brain interaction): A Rome Foundation Working Team Report. Gastroenterology. 2018 Mar. doi: 10.1053/j.gastro.2017.11.279.

4. Lacy BE et al. Management of chronic abdominal distension and bloating. Clin Gastroenterol Hepatol. 2021 Feb. doi: 10.1016/j.cgh.2020.03.056.

5. Mearin F et al. Bowel disorders. Gastroenterology. 2016 Feb. doi: 10.1053/j.gastro.2016.02.031.

6. Moshiree B et al. AGA Clinical Practice Update on evaluation and management of belching, abdominal bloating, and distention: expert review. Gastroenterology. 2023 Sep. doi: 10.1053/j.gastro.2023.04.039.

7. Viswanathan L and Rao SS. Intestinal disaccharidase deficiency in adults: evaluation and treatment. Curr Gastroenterol Rep 2023 May. doi: 10.1007/s11894-023-00870-z.

8. Wilder-Smith CH et al. Fructose and lactose intolerance and malabsorption testing: the relationship with symptoms in functional gastrointestinal disorders. Aliment Pharmacol Ther. 2013 Jun. doi: 10.1111/apt.12306.

9. Skodje GI et al. Fructan, rather than gluten, induces symptoms in patients with self-reported non-celiac gluten sensitivity. Gastroenterology. 2018 Feb. doi: 10.1053/j.gastro.2017.10.040.

10. Singh R et al. Current treatment options and therapeutic insights for gastrointestinal dysmotility and functional gastrointestinal disorders. Front Pharmacol. 2022 Jan. doi: 10.3389/fphar.2022.808195.

11. Accarino A et al. Abdominal distention results from caudo-ventral redistribution of contents. Gastroenterology 2009 May. doi: 10.1053/j.gastro.2009.01.067.

12. Shim L et al. Prolonged balloon expulsion is predictive of abdominal distension in bloating. Am J Gastroenterol. 2010 Apr. doi: 10.1038/ajg.2010.54.

13. Villoria A et al. Abdomino-phrenic dyssynergia in patients with abdominal bloating and distension. Am J Gastroenterol. 2011 May. doi: 10.1038/ajg.2010.408.

14. Neri L and Iovino P. Laxative Inadequate Relief Survey Group. Bloating is associated with worse quality of life, treatment satisfaction, and treatment responsiveness among patients with constipation-predominant irritable bowel syndrome and functional constipation. Neurogastroenterol Motil. 2016 Apr. doi: 10.1111/nmo.12758.

15. Saffouri GB et al. Small intestinal microbial dysbiosis underlies symptoms associated with functional gastrointestinal disorders. Nat Commun. 2019 May. doi: 10.1038/s41467-019-09964-7.

16. Villanueva-Millan MJ et al. Methanogens and hydrogen sulfide producing bacteria guide distinct gut microbe profiles and irritable bowel syndrome subtypes. Am J Gastroenterol. 2022 Dec. doi: 10.14309/ajg.0000000000001997.

17. Fernández-Bañares F et al. Sugar malabsorption in functional abdominal bloating: a pilot study on the long-term effect of dietary treatment. Clin Nutr. 2006 Oct. doi: 10.1016/j.clnu.2005.11.010.

18. Böhn L et al. Diet low in FODMAPs reduces symptoms of irritable bowel syndrome as well as traditional dietary advice: a randomized controlled trial. Gastroenterology. 2015 Nov. doi: 10.1053/j.gastro.2015.07.054.

19. Staudacher HM et al. Clinical trial: A Mediterranean diet is feasible and improves gastrointestinal and psychological symptoms in irritable bowel syndrome. Aliment Pharmacol Ther. 2024 Feb. doi: 10.1111/apt.17791.

20. Nelson AD et al. Systematic review and network meta-analysis: efficacy of licensed drugs for abdominal bloating in irritable bowel syndrome with constipation. Aliment Pharmacol Ther. 2021 Jul. doi: 10.1111/apt.16437.

21. Ringel-Kulka T et al. Probiotic bacteria Lactobacillus acidophilus NCFM and Bifidobacterium lactis Bi-07 versus placebo for the symptoms of bloating in patients with functional bowel disorders: a double-blind study. J Clin Gastroenterol. 2011 Jul. doi: 10.1097/MCG.0b013e31820ca4d6.

22. Pimentel M et al. Rifaximin therapy for patients with irritable bowel syndrome without constipation. N Engl J Med. 2011 Jan. doi: 10.1056/NEJMoa1004409.

23. Iovino P et al. Pelvic floor biofeedback is an effective treatment for severe bloating in disorders of gut-brain interaction with outlet dysfunction. Neurogastroenterol Motil 2022 May. doi: 10.1111/nmo.14264.

24. Talley NJ et al. Effect of amitriptyline and escitalopram on functional dyspepsia: A multicenter, randomized controlled study. Gastroenterology. 2015 Aug. doi: 10.1053/j.gastro.2015.04.020.

25. Keefer L et al. A Rome Working Team Report on brain-gut behavior therapies for disorders of gut-brain interaction. Gastroenterology. 2022 Jan. doi: 10.1053/j.gastro.2021.09.015.

The lowest point in the nascent career of Neelendu Dey, MD, helped seal his fate as a physician-scientist.

He had just started his first year as a resident at University of California, San Francisco. One of his patients was a 30-year-old woman who was dying of metastatic colorectal cancer. “I was in my mid-20s interacting with an individual just a few years older than I am, going through one of the most terrible health outcomes one could imagine,” Dr. Dey said.

He remembers asking the patient what he could do for her, how he could make her feel more comfortable. “That feeling of helplessness, particularly as we think about young people developing cancer, it really stuck with me through the years,” he said.

Dr. Dey, a graduate of the AGA Future Leaders Program, is now a gastroenterologist and researcher at the Fred Hutch Cancer Center in Seattle. In an interview, he talked about his dual role as a physician and scientist, and how those two interests are guiding his research in precancerous conditions of the colon.

Cases like that of the young woman with colon cancer “really help drive the urgency of the work we do, and the research questions we ask, as we try to move the ball forward and help folks at earlier stages,” he said.

Fred Hutch Cancer Center

Q: Why did you choose GI?

When you think about what sorts of chronic diseases really impact your quality of life, gut health is one of the chief contributors among various aspects of health. And that really appealed to me — the ability to take someone who is essentially handicapped by a series of illnesses and symptoms that derive from the GI tract and enable them to return to the person they want to be, to be productive in the way that they want to be, and have a rewarding life.

As I thought about how I wanted to contribute to the future of medicine, one of the ways in which I’ve always thought that I would do that is through research. When I considered the fields that really appealed to me, both from that clinical standpoint and research standpoint, GI was one that really stood out. There has been a lot of exciting research going on in GI. My lab currently studies the microbiome, and I feel like this is an area in which we can contribute.
 

Q: What role does digestive health play in overall health?

Obviously, the direct answer is gut health is so critical in something like nutritional intake. Some GI symptoms, if your gut health has gone awry, can really be detrimental in terms of quality of life. But one less obvious role that digestive health plays is its long-term effects. We’re starting to appreciate that gut health, the gut microbiome, and gut immune education are probably long-term players. Some experiences in early life might shape our immunity in ways that have consequences for us much later in life. Whether we get early life antibiotics, for example, may potentially contribute to colorectal cancer down the line. Thinking about the long-term players is more challenging, but it’s also an appealing opportunity as we think about how we can shape medicine moving forward.

Q: What practice challenges have you faced in your career?

First, being a physician-scientist. It’s challenging to be either a physician alone or to be a researcher alone. And trying to do both includes the challenges of both individual worlds. It just takes more time to get all the prerequisite training. And second, there are just challenges with getting the opportunities to contribute in the ways that you want — to get the research funding, to get the papers out, things like that.

Q: Tell me about the work you’ve been doing in your lab to develop microbiome-based strategies for preventing and treating cancer.

The microbiome presents several opportunities when it comes to cancer prevention. One is identifying markers of cancer risk, or of general good health down the line. Some of those biomarkers could — potentially — feed directly into personalized risk assessment and maybe even inform a future screening strategy. The second opportunity the microbiome presents is if we identify a microbe that influences your cancer risk, can we then understand and exploit, or utilize, that mechanism to mitigate cancer risk in the future? Our lab has done work looking at subspecies levels of microbes that track with health or cancer. We’ve done some work to identify what these subspecies groupings are and have identified some links to certain precancerous changes in the colon. We think that there’s an opportunity here for future interventions.

Q: Have you published other papers?

We recently published another paper describing how some microbes can interact with a tumor suppressor gene and are influenced in a sex-biased manner to drive tumorigenesis in a mouse model. We think, based on what we’re seeing in human data, that there may be some relationships and we’re exploring that now as well. 

Q: What is your vision for the future in GI, and in your career?

The vision that I have is to create clinical tools that can expand our reach and our effectiveness and cancer prevention. I think that there are opportunities for leveraging microbiome research to accomplish this. And one outcome I could imagine is leveraging some of these insights to expand noninvasive screening at even earlier ages than we do now. I mean, we just dialed back the recommended age for colonoscopy for average risk individuals to 45. But I could envision a future in which noninvasive screening starts earlier, in which the first stool-based tests that we deploy to assess personalized risk are used in the pediatric clinic.

Lightning Round

Texting or talking?

Talking

Favorite city in the United States besides the one you live in?

St. Louis

Cat or dog person?

Both

If you weren’t a GI, what would you be?

Musician

Best place you went on vacation?

Borneo

Favorite sport?

Soccer

Favorite ice cream?

Cashew-based salted caramel

What song do you have to sing along with when you hear it?

Sweet Child of Mine

Favorite movie or TV show?

25th Hour or Shawshank Redemption

Optimist or Pessimist?

Optimist

The lowest point in the nascent career of Neelendu Dey, MD, helped seal his fate as a physician-scientist.

He had just started his first year as a resident at University of California, San Francisco. One of his patients was a 30-year-old woman who was dying of metastatic colorectal cancer. “I was in my mid-20s interacting with an individual just a few years older than I am, going through one of the most terrible health outcomes one could imagine,” Dr. Dey said.

He remembers asking the patient what he could do for her, how he could make her feel more comfortable. “That feeling of helplessness, particularly as we think about young people developing cancer, it really stuck with me through the years,” he said.

Dr. Dey, a graduate of the AGA Future Leaders Program, is now a gastroenterologist and researcher at the Fred Hutch Cancer Center in Seattle. In an interview, he talked about his dual role as a physician and scientist, and how those two interests are guiding his research in precancerous conditions of the colon.

Cases like that of the young woman with colon cancer “really help drive the urgency of the work we do, and the research questions we ask, as we try to move the ball forward and help folks at earlier stages,” he said.

Fred Hutch Cancer Center

Q: Why did you choose GI?

When you think about what sorts of chronic diseases really impact your quality of life, gut health is one of the chief contributors among various aspects of health. And that really appealed to me — the ability to take someone who is essentially handicapped by a series of illnesses and symptoms that derive from the GI tract and enable them to return to the person they want to be, to be productive in the way that they want to be, and have a rewarding life.

As I thought about how I wanted to contribute to the future of medicine, one of the ways in which I’ve always thought that I would do that is through research. When I considered the fields that really appealed to me, both from that clinical standpoint and research standpoint, GI was one that really stood out. There has been a lot of exciting research going on in GI. My lab currently studies the microbiome, and I feel like this is an area in which we can contribute.
 

Q: What role does digestive health play in overall health?

Obviously, the direct answer is gut health is so critical in something like nutritional intake. Some GI symptoms, if your gut health has gone awry, can really be detrimental in terms of quality of life. But one less obvious role that digestive health plays is its long-term effects. We’re starting to appreciate that gut health, the gut microbiome, and gut immune education are probably long-term players. Some experiences in early life might shape our immunity in ways that have consequences for us much later in life. Whether we get early life antibiotics, for example, may potentially contribute to colorectal cancer down the line. Thinking about the long-term players is more challenging, but it’s also an appealing opportunity as we think about how we can shape medicine moving forward.

Q: What practice challenges have you faced in your career?

First, being a physician-scientist. It’s challenging to be either a physician alone or to be a researcher alone. And trying to do both includes the challenges of both individual worlds. It just takes more time to get all the prerequisite training. And second, there are just challenges with getting the opportunities to contribute in the ways that you want — to get the research funding, to get the papers out, things like that.

Q: Tell me about the work you’ve been doing in your lab to develop microbiome-based strategies for preventing and treating cancer.

The microbiome presents several opportunities when it comes to cancer prevention. One is identifying markers of cancer risk, or of general good health down the line. Some of those biomarkers could — potentially — feed directly into personalized risk assessment and maybe even inform a future screening strategy. The second opportunity the microbiome presents is if we identify a microbe that influences your cancer risk, can we then understand and exploit, or utilize, that mechanism to mitigate cancer risk in the future? Our lab has done work looking at subspecies levels of microbes that track with health or cancer. We’ve done some work to identify what these subspecies groupings are and have identified some links to certain precancerous changes in the colon. We think that there’s an opportunity here for future interventions.

Q: Have you published other papers?

We recently published another paper describing how some microbes can interact with a tumor suppressor gene and are influenced in a sex-biased manner to drive tumorigenesis in a mouse model. We think, based on what we’re seeing in human data, that there may be some relationships and we’re exploring that now as well. 

Q: What is your vision for the future in GI, and in your career?

The vision that I have is to create clinical tools that can expand our reach and our effectiveness and cancer prevention. I think that there are opportunities for leveraging microbiome research to accomplish this. And one outcome I could imagine is leveraging some of these insights to expand noninvasive screening at even earlier ages than we do now. I mean, we just dialed back the recommended age for colonoscopy for average risk individuals to 45. But I could envision a future in which noninvasive screening starts earlier, in which the first stool-based tests that we deploy to assess personalized risk are used in the pediatric clinic.

Lightning Round

Texting or talking?

Talking

Favorite city in the United States besides the one you live in?

St. Louis

Cat or dog person?

Both

If you weren’t a GI, what would you be?

Musician

Best place you went on vacation?

Borneo

Favorite sport?

Soccer

Favorite ice cream?

Cashew-based salted caramel

What song do you have to sing along with when you hear it?

Sweet Child of Mine

Favorite movie or TV show?

25th Hour or Shawshank Redemption

Optimist or Pessimist?

Optimist

The lowest point in the nascent career of Neelendu Dey, MD, helped seal his fate as a physician-scientist.

He had just started his first year as a resident at University of California, San Francisco. One of his patients was a 30-year-old woman who was dying of metastatic colorectal cancer. “I was in my mid-20s interacting with an individual just a few years older than I am, going through one of the most terrible health outcomes one could imagine,” Dr. Dey said.

He remembers asking the patient what he could do for her, how he could make her feel more comfortable. “That feeling of helplessness, particularly as we think about young people developing cancer, it really stuck with me through the years,” he said.

Dr. Dey, a graduate of the AGA Future Leaders Program, is now a gastroenterologist and researcher at the Fred Hutch Cancer Center in Seattle. In an interview, he talked about his dual role as a physician and scientist, and how those two interests are guiding his research in precancerous conditions of the colon.

Cases like that of the young woman with colon cancer “really help drive the urgency of the work we do, and the research questions we ask, as we try to move the ball forward and help folks at earlier stages,” he said.

Fred Hutch Cancer Center

Q: Why did you choose GI?

When you think about what sorts of chronic diseases really impact your quality of life, gut health is one of the chief contributors among various aspects of health. And that really appealed to me — the ability to take someone who is essentially handicapped by a series of illnesses and symptoms that derive from the GI tract and enable them to return to the person they want to be, to be productive in the way that they want to be, and have a rewarding life.

As I thought about how I wanted to contribute to the future of medicine, one of the ways in which I’ve always thought that I would do that is through research. When I considered the fields that really appealed to me, both from that clinical standpoint and research standpoint, GI was one that really stood out. There has been a lot of exciting research going on in GI. My lab currently studies the microbiome, and I feel like this is an area in which we can contribute.
 

Q: What role does digestive health play in overall health?

Obviously, the direct answer is gut health is so critical in something like nutritional intake. Some GI symptoms, if your gut health has gone awry, can really be detrimental in terms of quality of life. But one less obvious role that digestive health plays is its long-term effects. We’re starting to appreciate that gut health, the gut microbiome, and gut immune education are probably long-term players. Some experiences in early life might shape our immunity in ways that have consequences for us much later in life. Whether we get early life antibiotics, for example, may potentially contribute to colorectal cancer down the line. Thinking about the long-term players is more challenging, but it’s also an appealing opportunity as we think about how we can shape medicine moving forward.

Q: What practice challenges have you faced in your career?

First, being a physician-scientist. It’s challenging to be either a physician alone or to be a researcher alone. And trying to do both includes the challenges of both individual worlds. It just takes more time to get all the prerequisite training. And second, there are just challenges with getting the opportunities to contribute in the ways that you want — to get the research funding, to get the papers out, things like that.

Q: Tell me about the work you’ve been doing in your lab to develop microbiome-based strategies for preventing and treating cancer.

The microbiome presents several opportunities when it comes to cancer prevention. One is identifying markers of cancer risk, or of general good health down the line. Some of those biomarkers could — potentially — feed directly into personalized risk assessment and maybe even inform a future screening strategy. The second opportunity the microbiome presents is if we identify a microbe that influences your cancer risk, can we then understand and exploit, or utilize, that mechanism to mitigate cancer risk in the future? Our lab has done work looking at subspecies levels of microbes that track with health or cancer. We’ve done some work to identify what these subspecies groupings are and have identified some links to certain precancerous changes in the colon. We think that there’s an opportunity here for future interventions.

Q: Have you published other papers?

We recently published another paper describing how some microbes can interact with a tumor suppressor gene and are influenced in a sex-biased manner to drive tumorigenesis in a mouse model. We think, based on what we’re seeing in human data, that there may be some relationships and we’re exploring that now as well. 

Q: What is your vision for the future in GI, and in your career?

The vision that I have is to create clinical tools that can expand our reach and our effectiveness and cancer prevention. I think that there are opportunities for leveraging microbiome research to accomplish this. And one outcome I could imagine is leveraging some of these insights to expand noninvasive screening at even earlier ages than we do now. I mean, we just dialed back the recommended age for colonoscopy for average risk individuals to 45. But I could envision a future in which noninvasive screening starts earlier, in which the first stool-based tests that we deploy to assess personalized risk are used in the pediatric clinic.

Lightning Round

Texting or talking?

Talking

Favorite city in the United States besides the one you live in?

St. Louis

Cat or dog person?

Both

If you weren’t a GI, what would you be?

Musician

Best place you went on vacation?

Borneo

Favorite sport?

Soccer

Favorite ice cream?

Cashew-based salted caramel

What song do you have to sing along with when you hear it?

Sweet Child of Mine

Favorite movie or TV show?

25th Hour or Shawshank Redemption

Optimist or Pessimist?

Optimist

Recently, a patient of mine was hospitalized with chest pain. She was diagnosed with an acute coronary syndrome and started on a statin in addition to a beta-blocker, aspirin, and clopidogrel. After discharge, she had symptoms of dizziness and recurrent chest pain and her first thought was to stop the statin because she believed that her symptoms were statin-related side effects. I will cover a few areas where I think that there are some misunderstandings about statins.

Statins Are Not Bad For the Liver

When lovastatin first became available for prescription in the 1980s, frequent monitoring of transaminases was recommended. Patients and healthcare professionals became accustomed to frequent liver tests to monitor for statin toxicity, and to this day, some healthcare professionals still obtain liver function tests for this purpose.

But is there a reason to do this? Pfeffer and colleagues reported on the results of over 112,000 people enrolled in the West of Scotland Coronary Protection trial and found that the percentage of patients with any abnormal liver function test was similar (> 3 times the upper limit of normal for ALT) for patients taking pravastatin (1.4%) and for patients taking placebo (1.4%).¹ A panel of liver experts concurred that statin-associated transaminase elevations were not indicative of liver damage or dysfunction.² Furthermore, they noted that chronic liver disease and compensated cirrhosis were not contraindications to statin use.

In a small study, use of low-dose atorvastatin in patients with nonalcoholic steatohepatitis improved transaminase values in 75% of patients and liver steatosis and nonalcoholic fatty liver disease activity scores were significantly improved on biopsy in most of the patients.³ The US Food and Drug Administration (FDA) removed the recommendation for routine regular monitoring of liver function for patients on statins in 2012.⁴

Statins Do Not Cause Muscle Pain in Most Patients

Most muscle pain occurring in patients on statins is not due to the statin although patient concerns about muscle pain are common. In a meta-analysis of 19 large statin trials, 27.1% of participants treated with a statin reported at least one episode of muscle pain or weakness during a median of 4.3 years, compared with 26.6% of participants treated with placebo.⁵ Muscle pain for any reason is common, and patients on statins may stop therapy because of the symptoms.

Cohen and colleagues performed a survey of past and current statin users, asking about muscle symptoms.⁶ Muscle-related side effects were reported by 60% of former statin users and 25% of current users.

Herrett and colleagues performed an extensive series of n-of-1 trials involving 200 patients who had stopped or were considering stopping statins because of muscle symptoms.⁷ Participants received either 2-month blocks of atorvastatin 20 mg or 2-month blocks of placebo, six times. They rated their muscle symptoms on a visual analogue scale at the end of each block. There was no difference in muscle symptom scores between the statin and placebo periods.

Wood and colleagues took it a step further when they planned an n-of-1 trial that included statin, placebo, and no treatment.⁸ Each participant received four bottles of atorvastatin 20 mg, four bottles of placebo, and four empty bottles. Each month they used treatment from the bottles based on a random sequence and reported daily symptom scores. The mean symptom intensity score was 8.0 during no-tablet months, 15.4 during placebo months (P < .001, compared with no-tablet months), and 16.3 during statin months (P < .001, compared with no-tablet months; P = .39, compared with placebo).
 

Statins Are Likely Helpful In the Very Elderly

Should we be using statins for primary prevention in our very old patients? For many years the answer was generally “no” on the basis of a lack of evidence. Patients in their 80s often were not included in clinical trials. The much used American Heart Association risk calculator stops at age 79. Given the prevalence of coronary artery disease in patients as they reach their 80s, wouldn’t primary prevention really be secondary prevention? Xu and colleagues in a recent study compared outcomes for patients who were treated with statins for primary prevention with a group who were not. In the patients aged 75-84 there was a risk reduction for major cardiovascular events of 1.2% over 5 years, and for those 85 and older the risk reduction was 4.4%. Importantly, there were no significantly increased risks for myopathies and liver dysfunction in either age group.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].

References

1. Pfeffer MA et al. Circulation. 2002;105(20):2341-6.

2. Cohen DE et al. Am J Cardiol. 2006;97(8A):77C-81C.

3. Hyogo H et al. Metabolism. 2008;57(12):1711-8.

4. FDA Drug Safety Communication: Important safety label changes to cholesterol-lowering statin drugs. 2012 Feb 28.

5. Cholesterol Treatment Trialists’ Collaboration. Lancet. 2022;400(10355):832-45.

6. Cohen JD et al. J Clin Lipidol. 2012;6(3):208-15.

7. Herrett E et al. BMJ. 2021 Feb 24;372:n1355.

8. Wood FA et al. N Engl J Med. 2020;383(22):2182-4.

9. Xu W et al. Ann Intern Med. 2024;177(6):701-10.

Recently, a patient of mine was hospitalized with chest pain. She was diagnosed with an acute coronary syndrome and started on a statin in addition to a beta-blocker, aspirin, and clopidogrel. After discharge, she had symptoms of dizziness and recurrent chest pain and her first thought was to stop the statin because she believed that her symptoms were statin-related side effects. I will cover a few areas where I think that there are some misunderstandings about statins.

Statins Are Not Bad For the Liver

When lovastatin first became available for prescription in the 1980s, frequent monitoring of transaminases was recommended. Patients and healthcare professionals became accustomed to frequent liver tests to monitor for statin toxicity, and to this day, some healthcare professionals still obtain liver function tests for this purpose.

But is there a reason to do this? Pfeffer and colleagues reported on the results of over 112,000 people enrolled in the West of Scotland Coronary Protection trial and found that the percentage of patients with any abnormal liver function test was similar (> 3 times the upper limit of normal for ALT) for patients taking pravastatin (1.4%) and for patients taking placebo (1.4%).¹ A panel of liver experts concurred that statin-associated transaminase elevations were not indicative of liver damage or dysfunction.² Furthermore, they noted that chronic liver disease and compensated cirrhosis were not contraindications to statin use.

In a small study, use of low-dose atorvastatin in patients with nonalcoholic steatohepatitis improved transaminase values in 75% of patients and liver steatosis and nonalcoholic fatty liver disease activity scores were significantly improved on biopsy in most of the patients.³ The US Food and Drug Administration (FDA) removed the recommendation for routine regular monitoring of liver function for patients on statins in 2012.⁴

Statins Do Not Cause Muscle Pain in Most Patients

Most muscle pain occurring in patients on statins is not due to the statin although patient concerns about muscle pain are common. In a meta-analysis of 19 large statin trials, 27.1% of participants treated with a statin reported at least one episode of muscle pain or weakness during a median of 4.3 years, compared with 26.6% of participants treated with placebo.⁵ Muscle pain for any reason is common, and patients on statins may stop therapy because of the symptoms.

Cohen and colleagues performed a survey of past and current statin users, asking about muscle symptoms.⁶ Muscle-related side effects were reported by 60% of former statin users and 25% of current users.

Herrett and colleagues performed an extensive series of n-of-1 trials involving 200 patients who had stopped or were considering stopping statins because of muscle symptoms.⁷ Participants received either 2-month blocks of atorvastatin 20 mg or 2-month blocks of placebo, six times. They rated their muscle symptoms on a visual analogue scale at the end of each block. There was no difference in muscle symptom scores between the statin and placebo periods.

Wood and colleagues took it a step further when they planned an n-of-1 trial that included statin, placebo, and no treatment.⁸ Each participant received four bottles of atorvastatin 20 mg, four bottles of placebo, and four empty bottles. Each month they used treatment from the bottles based on a random sequence and reported daily symptom scores. The mean symptom intensity score was 8.0 during no-tablet months, 15.4 during placebo months (P < .001, compared with no-tablet months), and 16.3 during statin months (P < .001, compared with no-tablet months; P = .39, compared with placebo).
 

Statins Are Likely Helpful In the Very Elderly

Should we be using statins for primary prevention in our very old patients? For many years the answer was generally “no” on the basis of a lack of evidence. Patients in their 80s often were not included in clinical trials. The much used American Heart Association risk calculator stops at age 79. Given the prevalence of coronary artery disease in patients as they reach their 80s, wouldn’t primary prevention really be secondary prevention? Xu and colleagues in a recent study compared outcomes for patients who were treated with statins for primary prevention with a group who were not. In the patients aged 75-84 there was a risk reduction for major cardiovascular events of 1.2% over 5 years, and for those 85 and older the risk reduction was 4.4%. Importantly, there were no significantly increased risks for myopathies and liver dysfunction in either age group.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].

References

1. Pfeffer MA et al. Circulation. 2002;105(20):2341-6.

2. Cohen DE et al. Am J Cardiol. 2006;97(8A):77C-81C.

3. Hyogo H et al. Metabolism. 2008;57(12):1711-8.

4. FDA Drug Safety Communication: Important safety label changes to cholesterol-lowering statin drugs. 2012 Feb 28.

5. Cholesterol Treatment Trialists’ Collaboration. Lancet. 2022;400(10355):832-45.

6. Cohen JD et al. J Clin Lipidol. 2012;6(3):208-15.

7. Herrett E et al. BMJ. 2021 Feb 24;372:n1355.

8. Wood FA et al. N Engl J Med. 2020;383(22):2182-4.

9. Xu W et al. Ann Intern Med. 2024;177(6):701-10.

Recently, a patient of mine was hospitalized with chest pain. She was diagnosed with an acute coronary syndrome and started on a statin in addition to a beta-blocker, aspirin, and clopidogrel. After discharge, she had symptoms of dizziness and recurrent chest pain and her first thought was to stop the statin because she believed that her symptoms were statin-related side effects. I will cover a few areas where I think that there are some misunderstandings about statins.

Statins Are Not Bad For the Liver

When lovastatin first became available for prescription in the 1980s, frequent monitoring of transaminases was recommended. Patients and healthcare professionals became accustomed to frequent liver tests to monitor for statin toxicity, and to this day, some healthcare professionals still obtain liver function tests for this purpose.

But is there a reason to do this? Pfeffer and colleagues reported on the results of over 112,000 people enrolled in the West of Scotland Coronary Protection trial and found that the percentage of patients with any abnormal liver function test was similar (> 3 times the upper limit of normal for ALT) for patients taking pravastatin (1.4%) and for patients taking placebo (1.4%).¹ A panel of liver experts concurred that statin-associated transaminase elevations were not indicative of liver damage or dysfunction.² Furthermore, they noted that chronic liver disease and compensated cirrhosis were not contraindications to statin use.

In a small study, use of low-dose atorvastatin in patients with nonalcoholic steatohepatitis improved transaminase values in 75% of patients and liver steatosis and nonalcoholic fatty liver disease activity scores were significantly improved on biopsy in most of the patients.³ The US Food and Drug Administration (FDA) removed the recommendation for routine regular monitoring of liver function for patients on statins in 2012.⁴

Statins Do Not Cause Muscle Pain in Most Patients

Most muscle pain occurring in patients on statins is not due to the statin although patient concerns about muscle pain are common. In a meta-analysis of 19 large statin trials, 27.1% of participants treated with a statin reported at least one episode of muscle pain or weakness during a median of 4.3 years, compared with 26.6% of participants treated with placebo.⁵ Muscle pain for any reason is common, and patients on statins may stop therapy because of the symptoms.

Cohen and colleagues performed a survey of past and current statin users, asking about muscle symptoms.⁶ Muscle-related side effects were reported by 60% of former statin users and 25% of current users.

Herrett and colleagues performed an extensive series of n-of-1 trials involving 200 patients who had stopped or were considering stopping statins because of muscle symptoms.⁷ Participants received either 2-month blocks of atorvastatin 20 mg or 2-month blocks of placebo, six times. They rated their muscle symptoms on a visual analogue scale at the end of each block. There was no difference in muscle symptom scores between the statin and placebo periods.

Wood and colleagues took it a step further when they planned an n-of-1 trial that included statin, placebo, and no treatment.⁸ Each participant received four bottles of atorvastatin 20 mg, four bottles of placebo, and four empty bottles. Each month they used treatment from the bottles based on a random sequence and reported daily symptom scores. The mean symptom intensity score was 8.0 during no-tablet months, 15.4 during placebo months (P < .001, compared with no-tablet months), and 16.3 during statin months (P < .001, compared with no-tablet months; P = .39, compared with placebo).
 

Statins Are Likely Helpful In the Very Elderly

Should we be using statins for primary prevention in our very old patients? For many years the answer was generally “no” on the basis of a lack of evidence. Patients in their 80s often were not included in clinical trials. The much used American Heart Association risk calculator stops at age 79. Given the prevalence of coronary artery disease in patients as they reach their 80s, wouldn’t primary prevention really be secondary prevention? Xu and colleagues in a recent study compared outcomes for patients who were treated with statins for primary prevention with a group who were not. In the patients aged 75-84 there was a risk reduction for major cardiovascular events of 1.2% over 5 years, and for those 85 and older the risk reduction was 4.4%. Importantly, there were no significantly increased risks for myopathies and liver dysfunction in either age group.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. He is a member of the editorial advisory board of Internal Medicine News. Dr. Paauw has no conflicts to disclose. Contact him at [email protected].

References

1. Pfeffer MA et al. Circulation. 2002;105(20):2341-6.

2. Cohen DE et al. Am J Cardiol. 2006;97(8A):77C-81C.

3. Hyogo H et al. Metabolism. 2008;57(12):1711-8.

4. FDA Drug Safety Communication: Important safety label changes to cholesterol-lowering statin drugs. 2012 Feb 28.

5. Cholesterol Treatment Trialists’ Collaboration. Lancet. 2022;400(10355):832-45.

6. Cohen JD et al. J Clin Lipidol. 2012;6(3):208-15.

7. Herrett E et al. BMJ. 2021 Feb 24;372:n1355.

8. Wood FA et al. N Engl J Med. 2020;383(22):2182-4.

9. Xu W et al. Ann Intern Med. 2024;177(6):701-10.

Geographic spread of the ticks that most often cause Lyme disease in the United States and a rise in incidence of bites, resulting in 476,000 new US cases a year, have increased the chances that physicians who have never encountered a patient with Lyme disease will see their first cases.

“It’s increasing in areas where it was not seen before,” Steven E. Schutzer, MD, with the Department of Medicine, Rutgers New Jersey Medical School, Newark, said in an interview. Dr. Schutzer coauthored a report on diagnosing and treating Lyme disease with Patricia K. Coyle, MD, Department of Neurology, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York.

The report, a Curbside Consult published in New England Journal of Medicine Evidence, comes amid high season for Lyme disease. Bites from an ixodid (hard shield) tick — almost always the source of the disease in the United States — are most common from April through October.

Identifying the Bite

About 70%-90% of the time, Lyme disease will be signaled by erythema migrans (EM) or lesion expanding from the tick bite site, the authors wrote. The “classic” presentation looks like a bullseye, but most of the time the skin will show a variation of that, the authors noted.

“The presence of EM is considered the best clinical diagnostic marker for Lyme disease,” they wrote.

Other dermatologic conditions, however, can complicate diagnosis: “EM mimickers include contact dermatitis, other arthropod bites, fixed drug eruptions, granuloma annulare, cellulitis, dermatophytosis, and systemic lupus erythematosus,” they wrote.
 

Testing Steps

“The current recommendation is to do two-step testing almost simultaneously,” Dr. Schutzer said in an interview. The first, he said, is an ELISA (enzyme-linked immunosorbent assay)-type test and the second one, used for years, has been a pictoral view of a Western immunoblot showing which antigens of the Lyme bacteria, Borrelia burgdorferi, the antibodies are reacting to.

However, the pictoral view is subjective and some of the antigens could be cross-reactive. So the U.S. Food and Drug Administration (FDA) “has been allowing newer substitutes like a second ELISA-like assay that often uses more recombinant, less cross-reactive antigen targets,” he said. The authors advised that, “The second-tier test should not be performed alone without the first tier.”

Dr. Schutzer advised physicians to check with the lab they plan to use before sending samples.

“If you’re a practicing physician and you know you’re using a particular laboratory, you should familiarize yourself with them, talking to one of the clinical pathologists involved in advance to know what the limitations are.” Take the time to talk with the person overseeing the test and get tips on how they want the sample transported and how the cases should be reported, he said.

If the patient has neurological symptoms, he said, before treating talk with a neurologist who can advise whether, for instance, a spinal tap is in order or whether an emergency department visit is appropriate.

“If you just start proceeding you may mess up the diagnostic signs that could show up in a lab test. Don’t be hesitant to ask for extra input from colleagues,” Dr. Schutzer said.
 

Suspicion in Endemic Areas

On Long Island, New York, where Lyme disease is endemic, internist Ian Storch, DO, said he sees “a few cases a season.

“We have a lot of people over the summer going to the Hamptons and areas out east for the weekend and tick bites are not uncommon,” he said. “People panic.”

He said one thing it’s important to tell patients is that the tick has to be on the skin for 48-72 hours to transmit the disease. If individuals were in a wooded area and were fine before they got there and the tick was attached for less than 2 days, “they’re usually fine.”

Another issue, Dr. Storch said, is patients sometimes want to get tested for Lyme disease immediately after a tick bite. But the antibody test doesn’t turn positive for weeks, he noted, and you can get a false-negative result. “If you’re worried and you really want to test, you need to wait 6 weeks to do the blood test.”

In his region, he said that although a tick bite is a red flag, he may also suspect Lyme disease when a patient presents with otherwise unexplained joint pain, weakness, lethargy, or fever. “In our area, those are things that would make you test for Lyme.”

He also urged consideration of Lyme in this new age of long COVID. Weakness, fatigue, and lethargy are also classic symptoms of long COVID, he noted. “Keep Lyme disease in your differential because there is a lot of overlap with chronic Lyme disease,” Dr. Storch said.

Discerning Lyme from Southern Tick–Associated Rash Illness

Bonnie M. Word, MD, director of the Houston Travel Medicine Clinic in Texas, where Lyme disease is not endemic, said Lyme disease “will not and should not be on the initial differential diagnosis for those residing in nonendemic areas unless a history of travel to an endemic area is obtained.”

She noted the typical EM rash may not be as distinct or easy to discern on black and brown skin. In addition, she said, EM may have many variations in presentation, such as a crusted center or faint borders, which could lead to a delay in diagnosis and treatment. She suggested consulting the CDC guidance on Lyme disease rashes.

Another challenge in diagnosis, she said, is the patient who presents with what appears to be a classic EM lesion but does not live in a Lyme-endemic area. In Texas, Southern Tick–Associated Rash Illness (STARI) may present with a similar lesion, she said.

“It is transmitted by the Lone Star Tick, which is found in the southeast and south-central US,” Dr. Word said. “However, its habitat is moving northward and westerly,” she said.

Adding Lyme disease to the differential diagnosis is reasonable, she said, if a patient presents with neurologic symptoms “such as a facial palsy, meningitis, radiculitis, and carditis if in addition to their symptoms there is evidence of an epidemiologic link to a Lyme-endemic region.”

She noted that a detailed travel history is important as “Lyme is also endemic in Eastern Canada, Europe, states of the former Soviet Union, China, Mongolia, and Japan.”

Primary care physicians play a critical role in evaluating, diagnosing, and treating most cases of early Lyme disease, thus limiting the number of people who will develop disseminated or late Lyme disease, she said. “The two latter manifestations are most often treated by infectious disease, neurology, or rheumatology specialists.”

Treatment* 

Treatment is tailored to the clinical situation, Dr. Schutzer and Dr. Coyle write. A watch-and-wait approach may be appropriate in an asymptomatic but concerned person, even in an endemic area if the person has no known tick bite and no EM lesion.

If there is high risk of an infected ixodid tick bite in a high-incidence area and the tick was attached for at least 36 hours but less than 72 hours, one dose of doxycycline has been recommended as prophylaxis.

When a diagnosis of early nondisseminated Lyme disease is made after observation  of an EM lesion, oral antibiotics are typically used to treat for 10 to 14 days. Suggested oral antibiotics and doses are 100 mg of doxycycline twice a day, 500 mg of amoxicillin three times a day, or 500 mg of cefuroxime twice a day, the authors write.

Dr. Schutzer said he hopes the paper serves as a refresher for those physicians who regularly see Lyme disease cases and also helps those newly included in the disease’s spreading regions.

“The earlier you diagnose it, the earlier you can treat it and the better the chance for a favorable outcome,” he said.

Dr. Schutzer, Dr. Coyle, Dr. Storch, and Dr. Word reported no relevant financial relationships.

*This story was updated on August, 2, 2024.

Geographic spread of the ticks that most often cause Lyme disease in the United States and a rise in incidence of bites, resulting in 476,000 new US cases a year, have increased the chances that physicians who have never encountered a patient with Lyme disease will see their first cases.

“It’s increasing in areas where it was not seen before,” Steven E. Schutzer, MD, with the Department of Medicine, Rutgers New Jersey Medical School, Newark, said in an interview. Dr. Schutzer coauthored a report on diagnosing and treating Lyme disease with Patricia K. Coyle, MD, Department of Neurology, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York.

The report, a Curbside Consult published in New England Journal of Medicine Evidence, comes amid high season for Lyme disease. Bites from an ixodid (hard shield) tick — almost always the source of the disease in the United States — are most common from April through October.

Identifying the Bite

About 70%-90% of the time, Lyme disease will be signaled by erythema migrans (EM) or lesion expanding from the tick bite site, the authors wrote. The “classic” presentation looks like a bullseye, but most of the time the skin will show a variation of that, the authors noted.

“The presence of EM is considered the best clinical diagnostic marker for Lyme disease,” they wrote.

Other dermatologic conditions, however, can complicate diagnosis: “EM mimickers include contact dermatitis, other arthropod bites, fixed drug eruptions, granuloma annulare, cellulitis, dermatophytosis, and systemic lupus erythematosus,” they wrote.
 

Testing Steps

“The current recommendation is to do two-step testing almost simultaneously,” Dr. Schutzer said in an interview. The first, he said, is an ELISA (enzyme-linked immunosorbent assay)-type test and the second one, used for years, has been a pictoral view of a Western immunoblot showing which antigens of the Lyme bacteria, Borrelia burgdorferi, the antibodies are reacting to.

However, the pictoral view is subjective and some of the antigens could be cross-reactive. So the U.S. Food and Drug Administration (FDA) “has been allowing newer substitutes like a second ELISA-like assay that often uses more recombinant, less cross-reactive antigen targets,” he said. The authors advised that, “The second-tier test should not be performed alone without the first tier.”

Dr. Schutzer advised physicians to check with the lab they plan to use before sending samples.

“If you’re a practicing physician and you know you’re using a particular laboratory, you should familiarize yourself with them, talking to one of the clinical pathologists involved in advance to know what the limitations are.” Take the time to talk with the person overseeing the test and get tips on how they want the sample transported and how the cases should be reported, he said.

If the patient has neurological symptoms, he said, before treating talk with a neurologist who can advise whether, for instance, a spinal tap is in order or whether an emergency department visit is appropriate.

“If you just start proceeding you may mess up the diagnostic signs that could show up in a lab test. Don’t be hesitant to ask for extra input from colleagues,” Dr. Schutzer said.
 

Suspicion in Endemic Areas

On Long Island, New York, where Lyme disease is endemic, internist Ian Storch, DO, said he sees “a few cases a season.

“We have a lot of people over the summer going to the Hamptons and areas out east for the weekend and tick bites are not uncommon,” he said. “People panic.”

He said one thing it’s important to tell patients is that the tick has to be on the skin for 48-72 hours to transmit the disease. If individuals were in a wooded area and were fine before they got there and the tick was attached for less than 2 days, “they’re usually fine.”

Another issue, Dr. Storch said, is patients sometimes want to get tested for Lyme disease immediately after a tick bite. But the antibody test doesn’t turn positive for weeks, he noted, and you can get a false-negative result. “If you’re worried and you really want to test, you need to wait 6 weeks to do the blood test.”

In his region, he said that although a tick bite is a red flag, he may also suspect Lyme disease when a patient presents with otherwise unexplained joint pain, weakness, lethargy, or fever. “In our area, those are things that would make you test for Lyme.”

He also urged consideration of Lyme in this new age of long COVID. Weakness, fatigue, and lethargy are also classic symptoms of long COVID, he noted. “Keep Lyme disease in your differential because there is a lot of overlap with chronic Lyme disease,” Dr. Storch said.

Discerning Lyme from Southern Tick–Associated Rash Illness

Bonnie M. Word, MD, director of the Houston Travel Medicine Clinic in Texas, where Lyme disease is not endemic, said Lyme disease “will not and should not be on the initial differential diagnosis for those residing in nonendemic areas unless a history of travel to an endemic area is obtained.”

She noted the typical EM rash may not be as distinct or easy to discern on black and brown skin. In addition, she said, EM may have many variations in presentation, such as a crusted center or faint borders, which could lead to a delay in diagnosis and treatment. She suggested consulting the CDC guidance on Lyme disease rashes.

Another challenge in diagnosis, she said, is the patient who presents with what appears to be a classic EM lesion but does not live in a Lyme-endemic area. In Texas, Southern Tick–Associated Rash Illness (STARI) may present with a similar lesion, she said.

“It is transmitted by the Lone Star Tick, which is found in the southeast and south-central US,” Dr. Word said. “However, its habitat is moving northward and westerly,” she said.

Adding Lyme disease to the differential diagnosis is reasonable, she said, if a patient presents with neurologic symptoms “such as a facial palsy, meningitis, radiculitis, and carditis if in addition to their symptoms there is evidence of an epidemiologic link to a Lyme-endemic region.”

She noted that a detailed travel history is important as “Lyme is also endemic in Eastern Canada, Europe, states of the former Soviet Union, China, Mongolia, and Japan.”

Primary care physicians play a critical role in evaluating, diagnosing, and treating most cases of early Lyme disease, thus limiting the number of people who will develop disseminated or late Lyme disease, she said. “The two latter manifestations are most often treated by infectious disease, neurology, or rheumatology specialists.”

Treatment* 

Treatment is tailored to the clinical situation, Dr. Schutzer and Dr. Coyle write. A watch-and-wait approach may be appropriate in an asymptomatic but concerned person, even in an endemic area if the person has no known tick bite and no EM lesion.

If there is high risk of an infected ixodid tick bite in a high-incidence area and the tick was attached for at least 36 hours but less than 72 hours, one dose of doxycycline has been recommended as prophylaxis.

When a diagnosis of early nondisseminated Lyme disease is made after observation  of an EM lesion, oral antibiotics are typically used to treat for 10 to 14 days. Suggested oral antibiotics and doses are 100 mg of doxycycline twice a day, 500 mg of amoxicillin three times a day, or 500 mg of cefuroxime twice a day, the authors write.

Dr. Schutzer said he hopes the paper serves as a refresher for those physicians who regularly see Lyme disease cases and also helps those newly included in the disease’s spreading regions.

“The earlier you diagnose it, the earlier you can treat it and the better the chance for a favorable outcome,” he said.

Dr. Schutzer, Dr. Coyle, Dr. Storch, and Dr. Word reported no relevant financial relationships.

*This story was updated on August, 2, 2024.

Geographic spread of the ticks that most often cause Lyme disease in the United States and a rise in incidence of bites, resulting in 476,000 new US cases a year, have increased the chances that physicians who have never encountered a patient with Lyme disease will see their first cases.

“It’s increasing in areas where it was not seen before,” Steven E. Schutzer, MD, with the Department of Medicine, Rutgers New Jersey Medical School, Newark, said in an interview. Dr. Schutzer coauthored a report on diagnosing and treating Lyme disease with Patricia K. Coyle, MD, Department of Neurology, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York.

The report, a Curbside Consult published in New England Journal of Medicine Evidence, comes amid high season for Lyme disease. Bites from an ixodid (hard shield) tick — almost always the source of the disease in the United States — are most common from April through October.

Identifying the Bite

About 70%-90% of the time, Lyme disease will be signaled by erythema migrans (EM) or lesion expanding from the tick bite site, the authors wrote. The “classic” presentation looks like a bullseye, but most of the time the skin will show a variation of that, the authors noted.

“The presence of EM is considered the best clinical diagnostic marker for Lyme disease,” they wrote.

Other dermatologic conditions, however, can complicate diagnosis: “EM mimickers include contact dermatitis, other arthropod bites, fixed drug eruptions, granuloma annulare, cellulitis, dermatophytosis, and systemic lupus erythematosus,” they wrote.
 

Testing Steps

“The current recommendation is to do two-step testing almost simultaneously,” Dr. Schutzer said in an interview. The first, he said, is an ELISA (enzyme-linked immunosorbent assay)-type test and the second one, used for years, has been a pictoral view of a Western immunoblot showing which antigens of the Lyme bacteria, Borrelia burgdorferi, the antibodies are reacting to.

However, the pictoral view is subjective and some of the antigens could be cross-reactive. So the U.S. Food and Drug Administration (FDA) “has been allowing newer substitutes like a second ELISA-like assay that often uses more recombinant, less cross-reactive antigen targets,” he said. The authors advised that, “The second-tier test should not be performed alone without the first tier.”

Dr. Schutzer advised physicians to check with the lab they plan to use before sending samples.

“If you’re a practicing physician and you know you’re using a particular laboratory, you should familiarize yourself with them, talking to one of the clinical pathologists involved in advance to know what the limitations are.” Take the time to talk with the person overseeing the test and get tips on how they want the sample transported and how the cases should be reported, he said.

If the patient has neurological symptoms, he said, before treating talk with a neurologist who can advise whether, for instance, a spinal tap is in order or whether an emergency department visit is appropriate.

“If you just start proceeding you may mess up the diagnostic signs that could show up in a lab test. Don’t be hesitant to ask for extra input from colleagues,” Dr. Schutzer said.
 

Suspicion in Endemic Areas

On Long Island, New York, where Lyme disease is endemic, internist Ian Storch, DO, said he sees “a few cases a season.

“We have a lot of people over the summer going to the Hamptons and areas out east for the weekend and tick bites are not uncommon,” he said. “People panic.”

He said one thing it’s important to tell patients is that the tick has to be on the skin for 48-72 hours to transmit the disease. If individuals were in a wooded area and were fine before they got there and the tick was attached for less than 2 days, “they’re usually fine.”

Another issue, Dr. Storch said, is patients sometimes want to get tested for Lyme disease immediately after a tick bite. But the antibody test doesn’t turn positive for weeks, he noted, and you can get a false-negative result. “If you’re worried and you really want to test, you need to wait 6 weeks to do the blood test.”

In his region, he said that although a tick bite is a red flag, he may also suspect Lyme disease when a patient presents with otherwise unexplained joint pain, weakness, lethargy, or fever. “In our area, those are things that would make you test for Lyme.”

He also urged consideration of Lyme in this new age of long COVID. Weakness, fatigue, and lethargy are also classic symptoms of long COVID, he noted. “Keep Lyme disease in your differential because there is a lot of overlap with chronic Lyme disease,” Dr. Storch said.

Discerning Lyme from Southern Tick–Associated Rash Illness

Bonnie M. Word, MD, director of the Houston Travel Medicine Clinic in Texas, where Lyme disease is not endemic, said Lyme disease “will not and should not be on the initial differential diagnosis for those residing in nonendemic areas unless a history of travel to an endemic area is obtained.”

She noted the typical EM rash may not be as distinct or easy to discern on black and brown skin. In addition, she said, EM may have many variations in presentation, such as a crusted center or faint borders, which could lead to a delay in diagnosis and treatment. She suggested consulting the CDC guidance on Lyme disease rashes.

Another challenge in diagnosis, she said, is the patient who presents with what appears to be a classic EM lesion but does not live in a Lyme-endemic area. In Texas, Southern Tick–Associated Rash Illness (STARI) may present with a similar lesion, she said.

“It is transmitted by the Lone Star Tick, which is found in the southeast and south-central US,” Dr. Word said. “However, its habitat is moving northward and westerly,” she said.

Adding Lyme disease to the differential diagnosis is reasonable, she said, if a patient presents with neurologic symptoms “such as a facial palsy, meningitis, radiculitis, and carditis if in addition to their symptoms there is evidence of an epidemiologic link to a Lyme-endemic region.”

She noted that a detailed travel history is important as “Lyme is also endemic in Eastern Canada, Europe, states of the former Soviet Union, China, Mongolia, and Japan.”

Primary care physicians play a critical role in evaluating, diagnosing, and treating most cases of early Lyme disease, thus limiting the number of people who will develop disseminated or late Lyme disease, she said. “The two latter manifestations are most often treated by infectious disease, neurology, or rheumatology specialists.”

Treatment* 

Treatment is tailored to the clinical situation, Dr. Schutzer and Dr. Coyle write. A watch-and-wait approach may be appropriate in an asymptomatic but concerned person, even in an endemic area if the person has no known tick bite and no EM lesion.

If there is high risk of an infected ixodid tick bite in a high-incidence area and the tick was attached for at least 36 hours but less than 72 hours, one dose of doxycycline has been recommended as prophylaxis.

When a diagnosis of early nondisseminated Lyme disease is made after observation  of an EM lesion, oral antibiotics are typically used to treat for 10 to 14 days. Suggested oral antibiotics and doses are 100 mg of doxycycline twice a day, 500 mg of amoxicillin three times a day, or 500 mg of cefuroxime twice a day, the authors write.

Dr. Schutzer said he hopes the paper serves as a refresher for those physicians who regularly see Lyme disease cases and also helps those newly included in the disease’s spreading regions.

“The earlier you diagnose it, the earlier you can treat it and the better the chance for a favorable outcome,” he said.

Dr. Schutzer, Dr. Coyle, Dr. Storch, and Dr. Word reported no relevant financial relationships.

*This story was updated on August, 2, 2024.

When Bristeria Clark went into labor with her son in 2015, her contractions were steady at first. Then, they stalled. Her cervix stopped dilating. After a few hours, doctors at Phoebe Putney Memorial Hospital in Albany, Georgia, prepped Ms. Clark for an emergency cesarean section.

It wasn’t the vaginal birth Ms. Clark had hoped for during her pregnancy.

“I was freaking out. That was my first child. Like, of course you don’t plan that,” she said. “I just remember the gas pulling up to my face and I ended up going to sleep.”

She remembered feeling a rush of relief when she woke to see that her baby boy was healthy.

Ms. Clark, a 33-year-old nursing student who also works full-time in county government, had another C-section when her second child was born in 2020. This time, the cesarean was planned.

Ms. Clark said she’s grateful the physicians and nurses who delivered both her babies were kind and caring during her labor and delivery. But looking back, she said, she wishes she had had a doula for one-on-one support through pregnancy, childbirth, and the postpartum period. Now she wants to give other women the option she didn’t have.

Ms. Clark is a member of Morehouse School of Medicine’s first class of rural doulas, called Perinatal Patient Navigators.

The program recently graduated a dozen participants, all Black women from southwestern Georgia. They have completed more than 5 months of training and are scheduled to begin working with pregnant and postpartum patients this year.

“We’re developing a workforce that’s going to be providing the support that Black women and birthing people need,” Natalie Hernandez-Green, an associate professor of obstetrics and gynecology at Morehouse School of Medicine, Atlanta, Georgia, said at the doula commencement ceremony in Albany, Georgia.

Albany is Morehouse School of Medicine’s second Perinatal Patient Navigator program site. The first has been up and running in Atlanta since training began in the fall of 2022.

Georgia has one of the highest rates of maternal mortality in the country, according to an analysis by KFF, a health information nonprofit that includes KFF Health News. And Black Georgians are more than twice as likely as White Georgians to die of causes related to pregnancy.

“It doesn’t matter whether you’re rich or poor. Black women are dying at [an] alarming rate from pregnancy-related complications,” said Dr. Hernandez-Green, who is also executive director of the Center for Maternal Health Equity at Morehouse School of Medicine. “And we’re about to change that, one person at a time.”

The presence of a doula, along with regular nursing care, is associated with improved labor and delivery outcomes, reduced stress, and higher rates of patient satisfaction, according to the American College of Obstetricians and Gynecologists.

Multiple studies also link doulas to fewer expensive childbirth interventions, including cesarean births.

Doulas are not medical professionals. They are trained to offer education about the pregnancy and postpartum periods, to guide patients through the healthcare system, and to provide emotional and physical support before, during, and after childbirth.

Morehouse School of Medicine’s program is among a growing number of similar efforts being introduced across the country as more communities look to doulas to help address maternal mortality and poor maternal health outcomes, particularly for Black women and other women of color.

Now that she has graduated, Ms. Clark said she’s looking forward to helping other women in her community as a doula. “To be that person that would be there for my clients, treat them like a sister or like a mother, in a sense of just treating them with utmost respect,” she said. “The ultimate goal is to make them feel comfortable and let them know ‘I’m here to support you.’ ” Her training has inspired her to become an advocate for maternal health issues in southwestern Georgia.

Grants fund Morehouse School of Medicine’s doula program, which costs $350,000 a year to operate. Graduates are given a $2,000 training stipend and the program places five graduates with healthcare providers in southwestern Georgia. Grant money also pays the doulas’ salaries for 1 year. 

“It’s not sustainable if you’re chasing the next grant to fund it,” said Rachel Hardeman, a professor of health and racial equity at the University of Minnesota School of Public Health.

Thirteen states cover doulas through Medicaid, according to the Georgetown University Center for Children and Families.

Dr. Hardeman and others have found that when Medicaid programs cover doula care, states save millions of dollars in healthcare costs. “We were able to calculate the return on investment if Medicaid decided to reimburse doulas for pregnant people who are Medicaid beneficiaries,” she said.

That’s because doulas can help reduce the number of expensive medical interventions during and after birth, and improving delivery outcomes, including reduced cesarean sections.

Doulas can even reduce the likelihood of preterm birth. 

“An infant that is born at a very, very early gestational age is going to require a great deal of resources and interventions to ensure that they survive and then continue to thrive,” Dr. Hardeman said.

There is growing demand for doula services in Georgia, said Fowzio Jama, director of research for Healthy Mothers, Healthy Babies Coalition of Georgia. Her group recently completed a pilot study that offered doula services to about 170 Georgians covered under Medicaid. “We had a wait-list of over 200 clients and we wanted to give them the support that they needed, but we just couldn’t with the given resources that we had,” Ms. Jama said.

Doula services can cost hundreds or thousands of dollars out-of-pocket, making it too expensive for many low-income people, rural communities, and communities of color, many of which suffer from shortages in maternity care, according to the March of Dimes.

The Healthy Mothers, Healthy Babies study found that matching high-risk patients with doulas — particularly doulas from similar racial and ethnic backgrounds — had a positive effect on patients. 

“There was a reduced use of pitocin to induce labor. We saw fewer requests for pain medication. And with our infants, only 6% were low birth weight,” Ms. Jama said.

Still, she and others acknowledge that doulas alone can’t fix the problem of high maternal mortality and morbidity rates.

States, including Georgia, need to do more to bring comprehensive maternity care to communities that need more options, Dr. Hardeman said.

“I think it’s important to understand that doulas are not going to save us, and we should not put that expectation on them. Doulas are a tool,” she said. “They are a piece of the puzzle that is helping to impact a really, really complex issue.”

In the meantime, Joan Anderson, 55, said she’s excited to get to work supporting patients, especially from rural areas around Albany.

“I feel like I’m equipped to go out and be that voice, be that person that our community needs so bad,” said Ms. Anderson, a graduate of the Morehouse School of Medicine doula program. “I am encouraged to know that I will be joining in that mission, that fight for us, as far as maternal health is concerned.”

Ms. Anderson said that someday she wants to open a birthing center to provide maternity care. “We do not have one here in southwest Georgia at all,” Ms. Anderson said.

In addition to providing support during and after childbirth, Ms. Anderson and her fellow graduates are trained to assess their patients’ needs and connect them to services such as food assistance, mental health care, transportation to prenatal appointments, and breastfeeding assistance.

Their work is likely to have ripple effects across a largely rural corner of Georgia, said Sherrell Byrd, who co-founded and directs SOWEGA Rising, a nonprofit organization in southwestern Georgia.

“So many of the graduates are part of church networks, they are part of community organizations, some of them are our government workers. They’re very connected,” Ms. Byrd said. “And I think that connectedness is what’s going to help them be successful moving forward.”

This reporting is part of a fellowship with the Association of Health Care Journalists supported by The Commonwealth Fund. It comes from a partnership that includes WABE, NPR, and KFF Health News.

A version of this article first appeared on KFF Health News.

When Bristeria Clark went into labor with her son in 2015, her contractions were steady at first. Then, they stalled. Her cervix stopped dilating. After a few hours, doctors at Phoebe Putney Memorial Hospital in Albany, Georgia, prepped Ms. Clark for an emergency cesarean section.

It wasn’t the vaginal birth Ms. Clark had hoped for during her pregnancy.

“I was freaking out. That was my first child. Like, of course you don’t plan that,” she said. “I just remember the gas pulling up to my face and I ended up going to sleep.”

She remembered feeling a rush of relief when she woke to see that her baby boy was healthy.

Ms. Clark, a 33-year-old nursing student who also works full-time in county government, had another C-section when her second child was born in 2020. This time, the cesarean was planned.

Ms. Clark said she’s grateful the physicians and nurses who delivered both her babies were kind and caring during her labor and delivery. But looking back, she said, she wishes she had had a doula for one-on-one support through pregnancy, childbirth, and the postpartum period. Now she wants to give other women the option she didn’t have.

Ms. Clark is a member of Morehouse School of Medicine’s first class of rural doulas, called Perinatal Patient Navigators.

The program recently graduated a dozen participants, all Black women from southwestern Georgia. They have completed more than 5 months of training and are scheduled to begin working with pregnant and postpartum patients this year.

“We’re developing a workforce that’s going to be providing the support that Black women and birthing people need,” Natalie Hernandez-Green, an associate professor of obstetrics and gynecology at Morehouse School of Medicine, Atlanta, Georgia, said at the doula commencement ceremony in Albany, Georgia.

Albany is Morehouse School of Medicine’s second Perinatal Patient Navigator program site. The first has been up and running in Atlanta since training began in the fall of 2022.

Georgia has one of the highest rates of maternal mortality in the country, according to an analysis by KFF, a health information nonprofit that includes KFF Health News. And Black Georgians are more than twice as likely as White Georgians to die of causes related to pregnancy.

“It doesn’t matter whether you’re rich or poor. Black women are dying at [an] alarming rate from pregnancy-related complications,” said Dr. Hernandez-Green, who is also executive director of the Center for Maternal Health Equity at Morehouse School of Medicine. “And we’re about to change that, one person at a time.”

The presence of a doula, along with regular nursing care, is associated with improved labor and delivery outcomes, reduced stress, and higher rates of patient satisfaction, according to the American College of Obstetricians and Gynecologists.

Multiple studies also link doulas to fewer expensive childbirth interventions, including cesarean births.

Doulas are not medical professionals. They are trained to offer education about the pregnancy and postpartum periods, to guide patients through the healthcare system, and to provide emotional and physical support before, during, and after childbirth.

Morehouse School of Medicine’s program is among a growing number of similar efforts being introduced across the country as more communities look to doulas to help address maternal mortality and poor maternal health outcomes, particularly for Black women and other women of color.

Now that she has graduated, Ms. Clark said she’s looking forward to helping other women in her community as a doula. “To be that person that would be there for my clients, treat them like a sister or like a mother, in a sense of just treating them with utmost respect,” she said. “The ultimate goal is to make them feel comfortable and let them know ‘I’m here to support you.’ ” Her training has inspired her to become an advocate for maternal health issues in southwestern Georgia.

Grants fund Morehouse School of Medicine’s doula program, which costs $350,000 a year to operate. Graduates are given a $2,000 training stipend and the program places five graduates with healthcare providers in southwestern Georgia. Grant money also pays the doulas’ salaries for 1 year. 

“It’s not sustainable if you’re chasing the next grant to fund it,” said Rachel Hardeman, a professor of health and racial equity at the University of Minnesota School of Public Health.

Thirteen states cover doulas through Medicaid, according to the Georgetown University Center for Children and Families.

Dr. Hardeman and others have found that when Medicaid programs cover doula care, states save millions of dollars in healthcare costs. “We were able to calculate the return on investment if Medicaid decided to reimburse doulas for pregnant people who are Medicaid beneficiaries,” she said.

That’s because doulas can help reduce the number of expensive medical interventions during and after birth, and improving delivery outcomes, including reduced cesarean sections.

Doulas can even reduce the likelihood of preterm birth. 

“An infant that is born at a very, very early gestational age is going to require a great deal of resources and interventions to ensure that they survive and then continue to thrive,” Dr. Hardeman said.

There is growing demand for doula services in Georgia, said Fowzio Jama, director of research for Healthy Mothers, Healthy Babies Coalition of Georgia. Her group recently completed a pilot study that offered doula services to about 170 Georgians covered under Medicaid. “We had a wait-list of over 200 clients and we wanted to give them the support that they needed, but we just couldn’t with the given resources that we had,” Ms. Jama said.

Doula services can cost hundreds or thousands of dollars out-of-pocket, making it too expensive for many low-income people, rural communities, and communities of color, many of which suffer from shortages in maternity care, according to the March of Dimes.

The Healthy Mothers, Healthy Babies study found that matching high-risk patients with doulas — particularly doulas from similar racial and ethnic backgrounds — had a positive effect on patients. 

“There was a reduced use of pitocin to induce labor. We saw fewer requests for pain medication. And with our infants, only 6% were low birth weight,” Ms. Jama said.

Still, she and others acknowledge that doulas alone can’t fix the problem of high maternal mortality and morbidity rates.

States, including Georgia, need to do more to bring comprehensive maternity care to communities that need more options, Dr. Hardeman said.

“I think it’s important to understand that doulas are not going to save us, and we should not put that expectation on them. Doulas are a tool,” she said. “They are a piece of the puzzle that is helping to impact a really, really complex issue.”

In the meantime, Joan Anderson, 55, said she’s excited to get to work supporting patients, especially from rural areas around Albany.

“I feel like I’m equipped to go out and be that voice, be that person that our community needs so bad,” said Ms. Anderson, a graduate of the Morehouse School of Medicine doula program. “I am encouraged to know that I will be joining in that mission, that fight for us, as far as maternal health is concerned.”

Ms. Anderson said that someday she wants to open a birthing center to provide maternity care. “We do not have one here in southwest Georgia at all,” Ms. Anderson said.

In addition to providing support during and after childbirth, Ms. Anderson and her fellow graduates are trained to assess their patients’ needs and connect them to services such as food assistance, mental health care, transportation to prenatal appointments, and breastfeeding assistance.

Their work is likely to have ripple effects across a largely rural corner of Georgia, said Sherrell Byrd, who co-founded and directs SOWEGA Rising, a nonprofit organization in southwestern Georgia.

“So many of the graduates are part of church networks, they are part of community organizations, some of them are our government workers. They’re very connected,” Ms. Byrd said. “And I think that connectedness is what’s going to help them be successful moving forward.”

This reporting is part of a fellowship with the Association of Health Care Journalists supported by The Commonwealth Fund. It comes from a partnership that includes WABE, NPR, and KFF Health News.

A version of this article first appeared on KFF Health News.

When Bristeria Clark went into labor with her son in 2015, her contractions were steady at first. Then, they stalled. Her cervix stopped dilating. After a few hours, doctors at Phoebe Putney Memorial Hospital in Albany, Georgia, prepped Ms. Clark for an emergency cesarean section.

It wasn’t the vaginal birth Ms. Clark had hoped for during her pregnancy.

“I was freaking out. That was my first child. Like, of course you don’t plan that,” she said. “I just remember the gas pulling up to my face and I ended up going to sleep.”

She remembered feeling a rush of relief when she woke to see that her baby boy was healthy.

Ms. Clark, a 33-year-old nursing student who also works full-time in county government, had another C-section when her second child was born in 2020. This time, the cesarean was planned.

Ms. Clark said she’s grateful the physicians and nurses who delivered both her babies were kind and caring during her labor and delivery. But looking back, she said, she wishes she had had a doula for one-on-one support through pregnancy, childbirth, and the postpartum period. Now she wants to give other women the option she didn’t have.

Ms. Clark is a member of Morehouse School of Medicine’s first class of rural doulas, called Perinatal Patient Navigators.

The program recently graduated a dozen participants, all Black women from southwestern Georgia. They have completed more than 5 months of training and are scheduled to begin working with pregnant and postpartum patients this year.

“We’re developing a workforce that’s going to be providing the support that Black women and birthing people need,” Natalie Hernandez-Green, an associate professor of obstetrics and gynecology at Morehouse School of Medicine, Atlanta, Georgia, said at the doula commencement ceremony in Albany, Georgia.

Albany is Morehouse School of Medicine’s second Perinatal Patient Navigator program site. The first has been up and running in Atlanta since training began in the fall of 2022.

Georgia has one of the highest rates of maternal mortality in the country, according to an analysis by KFF, a health information nonprofit that includes KFF Health News. And Black Georgians are more than twice as likely as White Georgians to die of causes related to pregnancy.

“It doesn’t matter whether you’re rich or poor. Black women are dying at [an] alarming rate from pregnancy-related complications,” said Dr. Hernandez-Green, who is also executive director of the Center for Maternal Health Equity at Morehouse School of Medicine. “And we’re about to change that, one person at a time.”

The presence of a doula, along with regular nursing care, is associated with improved labor and delivery outcomes, reduced stress, and higher rates of patient satisfaction, according to the American College of Obstetricians and Gynecologists.

Multiple studies also link doulas to fewer expensive childbirth interventions, including cesarean births.

Doulas are not medical professionals. They are trained to offer education about the pregnancy and postpartum periods, to guide patients through the healthcare system, and to provide emotional and physical support before, during, and after childbirth.

Morehouse School of Medicine’s program is among a growing number of similar efforts being introduced across the country as more communities look to doulas to help address maternal mortality and poor maternal health outcomes, particularly for Black women and other women of color.

Now that she has graduated, Ms. Clark said she’s looking forward to helping other women in her community as a doula. “To be that person that would be there for my clients, treat them like a sister or like a mother, in a sense of just treating them with utmost respect,” she said. “The ultimate goal is to make them feel comfortable and let them know ‘I’m here to support you.’ ” Her training has inspired her to become an advocate for maternal health issues in southwestern Georgia.

Grants fund Morehouse School of Medicine’s doula program, which costs $350,000 a year to operate. Graduates are given a $2,000 training stipend and the program places five graduates with healthcare providers in southwestern Georgia. Grant money also pays the doulas’ salaries for 1 year. 

“It’s not sustainable if you’re chasing the next grant to fund it,” said Rachel Hardeman, a professor of health and racial equity at the University of Minnesota School of Public Health.

Thirteen states cover doulas through Medicaid, according to the Georgetown University Center for Children and Families.

Dr. Hardeman and others have found that when Medicaid programs cover doula care, states save millions of dollars in healthcare costs. “We were able to calculate the return on investment if Medicaid decided to reimburse doulas for pregnant people who are Medicaid beneficiaries,” she said.

That’s because doulas can help reduce the number of expensive medical interventions during and after birth, and improving delivery outcomes, including reduced cesarean sections.

Doulas can even reduce the likelihood of preterm birth. 

“An infant that is born at a very, very early gestational age is going to require a great deal of resources and interventions to ensure that they survive and then continue to thrive,” Dr. Hardeman said.

There is growing demand for doula services in Georgia, said Fowzio Jama, director of research for Healthy Mothers, Healthy Babies Coalition of Georgia. Her group recently completed a pilot study that offered doula services to about 170 Georgians covered under Medicaid. “We had a wait-list of over 200 clients and we wanted to give them the support that they needed, but we just couldn’t with the given resources that we had,” Ms. Jama said.

Doula services can cost hundreds or thousands of dollars out-of-pocket, making it too expensive for many low-income people, rural communities, and communities of color, many of which suffer from shortages in maternity care, according to the March of Dimes.

The Healthy Mothers, Healthy Babies study found that matching high-risk patients with doulas — particularly doulas from similar racial and ethnic backgrounds — had a positive effect on patients. 

“There was a reduced use of pitocin to induce labor. We saw fewer requests for pain medication. And with our infants, only 6% were low birth weight,” Ms. Jama said.

Still, she and others acknowledge that doulas alone can’t fix the problem of high maternal mortality and morbidity rates.

States, including Georgia, need to do more to bring comprehensive maternity care to communities that need more options, Dr. Hardeman said.

“I think it’s important to understand that doulas are not going to save us, and we should not put that expectation on them. Doulas are a tool,” she said. “They are a piece of the puzzle that is helping to impact a really, really complex issue.”

In the meantime, Joan Anderson, 55, said she’s excited to get to work supporting patients, especially from rural areas around Albany.

“I feel like I’m equipped to go out and be that voice, be that person that our community needs so bad,” said Ms. Anderson, a graduate of the Morehouse School of Medicine doula program. “I am encouraged to know that I will be joining in that mission, that fight for us, as far as maternal health is concerned.”

Ms. Anderson said that someday she wants to open a birthing center to provide maternity care. “We do not have one here in southwest Georgia at all,” Ms. Anderson said.

In addition to providing support during and after childbirth, Ms. Anderson and her fellow graduates are trained to assess their patients’ needs and connect them to services such as food assistance, mental health care, transportation to prenatal appointments, and breastfeeding assistance.

Their work is likely to have ripple effects across a largely rural corner of Georgia, said Sherrell Byrd, who co-founded and directs SOWEGA Rising, a nonprofit organization in southwestern Georgia.

“So many of the graduates are part of church networks, they are part of community organizations, some of them are our government workers. They’re very connected,” Ms. Byrd said. “And I think that connectedness is what’s going to help them be successful moving forward.”

This reporting is part of a fellowship with the Association of Health Care Journalists supported by The Commonwealth Fund. It comes from a partnership that includes WABE, NPR, and KFF Health News.

A version of this article first appeared on KFF Health News.