Mental Health

A large UK-based study has found that females, sexual minorities, and people experiencing socioeconomic disadvantage are most at-risk of “internalised” weight stigma, along with people who experienced family and media pressure to lose weight in childhood. This can continue to be the case as long as two decades after the childhood experiences.

“Internalised weight stigma” happens when a person adopts negative obesity-related stereotypes, such as thinking they are less attractive, less competent, or less valuable as a person due to their weight, even in situations where their BMI suggests such a view is not valid.

Researchers at the universities of Bristol and Leeds, with colleagues at institutions interested in weight and mental health issues, analyzed the link between internalised weight stigma in adulthood and adolescent experiences and social circumstances. Their work used data obtained as part of Bristol University’s ongoing Children of the 90s project. This recruited thousands of pregnant women between 1990 and 1991, and has now followed the health of them and their families for more than 30 years.

The investigation, published in The Lancet Regional Health, examined differences in internalised weight stigma in more than 4000 people aged 31 years, focusing on effects of sex, ethnicity, socioeconomic factors, sexual orientation, and family and wider social influences in childhood and adolescence. The data were obtained from responses to 11 targeted questions included within the more general questionnaire completed by Children of the 90s participants when aged 31.
 

Effects Unrelated to Weight

Social epidemiologist Amanda Hughes, BSc, MSc, PhD, at the MRC Epidemiology Unit in Bristol Medical School, first author of the research report, said that the study “was not about what weight you think you are, but about how that relates to your view of yourself as a human being.” She explained that the research identified factors that led to higher levels of long-term internalised weight stigma in adults two decades after negative experiences in childhood or youth, “regardless of what their actual weight was.” Even people in the acceptable BMI range had levels of internalised weight stigma that were associated with experiences around two decades earlier.

The headline finding of the study was that those most at risk of developing internalised weight stigma were females, sexual minorities, and people experiencing socioeconomic disadvantage. People who as teenagers felt pressure to lose weight from family, wider social interactions, or the media were also at elevated risk.

“There are definitely inequalities in who was affected by this psychologically,” Dr. Hughes said, and the inequalities were associated with the sex, nonheterosexuality, or socioeconomic circumstances, rather than being explained by differences in BMI. The differences in the psychological impact of negative early-life weight-related experiences, such as pressure from family, teasing, bullying, and general weight-shaming, showed up even among people of the same weight.

Dr. Hughes emphasized that the new value of this research comes from its sample size, the general spread of people sampled, and the long length of time over which the relationships between experiences and effects were analyzed. Previous evidence, globally, has come from small and nonrepresentative samples, such as psychology undergraduates or people engaged in weight management programs.

Rebecca Puhl, PhD, professor of human development and family sciences at Connecticut University, an internationally prominent researcher of internalized weight stigma issues, said: “This study adds new insights to the increasing evidence on internalised weight bias. Their findings that internalised weight bias is elevated among individuals with sexual minority identities and those with socioeconomically disadvantaged backgrounds highlight the importance of addressing weight stigma and its consequences among populations with multiple stigmatised identities.” She added that the findings “reiterate the need for far-reaching stigma reduction interventions.” Dr. Puhl was not involved in this study.
 

Promote Healthy, Not Thin

Dr. Hughes stressed that interventions to address the issue, by efforts to change attitudes in family life, the media, and other approaches, should continue to promote healthy weight management amongst youngsters, while avoiding the dangers of inappropriate stigma and the resulting mental health problems.

“The crucial thing is … don’t frame [nutritional guidance] in terms of: if you do these things you’ll be thinner and thinner is better,” Dr. Hughes said. She stressed that the most important approach is to promote good nutrition for health, without making it all about being thin.

Dr. Hughes said there are many further things the researchers would like to do to take their work forward, including getting a more detailed look at the psychological processes involved and the relationship between internalised weight stigma and other aspects of mental health.

Dr. Hughes has no relevant interests to disclose. Dr. Puhl has no relevant interests to disclose, but is currently receiving funding from Eli Lilly.

A version of this article appeared on Medscape.com.

A large UK-based study has found that females, sexual minorities, and people experiencing socioeconomic disadvantage are most at-risk of “internalised” weight stigma, along with people who experienced family and media pressure to lose weight in childhood. This can continue to be the case as long as two decades after the childhood experiences.

“Internalised weight stigma” happens when a person adopts negative obesity-related stereotypes, such as thinking they are less attractive, less competent, or less valuable as a person due to their weight, even in situations where their BMI suggests such a view is not valid.

Researchers at the universities of Bristol and Leeds, with colleagues at institutions interested in weight and mental health issues, analyzed the link between internalised weight stigma in adulthood and adolescent experiences and social circumstances. Their work used data obtained as part of Bristol University’s ongoing Children of the 90s project. This recruited thousands of pregnant women between 1990 and 1991, and has now followed the health of them and their families for more than 30 years.

The investigation, published in The Lancet Regional Health, examined differences in internalised weight stigma in more than 4000 people aged 31 years, focusing on effects of sex, ethnicity, socioeconomic factors, sexual orientation, and family and wider social influences in childhood and adolescence. The data were obtained from responses to 11 targeted questions included within the more general questionnaire completed by Children of the 90s participants when aged 31.
 

Effects Unrelated to Weight

Social epidemiologist Amanda Hughes, BSc, MSc, PhD, at the MRC Epidemiology Unit in Bristol Medical School, first author of the research report, said that the study “was not about what weight you think you are, but about how that relates to your view of yourself as a human being.” She explained that the research identified factors that led to higher levels of long-term internalised weight stigma in adults two decades after negative experiences in childhood or youth, “regardless of what their actual weight was.” Even people in the acceptable BMI range had levels of internalised weight stigma that were associated with experiences around two decades earlier.

The headline finding of the study was that those most at risk of developing internalised weight stigma were females, sexual minorities, and people experiencing socioeconomic disadvantage. People who as teenagers felt pressure to lose weight from family, wider social interactions, or the media were also at elevated risk.

“There are definitely inequalities in who was affected by this psychologically,” Dr. Hughes said, and the inequalities were associated with the sex, nonheterosexuality, or socioeconomic circumstances, rather than being explained by differences in BMI. The differences in the psychological impact of negative early-life weight-related experiences, such as pressure from family, teasing, bullying, and general weight-shaming, showed up even among people of the same weight.

Dr. Hughes emphasized that the new value of this research comes from its sample size, the general spread of people sampled, and the long length of time over which the relationships between experiences and effects were analyzed. Previous evidence, globally, has come from small and nonrepresentative samples, such as psychology undergraduates or people engaged in weight management programs.

Rebecca Puhl, PhD, professor of human development and family sciences at Connecticut University, an internationally prominent researcher of internalized weight stigma issues, said: “This study adds new insights to the increasing evidence on internalised weight bias. Their findings that internalised weight bias is elevated among individuals with sexual minority identities and those with socioeconomically disadvantaged backgrounds highlight the importance of addressing weight stigma and its consequences among populations with multiple stigmatised identities.” She added that the findings “reiterate the need for far-reaching stigma reduction interventions.” Dr. Puhl was not involved in this study.
 

Promote Healthy, Not Thin

Dr. Hughes stressed that interventions to address the issue, by efforts to change attitudes in family life, the media, and other approaches, should continue to promote healthy weight management amongst youngsters, while avoiding the dangers of inappropriate stigma and the resulting mental health problems.

“The crucial thing is … don’t frame [nutritional guidance] in terms of: if you do these things you’ll be thinner and thinner is better,” Dr. Hughes said. She stressed that the most important approach is to promote good nutrition for health, without making it all about being thin.

Dr. Hughes said there are many further things the researchers would like to do to take their work forward, including getting a more detailed look at the psychological processes involved and the relationship between internalised weight stigma and other aspects of mental health.

Dr. Hughes has no relevant interests to disclose. Dr. Puhl has no relevant interests to disclose, but is currently receiving funding from Eli Lilly.

A version of this article appeared on Medscape.com.

A large UK-based study has found that females, sexual minorities, and people experiencing socioeconomic disadvantage are most at-risk of “internalised” weight stigma, along with people who experienced family and media pressure to lose weight in childhood. This can continue to be the case as long as two decades after the childhood experiences.

“Internalised weight stigma” happens when a person adopts negative obesity-related stereotypes, such as thinking they are less attractive, less competent, or less valuable as a person due to their weight, even in situations where their BMI suggests such a view is not valid.

Researchers at the universities of Bristol and Leeds, with colleagues at institutions interested in weight and mental health issues, analyzed the link between internalised weight stigma in adulthood and adolescent experiences and social circumstances. Their work used data obtained as part of Bristol University’s ongoing Children of the 90s project. This recruited thousands of pregnant women between 1990 and 1991, and has now followed the health of them and their families for more than 30 years.

The investigation, published in The Lancet Regional Health, examined differences in internalised weight stigma in more than 4000 people aged 31 years, focusing on effects of sex, ethnicity, socioeconomic factors, sexual orientation, and family and wider social influences in childhood and adolescence. The data were obtained from responses to 11 targeted questions included within the more general questionnaire completed by Children of the 90s participants when aged 31.
 

Effects Unrelated to Weight

Social epidemiologist Amanda Hughes, BSc, MSc, PhD, at the MRC Epidemiology Unit in Bristol Medical School, first author of the research report, said that the study “was not about what weight you think you are, but about how that relates to your view of yourself as a human being.” She explained that the research identified factors that led to higher levels of long-term internalised weight stigma in adults two decades after negative experiences in childhood or youth, “regardless of what their actual weight was.” Even people in the acceptable BMI range had levels of internalised weight stigma that were associated with experiences around two decades earlier.

The headline finding of the study was that those most at risk of developing internalised weight stigma were females, sexual minorities, and people experiencing socioeconomic disadvantage. People who as teenagers felt pressure to lose weight from family, wider social interactions, or the media were also at elevated risk.

“There are definitely inequalities in who was affected by this psychologically,” Dr. Hughes said, and the inequalities were associated with the sex, nonheterosexuality, or socioeconomic circumstances, rather than being explained by differences in BMI. The differences in the psychological impact of negative early-life weight-related experiences, such as pressure from family, teasing, bullying, and general weight-shaming, showed up even among people of the same weight.

Dr. Hughes emphasized that the new value of this research comes from its sample size, the general spread of people sampled, and the long length of time over which the relationships between experiences and effects were analyzed. Previous evidence, globally, has come from small and nonrepresentative samples, such as psychology undergraduates or people engaged in weight management programs.

Rebecca Puhl, PhD, professor of human development and family sciences at Connecticut University, an internationally prominent researcher of internalized weight stigma issues, said: “This study adds new insights to the increasing evidence on internalised weight bias. Their findings that internalised weight bias is elevated among individuals with sexual minority identities and those with socioeconomically disadvantaged backgrounds highlight the importance of addressing weight stigma and its consequences among populations with multiple stigmatised identities.” She added that the findings “reiterate the need for far-reaching stigma reduction interventions.” Dr. Puhl was not involved in this study.
 

Promote Healthy, Not Thin

Dr. Hughes stressed that interventions to address the issue, by efforts to change attitudes in family life, the media, and other approaches, should continue to promote healthy weight management amongst youngsters, while avoiding the dangers of inappropriate stigma and the resulting mental health problems.

“The crucial thing is … don’t frame [nutritional guidance] in terms of: if you do these things you’ll be thinner and thinner is better,” Dr. Hughes said. She stressed that the most important approach is to promote good nutrition for health, without making it all about being thin.

Dr. Hughes said there are many further things the researchers would like to do to take their work forward, including getting a more detailed look at the psychological processes involved and the relationship between internalised weight stigma and other aspects of mental health.

Dr. Hughes has no relevant interests to disclose. Dr. Puhl has no relevant interests to disclose, but is currently receiving funding from Eli Lilly.

A version of this article appeared on Medscape.com.

TOPLINE:

The number of suicides among US college students has doubled over the past two decades and is now the second-most common cause of death after accidents in this population, a new study by the National Collegiate Athletic Association (NCAA) found.

METHODOLOGY:

• Investigators analyzed deaths between 2002 and 2022, using Poisson regression models to assess changes in incidence rates over time.
• Data were drawn from the NCAA death database, which includes death from any cause, and included demographic characteristics such as age and race and sporting discipline.
• They utilized linear and quadratic fits between year and suicide incidence for men and women.
• Given the low incidence of suicide deaths per year, the incidence rate was multiplied by 100,000 to calculate the incidence per 100,000 athlete-years (AYs).
•  

TAKEAWAY:

• Of 1102 total deaths, 11.6% were due to suicide (98 men, 30 women).
• Athletes who died by suicide ranged in age from 17 to 24 years (mean, 20 years) were predominantly men (77%) and White (59%), with the highest suicide incidence rate among male cross-country athletes (1:29 per 815 AYs).
• The overall incidence of suicide was 1:71 per 145 AYs.
• Over the last 10 years, suicide was the second most common cause of death after accidents, with the proportion of deaths by suicide doubling from the first to the second decades (7.6% to 15.3%).
• Among men, the suicide incidence rate increased in a linear fashion (5-year incidence rate ratio, 1.32; 95% CI, 1.14-1.53), while among women, a quadratic association was identified (P = .002), with the incidence rate reaching its lowest point in women from 2010 to 2011 and increasing thereafter.

IN PRACTICE:

“Athletes are generally thought of as one of the healthiest populations in our society, yet the pressures of school, internal and external performance expectations, time demands, injury, athletic identity, and physical fatigue can lead to depression, mental health problems, and suicide,” the authors wrote. “Although the rate of suicide among collegiate athletes remains lower than the general population, it is important to recognize the parallel increase to ensure this population is not overlooked when assessing for risk factors and implementing prevention strategies.”

SOURCE:

Bridget M. Whelan, MPH, research scientist in the Department of Family Medicine, Sports Medicine Section, University of Washington School of Medicine, Seattle, was the lead and corresponding author on the study, which was published online in the British Journal of Sports Medicine.

LIMITATIONS:

There is no mandatory reporting system for athlete deaths in the United States, and investigators’ search identified 16 deaths with unknown causes, suggesting reported suicide incidence rates may be underestimated. Additionally, in cases of overdose that were not clearly intentional, the death was listed as “overdose,” possibly resulting in underreporting of suicide.

DISCLOSURES:

No source of study funding was listed. The authors disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

TOPLINE:

The number of suicides among US college students has doubled over the past two decades and is now the second-most common cause of death after accidents in this population, a new study by the National Collegiate Athletic Association (NCAA) found.

METHODOLOGY:

• Investigators analyzed deaths between 2002 and 2022, using Poisson regression models to assess changes in incidence rates over time.
• Data were drawn from the NCAA death database, which includes death from any cause, and included demographic characteristics such as age and race and sporting discipline.
• They utilized linear and quadratic fits between year and suicide incidence for men and women.
• Given the low incidence of suicide deaths per year, the incidence rate was multiplied by 100,000 to calculate the incidence per 100,000 athlete-years (AYs).
•  

TAKEAWAY:

• Of 1102 total deaths, 11.6% were due to suicide (98 men, 30 women).
• Athletes who died by suicide ranged in age from 17 to 24 years (mean, 20 years) were predominantly men (77%) and White (59%), with the highest suicide incidence rate among male cross-country athletes (1:29 per 815 AYs).
• The overall incidence of suicide was 1:71 per 145 AYs.
• Over the last 10 years, suicide was the second most common cause of death after accidents, with the proportion of deaths by suicide doubling from the first to the second decades (7.6% to 15.3%).
• Among men, the suicide incidence rate increased in a linear fashion (5-year incidence rate ratio, 1.32; 95% CI, 1.14-1.53), while among women, a quadratic association was identified (P = .002), with the incidence rate reaching its lowest point in women from 2010 to 2011 and increasing thereafter.

IN PRACTICE:

“Athletes are generally thought of as one of the healthiest populations in our society, yet the pressures of school, internal and external performance expectations, time demands, injury, athletic identity, and physical fatigue can lead to depression, mental health problems, and suicide,” the authors wrote. “Although the rate of suicide among collegiate athletes remains lower than the general population, it is important to recognize the parallel increase to ensure this population is not overlooked when assessing for risk factors and implementing prevention strategies.”

SOURCE:

Bridget M. Whelan, MPH, research scientist in the Department of Family Medicine, Sports Medicine Section, University of Washington School of Medicine, Seattle, was the lead and corresponding author on the study, which was published online in the British Journal of Sports Medicine.

LIMITATIONS:

There is no mandatory reporting system for athlete deaths in the United States, and investigators’ search identified 16 deaths with unknown causes, suggesting reported suicide incidence rates may be underestimated. Additionally, in cases of overdose that were not clearly intentional, the death was listed as “overdose,” possibly resulting in underreporting of suicide.

DISCLOSURES:

No source of study funding was listed. The authors disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

TOPLINE:

The number of suicides among US college students has doubled over the past two decades and is now the second-most common cause of death after accidents in this population, a new study by the National Collegiate Athletic Association (NCAA) found.

METHODOLOGY:

• Investigators analyzed deaths between 2002 and 2022, using Poisson regression models to assess changes in incidence rates over time.
• Data were drawn from the NCAA death database, which includes death from any cause, and included demographic characteristics such as age and race and sporting discipline.
• They utilized linear and quadratic fits between year and suicide incidence for men and women.
• Given the low incidence of suicide deaths per year, the incidence rate was multiplied by 100,000 to calculate the incidence per 100,000 athlete-years (AYs).
•  

TAKEAWAY:

• Of 1102 total deaths, 11.6% were due to suicide (98 men, 30 women).
• Athletes who died by suicide ranged in age from 17 to 24 years (mean, 20 years) were predominantly men (77%) and White (59%), with the highest suicide incidence rate among male cross-country athletes (1:29 per 815 AYs).
• The overall incidence of suicide was 1:71 per 145 AYs.
• Over the last 10 years, suicide was the second most common cause of death after accidents, with the proportion of deaths by suicide doubling from the first to the second decades (7.6% to 15.3%).
• Among men, the suicide incidence rate increased in a linear fashion (5-year incidence rate ratio, 1.32; 95% CI, 1.14-1.53), while among women, a quadratic association was identified (P = .002), with the incidence rate reaching its lowest point in women from 2010 to 2011 and increasing thereafter.

IN PRACTICE:

“Athletes are generally thought of as one of the healthiest populations in our society, yet the pressures of school, internal and external performance expectations, time demands, injury, athletic identity, and physical fatigue can lead to depression, mental health problems, and suicide,” the authors wrote. “Although the rate of suicide among collegiate athletes remains lower than the general population, it is important to recognize the parallel increase to ensure this population is not overlooked when assessing for risk factors and implementing prevention strategies.”

SOURCE:

Bridget M. Whelan, MPH, research scientist in the Department of Family Medicine, Sports Medicine Section, University of Washington School of Medicine, Seattle, was the lead and corresponding author on the study, which was published online in the British Journal of Sports Medicine.

LIMITATIONS:

There is no mandatory reporting system for athlete deaths in the United States, and investigators’ search identified 16 deaths with unknown causes, suggesting reported suicide incidence rates may be underestimated. Additionally, in cases of overdose that were not clearly intentional, the death was listed as “overdose,” possibly resulting in underreporting of suicide.

DISCLOSURES:

No source of study funding was listed. The authors disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

Girls are catching up with and sometimes surpassing boys in terms of adolescent substance use, warned the authors of a new report detailing trends across several regions between 2018 and 2022. The latest 4-yearly Health Behaviour in School-Aged Children study, in collaboration with the World Health Organization (WHO) Regional Office for Europe, concluded that substance use remains “a crucial public health problem among adolescents” despite overall declines in smoking, alcohol, and cannabis use.

The new report: A focus on adolescent substance use in Europe, central Asia, and Canada, detailed substance use among adolescents aged 11, 13, and 15 years across 44 countries and regions in Europe, Central Asia, and Canada in the 2021-2022 school-based survey.

Principal findings included:

• Cigarette smoking: Lifetime smoking declined between 2018 and 2022, particularly among 13-year-old boys and 15-year-old boys and girls. There was also a small but significant decrease in current smoking among 15-year-old boys.
• Alcohol use: Lifetime use decreased overall in boys between 2018 and 2022, particularly among 15-year-olds. An increase was observed among 11- and 13-year-old girls but not 15-year-old girls. There was a small but significant decrease in the proportion of current drinkers among 15-year-old boys, with no change among 11- and 13-year-old boys. Current alcohol use increased among girls in all age groups.
• Cannabis use: Lifetime use among 15-year-olds decreased slightly from 14% to 12% between 2018 and 2022, while 6% of 15-year-olds reported having used cannabis in the previous 30 days.
• Vaping: In 2022 vapes (e-cigarettes) were more popular among adolescents than conventional tobacco cigarettes.

Traditional Gender Gap Narrowing or Reversing

Report coauthor Judith Brown from the University of Glasgow, Glasgow, Scotland, and a project manager for the Scottish survey, said that “there was an overall increase in current alcohol use and drunkenness among older girls” despite the overall decrease in boys’ alcohol use.

She explained: “Substance use has traditionally been more prevalent among boys, and the survey findings confirm a well-established gender difference, with higher prevalence in boys than in girls among 11-year-olds. By the age of 13, however, gender differences diminish or even disappear in many countries and regions.”

“Among 15-year-olds, girls often reported more frequent substance use than boys. While this pattern has been known for cigarette smoking in many countries and regions for about two decades, especially among 15-year-olds, it is a new phenomenon for behaviors related to other substances (such as alcohol consumption and drunkenness) in most countries and regions. Historically, prevalence for these behaviors has been higher among boys than girls.”

The new survey results highlight this gender reversal for several substances, she said. “Cannabis is the only substance for which both lifetime and current use is consistently higher in boys.”
 

Vaping Is an Emerging Public Health Concern

Dr. Brown added that the 2022 survey was the first time that vaping data had been collected from all countries. Although this is against the background of continuing decreases in smoking rates, “researchers suggest the transition to e-cigarettes, as a more popular choice than conventional cigarettes, highlights an urgent need for more targeted interventions to address this emerging public health concern.”

The report authors commented that because young people’s brains are still developing, they are “very sensitive to substances such as nicotine,” making it “easier for them to get hooked.”

Margreet de Looze, PhD, assistant professor of interdisciplinary social science at Utrecht University in Utrecht, the Netherlands, agreed with the authors’ concerns. “Vaping is extremely attractive for young people,” she said, “because the taste is more attractive than that of traditional cigarettes.” Until recently, many people were not aware of health hazards attached to vaping. “While more research is needed, vaping may function as a first step toward tobacco use and is hazardous for young people’s health. Therefore, it should be strongly discouraged.”
 

Substance Use Trends May Be Stabilizing or Rising Again

Increased awareness of the harmful effects of alcohol for adolescent development is also one postulated reason for declining adolescent alcohol consumption in both Europe and North America over the past two decades, which Dr. de Looze’s research has explored. Her work has also noted the “growing trend” of young people abstaining from alcohol altogether and some evidence of reductions in adolescent risk behaviors more generally, including early sexual initiation and juvenile crime.

“It may be good to realize that, in fact, the current generation of youth in many respects is healthier and reports less risky health behaviors as compared to previous generations,” she said.

However, “The declining trend in adolescent substance use that took place in many countries since the beginning of the 21st century seems to have stabilized, and moreover, in some countries and subgroups of adolescents, substance use appears to be on the rise again.” She cited particularly an overall increase in current alcohol use and drunkenness among older girls between 2018 and 2022. “It appears that, especially for girls, recent trends over time are less favorable as compared with boys.”
 

Multiple Influences on Adolescent Substance Abuse

Peer group influences are known to come to the fore during adolescence, and Dr. de Looze added that the early 21st century saw marked reductions in adolescent face-to-face contacts with their peers due to the rise in digital communications. “Adolescents typically use substances in the presence of peers (and in the absence of adults/parents), as it increases their status in their peer group.” Reduced in person interactions with friends may therefore have contributed to the earlier decline in substance use.

However, her team had found that adolescents who spend much time online with friends often also spend much time with friends offline. “They are what you could call the ‘social’ youth, who just spend much time with peers, be it offline or online,” she said. “More research is needed to disentangle exactly how, what kind, for whom the digital environment may be related to young people’s substance use,” she said.

“We also see that young people actively select their friends. So, if you are curious and a bit of a sensation-seeker yourself, you are more likely to become friends with youth who are just like you, and together, you may be more likely to try out substances.”

Factors underlying adolescent substance use and differences between countries are influenced by a complex interplay of factors, said Carina Ferreira-Borges, PhD, regional adviser for alcohol, illicit drugs, and prison health at the WHO Regional Office for Europe.

“Prevention measures definitely play a critical role in reducing substance use,” she said, “but other factors, such as cultural norms and socioeconomic conditions, also significantly impact these patterns.”

“Variations in substance use among countries can be attributed to different levels of implemented polices, public health initiatives, and the extent to which substance use is normalized or stigmatized within each society.”
 

Policy Efforts Must Be Targeted

“To address these disparities effectively, interventions and population-level policies need to be culturally adapted and target the specific environments where substance use is normalized among adolescents. By understanding and modifying the broader context in which young people make choices about substance use, we can better influence their behavior and health outcomes.”

Dr. de Looze cautioned, “In the past two decades, public health efforts in many countries have focused on reducing young people’s engagement in substance use. It is important that these efforts continue, as every year a new generation of youth is born. If public health efforts do not continue to focus on supporting a healthy lifestyle among young people, it should not come as a surprise that rates start or continue to rise again.”

A version of this article appeared on Medscape.com.

Girls are catching up with and sometimes surpassing boys in terms of adolescent substance use, warned the authors of a new report detailing trends across several regions between 2018 and 2022. The latest 4-yearly Health Behaviour in School-Aged Children study, in collaboration with the World Health Organization (WHO) Regional Office for Europe, concluded that substance use remains “a crucial public health problem among adolescents” despite overall declines in smoking, alcohol, and cannabis use.

The new report: A focus on adolescent substance use in Europe, central Asia, and Canada, detailed substance use among adolescents aged 11, 13, and 15 years across 44 countries and regions in Europe, Central Asia, and Canada in the 2021-2022 school-based survey.

Principal findings included:

• Cigarette smoking: Lifetime smoking declined between 2018 and 2022, particularly among 13-year-old boys and 15-year-old boys and girls. There was also a small but significant decrease in current smoking among 15-year-old boys.
• Alcohol use: Lifetime use decreased overall in boys between 2018 and 2022, particularly among 15-year-olds. An increase was observed among 11- and 13-year-old girls but not 15-year-old girls. There was a small but significant decrease in the proportion of current drinkers among 15-year-old boys, with no change among 11- and 13-year-old boys. Current alcohol use increased among girls in all age groups.
• Cannabis use: Lifetime use among 15-year-olds decreased slightly from 14% to 12% between 2018 and 2022, while 6% of 15-year-olds reported having used cannabis in the previous 30 days.
• Vaping: In 2022 vapes (e-cigarettes) were more popular among adolescents than conventional tobacco cigarettes.

Traditional Gender Gap Narrowing or Reversing

Report coauthor Judith Brown from the University of Glasgow, Glasgow, Scotland, and a project manager for the Scottish survey, said that “there was an overall increase in current alcohol use and drunkenness among older girls” despite the overall decrease in boys’ alcohol use.

She explained: “Substance use has traditionally been more prevalent among boys, and the survey findings confirm a well-established gender difference, with higher prevalence in boys than in girls among 11-year-olds. By the age of 13, however, gender differences diminish or even disappear in many countries and regions.”

“Among 15-year-olds, girls often reported more frequent substance use than boys. While this pattern has been known for cigarette smoking in many countries and regions for about two decades, especially among 15-year-olds, it is a new phenomenon for behaviors related to other substances (such as alcohol consumption and drunkenness) in most countries and regions. Historically, prevalence for these behaviors has been higher among boys than girls.”

The new survey results highlight this gender reversal for several substances, she said. “Cannabis is the only substance for which both lifetime and current use is consistently higher in boys.”
 

Vaping Is an Emerging Public Health Concern

Dr. Brown added that the 2022 survey was the first time that vaping data had been collected from all countries. Although this is against the background of continuing decreases in smoking rates, “researchers suggest the transition to e-cigarettes, as a more popular choice than conventional cigarettes, highlights an urgent need for more targeted interventions to address this emerging public health concern.”

The report authors commented that because young people’s brains are still developing, they are “very sensitive to substances such as nicotine,” making it “easier for them to get hooked.”

Margreet de Looze, PhD, assistant professor of interdisciplinary social science at Utrecht University in Utrecht, the Netherlands, agreed with the authors’ concerns. “Vaping is extremely attractive for young people,” she said, “because the taste is more attractive than that of traditional cigarettes.” Until recently, many people were not aware of health hazards attached to vaping. “While more research is needed, vaping may function as a first step toward tobacco use and is hazardous for young people’s health. Therefore, it should be strongly discouraged.”
 

Substance Use Trends May Be Stabilizing or Rising Again

Increased awareness of the harmful effects of alcohol for adolescent development is also one postulated reason for declining adolescent alcohol consumption in both Europe and North America over the past two decades, which Dr. de Looze’s research has explored. Her work has also noted the “growing trend” of young people abstaining from alcohol altogether and some evidence of reductions in adolescent risk behaviors more generally, including early sexual initiation and juvenile crime.

“It may be good to realize that, in fact, the current generation of youth in many respects is healthier and reports less risky health behaviors as compared to previous generations,” she said.

However, “The declining trend in adolescent substance use that took place in many countries since the beginning of the 21st century seems to have stabilized, and moreover, in some countries and subgroups of adolescents, substance use appears to be on the rise again.” She cited particularly an overall increase in current alcohol use and drunkenness among older girls between 2018 and 2022. “It appears that, especially for girls, recent trends over time are less favorable as compared with boys.”
 

Multiple Influences on Adolescent Substance Abuse

Peer group influences are known to come to the fore during adolescence, and Dr. de Looze added that the early 21st century saw marked reductions in adolescent face-to-face contacts with their peers due to the rise in digital communications. “Adolescents typically use substances in the presence of peers (and in the absence of adults/parents), as it increases their status in their peer group.” Reduced in person interactions with friends may therefore have contributed to the earlier decline in substance use.

However, her team had found that adolescents who spend much time online with friends often also spend much time with friends offline. “They are what you could call the ‘social’ youth, who just spend much time with peers, be it offline or online,” she said. “More research is needed to disentangle exactly how, what kind, for whom the digital environment may be related to young people’s substance use,” she said.

“We also see that young people actively select their friends. So, if you are curious and a bit of a sensation-seeker yourself, you are more likely to become friends with youth who are just like you, and together, you may be more likely to try out substances.”

Factors underlying adolescent substance use and differences between countries are influenced by a complex interplay of factors, said Carina Ferreira-Borges, PhD, regional adviser for alcohol, illicit drugs, and prison health at the WHO Regional Office for Europe.

“Prevention measures definitely play a critical role in reducing substance use,” she said, “but other factors, such as cultural norms and socioeconomic conditions, also significantly impact these patterns.”

“Variations in substance use among countries can be attributed to different levels of implemented polices, public health initiatives, and the extent to which substance use is normalized or stigmatized within each society.”
 

Policy Efforts Must Be Targeted

“To address these disparities effectively, interventions and population-level policies need to be culturally adapted and target the specific environments where substance use is normalized among adolescents. By understanding and modifying the broader context in which young people make choices about substance use, we can better influence their behavior and health outcomes.”

Dr. de Looze cautioned, “In the past two decades, public health efforts in many countries have focused on reducing young people’s engagement in substance use. It is important that these efforts continue, as every year a new generation of youth is born. If public health efforts do not continue to focus on supporting a healthy lifestyle among young people, it should not come as a surprise that rates start or continue to rise again.”

A version of this article appeared on Medscape.com.

Girls are catching up with and sometimes surpassing boys in terms of adolescent substance use, warned the authors of a new report detailing trends across several regions between 2018 and 2022. The latest 4-yearly Health Behaviour in School-Aged Children study, in collaboration with the World Health Organization (WHO) Regional Office for Europe, concluded that substance use remains “a crucial public health problem among adolescents” despite overall declines in smoking, alcohol, and cannabis use.

The new report: A focus on adolescent substance use in Europe, central Asia, and Canada, detailed substance use among adolescents aged 11, 13, and 15 years across 44 countries and regions in Europe, Central Asia, and Canada in the 2021-2022 school-based survey.

Principal findings included:

• Cigarette smoking: Lifetime smoking declined between 2018 and 2022, particularly among 13-year-old boys and 15-year-old boys and girls. There was also a small but significant decrease in current smoking among 15-year-old boys.
• Alcohol use: Lifetime use decreased overall in boys between 2018 and 2022, particularly among 15-year-olds. An increase was observed among 11- and 13-year-old girls but not 15-year-old girls. There was a small but significant decrease in the proportion of current drinkers among 15-year-old boys, with no change among 11- and 13-year-old boys. Current alcohol use increased among girls in all age groups.
• Cannabis use: Lifetime use among 15-year-olds decreased slightly from 14% to 12% between 2018 and 2022, while 6% of 15-year-olds reported having used cannabis in the previous 30 days.
• Vaping: In 2022 vapes (e-cigarettes) were more popular among adolescents than conventional tobacco cigarettes.

Traditional Gender Gap Narrowing or Reversing

Report coauthor Judith Brown from the University of Glasgow, Glasgow, Scotland, and a project manager for the Scottish survey, said that “there was an overall increase in current alcohol use and drunkenness among older girls” despite the overall decrease in boys’ alcohol use.

She explained: “Substance use has traditionally been more prevalent among boys, and the survey findings confirm a well-established gender difference, with higher prevalence in boys than in girls among 11-year-olds. By the age of 13, however, gender differences diminish or even disappear in many countries and regions.”

“Among 15-year-olds, girls often reported more frequent substance use than boys. While this pattern has been known for cigarette smoking in many countries and regions for about two decades, especially among 15-year-olds, it is a new phenomenon for behaviors related to other substances (such as alcohol consumption and drunkenness) in most countries and regions. Historically, prevalence for these behaviors has been higher among boys than girls.”

The new survey results highlight this gender reversal for several substances, she said. “Cannabis is the only substance for which both lifetime and current use is consistently higher in boys.”
 

Vaping Is an Emerging Public Health Concern

Dr. Brown added that the 2022 survey was the first time that vaping data had been collected from all countries. Although this is against the background of continuing decreases in smoking rates, “researchers suggest the transition to e-cigarettes, as a more popular choice than conventional cigarettes, highlights an urgent need for more targeted interventions to address this emerging public health concern.”

The report authors commented that because young people’s brains are still developing, they are “very sensitive to substances such as nicotine,” making it “easier for them to get hooked.”

Margreet de Looze, PhD, assistant professor of interdisciplinary social science at Utrecht University in Utrecht, the Netherlands, agreed with the authors’ concerns. “Vaping is extremely attractive for young people,” she said, “because the taste is more attractive than that of traditional cigarettes.” Until recently, many people were not aware of health hazards attached to vaping. “While more research is needed, vaping may function as a first step toward tobacco use and is hazardous for young people’s health. Therefore, it should be strongly discouraged.”
 

Substance Use Trends May Be Stabilizing or Rising Again

Increased awareness of the harmful effects of alcohol for adolescent development is also one postulated reason for declining adolescent alcohol consumption in both Europe and North America over the past two decades, which Dr. de Looze’s research has explored. Her work has also noted the “growing trend” of young people abstaining from alcohol altogether and some evidence of reductions in adolescent risk behaviors more generally, including early sexual initiation and juvenile crime.

“It may be good to realize that, in fact, the current generation of youth in many respects is healthier and reports less risky health behaviors as compared to previous generations,” she said.

However, “The declining trend in adolescent substance use that took place in many countries since the beginning of the 21st century seems to have stabilized, and moreover, in some countries and subgroups of adolescents, substance use appears to be on the rise again.” She cited particularly an overall increase in current alcohol use and drunkenness among older girls between 2018 and 2022. “It appears that, especially for girls, recent trends over time are less favorable as compared with boys.”
 

Multiple Influences on Adolescent Substance Abuse

Peer group influences are known to come to the fore during adolescence, and Dr. de Looze added that the early 21st century saw marked reductions in adolescent face-to-face contacts with their peers due to the rise in digital communications. “Adolescents typically use substances in the presence of peers (and in the absence of adults/parents), as it increases their status in their peer group.” Reduced in person interactions with friends may therefore have contributed to the earlier decline in substance use.

However, her team had found that adolescents who spend much time online with friends often also spend much time with friends offline. “They are what you could call the ‘social’ youth, who just spend much time with peers, be it offline or online,” she said. “More research is needed to disentangle exactly how, what kind, for whom the digital environment may be related to young people’s substance use,” she said.

“We also see that young people actively select their friends. So, if you are curious and a bit of a sensation-seeker yourself, you are more likely to become friends with youth who are just like you, and together, you may be more likely to try out substances.”

Factors underlying adolescent substance use and differences between countries are influenced by a complex interplay of factors, said Carina Ferreira-Borges, PhD, regional adviser for alcohol, illicit drugs, and prison health at the WHO Regional Office for Europe.

“Prevention measures definitely play a critical role in reducing substance use,” she said, “but other factors, such as cultural norms and socioeconomic conditions, also significantly impact these patterns.”

“Variations in substance use among countries can be attributed to different levels of implemented polices, public health initiatives, and the extent to which substance use is normalized or stigmatized within each society.”
 

Policy Efforts Must Be Targeted

“To address these disparities effectively, interventions and population-level policies need to be culturally adapted and target the specific environments where substance use is normalized among adolescents. By understanding and modifying the broader context in which young people make choices about substance use, we can better influence their behavior and health outcomes.”

Dr. de Looze cautioned, “In the past two decades, public health efforts in many countries have focused on reducing young people’s engagement in substance use. It is important that these efforts continue, as every year a new generation of youth is born. If public health efforts do not continue to focus on supporting a healthy lifestyle among young people, it should not come as a surprise that rates start or continue to rise again.”

A version of this article appeared on Medscape.com.

TOPLINE:

Decreased total sleep time (TST) and increased resting heart rate (RHR), heart rate variability (HRV), and average nightly respiratory rate (ARR) as measured by a multisensor device worn during sleep accurately correlated with self-reported stress levels in college students, a new study suggests. Investigators say the findings support the potential utility of wearable devices to collect data that identify young adults at greatest risk for stress. 

METHODOLOGY:

• First-semester college students (n = 525; aged 18-24 years) enrolled in the Lived Experiences measured Using Rings Study (LEMURS) provided continuous biometric data via a wearable device (Oura Ring; Oura Health) and answered weekly surveys regarding stress levels.
• The researchers used mixed-effects regression models to identify associations between perceived stress scores and average nightly TST, RHR, HRV, and ARR.

TAKEAWAY:

• Consistent associations were found between perceived stress scores and TST, RHR, HRV, and ARR, which persisted even after controlling for gender and week of the semester.
• Risk for moderate to high stress decreased by 38% with every additional hour of TST (P < .01) and by 1.2% with each millisecond increase in HRV (P < .05).
• Moderate to high stress risk increased by 3.6% with each beat-per-minute-increase in RHR (P < .01) and by 23% with each additional breath-per-minute increase in ARR (P < .01).
• Participants who identified as female, nonbinary, or transgender reported significantly higher stress throughout the study.

IN PRACTICE:

“The present work highlights the potential utility of monitoring sleep, suggesting that these measures may identify within individual changes that are concerning for stress. As the demand for mental health services grows, determining which wearable-derived sleep estimates provide information about well-being and can predict worsening mental health in young adults is an important area of study,” study authors wrote.

SOURCE:

The study, led by Laura S.P. Bloomfield, University of Vermont, Burlington, Vermont, was published online in PLOS Digital Health.

LIMITATIONS:

The study focused on raw sleep measures; the researchers suggest that future studies evaluate additional sleep variables (eg, daytime naps), which have been associated with mental health in college students. In addition, the researchers did not have stress or sleep data before participants started college, so they could not assess the impact of starting college on participants’ sleep.

DISCLOSURES:

Bloomfield was supported by the Gund Fellowship and received a partial salary from the Mass Mutual Insurance Wellness Initiative. Other authors’ funding is reported in the original article.

A version of this article appeared on Medscape.com.

TOPLINE:

Decreased total sleep time (TST) and increased resting heart rate (RHR), heart rate variability (HRV), and average nightly respiratory rate (ARR) as measured by a multisensor device worn during sleep accurately correlated with self-reported stress levels in college students, a new study suggests. Investigators say the findings support the potential utility of wearable devices to collect data that identify young adults at greatest risk for stress. 

METHODOLOGY:

• First-semester college students (n = 525; aged 18-24 years) enrolled in the Lived Experiences measured Using Rings Study (LEMURS) provided continuous biometric data via a wearable device (Oura Ring; Oura Health) and answered weekly surveys regarding stress levels.
• The researchers used mixed-effects regression models to identify associations between perceived stress scores and average nightly TST, RHR, HRV, and ARR.

TAKEAWAY:

• Consistent associations were found between perceived stress scores and TST, RHR, HRV, and ARR, which persisted even after controlling for gender and week of the semester.
• Risk for moderate to high stress decreased by 38% with every additional hour of TST (P < .01) and by 1.2% with each millisecond increase in HRV (P < .05).
• Moderate to high stress risk increased by 3.6% with each beat-per-minute-increase in RHR (P < .01) and by 23% with each additional breath-per-minute increase in ARR (P < .01).
• Participants who identified as female, nonbinary, or transgender reported significantly higher stress throughout the study.

IN PRACTICE:

“The present work highlights the potential utility of monitoring sleep, suggesting that these measures may identify within individual changes that are concerning for stress. As the demand for mental health services grows, determining which wearable-derived sleep estimates provide information about well-being and can predict worsening mental health in young adults is an important area of study,” study authors wrote.

SOURCE:

The study, led by Laura S.P. Bloomfield, University of Vermont, Burlington, Vermont, was published online in PLOS Digital Health.

LIMITATIONS:

The study focused on raw sleep measures; the researchers suggest that future studies evaluate additional sleep variables (eg, daytime naps), which have been associated with mental health in college students. In addition, the researchers did not have stress or sleep data before participants started college, so they could not assess the impact of starting college on participants’ sleep.

DISCLOSURES:

Bloomfield was supported by the Gund Fellowship and received a partial salary from the Mass Mutual Insurance Wellness Initiative. Other authors’ funding is reported in the original article.

A version of this article appeared on Medscape.com.

TOPLINE:

Decreased total sleep time (TST) and increased resting heart rate (RHR), heart rate variability (HRV), and average nightly respiratory rate (ARR) as measured by a multisensor device worn during sleep accurately correlated with self-reported stress levels in college students, a new study suggests. Investigators say the findings support the potential utility of wearable devices to collect data that identify young adults at greatest risk for stress. 

METHODOLOGY:

• First-semester college students (n = 525; aged 18-24 years) enrolled in the Lived Experiences measured Using Rings Study (LEMURS) provided continuous biometric data via a wearable device (Oura Ring; Oura Health) and answered weekly surveys regarding stress levels.
• The researchers used mixed-effects regression models to identify associations between perceived stress scores and average nightly TST, RHR, HRV, and ARR.

TAKEAWAY:

• Consistent associations were found between perceived stress scores and TST, RHR, HRV, and ARR, which persisted even after controlling for gender and week of the semester.
• Risk for moderate to high stress decreased by 38% with every additional hour of TST (P < .01) and by 1.2% with each millisecond increase in HRV (P < .05).
• Moderate to high stress risk increased by 3.6% with each beat-per-minute-increase in RHR (P < .01) and by 23% with each additional breath-per-minute increase in ARR (P < .01).
• Participants who identified as female, nonbinary, or transgender reported significantly higher stress throughout the study.

IN PRACTICE:

“The present work highlights the potential utility of monitoring sleep, suggesting that these measures may identify within individual changes that are concerning for stress. As the demand for mental health services grows, determining which wearable-derived sleep estimates provide information about well-being and can predict worsening mental health in young adults is an important area of study,” study authors wrote.

SOURCE:

The study, led by Laura S.P. Bloomfield, University of Vermont, Burlington, Vermont, was published online in PLOS Digital Health.

LIMITATIONS:

The study focused on raw sleep measures; the researchers suggest that future studies evaluate additional sleep variables (eg, daytime naps), which have been associated with mental health in college students. In addition, the researchers did not have stress or sleep data before participants started college, so they could not assess the impact of starting college on participants’ sleep.

DISCLOSURES:

Bloomfield was supported by the Gund Fellowship and received a partial salary from the Mass Mutual Insurance Wellness Initiative. Other authors’ funding is reported in the original article.

A version of this article appeared on Medscape.com.

BOSTON — The US Food and Drug Administration (FDA) approved 55 new medications in 2023 and 11 more in 2024 to date. During a presentation on April 18 at the annual American College of Physicians Internal Medicine Meeting, Gerald Smetana, MD, professor of medicine in the Division of General Medicine at Beth Israel Deaconess Medical Center in Boston, reviewed four of these new therapies that are likely to be particularly important for primary care clinicians. 

A New First-Line for GERD?

Vonoprazan, an oral potassium-competitive acid blocker — which received FDA approval in November 2023 — may be a good alternative for patients whose symptoms continue to linger despite taking medications designated to treat gastroesophageal reflux disease (GERD). 

GERD is the most common gastrointestinal symptom encountered by primary care physicians. Proton-pump inhibitors (PPIs) are the first-line treatment for the condition but can have long-term side effects such as Clostridioides difficile infection and kidney lesions.

“We know that not all patients are going to have symptom relief with H2 blockers and PPIs, so there’s an opportunity for patients who don’t get full symptom relief,” Dr. Smetana told attendees. 

Vonoprazan blocks potassium binding to ATPase proton pumps and inhibits the secretion of gastric acid.

The approval of vonoprazan for erosive GERD was based on results from the phase 3 PHALCON-EE study, a randomized, double-blind, multicenter study that found the drug to be more effective than lansoprazole in treating erosive esophagitis.

Vonoprazan “has more rapid absorption than PPIs [and a] longer half-life and is more potent than PPIs, so theoretically it could be more effective in certain settings,” Dr. Smetana said.

Vonoprazan is FDA approved for only 6 months of use. Despite its efficacy, cost may be a barrier to many patients. H2 blockers generally cost patients less than $10 for 1 month’s supply, whereas vonoprazan can cost up to $650.
 

Nonhormonal Drug for Menopause

Fezolinetant, the first neurokinin receptor antagonist to receive approval from the FDA to treat vasomotor symptoms, may be an option for women concerned about hormone-based therapy for menopausal hot flashes.

“[Fezolinetant] specifically works in the area of the brain that’s involved in body temperature regulation and sweating,” Dr. Smetana said.

Results from the SKYLIGHT 1 randomized controlled trial of fezolinetant found the medication reduced the frequency and severity of hot flashes. Some of the side effects include abdominal pain, diarrhea, and insomnia. 

Other nonestrogen treatments, including selective serotonin reuptake inhibitors (SSRIs), gabapentin, cognitive-behavioral therapy, and hypnosis, are modestly effective, according to the North American Menopause Society.

“[Fezolinetant] offers a different option that physicians may be more comfortable prescribing,” Dr. Smetana said. “And I think this will be an important addition to nonhormonal therapy.”
 

RSV Vaccine for Everyone 

Once considered an illness that is more prevalent in young children, respiratory syncytial virus (RSV) has become more prevalent and severe among older adults. Between 60,000 and 120,000 older adults are hospitalized and 6000-10,000 die of RSV infection each year, according to the US Centers for Disease Control and Prevention. 

The FDA has approved two RSV vaccines approved for older adults, but clinicians may find it challenging to get older patients vaccinated for this and other preventable illnesses.

Patients who received the RSV vaccine had an 83% relative risk reduction for the illness, according to a recent study, and an overall lower risk for hospitalization.

Moderna is developing an mRNA vaccine for RSV that is similar to many COVID-19 vaccines. A study published in 2023 in The New England Journal of Medicine found no cases of neuroinflammatory disorders among patients who received the mRNA RSV vaccine, with a median follow-up of 112 days.

“This is important given ongoing concerns of neurological safety,” among older adults who receive the RSV vaccine, Dr. Smetana said.

As of March 2024, the CDC recommends shared decision-making for adults older than 60 years and for healthcare providers to “consider” rather than “recommend” the vaccine for their patients. The agency’s Adult RSV Work Group plans to meet at June 2024 to reconsider whether shared clinical decision-making remains the preferred policy option.
 

New Antidepressants

A medication thrice rejected by the FDA is now heading a new class of drugs to treat major depressive disorder.

Gepirone, a 5-HT1A receptor agonist, has a different mechanism of action from that of SSRIs, which are currently considered the first-line treatment for depression. 

Gepirone was rejected by the FDA in 2002, 2004, and 2007, with concerns that the efficacy studies were too small. In 2015, an FDA advisory committee agreed that the evidence to date did not support approval of an extended-release form of the drug. But the agency decided to approve the medication in September 2023.

“So why is this medication worth discussing now?” Dr. Smetana said. “It’s because the side effect profile is different from existing antidepressants.” 

Many patients may stop using SSRIs because of side effects such as insomnia and loss of libido, Dr. Smetana said. Gepirone has the potential to avoid activation of other 5-HT receptors that mediate side effects, he said. 

Studies suggest that gepirone reduces both anxiety and depression scores on the Hamilton Depression Rating Scale in patients who have both conditions and decreases rates of depression relapse compared with placebo through at least 48 weeks. The drug also may be less likely than SSRIs to cause sexual dysfunction in men, Dr. Smetana said. 

Gepirone will be available to prescribe to patients in fall 2024.

Dr. Smetana reported no relevant financial conflicts of interest. 
 

A version of this article appeared on Medscape.com.

BOSTON — The US Food and Drug Administration (FDA) approved 55 new medications in 2023 and 11 more in 2024 to date. During a presentation on April 18 at the annual American College of Physicians Internal Medicine Meeting, Gerald Smetana, MD, professor of medicine in the Division of General Medicine at Beth Israel Deaconess Medical Center in Boston, reviewed four of these new therapies that are likely to be particularly important for primary care clinicians. 

A New First-Line for GERD?

Vonoprazan, an oral potassium-competitive acid blocker — which received FDA approval in November 2023 — may be a good alternative for patients whose symptoms continue to linger despite taking medications designated to treat gastroesophageal reflux disease (GERD). 

GERD is the most common gastrointestinal symptom encountered by primary care physicians. Proton-pump inhibitors (PPIs) are the first-line treatment for the condition but can have long-term side effects such as Clostridioides difficile infection and kidney lesions.

“We know that not all patients are going to have symptom relief with H2 blockers and PPIs, so there’s an opportunity for patients who don’t get full symptom relief,” Dr. Smetana told attendees. 

Vonoprazan blocks potassium binding to ATPase proton pumps and inhibits the secretion of gastric acid.

The approval of vonoprazan for erosive GERD was based on results from the phase 3 PHALCON-EE study, a randomized, double-blind, multicenter study that found the drug to be more effective than lansoprazole in treating erosive esophagitis.

Vonoprazan “has more rapid absorption than PPIs [and a] longer half-life and is more potent than PPIs, so theoretically it could be more effective in certain settings,” Dr. Smetana said.

Vonoprazan is FDA approved for only 6 months of use. Despite its efficacy, cost may be a barrier to many patients. H2 blockers generally cost patients less than $10 for 1 month’s supply, whereas vonoprazan can cost up to $650.
 

Nonhormonal Drug for Menopause

Fezolinetant, the first neurokinin receptor antagonist to receive approval from the FDA to treat vasomotor symptoms, may be an option for women concerned about hormone-based therapy for menopausal hot flashes.

“[Fezolinetant] specifically works in the area of the brain that’s involved in body temperature regulation and sweating,” Dr. Smetana said.

Results from the SKYLIGHT 1 randomized controlled trial of fezolinetant found the medication reduced the frequency and severity of hot flashes. Some of the side effects include abdominal pain, diarrhea, and insomnia. 

Other nonestrogen treatments, including selective serotonin reuptake inhibitors (SSRIs), gabapentin, cognitive-behavioral therapy, and hypnosis, are modestly effective, according to the North American Menopause Society.

“[Fezolinetant] offers a different option that physicians may be more comfortable prescribing,” Dr. Smetana said. “And I think this will be an important addition to nonhormonal therapy.”
 

RSV Vaccine for Everyone 

Once considered an illness that is more prevalent in young children, respiratory syncytial virus (RSV) has become more prevalent and severe among older adults. Between 60,000 and 120,000 older adults are hospitalized and 6000-10,000 die of RSV infection each year, according to the US Centers for Disease Control and Prevention. 

The FDA has approved two RSV vaccines approved for older adults, but clinicians may find it challenging to get older patients vaccinated for this and other preventable illnesses.

Patients who received the RSV vaccine had an 83% relative risk reduction for the illness, according to a recent study, and an overall lower risk for hospitalization.

Moderna is developing an mRNA vaccine for RSV that is similar to many COVID-19 vaccines. A study published in 2023 in The New England Journal of Medicine found no cases of neuroinflammatory disorders among patients who received the mRNA RSV vaccine, with a median follow-up of 112 days.

“This is important given ongoing concerns of neurological safety,” among older adults who receive the RSV vaccine, Dr. Smetana said.

As of March 2024, the CDC recommends shared decision-making for adults older than 60 years and for healthcare providers to “consider” rather than “recommend” the vaccine for their patients. The agency’s Adult RSV Work Group plans to meet at June 2024 to reconsider whether shared clinical decision-making remains the preferred policy option.
 

New Antidepressants

A medication thrice rejected by the FDA is now heading a new class of drugs to treat major depressive disorder.

Gepirone, a 5-HT1A receptor agonist, has a different mechanism of action from that of SSRIs, which are currently considered the first-line treatment for depression. 

Gepirone was rejected by the FDA in 2002, 2004, and 2007, with concerns that the efficacy studies were too small. In 2015, an FDA advisory committee agreed that the evidence to date did not support approval of an extended-release form of the drug. But the agency decided to approve the medication in September 2023.

“So why is this medication worth discussing now?” Dr. Smetana said. “It’s because the side effect profile is different from existing antidepressants.” 

Many patients may stop using SSRIs because of side effects such as insomnia and loss of libido, Dr. Smetana said. Gepirone has the potential to avoid activation of other 5-HT receptors that mediate side effects, he said. 

Studies suggest that gepirone reduces both anxiety and depression scores on the Hamilton Depression Rating Scale in patients who have both conditions and decreases rates of depression relapse compared with placebo through at least 48 weeks. The drug also may be less likely than SSRIs to cause sexual dysfunction in men, Dr. Smetana said. 

Gepirone will be available to prescribe to patients in fall 2024.

Dr. Smetana reported no relevant financial conflicts of interest. 
 

A version of this article appeared on Medscape.com.

BOSTON — The US Food and Drug Administration (FDA) approved 55 new medications in 2023 and 11 more in 2024 to date. During a presentation on April 18 at the annual American College of Physicians Internal Medicine Meeting, Gerald Smetana, MD, professor of medicine in the Division of General Medicine at Beth Israel Deaconess Medical Center in Boston, reviewed four of these new therapies that are likely to be particularly important for primary care clinicians. 

A New First-Line for GERD?

Vonoprazan, an oral potassium-competitive acid blocker — which received FDA approval in November 2023 — may be a good alternative for patients whose symptoms continue to linger despite taking medications designated to treat gastroesophageal reflux disease (GERD). 

GERD is the most common gastrointestinal symptom encountered by primary care physicians. Proton-pump inhibitors (PPIs) are the first-line treatment for the condition but can have long-term side effects such as Clostridioides difficile infection and kidney lesions.

“We know that not all patients are going to have symptom relief with H2 blockers and PPIs, so there’s an opportunity for patients who don’t get full symptom relief,” Dr. Smetana told attendees. 

Vonoprazan blocks potassium binding to ATPase proton pumps and inhibits the secretion of gastric acid.

The approval of vonoprazan for erosive GERD was based on results from the phase 3 PHALCON-EE study, a randomized, double-blind, multicenter study that found the drug to be more effective than lansoprazole in treating erosive esophagitis.

Vonoprazan “has more rapid absorption than PPIs [and a] longer half-life and is more potent than PPIs, so theoretically it could be more effective in certain settings,” Dr. Smetana said.

Vonoprazan is FDA approved for only 6 months of use. Despite its efficacy, cost may be a barrier to many patients. H2 blockers generally cost patients less than $10 for 1 month’s supply, whereas vonoprazan can cost up to $650.
 

Nonhormonal Drug for Menopause

Fezolinetant, the first neurokinin receptor antagonist to receive approval from the FDA to treat vasomotor symptoms, may be an option for women concerned about hormone-based therapy for menopausal hot flashes.

“[Fezolinetant] specifically works in the area of the brain that’s involved in body temperature regulation and sweating,” Dr. Smetana said.

Results from the SKYLIGHT 1 randomized controlled trial of fezolinetant found the medication reduced the frequency and severity of hot flashes. Some of the side effects include abdominal pain, diarrhea, and insomnia. 

Other nonestrogen treatments, including selective serotonin reuptake inhibitors (SSRIs), gabapentin, cognitive-behavioral therapy, and hypnosis, are modestly effective, according to the North American Menopause Society.

“[Fezolinetant] offers a different option that physicians may be more comfortable prescribing,” Dr. Smetana said. “And I think this will be an important addition to nonhormonal therapy.”
 

RSV Vaccine for Everyone 

Once considered an illness that is more prevalent in young children, respiratory syncytial virus (RSV) has become more prevalent and severe among older adults. Between 60,000 and 120,000 older adults are hospitalized and 6000-10,000 die of RSV infection each year, according to the US Centers for Disease Control and Prevention. 

The FDA has approved two RSV vaccines approved for older adults, but clinicians may find it challenging to get older patients vaccinated for this and other preventable illnesses.

Patients who received the RSV vaccine had an 83% relative risk reduction for the illness, according to a recent study, and an overall lower risk for hospitalization.

Moderna is developing an mRNA vaccine for RSV that is similar to many COVID-19 vaccines. A study published in 2023 in The New England Journal of Medicine found no cases of neuroinflammatory disorders among patients who received the mRNA RSV vaccine, with a median follow-up of 112 days.

“This is important given ongoing concerns of neurological safety,” among older adults who receive the RSV vaccine, Dr. Smetana said.

As of March 2024, the CDC recommends shared decision-making for adults older than 60 years and for healthcare providers to “consider” rather than “recommend” the vaccine for their patients. The agency’s Adult RSV Work Group plans to meet at June 2024 to reconsider whether shared clinical decision-making remains the preferred policy option.
 

New Antidepressants

A medication thrice rejected by the FDA is now heading a new class of drugs to treat major depressive disorder.

Gepirone, a 5-HT1A receptor agonist, has a different mechanism of action from that of SSRIs, which are currently considered the first-line treatment for depression. 

Gepirone was rejected by the FDA in 2002, 2004, and 2007, with concerns that the efficacy studies were too small. In 2015, an FDA advisory committee agreed that the evidence to date did not support approval of an extended-release form of the drug. But the agency decided to approve the medication in September 2023.

“So why is this medication worth discussing now?” Dr. Smetana said. “It’s because the side effect profile is different from existing antidepressants.” 

Many patients may stop using SSRIs because of side effects such as insomnia and loss of libido, Dr. Smetana said. Gepirone has the potential to avoid activation of other 5-HT receptors that mediate side effects, he said. 

Studies suggest that gepirone reduces both anxiety and depression scores on the Hamilton Depression Rating Scale in patients who have both conditions and decreases rates of depression relapse compared with placebo through at least 48 weeks. The drug also may be less likely than SSRIs to cause sexual dysfunction in men, Dr. Smetana said. 

Gepirone will be available to prescribe to patients in fall 2024.

Dr. Smetana reported no relevant financial conflicts of interest. 
 

A version of this article appeared on Medscape.com.

BUDAPEST, HUNGARY — Self-perceived loneliness during childhood is linked to a more than twofold increased risk for subsequent first-episode psychosis (FEP) — new findings that may point to a novel marker for the disorder.

The association between loneliness and FEP “appears to extend beyond the effects of objective social isolation,” said study presenter Covadonga M. Díaz-Caneja, MD, PhD, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, Madrid, and “is particularly pronounced in females.”

“These findings suggest the potential of childhood loneliness as an early risk marker for psychosis that could help guide targeted interventions,” she added.

The results were presented at the European Psychiatric Association 2024 Congress.
 

Isolation a Major Risk Factor

There are two components to isolation, both of which are “major risk factors” for morbidity, mortality, and the onset of mental disorders, said Dr. Díaz-Caneja.

The first is “objective social isolation,” which consists of a demonstrable lack of social connections, including social interactions, contacts, and relationships, while the other is a perceived sense of isolation, or “loneliness,” defined as a “subjective feeling of distress associated with a lack of meaningful relationships,” regardless of the amount of actual social contact an individual experiences.

Childhood loneliness occurs before age 12 and is becoming increasingly prevalent, said Dr. Díaz-Caneja. A recent survey shows that approximately one third of children report they often feel lonely.

Genetic and observational research has shown there is a bidirectional relationship between loneliness and psychosis and that patients with schizophrenia are more likely to report loneliness than is the general population.

Dr. Díaz-Caneja noted that there is no previous research that has assessed the potential association between childhood loneliness and subsequent psychosis.

To investigate, the researchers conducted an observational, case-control study in seven university hospitals in Madrid. It included individuals aged 7-40 years, including FEP patients with a psychosis duration of less than 2 years, and healthy controls from the same geographic areas.

They assessed childhood objective social isolation using the Premorbid Adjustment Scale and examined childhood loneliness with the single item: “Have you ever felt lonely for more than 6 months before the age of 12?”

A range of measures and questionnaires were also administered to assess participants’ symptom scores, alongside the Global Assessment of Functioning (GAF).
 

Alone vs Lonely

Two hundred eighty-five patients with FEP participated in the study. They had a mean age of 24.5 years, and 32.6% were female. The study also included 261 healthy controls (average age, 25.9 years; 48.7% female).

After the researchers adjusted for age, gender, ethnicity, and socioeconomic status, loneliness during childhood was associated with a significantly increased risk for FEP (odds ratio [OR], 2.17; 95% CI, 1.40-3.51), which increased (OR, 2.70; 95% CI, 1.58-4.62) after further adjustment for objective social isolation.

Further analysis revealed that in those who did not have objective social isolation in childhood, loneliness was associated with a significantly increased risk for FEP (OR, 2.68; 95% CI, 1.56-4.60).

However, the relationship between loneliness and FEP was not significant in participants who were objectively socially isolated during childhood (OR, 0.33; 95% CI, 0.08-1.45).

Compared with males, females reporting loneliness had a markedly increased risk for FEP (OR, 4.74; 95% CI, 2.23-10.05 vs OR, 1.17; 95% CI, 0.63-2.19).

However, females had a reduced risk of receiving a diagnosis of schizophrenia spectrum disorder (OR, 0.155; 95% CI, 0.048-0.506), indicating that loneliness influenced the type of diagnosis, she noted.

There was a significant positive relationship between loneliness in childhood and symptom scores in men, and a negative association with GAF scores in men.

Dr. Díaz-Caneja noted that the study is preliminary and a “work in progress.” The investigators plan to increase the sample size and will conduct more complex analyses, she said.

“We also of course have to bear in mind that it is a cross-sectional study and that there may be some kind of recall biases [because] we are asking patients now about what happened in the past.”

She noted that it’s unclear whether the results can be extrapolated to individuals who are currently experiencing loneliness because “the determinants of loneliness 10 years ago or 15 years ago may be different.”
 

How, When to Intervene

Session chair Judit Lazáry, MD, PhD, Department of Clinical and Theoretical Mental Health, Kútvölgyi Clinical Center, Semmelweis University, Budapest, Hungary, told this news organization that the association between loneliness and FEP was “not surprising.”

She explained there are a lot of data indicating that premorbid symptoms in childhood are “predictive signs for the later onset of psychosis,” and loneliness may be “a part of that.”

Individuals experiencing loneliness are more anxious and have difficulties in cultivating and maintaining relationships. In addition, they tend to socially isolate, she said.

The key question, said Dr. Lazáry, is: “How can we intervene to prevent the onset of psychosis? What is the point at which we can support the young person?”

This is challenging, she added, because while “you can detect that a kid is always alone, you cannot detect the feeling of loneliness,” and children can’t always easily express themselves.

Another potential confounder is that in adults with current psychosis, the self-perception that they were lonely during childhood may be a consequence of the disorder.

In addition, she said, individuals with psychosis often experience cognitive impairment, which could affect memory reliability.

Nevertheless, said Dr. Lazáry, the study’s findings suggest that a young person reporting loneliness in childhood may be “another symptom that we have to investigate.”

No funding was declared.

Dr. Díaz-Caneja declared a relationship with Angelini, Janssen, and Viatris and grant support from Instituto de Salud Carlos III, the Spanish Ministry of Science and Innovation, and the European Commission.
 

A version of this article appeared on Medscape.com.

BUDAPEST, HUNGARY — Self-perceived loneliness during childhood is linked to a more than twofold increased risk for subsequent first-episode psychosis (FEP) — new findings that may point to a novel marker for the disorder.

The association between loneliness and FEP “appears to extend beyond the effects of objective social isolation,” said study presenter Covadonga M. Díaz-Caneja, MD, PhD, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, Madrid, and “is particularly pronounced in females.”

“These findings suggest the potential of childhood loneliness as an early risk marker for psychosis that could help guide targeted interventions,” she added.

The results were presented at the European Psychiatric Association 2024 Congress.
 

Isolation a Major Risk Factor

There are two components to isolation, both of which are “major risk factors” for morbidity, mortality, and the onset of mental disorders, said Dr. Díaz-Caneja.

The first is “objective social isolation,” which consists of a demonstrable lack of social connections, including social interactions, contacts, and relationships, while the other is a perceived sense of isolation, or “loneliness,” defined as a “subjective feeling of distress associated with a lack of meaningful relationships,” regardless of the amount of actual social contact an individual experiences.

Childhood loneliness occurs before age 12 and is becoming increasingly prevalent, said Dr. Díaz-Caneja. A recent survey shows that approximately one third of children report they often feel lonely.

Genetic and observational research has shown there is a bidirectional relationship between loneliness and psychosis and that patients with schizophrenia are more likely to report loneliness than is the general population.

Dr. Díaz-Caneja noted that there is no previous research that has assessed the potential association between childhood loneliness and subsequent psychosis.

To investigate, the researchers conducted an observational, case-control study in seven university hospitals in Madrid. It included individuals aged 7-40 years, including FEP patients with a psychosis duration of less than 2 years, and healthy controls from the same geographic areas.

They assessed childhood objective social isolation using the Premorbid Adjustment Scale and examined childhood loneliness with the single item: “Have you ever felt lonely for more than 6 months before the age of 12?”

A range of measures and questionnaires were also administered to assess participants’ symptom scores, alongside the Global Assessment of Functioning (GAF).
 

Alone vs Lonely

Two hundred eighty-five patients with FEP participated in the study. They had a mean age of 24.5 years, and 32.6% were female. The study also included 261 healthy controls (average age, 25.9 years; 48.7% female).

After the researchers adjusted for age, gender, ethnicity, and socioeconomic status, loneliness during childhood was associated with a significantly increased risk for FEP (odds ratio [OR], 2.17; 95% CI, 1.40-3.51), which increased (OR, 2.70; 95% CI, 1.58-4.62) after further adjustment for objective social isolation.

Further analysis revealed that in those who did not have objective social isolation in childhood, loneliness was associated with a significantly increased risk for FEP (OR, 2.68; 95% CI, 1.56-4.60).

However, the relationship between loneliness and FEP was not significant in participants who were objectively socially isolated during childhood (OR, 0.33; 95% CI, 0.08-1.45).

Compared with males, females reporting loneliness had a markedly increased risk for FEP (OR, 4.74; 95% CI, 2.23-10.05 vs OR, 1.17; 95% CI, 0.63-2.19).

However, females had a reduced risk of receiving a diagnosis of schizophrenia spectrum disorder (OR, 0.155; 95% CI, 0.048-0.506), indicating that loneliness influenced the type of diagnosis, she noted.

There was a significant positive relationship between loneliness in childhood and symptom scores in men, and a negative association with GAF scores in men.

Dr. Díaz-Caneja noted that the study is preliminary and a “work in progress.” The investigators plan to increase the sample size and will conduct more complex analyses, she said.

“We also of course have to bear in mind that it is a cross-sectional study and that there may be some kind of recall biases [because] we are asking patients now about what happened in the past.”

She noted that it’s unclear whether the results can be extrapolated to individuals who are currently experiencing loneliness because “the determinants of loneliness 10 years ago or 15 years ago may be different.”
 

How, When to Intervene

Session chair Judit Lazáry, MD, PhD, Department of Clinical and Theoretical Mental Health, Kútvölgyi Clinical Center, Semmelweis University, Budapest, Hungary, told this news organization that the association between loneliness and FEP was “not surprising.”

She explained there are a lot of data indicating that premorbid symptoms in childhood are “predictive signs for the later onset of psychosis,” and loneliness may be “a part of that.”

Individuals experiencing loneliness are more anxious and have difficulties in cultivating and maintaining relationships. In addition, they tend to socially isolate, she said.

The key question, said Dr. Lazáry, is: “How can we intervene to prevent the onset of psychosis? What is the point at which we can support the young person?”

This is challenging, she added, because while “you can detect that a kid is always alone, you cannot detect the feeling of loneliness,” and children can’t always easily express themselves.

Another potential confounder is that in adults with current psychosis, the self-perception that they were lonely during childhood may be a consequence of the disorder.

In addition, she said, individuals with psychosis often experience cognitive impairment, which could affect memory reliability.

Nevertheless, said Dr. Lazáry, the study’s findings suggest that a young person reporting loneliness in childhood may be “another symptom that we have to investigate.”

No funding was declared.

Dr. Díaz-Caneja declared a relationship with Angelini, Janssen, and Viatris and grant support from Instituto de Salud Carlos III, the Spanish Ministry of Science and Innovation, and the European Commission.
 

A version of this article appeared on Medscape.com.

BUDAPEST, HUNGARY — Self-perceived loneliness during childhood is linked to a more than twofold increased risk for subsequent first-episode psychosis (FEP) — new findings that may point to a novel marker for the disorder.

The association between loneliness and FEP “appears to extend beyond the effects of objective social isolation,” said study presenter Covadonga M. Díaz-Caneja, MD, PhD, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, Madrid, and “is particularly pronounced in females.”

“These findings suggest the potential of childhood loneliness as an early risk marker for psychosis that could help guide targeted interventions,” she added.

The results were presented at the European Psychiatric Association 2024 Congress.
 

Isolation a Major Risk Factor

There are two components to isolation, both of which are “major risk factors” for morbidity, mortality, and the onset of mental disorders, said Dr. Díaz-Caneja.

The first is “objective social isolation,” which consists of a demonstrable lack of social connections, including social interactions, contacts, and relationships, while the other is a perceived sense of isolation, or “loneliness,” defined as a “subjective feeling of distress associated with a lack of meaningful relationships,” regardless of the amount of actual social contact an individual experiences.

Childhood loneliness occurs before age 12 and is becoming increasingly prevalent, said Dr. Díaz-Caneja. A recent survey shows that approximately one third of children report they often feel lonely.

Genetic and observational research has shown there is a bidirectional relationship between loneliness and psychosis and that patients with schizophrenia are more likely to report loneliness than is the general population.

Dr. Díaz-Caneja noted that there is no previous research that has assessed the potential association between childhood loneliness and subsequent psychosis.

To investigate, the researchers conducted an observational, case-control study in seven university hospitals in Madrid. It included individuals aged 7-40 years, including FEP patients with a psychosis duration of less than 2 years, and healthy controls from the same geographic areas.

They assessed childhood objective social isolation using the Premorbid Adjustment Scale and examined childhood loneliness with the single item: “Have you ever felt lonely for more than 6 months before the age of 12?”

A range of measures and questionnaires were also administered to assess participants’ symptom scores, alongside the Global Assessment of Functioning (GAF).
 

Alone vs Lonely

Two hundred eighty-five patients with FEP participated in the study. They had a mean age of 24.5 years, and 32.6% were female. The study also included 261 healthy controls (average age, 25.9 years; 48.7% female).

After the researchers adjusted for age, gender, ethnicity, and socioeconomic status, loneliness during childhood was associated with a significantly increased risk for FEP (odds ratio [OR], 2.17; 95% CI, 1.40-3.51), which increased (OR, 2.70; 95% CI, 1.58-4.62) after further adjustment for objective social isolation.

Further analysis revealed that in those who did not have objective social isolation in childhood, loneliness was associated with a significantly increased risk for FEP (OR, 2.68; 95% CI, 1.56-4.60).

However, the relationship between loneliness and FEP was not significant in participants who were objectively socially isolated during childhood (OR, 0.33; 95% CI, 0.08-1.45).

Compared with males, females reporting loneliness had a markedly increased risk for FEP (OR, 4.74; 95% CI, 2.23-10.05 vs OR, 1.17; 95% CI, 0.63-2.19).

However, females had a reduced risk of receiving a diagnosis of schizophrenia spectrum disorder (OR, 0.155; 95% CI, 0.048-0.506), indicating that loneliness influenced the type of diagnosis, she noted.

There was a significant positive relationship between loneliness in childhood and symptom scores in men, and a negative association with GAF scores in men.

Dr. Díaz-Caneja noted that the study is preliminary and a “work in progress.” The investigators plan to increase the sample size and will conduct more complex analyses, she said.

“We also of course have to bear in mind that it is a cross-sectional study and that there may be some kind of recall biases [because] we are asking patients now about what happened in the past.”

She noted that it’s unclear whether the results can be extrapolated to individuals who are currently experiencing loneliness because “the determinants of loneliness 10 years ago or 15 years ago may be different.”
 

How, When to Intervene

Session chair Judit Lazáry, MD, PhD, Department of Clinical and Theoretical Mental Health, Kútvölgyi Clinical Center, Semmelweis University, Budapest, Hungary, told this news organization that the association between loneliness and FEP was “not surprising.”

She explained there are a lot of data indicating that premorbid symptoms in childhood are “predictive signs for the later onset of psychosis,” and loneliness may be “a part of that.”

Individuals experiencing loneliness are more anxious and have difficulties in cultivating and maintaining relationships. In addition, they tend to socially isolate, she said.

The key question, said Dr. Lazáry, is: “How can we intervene to prevent the onset of psychosis? What is the point at which we can support the young person?”

This is challenging, she added, because while “you can detect that a kid is always alone, you cannot detect the feeling of loneliness,” and children can’t always easily express themselves.

Another potential confounder is that in adults with current psychosis, the self-perception that they were lonely during childhood may be a consequence of the disorder.

In addition, she said, individuals with psychosis often experience cognitive impairment, which could affect memory reliability.

Nevertheless, said Dr. Lazáry, the study’s findings suggest that a young person reporting loneliness in childhood may be “another symptom that we have to investigate.”

No funding was declared.

Dr. Díaz-Caneja declared a relationship with Angelini, Janssen, and Viatris and grant support from Instituto de Salud Carlos III, the Spanish Ministry of Science and Innovation, and the European Commission.
 

A version of this article appeared on Medscape.com.

The first peer-reviewed consensus statement on healthcare for children with neurodevelopmental disabilities (NDDs) is meant to start correcting the inequitable access to appropriate care that these children experience compared with their peers without NDDs. The statement was published in Pediatrics.

The disparities in healthcare culture, mindset, and practice often start in childhood for young people with conditions including autism spectrum disorder (ASD), intellectual disability, and attention-deficit/hyperactivity disorder (ADHD), wrote co–first authors Carol Weitzman, MD, co-director of the Autism Spectrum Center at Boston Children’s Hospital, Boston, Massachusetts, and Cy Nadler, PhD, section chief of Autism Psychology at Children’s Mercy in Kansas City, Missouri, and colleagues.

Without better access to safe and appropriate care, people with NDDs experience more seclusion, accidents, restraints, and injury in healthcare encounters, the researchers wrote.
 

‘Accessible, Humane, Effective Care’

“At the heart of this consensus statement is an affirmation that all people are entitled to healthcare that is accessible, humane, and effective,” they wrote.

The consensus statement was developed as part of the Supporting Access for Everyone (SAFE) Initiative, launched by the Developmental Behavioral Pediatric Research Network and the Association of University Centers on Disability. The consensus panel comprised professionals, caregivers, and adults with NDDs. After a 2-day public forum, the consensus panel held a conference and developed a statement on SAFE care, an NDD Health Care Bill of Rights and Transition Considerations. They developed 10 statements across five domains: training; communication; access and planning; diversity, equity, inclusion, belonging, and anti-ableism; and policy and structural change.
 

Asking the Patient ‘What do You Need?’

One theme in the statement that may have the most impact is “the importance of asking the person in front of you what they need,” and building a care plan around that, said senior author Marilyn Augustyn, MD, Director of the Division of Developmental and Behavioral Pediatrics at Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts. “The medical community hasn’t done that very well for individuals with neurodevelopmental disabilities.”

Dr. Weitzman added: “Traditionally in healthcare settings, we’ve asked people to check their disabilities at the door.” Many people with neurodevelopmental disabilities often have “invisible disabilities,” she said, explaining that patients may have accommodation needs that aren’t immediately obvious, but could improve their access to care, so asking them what they need is critical.
 

Examples of ‘Ableism’

The consensus statement also calls attention to structural “ableism” or policies or practices that favor able-bodied people over those with disabilities and details the need for more training and changed policies.

The paper gives some examples of ableism, such as inappropriately excluding people with NDDs from research; staff assuming nonspeaking patients have no capacity for communication; or lack of awareness of sensory needs before using cold stethoscopes or flashing direct light into eyes.

Dr. Weitzman says this work is just the beginning of a complex process. It is intended to be the driver for developing curriculum to train all clinicians and others working with patients about neurodevelopmental disabilities. The hope is it will lead to more research to formalize best practices and make policies mandatory rather than optional.

The urgency in highlighting these issues is partly related to the prevalence of children and adolescents with neurodevelopmental disabilities, which the paper states is approximately 1 in 6.

But there are personal reasons as well for the team who developed the statement.

“We just believe that it is just a human right,” Dr. Weitzman said. “Having a neurodevelopmental disability does not make you any less entitled to good care. “

Dr. Augustyn added, “The children I’ve had the honor of caring for for the last 30 years deserve all this care and more. I think it’s time.”

This work was supported by the Developmental Behavioral Pediatric Research Network and the Association of University Centers on Disability. Dr. Weitzman is a past consultant for Helios/Meliora. The other authors report no relevant financial relationships.

The first peer-reviewed consensus statement on healthcare for children with neurodevelopmental disabilities (NDDs) is meant to start correcting the inequitable access to appropriate care that these children experience compared with their peers without NDDs. The statement was published in Pediatrics.

The disparities in healthcare culture, mindset, and practice often start in childhood for young people with conditions including autism spectrum disorder (ASD), intellectual disability, and attention-deficit/hyperactivity disorder (ADHD), wrote co–first authors Carol Weitzman, MD, co-director of the Autism Spectrum Center at Boston Children’s Hospital, Boston, Massachusetts, and Cy Nadler, PhD, section chief of Autism Psychology at Children’s Mercy in Kansas City, Missouri, and colleagues.

Without better access to safe and appropriate care, people with NDDs experience more seclusion, accidents, restraints, and injury in healthcare encounters, the researchers wrote.
 

‘Accessible, Humane, Effective Care’

“At the heart of this consensus statement is an affirmation that all people are entitled to healthcare that is accessible, humane, and effective,” they wrote.

The consensus statement was developed as part of the Supporting Access for Everyone (SAFE) Initiative, launched by the Developmental Behavioral Pediatric Research Network and the Association of University Centers on Disability. The consensus panel comprised professionals, caregivers, and adults with NDDs. After a 2-day public forum, the consensus panel held a conference and developed a statement on SAFE care, an NDD Health Care Bill of Rights and Transition Considerations. They developed 10 statements across five domains: training; communication; access and planning; diversity, equity, inclusion, belonging, and anti-ableism; and policy and structural change.
 

Asking the Patient ‘What do You Need?’

One theme in the statement that may have the most impact is “the importance of asking the person in front of you what they need,” and building a care plan around that, said senior author Marilyn Augustyn, MD, Director of the Division of Developmental and Behavioral Pediatrics at Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts. “The medical community hasn’t done that very well for individuals with neurodevelopmental disabilities.”

Dr. Weitzman added: “Traditionally in healthcare settings, we’ve asked people to check their disabilities at the door.” Many people with neurodevelopmental disabilities often have “invisible disabilities,” she said, explaining that patients may have accommodation needs that aren’t immediately obvious, but could improve their access to care, so asking them what they need is critical.
 

Examples of ‘Ableism’

The consensus statement also calls attention to structural “ableism” or policies or practices that favor able-bodied people over those with disabilities and details the need for more training and changed policies.

The paper gives some examples of ableism, such as inappropriately excluding people with NDDs from research; staff assuming nonspeaking patients have no capacity for communication; or lack of awareness of sensory needs before using cold stethoscopes or flashing direct light into eyes.

Dr. Weitzman says this work is just the beginning of a complex process. It is intended to be the driver for developing curriculum to train all clinicians and others working with patients about neurodevelopmental disabilities. The hope is it will lead to more research to formalize best practices and make policies mandatory rather than optional.

The urgency in highlighting these issues is partly related to the prevalence of children and adolescents with neurodevelopmental disabilities, which the paper states is approximately 1 in 6.

But there are personal reasons as well for the team who developed the statement.

“We just believe that it is just a human right,” Dr. Weitzman said. “Having a neurodevelopmental disability does not make you any less entitled to good care. “

Dr. Augustyn added, “The children I’ve had the honor of caring for for the last 30 years deserve all this care and more. I think it’s time.”

This work was supported by the Developmental Behavioral Pediatric Research Network and the Association of University Centers on Disability. Dr. Weitzman is a past consultant for Helios/Meliora. The other authors report no relevant financial relationships.

The first peer-reviewed consensus statement on healthcare for children with neurodevelopmental disabilities (NDDs) is meant to start correcting the inequitable access to appropriate care that these children experience compared with their peers without NDDs. The statement was published in Pediatrics.

The disparities in healthcare culture, mindset, and practice often start in childhood for young people with conditions including autism spectrum disorder (ASD), intellectual disability, and attention-deficit/hyperactivity disorder (ADHD), wrote co–first authors Carol Weitzman, MD, co-director of the Autism Spectrum Center at Boston Children’s Hospital, Boston, Massachusetts, and Cy Nadler, PhD, section chief of Autism Psychology at Children’s Mercy in Kansas City, Missouri, and colleagues.

Without better access to safe and appropriate care, people with NDDs experience more seclusion, accidents, restraints, and injury in healthcare encounters, the researchers wrote.
 

‘Accessible, Humane, Effective Care’

“At the heart of this consensus statement is an affirmation that all people are entitled to healthcare that is accessible, humane, and effective,” they wrote.

The consensus statement was developed as part of the Supporting Access for Everyone (SAFE) Initiative, launched by the Developmental Behavioral Pediatric Research Network and the Association of University Centers on Disability. The consensus panel comprised professionals, caregivers, and adults with NDDs. After a 2-day public forum, the consensus panel held a conference and developed a statement on SAFE care, an NDD Health Care Bill of Rights and Transition Considerations. They developed 10 statements across five domains: training; communication; access and planning; diversity, equity, inclusion, belonging, and anti-ableism; and policy and structural change.
 

Asking the Patient ‘What do You Need?’

One theme in the statement that may have the most impact is “the importance of asking the person in front of you what they need,” and building a care plan around that, said senior author Marilyn Augustyn, MD, Director of the Division of Developmental and Behavioral Pediatrics at Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts. “The medical community hasn’t done that very well for individuals with neurodevelopmental disabilities.”

Dr. Weitzman added: “Traditionally in healthcare settings, we’ve asked people to check their disabilities at the door.” Many people with neurodevelopmental disabilities often have “invisible disabilities,” she said, explaining that patients may have accommodation needs that aren’t immediately obvious, but could improve their access to care, so asking them what they need is critical.
 

Examples of ‘Ableism’

The consensus statement also calls attention to structural “ableism” or policies or practices that favor able-bodied people over those with disabilities and details the need for more training and changed policies.

The paper gives some examples of ableism, such as inappropriately excluding people with NDDs from research; staff assuming nonspeaking patients have no capacity for communication; or lack of awareness of sensory needs before using cold stethoscopes or flashing direct light into eyes.

Dr. Weitzman says this work is just the beginning of a complex process. It is intended to be the driver for developing curriculum to train all clinicians and others working with patients about neurodevelopmental disabilities. The hope is it will lead to more research to formalize best practices and make policies mandatory rather than optional.

The urgency in highlighting these issues is partly related to the prevalence of children and adolescents with neurodevelopmental disabilities, which the paper states is approximately 1 in 6.

But there are personal reasons as well for the team who developed the statement.

“We just believe that it is just a human right,” Dr. Weitzman said. “Having a neurodevelopmental disability does not make you any less entitled to good care. “

Dr. Augustyn added, “The children I’ve had the honor of caring for for the last 30 years deserve all this care and more. I think it’s time.”

This work was supported by the Developmental Behavioral Pediatric Research Network and the Association of University Centers on Disability. Dr. Weitzman is a past consultant for Helios/Meliora. The other authors report no relevant financial relationships.

The ketogenic diet shows promise in reducing the symptoms of bipolar disorder and schizophrenia and reversing metabolic syndrome, results of a new pilot study show. 

Participants who adhered to the high-fat, low-carb diet experienced a 30% reduction in psychiatric symptoms and an average 10% reduction in weight. 

“We’re seeing huge changes,” first author Shebani Sethi, MD, of Stanford University in Stanford, California said in a press release. “Even if you’re on antipsychotic drugs, we can still reverse the obesity, the metabolic syndrome, and the insulin resistance. I think that’s very encouraging for patients.”

The findings were published online in Psychiatric Research. 
 

Neuroprotective Effect? 

Recent research supports the hypothesis that psychiatric illness may stem, at least in part, from deficits in brain metabolism and that a keto diet may be neuroprotective by reducing inflammation and oxidative stress. 

The pilot study included 21 participants with schizophrenia (n = 5) or bipolar disorder (n = 16) who were aged 18-75 years. All were currently taking psychotropic medications. Participants were overweight (body mass index [BMI] ≥ 25) and had gained more than 5% of their body mass while taking psychotropic medication, or they had at least one metabolic abnormality, such as insulin resistance or dyslipidemia. 

At baseline, participants received a physical and psychiatric evaluation and 1 hour of instruction on how to implement the keto diet, which included 10% carbohydrate, 30% protein, and 60% fat. 

Investigators monitored blood ketone levels at least once a week and defined participants as keto-adherent if their levels were 0.5-5 mM for 80%-100% of the times they were measured.

Health coaches checked in with participants for about 5-10 minutes each week to answer diet-related questions.

Psychiatric assessments, which included mood rating and global functioning scales, were completed at baseline, 2 months, and at the end of the 4-month study. 

The research team tracked participants’ adherence to the diet by weekly measurement of blood ketone levels. 

By the end of the trial, 14 patients had been fully adherent with the diet, six had been semi-adherent, and only one had been nonadherent. Higher ketone levels, suggesting greater adherence, correlated with better metabolic health.

As measured by the Clinical Global Impression-Schizophrenia and Clinical Global Impression for Bipolar Disorder–Overall Severity, participants experienced a 31% reduction in symptom severity (P < .001). Overall, 43% (P < .02) of participants achieved recovery as defined by the Clinical Mood Monitoring Form criteria: 50% of the adherent group and 33% of those who were semi-adherent.
 

Metabolic Benefits

Initially, 29% of participants had metabolic syndrome and more than 85% had co-occurring medical conditions such as obesity, hyperlipidemia, or prediabetes. By the end of the study, none met criteria for metabolic syndrome.

On average, participants experienced a 10% reduction in weight and BMI. Waist circumference was reduced by 11%, fat mass index dropped by 17%, and systolic blood pressure decreased by 6%. In addition, metabolic markers including visceral fat, inflammation, A1c, and insulin resistance also improved. All outcomes were significant at P < .001 except for systolic blood pressure, at P < .005.

There was also a 20% reduction in triglycerides and a 21% increase in low-density lipoprotein cholesterol (both at P < .02). 

The study’s limitations include its small sample size, the lack of control arm, and short duration.

“Mental health and physical health are interconnected and addressing metabolic issues can complement psychiatric treatment to enhance overall well-being. Understanding the

mechanisms and potential synergies between psychiatric treatment and metabolic improvements can also inform the development of more effective interventions,” the researchers wrote. 

The study was funded by the Baszucki Group, Kuen Lau Fund, and the Obesity Treatment Foundation. The authors declare no competing interests.

A version of this article appeared on Medscape.com.

The ketogenic diet shows promise in reducing the symptoms of bipolar disorder and schizophrenia and reversing metabolic syndrome, results of a new pilot study show. 

Participants who adhered to the high-fat, low-carb diet experienced a 30% reduction in psychiatric symptoms and an average 10% reduction in weight. 

“We’re seeing huge changes,” first author Shebani Sethi, MD, of Stanford University in Stanford, California said in a press release. “Even if you’re on antipsychotic drugs, we can still reverse the obesity, the metabolic syndrome, and the insulin resistance. I think that’s very encouraging for patients.”

The findings were published online in Psychiatric Research. 
 

Neuroprotective Effect? 

Recent research supports the hypothesis that psychiatric illness may stem, at least in part, from deficits in brain metabolism and that a keto diet may be neuroprotective by reducing inflammation and oxidative stress. 

The pilot study included 21 participants with schizophrenia (n = 5) or bipolar disorder (n = 16) who were aged 18-75 years. All were currently taking psychotropic medications. Participants were overweight (body mass index [BMI] ≥ 25) and had gained more than 5% of their body mass while taking psychotropic medication, or they had at least one metabolic abnormality, such as insulin resistance or dyslipidemia. 

At baseline, participants received a physical and psychiatric evaluation and 1 hour of instruction on how to implement the keto diet, which included 10% carbohydrate, 30% protein, and 60% fat. 

Investigators monitored blood ketone levels at least once a week and defined participants as keto-adherent if their levels were 0.5-5 mM for 80%-100% of the times they were measured.

Health coaches checked in with participants for about 5-10 minutes each week to answer diet-related questions.

Psychiatric assessments, which included mood rating and global functioning scales, were completed at baseline, 2 months, and at the end of the 4-month study. 

The research team tracked participants’ adherence to the diet by weekly measurement of blood ketone levels. 

By the end of the trial, 14 patients had been fully adherent with the diet, six had been semi-adherent, and only one had been nonadherent. Higher ketone levels, suggesting greater adherence, correlated with better metabolic health.

As measured by the Clinical Global Impression-Schizophrenia and Clinical Global Impression for Bipolar Disorder–Overall Severity, participants experienced a 31% reduction in symptom severity (P < .001). Overall, 43% (P < .02) of participants achieved recovery as defined by the Clinical Mood Monitoring Form criteria: 50% of the adherent group and 33% of those who were semi-adherent.
 

Metabolic Benefits

Initially, 29% of participants had metabolic syndrome and more than 85% had co-occurring medical conditions such as obesity, hyperlipidemia, or prediabetes. By the end of the study, none met criteria for metabolic syndrome.

On average, participants experienced a 10% reduction in weight and BMI. Waist circumference was reduced by 11%, fat mass index dropped by 17%, and systolic blood pressure decreased by 6%. In addition, metabolic markers including visceral fat, inflammation, A1c, and insulin resistance also improved. All outcomes were significant at P < .001 except for systolic blood pressure, at P < .005.

There was also a 20% reduction in triglycerides and a 21% increase in low-density lipoprotein cholesterol (both at P < .02). 

The study’s limitations include its small sample size, the lack of control arm, and short duration.

“Mental health and physical health are interconnected and addressing metabolic issues can complement psychiatric treatment to enhance overall well-being. Understanding the

mechanisms and potential synergies between psychiatric treatment and metabolic improvements can also inform the development of more effective interventions,” the researchers wrote. 

The study was funded by the Baszucki Group, Kuen Lau Fund, and the Obesity Treatment Foundation. The authors declare no competing interests.

A version of this article appeared on Medscape.com.

The ketogenic diet shows promise in reducing the symptoms of bipolar disorder and schizophrenia and reversing metabolic syndrome, results of a new pilot study show. 

Participants who adhered to the high-fat, low-carb diet experienced a 30% reduction in psychiatric symptoms and an average 10% reduction in weight. 

“We’re seeing huge changes,” first author Shebani Sethi, MD, of Stanford University in Stanford, California said in a press release. “Even if you’re on antipsychotic drugs, we can still reverse the obesity, the metabolic syndrome, and the insulin resistance. I think that’s very encouraging for patients.”

The findings were published online in Psychiatric Research. 
 

Neuroprotective Effect? 

Recent research supports the hypothesis that psychiatric illness may stem, at least in part, from deficits in brain metabolism and that a keto diet may be neuroprotective by reducing inflammation and oxidative stress. 

The pilot study included 21 participants with schizophrenia (n = 5) or bipolar disorder (n = 16) who were aged 18-75 years. All were currently taking psychotropic medications. Participants were overweight (body mass index [BMI] ≥ 25) and had gained more than 5% of their body mass while taking psychotropic medication, or they had at least one metabolic abnormality, such as insulin resistance or dyslipidemia. 

At baseline, participants received a physical and psychiatric evaluation and 1 hour of instruction on how to implement the keto diet, which included 10% carbohydrate, 30% protein, and 60% fat. 

Investigators monitored blood ketone levels at least once a week and defined participants as keto-adherent if their levels were 0.5-5 mM for 80%-100% of the times they were measured.

Health coaches checked in with participants for about 5-10 minutes each week to answer diet-related questions.

Psychiatric assessments, which included mood rating and global functioning scales, were completed at baseline, 2 months, and at the end of the 4-month study. 

The research team tracked participants’ adherence to the diet by weekly measurement of blood ketone levels. 

By the end of the trial, 14 patients had been fully adherent with the diet, six had been semi-adherent, and only one had been nonadherent. Higher ketone levels, suggesting greater adherence, correlated with better metabolic health.

As measured by the Clinical Global Impression-Schizophrenia and Clinical Global Impression for Bipolar Disorder–Overall Severity, participants experienced a 31% reduction in symptom severity (P < .001). Overall, 43% (P < .02) of participants achieved recovery as defined by the Clinical Mood Monitoring Form criteria: 50% of the adherent group and 33% of those who were semi-adherent.
 

Metabolic Benefits

Initially, 29% of participants had metabolic syndrome and more than 85% had co-occurring medical conditions such as obesity, hyperlipidemia, or prediabetes. By the end of the study, none met criteria for metabolic syndrome.

On average, participants experienced a 10% reduction in weight and BMI. Waist circumference was reduced by 11%, fat mass index dropped by 17%, and systolic blood pressure decreased by 6%. In addition, metabolic markers including visceral fat, inflammation, A1c, and insulin resistance also improved. All outcomes were significant at P < .001 except for systolic blood pressure, at P < .005.

There was also a 20% reduction in triglycerides and a 21% increase in low-density lipoprotein cholesterol (both at P < .02). 

The study’s limitations include its small sample size, the lack of control arm, and short duration.

“Mental health and physical health are interconnected and addressing metabolic issues can complement psychiatric treatment to enhance overall well-being. Understanding the

mechanisms and potential synergies between psychiatric treatment and metabolic improvements can also inform the development of more effective interventions,” the researchers wrote. 

The study was funded by the Baszucki Group, Kuen Lau Fund, and the Obesity Treatment Foundation. The authors declare no competing interests.

A version of this article appeared on Medscape.com.

Antipsychotic use in older adults with dementia is associated with a significant increased risk for stroke, myocardial infarction, heart failure, pneumonia, fracture, acute kidney injury, and a range of other health problems compared with nonuse, new research showed.

The adverse events are far broader and pose more severe health risks than previously reported, investigators noted, and suggested greater caution is needed when prescribing antipsychotics to treat psychological symptoms of dementia.

The matched cohort study used patient registry data on nearly 174,000 people with dementia and compared those who were prescribed an antipsychotic on or after their dementia diagnosis with those who had not received a prescription for the drugs.

Any antipsychotic use was associated with double the risk for pneumonia, a 1.7-fold increased risk for acute kidney injury, and 1.6-fold higher odds of venous thromboembolism compared to nonuse.

Investigators found an increased risk for all outcomes studied, except for ventricular arrythmia, and risk was highest for most within the first week of treatment.

“Any potential benefits of antipsychotic treatment therefore need to be weighed against the risk of serious harm across multiple outcomes. Although there may be times when an antipsychotic prescription is the least bad option, clinicians should actively consider the risks, considering patients’ pre-existing comorbidities and living support,” lead investigator Pearl Mok, research fellow at the Centre for Pharmacoepidemiology and Drug Safety, The University of Manchester, Manchester, England, and colleagues wrote.

The findings were published online in The BMJ.
 

High Risk

Depression, aggression, anxiety, psychosis, and other behavioral and psychological symptoms are common in people with dementia. Despite earlier reports of increased risk for stroke and mortality with antipsychotic use, the drugs are frequently prescribed to treat these symptoms.

While some preliminary studies identified other adverse outcomes from antipsychotic use, results are limited and inconsistent.

Investigators used primary and secondary care data from the Clinical Practice Research Datalink in England. A total of 173,910 adults (63% women) had a dementia diagnosis between January 1998 and May 2018.

Of the total cohort, 35,339 patients were prescribed an antipsychotic on, or after, a dementia diagnosis. Each was matched with up to 15 patients with dementia with no history of antipsychotic use following diagnosis.

Almost 80% of antipsychotic prescriptions were for risperidone, quetiapine, haloperidol, and olanzapine.

Any antipsychotic use was associated with significantly higher risks for pneumonia (hazard ratio [HR], 2.03; 95% CI, 1.96-2.10), acute kidney injury (HR, 1.57; 95% CI, 1.48-1.66), stroke (HR, 1.54; 95% CI, 1.46-1.63), venous thromboembolism (HR, 1.52; 95% CI, 1.38-1.67), fracture (HR, 1.36; 95% CI, 1.30-1.44), myocardial infarction (HR, 1.22; 95% CI, 1.12-1.34), and heart failure (HR, 1.16; 95% CI, 1.09-1.24).

The risk for all conditions was highest within the first 3 months of treatment, with a cumulative incidence of pneumonia among antipsychotic users of 4.48% vs 1.49% among nonusers. At 1 year, this increased to 10.41% for users vs 5.63% for nonusers.

“Given the higher risks of adverse events in the early days after drug initiation, clinical examinations should be taken before, and clinical reviews conducted shortly after, the start of treatment,” the authors wrote. “Our study reaffirms that these drugs should only be prescribed for the shortest period possible.”
 

‘Serious Harms’

In an accompanying editorial, Raya Elfadel Kheirbek, MD, and Cristina LaFont, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, said the findings “highlight the need for careful justification of antipsychotic use in dementia care, including a comprehensive assessment of the benefits weighed against a broader range of serious harms than previously acknowledged.”

“Using antipsychotics for the management of dementia-related behaviors requires nuanced decision-making after careful assessment, informed by a personalized approach,” they continued. “Dr. Mok and colleagues call for a critical re-evaluation of antipsychotic use in this clinical setting.”

While the findings add to and expand what was already known, “we need to be clear that they don’t show antipsychotics cause all the adverse outcomes reported,” Masud Husain, DPhil, professor of neurology, University of Oxford, England, said in a statement.

While investigators attempted to use matched controls with dementia who had not received antipsychotics, “the people who were prescribed the drugs may simply have been more vulnerable to some of the conditions that occurred more frequently in them, such as pneumonia and cardiovascular disorders,” said Dr. Husain, who was not part of the research.

Although the study was not designed to explore reverse causality, the findings are important for clinicians who prescribe antipsychotics for patients with dementia, Robert Howard, professor of old age psychiatry, at the University of College London, London, England said in a statement.

“Initiation of these drugs in people with dementia should only ever be under specialist supervision, with involvement of patients and family members in informed discussion and review,” said Dr. Howard, who was not involved in the study.

The study was funded by the National Institute for Health and Care Research. Dr. Mok reported no relevant conflicts. Other authors’ disclosures are included in the original article. Dr. Hussain, Dr. Howard, Dr. Kheirbek, and Dr. LeFon reported no relevant conflicts.

A version of this article appeared on Medscape.com.

Antipsychotic use in older adults with dementia is associated with a significant increased risk for stroke, myocardial infarction, heart failure, pneumonia, fracture, acute kidney injury, and a range of other health problems compared with nonuse, new research showed.

The adverse events are far broader and pose more severe health risks than previously reported, investigators noted, and suggested greater caution is needed when prescribing antipsychotics to treat psychological symptoms of dementia.

The matched cohort study used patient registry data on nearly 174,000 people with dementia and compared those who were prescribed an antipsychotic on or after their dementia diagnosis with those who had not received a prescription for the drugs.

Any antipsychotic use was associated with double the risk for pneumonia, a 1.7-fold increased risk for acute kidney injury, and 1.6-fold higher odds of venous thromboembolism compared to nonuse.

Investigators found an increased risk for all outcomes studied, except for ventricular arrythmia, and risk was highest for most within the first week of treatment.

“Any potential benefits of antipsychotic treatment therefore need to be weighed against the risk of serious harm across multiple outcomes. Although there may be times when an antipsychotic prescription is the least bad option, clinicians should actively consider the risks, considering patients’ pre-existing comorbidities and living support,” lead investigator Pearl Mok, research fellow at the Centre for Pharmacoepidemiology and Drug Safety, The University of Manchester, Manchester, England, and colleagues wrote.

The findings were published online in The BMJ.
 

High Risk

Depression, aggression, anxiety, psychosis, and other behavioral and psychological symptoms are common in people with dementia. Despite earlier reports of increased risk for stroke and mortality with antipsychotic use, the drugs are frequently prescribed to treat these symptoms.

While some preliminary studies identified other adverse outcomes from antipsychotic use, results are limited and inconsistent.

Investigators used primary and secondary care data from the Clinical Practice Research Datalink in England. A total of 173,910 adults (63% women) had a dementia diagnosis between January 1998 and May 2018.

Of the total cohort, 35,339 patients were prescribed an antipsychotic on, or after, a dementia diagnosis. Each was matched with up to 15 patients with dementia with no history of antipsychotic use following diagnosis.

Almost 80% of antipsychotic prescriptions were for risperidone, quetiapine, haloperidol, and olanzapine.

Any antipsychotic use was associated with significantly higher risks for pneumonia (hazard ratio [HR], 2.03; 95% CI, 1.96-2.10), acute kidney injury (HR, 1.57; 95% CI, 1.48-1.66), stroke (HR, 1.54; 95% CI, 1.46-1.63), venous thromboembolism (HR, 1.52; 95% CI, 1.38-1.67), fracture (HR, 1.36; 95% CI, 1.30-1.44), myocardial infarction (HR, 1.22; 95% CI, 1.12-1.34), and heart failure (HR, 1.16; 95% CI, 1.09-1.24).

The risk for all conditions was highest within the first 3 months of treatment, with a cumulative incidence of pneumonia among antipsychotic users of 4.48% vs 1.49% among nonusers. At 1 year, this increased to 10.41% for users vs 5.63% for nonusers.

“Given the higher risks of adverse events in the early days after drug initiation, clinical examinations should be taken before, and clinical reviews conducted shortly after, the start of treatment,” the authors wrote. “Our study reaffirms that these drugs should only be prescribed for the shortest period possible.”
 

‘Serious Harms’

In an accompanying editorial, Raya Elfadel Kheirbek, MD, and Cristina LaFont, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, said the findings “highlight the need for careful justification of antipsychotic use in dementia care, including a comprehensive assessment of the benefits weighed against a broader range of serious harms than previously acknowledged.”

“Using antipsychotics for the management of dementia-related behaviors requires nuanced decision-making after careful assessment, informed by a personalized approach,” they continued. “Dr. Mok and colleagues call for a critical re-evaluation of antipsychotic use in this clinical setting.”

While the findings add to and expand what was already known, “we need to be clear that they don’t show antipsychotics cause all the adverse outcomes reported,” Masud Husain, DPhil, professor of neurology, University of Oxford, England, said in a statement.

While investigators attempted to use matched controls with dementia who had not received antipsychotics, “the people who were prescribed the drugs may simply have been more vulnerable to some of the conditions that occurred more frequently in them, such as pneumonia and cardiovascular disorders,” said Dr. Husain, who was not part of the research.

Although the study was not designed to explore reverse causality, the findings are important for clinicians who prescribe antipsychotics for patients with dementia, Robert Howard, professor of old age psychiatry, at the University of College London, London, England said in a statement.

“Initiation of these drugs in people with dementia should only ever be under specialist supervision, with involvement of patients and family members in informed discussion and review,” said Dr. Howard, who was not involved in the study.

The study was funded by the National Institute for Health and Care Research. Dr. Mok reported no relevant conflicts. Other authors’ disclosures are included in the original article. Dr. Hussain, Dr. Howard, Dr. Kheirbek, and Dr. LeFon reported no relevant conflicts.

A version of this article appeared on Medscape.com.

Antipsychotic use in older adults with dementia is associated with a significant increased risk for stroke, myocardial infarction, heart failure, pneumonia, fracture, acute kidney injury, and a range of other health problems compared with nonuse, new research showed.

The adverse events are far broader and pose more severe health risks than previously reported, investigators noted, and suggested greater caution is needed when prescribing antipsychotics to treat psychological symptoms of dementia.

The matched cohort study used patient registry data on nearly 174,000 people with dementia and compared those who were prescribed an antipsychotic on or after their dementia diagnosis with those who had not received a prescription for the drugs.

Any antipsychotic use was associated with double the risk for pneumonia, a 1.7-fold increased risk for acute kidney injury, and 1.6-fold higher odds of venous thromboembolism compared to nonuse.

Investigators found an increased risk for all outcomes studied, except for ventricular arrythmia, and risk was highest for most within the first week of treatment.

“Any potential benefits of antipsychotic treatment therefore need to be weighed against the risk of serious harm across multiple outcomes. Although there may be times when an antipsychotic prescription is the least bad option, clinicians should actively consider the risks, considering patients’ pre-existing comorbidities and living support,” lead investigator Pearl Mok, research fellow at the Centre for Pharmacoepidemiology and Drug Safety, The University of Manchester, Manchester, England, and colleagues wrote.

The findings were published online in The BMJ.
 

High Risk

Depression, aggression, anxiety, psychosis, and other behavioral and psychological symptoms are common in people with dementia. Despite earlier reports of increased risk for stroke and mortality with antipsychotic use, the drugs are frequently prescribed to treat these symptoms.

While some preliminary studies identified other adverse outcomes from antipsychotic use, results are limited and inconsistent.

Investigators used primary and secondary care data from the Clinical Practice Research Datalink in England. A total of 173,910 adults (63% women) had a dementia diagnosis between January 1998 and May 2018.

Of the total cohort, 35,339 patients were prescribed an antipsychotic on, or after, a dementia diagnosis. Each was matched with up to 15 patients with dementia with no history of antipsychotic use following diagnosis.

Almost 80% of antipsychotic prescriptions were for risperidone, quetiapine, haloperidol, and olanzapine.

Any antipsychotic use was associated with significantly higher risks for pneumonia (hazard ratio [HR], 2.03; 95% CI, 1.96-2.10), acute kidney injury (HR, 1.57; 95% CI, 1.48-1.66), stroke (HR, 1.54; 95% CI, 1.46-1.63), venous thromboembolism (HR, 1.52; 95% CI, 1.38-1.67), fracture (HR, 1.36; 95% CI, 1.30-1.44), myocardial infarction (HR, 1.22; 95% CI, 1.12-1.34), and heart failure (HR, 1.16; 95% CI, 1.09-1.24).

The risk for all conditions was highest within the first 3 months of treatment, with a cumulative incidence of pneumonia among antipsychotic users of 4.48% vs 1.49% among nonusers. At 1 year, this increased to 10.41% for users vs 5.63% for nonusers.

“Given the higher risks of adverse events in the early days after drug initiation, clinical examinations should be taken before, and clinical reviews conducted shortly after, the start of treatment,” the authors wrote. “Our study reaffirms that these drugs should only be prescribed for the shortest period possible.”
 

‘Serious Harms’

In an accompanying editorial, Raya Elfadel Kheirbek, MD, and Cristina LaFont, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, said the findings “highlight the need for careful justification of antipsychotic use in dementia care, including a comprehensive assessment of the benefits weighed against a broader range of serious harms than previously acknowledged.”

“Using antipsychotics for the management of dementia-related behaviors requires nuanced decision-making after careful assessment, informed by a personalized approach,” they continued. “Dr. Mok and colleagues call for a critical re-evaluation of antipsychotic use in this clinical setting.”

While the findings add to and expand what was already known, “we need to be clear that they don’t show antipsychotics cause all the adverse outcomes reported,” Masud Husain, DPhil, professor of neurology, University of Oxford, England, said in a statement.

While investigators attempted to use matched controls with dementia who had not received antipsychotics, “the people who were prescribed the drugs may simply have been more vulnerable to some of the conditions that occurred more frequently in them, such as pneumonia and cardiovascular disorders,” said Dr. Husain, who was not part of the research.

Although the study was not designed to explore reverse causality, the findings are important for clinicians who prescribe antipsychotics for patients with dementia, Robert Howard, professor of old age psychiatry, at the University of College London, London, England said in a statement.

“Initiation of these drugs in people with dementia should only ever be under specialist supervision, with involvement of patients and family members in informed discussion and review,” said Dr. Howard, who was not involved in the study.

The study was funded by the National Institute for Health and Care Research. Dr. Mok reported no relevant conflicts. Other authors’ disclosures are included in the original article. Dr. Hussain, Dr. Howard, Dr. Kheirbek, and Dr. LeFon reported no relevant conflicts.

A version of this article appeared on Medscape.com.

Is picky eating a problem? Well, yes and no. We have all had parents come to us with concerns about their child’s picky eating. At this point in history, we may feel grateful not to be facing another of the myriad of our child patients who are seriously overweight. So, should we just tell parents to not worry about it?

About 18% of young children are picky eaters; 7% of older children, even adolescents, are still picky eaters. The lack of variety eaten can limit growth and nutrition — in particular iron, and vitamins A and C — and limit them socially at older ages because people think they’re weird because they don’t eat typical foods. The crying, tantrums, gagging, even vomiting at the sight of certain foods that may be part of picky eating is hard on families and may make them all less welcome as guests/friends. We know that if eating issues are not addressed early, they tend to persist. For example, the fruit variety eaten is actually higher at 27 months than it is at 60 months without intervention. The fruit variety eaten at 2 years of age actually predicts what the child will eat when they’re 6-8 years old. About 40% of irregular eaters at age 5 are still irregular eaters at age 14.
 

Practical Advice for Dealing With Picky Eating

There are some things you may not know about this common condition that could change your approach. Infants in the first year of life will naturally turn away from the bottle or breast when sated. But babies need to learn to eat solids, and it is actually stressful. Pushing food out is their first response. If progressively more textured foods are not provided between 6 and 10 months of age, the baby may struggle with accepting solids subsequently. Babies around 8 months want to grab everything, including the spoon, and want to feed themselves. If parents push the spoon and thwart participation, refusal to be fed — the so-called Battle of the Spoon, the most common reason for stalled weight gain at this age — may ensue. Instead, caregivers need to give the baby his/her own spoon to hold, and allow finger feeding, no matter how messy! The parent’s job is to provide healthy food in reasonable amounts, and the child’s job is to eat what they want of it.

But, often suddenly, typically around 21 months, children may become picky. What happened? This is an age of perceiving differences and developing a strong sense of autonomy. Foods recently eaten without protest may now be dramatically rejected. Whole food categories or textures (think slimy) may be refused, especially vegetables and meat. Food cut in their preferred shape, their favorite brand, or delivered in the same cup may be demanded with alternatives refused. Foods that touch together on the plate or are covered with sauce may cause a tantrum. Some of this pickiness may reflect sensitive or intense temperament. Some food preferences are cultural (borscht?), or familial (no fruit), but others are nearly universal because of the heightened sensitivity of taste at this age (spinach, for example, as it contains oxalic acid).

Young children refusing foods can have their autonomy honored by providing only healthy foods on a low table to eat as they please without commentary, but continue seating them with family for meals, allowing exit (no return) from that meal if they choose. The desire to be social and removal of pressure results in eating regular meals within a week in most cases.

Any of these new reactions may persist for years. In most cases, picky eaters get adequate nutrition and grow fine without any intervention. Removing the power struggle or parental discord is generally more important than getting the child to accept a few more foods. Keep in mind that children may have picky eating because mealtime interactions are aversive or in order to get attention or a special menu — both reinforcers to avoid.

But there are some ways food selectivity can be reduced. Modeling eating a variety of foods can make a difference but is best done without comment (seen as pressure). Seeing heroes or peers eat the food that might otherwise be undesired by a picky eater (recall Popeye, who ate his spinach), is based on this. Having a peer come over who will eat that specific food (Mikey likes it!) can be very helpful.

There are other practices that can improve picky eating and are good general feeding advice. Maintaining three meals and three snacks, always at the table with adult company, can reduce grazing on perhaps tasty and filling foods or drinks (milk being the worst) that replace the drive for eating less desired foods once seated. Providing the child a multivitamin can help parents avoid showing panic or pressure when working to increase food variety. All the foods prepared for the family should be put on the plate to increase exposure, along with at least one item the child is known to eat. Family meals have many benefits (eg, language development), and it has been shown that children who sit at a meal for 20-30 minutes eat significantly more undesired fruits and vegetables than those seated for less time. Boredom helps with exploration!

Sometimes a new brand or new way of preparing a food that they currently won’t eat, or sprinkling a new food on a currently accepted food (eg, chocolate on a fruit) will encourage eating it. Adding a food similar to one they are already eating may help.

It is wise to avoid supplements, however. While nutritionally sound and supportive of growth, supplements are usually calorie dense, and they remove the drive to eat at meals, as well as not providing the variety of components needed to reduce selectivity.
 

Advice for Severe Cases

If picky eating is severe or growth is impaired, and the eating pattern does not respond to these adjustments and parent counseling, more may be needed. One of the main things known to increase the variety eaten is repeated tasting. Looks are not enough. A proven method includes giving praise and sticker rewards for eating a little piece of the same undesired vegetable/food presented to them each day for at least 14 days in a row. This method may expand the range of foods eaten as well as the range of those liked. Even a microscopic amount, the size of a grain of rice of an undesired food, if ingested regularly and repeatedly, will increase acceptance!

A feeding program for serious problems with food selectivity at Penn State has the child given A) a pea-sized amount of an undesired food and B) a bite-sized amount of an accepted food. The child is required to eat A in order to get B, plus a small drink. This is done repeatedly for about 10 minutes. If the child does not eat anything, they don’t get anything more until the next meal. An alternative to this is insisting on one bite per meal or one bite per day of an undesired food. One can also mix in, in increasing amounts, an undesired liquid into a desired liquid. While families travel far for this special program when selectivity is extreme, the “praise and sticker” method has been shown effective done at home.

In extreme cases of food selectivity or refusal, we need to consider medical problems as a potential cause, especially if choking, gagging, or vomiting occur or if there is poor weight gain or complications such as rash, abdominal pain, or diarrhea. An episode of food poisoning or an allergic reaction (anaphylaxis can present as diarrhea) can trigger onset of a lifelong aversion to that food. Omitting foods that have sickened a person is reasonable. Gastroesophageal reflux and eosinophilic esophagitis, oral-motor incoordination and choking, dental caries, tracheo-esophageal fistulas with aspiration, constipation, sensory issues, and sometimes lactose intolerance all may cause food refusal through the conditioned responses to the discomfort. Children with autism often have a combination of these factors producing severe food selectivity for which the above methods can be helpful.

Parents everywhere take feeding their children as one of their highest priorities. Along with empathy for their concern, understanding potential contributing factors and some practical prevention and intervention steps for picky eating can help you partner on what can be a long journey. On a positive note, you can reassure parents that studies also show that picky eaters are less likely to go on to be overweight!
 

Dr. Howard is assistant professor of pediatrics at The Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at [email protected].

Is picky eating a problem? Well, yes and no. We have all had parents come to us with concerns about their child’s picky eating. At this point in history, we may feel grateful not to be facing another of the myriad of our child patients who are seriously overweight. So, should we just tell parents to not worry about it?

About 18% of young children are picky eaters; 7% of older children, even adolescents, are still picky eaters. The lack of variety eaten can limit growth and nutrition — in particular iron, and vitamins A and C — and limit them socially at older ages because people think they’re weird because they don’t eat typical foods. The crying, tantrums, gagging, even vomiting at the sight of certain foods that may be part of picky eating is hard on families and may make them all less welcome as guests/friends. We know that if eating issues are not addressed early, they tend to persist. For example, the fruit variety eaten is actually higher at 27 months than it is at 60 months without intervention. The fruit variety eaten at 2 years of age actually predicts what the child will eat when they’re 6-8 years old. About 40% of irregular eaters at age 5 are still irregular eaters at age 14.
 

Practical Advice for Dealing With Picky Eating

There are some things you may not know about this common condition that could change your approach. Infants in the first year of life will naturally turn away from the bottle or breast when sated. But babies need to learn to eat solids, and it is actually stressful. Pushing food out is their first response. If progressively more textured foods are not provided between 6 and 10 months of age, the baby may struggle with accepting solids subsequently. Babies around 8 months want to grab everything, including the spoon, and want to feed themselves. If parents push the spoon and thwart participation, refusal to be fed — the so-called Battle of the Spoon, the most common reason for stalled weight gain at this age — may ensue. Instead, caregivers need to give the baby his/her own spoon to hold, and allow finger feeding, no matter how messy! The parent’s job is to provide healthy food in reasonable amounts, and the child’s job is to eat what they want of it.

But, often suddenly, typically around 21 months, children may become picky. What happened? This is an age of perceiving differences and developing a strong sense of autonomy. Foods recently eaten without protest may now be dramatically rejected. Whole food categories or textures (think slimy) may be refused, especially vegetables and meat. Food cut in their preferred shape, their favorite brand, or delivered in the same cup may be demanded with alternatives refused. Foods that touch together on the plate or are covered with sauce may cause a tantrum. Some of this pickiness may reflect sensitive or intense temperament. Some food preferences are cultural (borscht?), or familial (no fruit), but others are nearly universal because of the heightened sensitivity of taste at this age (spinach, for example, as it contains oxalic acid).

Young children refusing foods can have their autonomy honored by providing only healthy foods on a low table to eat as they please without commentary, but continue seating them with family for meals, allowing exit (no return) from that meal if they choose. The desire to be social and removal of pressure results in eating regular meals within a week in most cases.

Any of these new reactions may persist for years. In most cases, picky eaters get adequate nutrition and grow fine without any intervention. Removing the power struggle or parental discord is generally more important than getting the child to accept a few more foods. Keep in mind that children may have picky eating because mealtime interactions are aversive or in order to get attention or a special menu — both reinforcers to avoid.

But there are some ways food selectivity can be reduced. Modeling eating a variety of foods can make a difference but is best done without comment (seen as pressure). Seeing heroes or peers eat the food that might otherwise be undesired by a picky eater (recall Popeye, who ate his spinach), is based on this. Having a peer come over who will eat that specific food (Mikey likes it!) can be very helpful.

There are other practices that can improve picky eating and are good general feeding advice. Maintaining three meals and three snacks, always at the table with adult company, can reduce grazing on perhaps tasty and filling foods or drinks (milk being the worst) that replace the drive for eating less desired foods once seated. Providing the child a multivitamin can help parents avoid showing panic or pressure when working to increase food variety. All the foods prepared for the family should be put on the plate to increase exposure, along with at least one item the child is known to eat. Family meals have many benefits (eg, language development), and it has been shown that children who sit at a meal for 20-30 minutes eat significantly more undesired fruits and vegetables than those seated for less time. Boredom helps with exploration!

Sometimes a new brand or new way of preparing a food that they currently won’t eat, or sprinkling a new food on a currently accepted food (eg, chocolate on a fruit) will encourage eating it. Adding a food similar to one they are already eating may help.

It is wise to avoid supplements, however. While nutritionally sound and supportive of growth, supplements are usually calorie dense, and they remove the drive to eat at meals, as well as not providing the variety of components needed to reduce selectivity.
 

Advice for Severe Cases

If picky eating is severe or growth is impaired, and the eating pattern does not respond to these adjustments and parent counseling, more may be needed. One of the main things known to increase the variety eaten is repeated tasting. Looks are not enough. A proven method includes giving praise and sticker rewards for eating a little piece of the same undesired vegetable/food presented to them each day for at least 14 days in a row. This method may expand the range of foods eaten as well as the range of those liked. Even a microscopic amount, the size of a grain of rice of an undesired food, if ingested regularly and repeatedly, will increase acceptance!

A feeding program for serious problems with food selectivity at Penn State has the child given A) a pea-sized amount of an undesired food and B) a bite-sized amount of an accepted food. The child is required to eat A in order to get B, plus a small drink. This is done repeatedly for about 10 minutes. If the child does not eat anything, they don’t get anything more until the next meal. An alternative to this is insisting on one bite per meal or one bite per day of an undesired food. One can also mix in, in increasing amounts, an undesired liquid into a desired liquid. While families travel far for this special program when selectivity is extreme, the “praise and sticker” method has been shown effective done at home.

In extreme cases of food selectivity or refusal, we need to consider medical problems as a potential cause, especially if choking, gagging, or vomiting occur or if there is poor weight gain or complications such as rash, abdominal pain, or diarrhea. An episode of food poisoning or an allergic reaction (anaphylaxis can present as diarrhea) can trigger onset of a lifelong aversion to that food. Omitting foods that have sickened a person is reasonable. Gastroesophageal reflux and eosinophilic esophagitis, oral-motor incoordination and choking, dental caries, tracheo-esophageal fistulas with aspiration, constipation, sensory issues, and sometimes lactose intolerance all may cause food refusal through the conditioned responses to the discomfort. Children with autism often have a combination of these factors producing severe food selectivity for which the above methods can be helpful.

Parents everywhere take feeding their children as one of their highest priorities. Along with empathy for their concern, understanding potential contributing factors and some practical prevention and intervention steps for picky eating can help you partner on what can be a long journey. On a positive note, you can reassure parents that studies also show that picky eaters are less likely to go on to be overweight!
 

Dr. Howard is assistant professor of pediatrics at The Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at [email protected].

Is picky eating a problem? Well, yes and no. We have all had parents come to us with concerns about their child’s picky eating. At this point in history, we may feel grateful not to be facing another of the myriad of our child patients who are seriously overweight. So, should we just tell parents to not worry about it?

About 18% of young children are picky eaters; 7% of older children, even adolescents, are still picky eaters. The lack of variety eaten can limit growth and nutrition — in particular iron, and vitamins A and C — and limit them socially at older ages because people think they’re weird because they don’t eat typical foods. The crying, tantrums, gagging, even vomiting at the sight of certain foods that may be part of picky eating is hard on families and may make them all less welcome as guests/friends. We know that if eating issues are not addressed early, they tend to persist. For example, the fruit variety eaten is actually higher at 27 months than it is at 60 months without intervention. The fruit variety eaten at 2 years of age actually predicts what the child will eat when they’re 6-8 years old. About 40% of irregular eaters at age 5 are still irregular eaters at age 14.
 

Practical Advice for Dealing With Picky Eating

There are some things you may not know about this common condition that could change your approach. Infants in the first year of life will naturally turn away from the bottle or breast when sated. But babies need to learn to eat solids, and it is actually stressful. Pushing food out is their first response. If progressively more textured foods are not provided between 6 and 10 months of age, the baby may struggle with accepting solids subsequently. Babies around 8 months want to grab everything, including the spoon, and want to feed themselves. If parents push the spoon and thwart participation, refusal to be fed — the so-called Battle of the Spoon, the most common reason for stalled weight gain at this age — may ensue. Instead, caregivers need to give the baby his/her own spoon to hold, and allow finger feeding, no matter how messy! The parent’s job is to provide healthy food in reasonable amounts, and the child’s job is to eat what they want of it.

But, often suddenly, typically around 21 months, children may become picky. What happened? This is an age of perceiving differences and developing a strong sense of autonomy. Foods recently eaten without protest may now be dramatically rejected. Whole food categories or textures (think slimy) may be refused, especially vegetables and meat. Food cut in their preferred shape, their favorite brand, or delivered in the same cup may be demanded with alternatives refused. Foods that touch together on the plate or are covered with sauce may cause a tantrum. Some of this pickiness may reflect sensitive or intense temperament. Some food preferences are cultural (borscht?), or familial (no fruit), but others are nearly universal because of the heightened sensitivity of taste at this age (spinach, for example, as it contains oxalic acid).

Young children refusing foods can have their autonomy honored by providing only healthy foods on a low table to eat as they please without commentary, but continue seating them with family for meals, allowing exit (no return) from that meal if they choose. The desire to be social and removal of pressure results in eating regular meals within a week in most cases.

Any of these new reactions may persist for years. In most cases, picky eaters get adequate nutrition and grow fine without any intervention. Removing the power struggle or parental discord is generally more important than getting the child to accept a few more foods. Keep in mind that children may have picky eating because mealtime interactions are aversive or in order to get attention or a special menu — both reinforcers to avoid.

But there are some ways food selectivity can be reduced. Modeling eating a variety of foods can make a difference but is best done without comment (seen as pressure). Seeing heroes or peers eat the food that might otherwise be undesired by a picky eater (recall Popeye, who ate his spinach), is based on this. Having a peer come over who will eat that specific food (Mikey likes it!) can be very helpful.

There are other practices that can improve picky eating and are good general feeding advice. Maintaining three meals and three snacks, always at the table with adult company, can reduce grazing on perhaps tasty and filling foods or drinks (milk being the worst) that replace the drive for eating less desired foods once seated. Providing the child a multivitamin can help parents avoid showing panic or pressure when working to increase food variety. All the foods prepared for the family should be put on the plate to increase exposure, along with at least one item the child is known to eat. Family meals have many benefits (eg, language development), and it has been shown that children who sit at a meal for 20-30 minutes eat significantly more undesired fruits and vegetables than those seated for less time. Boredom helps with exploration!

Sometimes a new brand or new way of preparing a food that they currently won’t eat, or sprinkling a new food on a currently accepted food (eg, chocolate on a fruit) will encourage eating it. Adding a food similar to one they are already eating may help.

It is wise to avoid supplements, however. While nutritionally sound and supportive of growth, supplements are usually calorie dense, and they remove the drive to eat at meals, as well as not providing the variety of components needed to reduce selectivity.
 

Advice for Severe Cases

If picky eating is severe or growth is impaired, and the eating pattern does not respond to these adjustments and parent counseling, more may be needed. One of the main things known to increase the variety eaten is repeated tasting. Looks are not enough. A proven method includes giving praise and sticker rewards for eating a little piece of the same undesired vegetable/food presented to them each day for at least 14 days in a row. This method may expand the range of foods eaten as well as the range of those liked. Even a microscopic amount, the size of a grain of rice of an undesired food, if ingested regularly and repeatedly, will increase acceptance!

A feeding program for serious problems with food selectivity at Penn State has the child given A) a pea-sized amount of an undesired food and B) a bite-sized amount of an accepted food. The child is required to eat A in order to get B, plus a small drink. This is done repeatedly for about 10 minutes. If the child does not eat anything, they don’t get anything more until the next meal. An alternative to this is insisting on one bite per meal or one bite per day of an undesired food. One can also mix in, in increasing amounts, an undesired liquid into a desired liquid. While families travel far for this special program when selectivity is extreme, the “praise and sticker” method has been shown effective done at home.

In extreme cases of food selectivity or refusal, we need to consider medical problems as a potential cause, especially if choking, gagging, or vomiting occur or if there is poor weight gain or complications such as rash, abdominal pain, or diarrhea. An episode of food poisoning or an allergic reaction (anaphylaxis can present as diarrhea) can trigger onset of a lifelong aversion to that food. Omitting foods that have sickened a person is reasonable. Gastroesophageal reflux and eosinophilic esophagitis, oral-motor incoordination and choking, dental caries, tracheo-esophageal fistulas with aspiration, constipation, sensory issues, and sometimes lactose intolerance all may cause food refusal through the conditioned responses to the discomfort. Children with autism often have a combination of these factors producing severe food selectivity for which the above methods can be helpful.

Parents everywhere take feeding their children as one of their highest priorities. Along with empathy for their concern, understanding potential contributing factors and some practical prevention and intervention steps for picky eating can help you partner on what can be a long journey. On a positive note, you can reassure parents that studies also show that picky eaters are less likely to go on to be overweight!
 

Dr. Howard is assistant professor of pediatrics at The Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at [email protected].