April 22, 2025 • 33 mins
The NACE Journal Club with Dr. Neil Skolnik, provides review and analysis of recently published journal articles important to the practice of primary care medicine. In this episode Dr. Skolnik and guests review the following publications:
1. Adverse Outcomes Associated With Inhaled Corticosteroid Use in Individuals With Chronic Obstructive Pulmonary Disease. Annals of Family Medicine 2025. Discussion by:
Guest:
Barbara Yawn, MD, MSc, MPH
Adjunct Professor, Department of Family and Community Health
University of Minnesota
Former Chief Scientific Officer at the COPD Foundation
2. Optimal dietary patterns for healthy aging. Nature Medicine. Discussion by:
Guest:
Jessica Stieritz, MD
Resident– Family Medicine Residency Program
Jefferson Health – Abington
3. Amount and intensity of daily total physical activity, step count and risk of incident cancer. British Journal of Sports Medicine. Discussion by:
Guest:
William Callahan, D.O.
Associate Director – Family Medicine Residency Program
Jefferson Health – Abington
Medical Director and Host, Neil Skolnik, MD, is an academic family physician who sees patients and teaches residents and medical students as professor of Family and Community Medicine at the Sidney Kimmel Medical College, Thomas Jefferson University and Associate Director, Family Medicine Residency Program at Abington Jefferson Health in Pennsylvania. Dr. Skolnik graduated from Emory University School of Medicine in Atlanta, Georgia, and did his residency training at Thomas Jefferson University Hospital in Philadelphia, PA.
This Podcast Episode does not offer CME/CE Credit.
Please visit http://naceonline.com to engage in more live and on demand CME/CE content.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
SPEAKER_01 (00:00):
Welcome to the NACE Journal Club, where we go over
some of the most importantarticles to come out in the
medical literature relevant toprimary care every month.
(00:23):
I'm Dr.
Neal Skolnick.
This month, We have a reallyexciting group of articles,
beginning with an article fromAnnals of Family Medicine that
looks at the adverse effectsfrom inhaled corticosteroids,
that's ICS, used for COPD.
And you're going to be surprisedat these results.
(00:46):
Then an article on optimaldietary patterns for healthy
aging published in NatureMedicine.
And wow.
you're going to find out thatyou might be able to improve the
likelihood substantially ofliving to age 75 completely
(01:07):
healthy just by eating right.
And then a discussion ofphysical activity and how good
physical activity can decreasesubstantially your risk of
developing a number of differenttypes of cancer.
And that was from the BritishJournal of Sports Medicine.
(01:28):
For our first article, we'regoing to discuss an article
published in the Annals ofFamily Medicine titled Adverse
Outcomes Associated with InhaleCorticosteroid Use in
Individuals with COPD.
Joining us to discuss thisarticle is one of the authors,
Dr.
Barbara Yon, who is an adjunctprofessor in the Department of
(01:51):
Family and Community Health,University of Minnesota, and is
the former chief scientificofficer at the COPD Foundation.
She is a clinical researcher.
She's been an author on over 400publications, three books, and
is, I can tell you, an amazingprimary care educator who just
(02:12):
spans detailed knowledge ofspecialty care with our needs as
primary care clinicians.
Barbara, welcome to our podcast.
Thank you for having me joinyou.
Barbara, can you go over thebackground on this issue?
Why did you all choose to studythis?
SPEAKER_02 (02:32):
Certainly.
There's been a lot of attentionin asthma of corticosteroids and
the potential side effects.
and then also COPD.
But most of that attention hasbeen on systemic
corticosteroids, oralprednisone, for example.
But we wanted to see aboutinhaled corticosteroids because
(02:57):
they're used very, very widely.
Almost 60% of the prescriptionsfor first-time COPD diagnosis
include an inhaledcorticosteroid.
And we know the indications forinhaled corticosteroid or ICS
are really limited.
It's only if someone has alsofeatures of asthma like COPD,
(03:22):
asthma overlap syndrome, or ifthey have a high eosinophil
count and have lots ofexacerbations, frequent,
moderate, and severeexacerbations, and they've
failed on lava-lama therapy withdual bronchodilator therapy.
Then there are candidates for
SPEAKER_01 (03:44):
ICS.
And Barbara, it's so importantthat you went over and thank you
for going over it in that detailbecause I think a lot of people
in primary care get confused,frankly, between the treatment
algorithms for asthma where ICSis a foundational therapy and
COPD where it's not.
The details are what you justsaid.
(04:06):
So that Even when people I knowI have taught on this, when I
explain this, people go, butICS, not a big deal.
Well, tell us how you went aheadand looked at that question.
And that's exactly what we
SPEAKER_02 (04:24):
were responding to is people saying it's no big
deal.
So we use this large dark netdata set from multiple health
care systems.
that they use for practiceimprovement.
And it has a lot of primary carepatients in it.
We included everybody over theage of 45.
(04:44):
We had a few exclusion criteria,like being treated actively for
a malignancy or if you had TB.
But otherwise, everybody wasincluded.
And we took two groups.
The prevalence group, those werepeople who had COPD diagnosis,
any time during our period ofobservation, which was actually
(05:08):
almost six years, and people whohad a new diagnosis of COPD
called the inception cohortafter six months.
So we could look at people whohad ongoing therapy with ICS,
people who had new therapy withICS, and people who had no
(05:29):
therapy with ICS with theirCOPD.
And what we did is divide theminto people who had 24 months or
longer ICS exposure, people whohad less than four months,
including no exposure, and wecompared several outcomes, the
kinds of outcomes we care aboutfor corticosteroids like
(05:53):
diabetes, pneumonia, fractures,cataracts, and compared what
happened in the shorter term andthe longer term exposures.
SPEAKER_01 (06:04):
And Barbara, there's no doubt that primary care docs
had input into organizing thisbecause even the way you said
it, you know, outcomes that wecare about is what the way we
like to organize our thinking.
What were the results?
SPEAKER_02 (06:19):
What the results showed is that in the group more
than 24 months, they had clearindications of increased risk
for all of these things.
We use a composite outcome forour primary outcome, and that
was, did you have either newonset diabetes, new cataracts,
(06:42):
new osteoporosis, new fracture,or new pneumonia?
And that was clearly over twoand a half times more common But
then we went on to look at eachof those individually, because
sometimes, you know, when youhave a huge data set, a 1% or
even a 5% increase and you getstatistical significance.
(07:07):
Well, we wanted to show, wasthis really clinically
significant?
And just to give you a couple ofquick examples, the diabetes,
for example, in the long-termprevalence cohort, 13.3%.
5% developed new-onset diabetes,as opposed to short-term, 4%.
(07:28):
So, more than four times asmany.
The osteoporosis was 5 versus3.3.
The fractures, which I think arereally important because, as you
know, hip fractures have highmortality, about 2.8 versus 1.3.
So we're not talking just alittle half a percent or 10%
(07:54):
increase.
We're talking very largeincreases.
And in fact, the number neededto harm was only five.
That means that you only have totreat five people to have one of
these adverse outcomes occuronce.
in a period of 24 to 25 months,starting at 24 months.
SPEAKER_01 (08:18):
Robert, this is such an important set of results, and
thanks for clarifying that it'snot just an increase in relative
risk, but a very importantclinically relevant increase in
absolute risk.
Now, what would you say, beforewe get on to clinical
implications, if one of ourlisteners were to say, but wait
a minute, I thought in theclinical trials that There was
not a big difference in sideeffects between people who got
(08:42):
ICS and those who don't.
They're right.
There wasn't.
But how
SPEAKER_02 (08:45):
long do those clinical trials last?
Most of them last 12 months orless.
It is extremely rare to find,and we couldn't find anything in
the literature, reportingoutcomes longer than 12 months
in those
SPEAKER_01 (09:03):
clinical trials.
So it's really important thatreal-world studies have an
important place in looking atlonger-term implications of
treatment.
What do you see as the clinicalimplications of these results?
SPEAKER_02 (09:17):
Well, I think first we have to realize, you say, oh,
I'm just going to start ICS.
But when you start ICS, italmost never gets stopped.
So you start ICS, and peoplewith COPD don't live just a year
or two.
They live 5, 10, 15, 20 yearswith their condition, and that
(09:38):
could mean that long of an ICSexposure.
So I think the clinicalimplications are you need to do
a risk-benefit assessment.
If these people truly haverecurrent exacerbations,
especially if they're in thehospital, ICS is absolutely
(10:00):
something you want to try andsee if it helps.
But if these people are nothaving exacerbations, and that's
somewhere between 40% and 60% ofpeople with COPD, then realize
that these risks we're talkingabout are significant risks.
They're risks for loss.
(10:21):
They're risks for morbidity.
and their risks for mortality.
And so think about it and helppresent the patient the
understanding of the risks andbenefits of starting that ICS.
SPEAKER_01 (10:36):
Dr.
Barb Rion, I think this is oneof those papers that go on my
list of ones that I will quoteto the residents when we're on
rounds so that they know thiswell.
I want to thank you so much forjoining us.
Thank you for having me.
Our next article was publishedin Nature Medicine and is titled
Optimal Dietary Patterns forHealthy Aging.
(10:59):
Joining us to discuss thisreally important article is
Jessica Sturitz, who is aresident in the Family Medicine
Residency Program at JeffersonHealth Edmonton.
Welcome, Jessica.
Hi, thank you so much.
Jessica, this is such animportant topic because We are
not and should not be just abouttreating disease.
(11:22):
We should also be about helpingpeople stay healthy for as long
as possible.
Can you give us a little bit ofbackground on why they looked at
this?
SPEAKER_00 (11:34):
Absolutely.
As we know in the United States,as well as globally, the
population is aging.
And as part of that, thepopulation as a whole has more
chronic disease burden.
In fact, 80% of older adultshave at least one chronic health
condition.
So it's a population issue thatwe'll be seeing more and more in
(11:57):
all of our offices movingforward.
And as you alluded to, the WHOrecently shifted focus from the
traditional disease-centricapproach to aging to
prioritizing the preservation offunctional ability, preventing
capacity decline, and And ingeneral, just prioritizing
overall health and well-being asa central model for healthy
(12:17):
aging.
So as we're moving towards thismodel, we're thinking about ways
that we can achieve this from aprimary care standpoint.
And diet is actually the firstleading behavioral risk factor
modification fornon-communicable diseases or
mortality burden globally.
In fact, it surpasses tobaccouse in the United States adults.
(12:41):
as behavioral risk factormodification that can make a
substantial impact on adulthealth.
And so this topic of diet inmoving forward in the aging
model, as well as just overallhealth for all individuals, will
become increasingly important, Ithink, as we dive more and more
into the literature and theresearch behind this.
SPEAKER_01 (13:04):
And that's impressive.
And I don't think that most ofus recognize that it's the
leading behavioral risk factorfor non-communicable diseases.
And therefore, it's important.
In many ways, I've seen moreemphasis on healthy aging in the
lay literature.
And this has become somethingthat's out there a lot now than
(13:25):
I have in the medicalliterature.
So it's so important that insome ways, we catch up to where
our patients want to be.
How do they look at the questionof what is an optimal diet that
leads to healthy aging?
SPEAKER_00 (13:41):
Yeah, absolutely.
So they took longitudinalquestionnaire data from these
groups of people, particularlythe Nurses' Health Study and the
Health Professionals' Follow-UpStudy.
And essentially, these werelarge pools of data that were
able to be followed over a longperiod of time, up to 30 years
in some cases.
(14:01):
And the follow-up rate was over90%, so really good retention
data, really important data tobe able to look at.
And essentially, they mailed outquestionnaires to these
participants every four years tomeasure their dietary intake.
And they asked them, howfrequently did you consume these
foods in the past 12 months?
And then based on these nutrientand food intakes, they
(14:23):
calculated, they divided thegroups into eight dietary
pattern scores.
And for each individual, theycalculated their score for each
of the eight dietary patterns.
SPEAKER_01 (14:35):
And...
And they related that to healthyaging.
What did they find?
SPEAKER_00 (14:41):
Yeah.
So essentially, the overarchingfinding of the article is that
long-term adherence to any ofthe dietary patterns is
associated very strongly withhealthy aging.
And they define healthy aging assurviving to the age of 70 years
without the presence of 11 majorchronic diseases and The 11
(15:02):
major chronic diseases wereselected because they are the
primary causes of mortality inthe United States or are
considered to be highlydebilitating.
So they include things likeCOPD, diabetes, MI, things that
you or I would think ofnaturally as participating
strongly in the chronic diseaseburden for people.
SPEAKER_01 (15:22):
Yeah, and it's interesting because when we
think about the patients we see,so many people have one or more
of those diseases.
SPEAKER_00 (15:32):
Absolutely.
Yeah, so essentially, healthyaging is then surviving to the
age of 70 without one of those11 things and no impairment in
cognitive function, physicalfunction, or mental health.
SPEAKER_01 (15:45):
And so what did they find with regard to the
magnitude of effects?
They defined these differenthealthy eating patterns, and
we're going to guess that itmade at least a little bit of
difference.
What was the magnitude ofeffect?
What'd they find?
SPEAKER_00 (15:59):
Yeah.
So essentially, as we talkedabout, they did score eight of
these things.
And all eight, like I hadmentioned before, were
associated with greater odds ofhealthy aging.
But I wanted to highlight one,which was the AHEI.
Essentially, they found that thestatistical analysis gets into
(16:20):
the weeds a little bit, and Idon't think it's salient to this
discussion.
But They compared the topquintile scorers for the AHEI to
the lowest quintile scorers forthe AHEI.
And they found that people inthe top quintile had an 86%
greater odds in achievinghealthy aging using an age
cutoff of 70 years.
(16:42):
And even further than that, 2.24times greater odds when they
increase the age cutoff to 75years.
So if you think about that, 86%is a really high, really strong
number that we're talking about.
SPEAKER_01 (16:56):
And we're talking about things that are common.
So when you see an 86%improvement or up to age 75,
over twofold better odds ofachieving our goal, healthy
aging, when we talk about thatlevel of effect in something
that's very rare, we go, okay,it's important, relative risk,
(17:17):
but not absolute.
This is...
fairly common.
There are a lot of people thatage healthily, fortunately, and
this could enormously increasethe number.
Now, to better understand this,when you talk about that
alternative healthy diet, whatwas it called and what is it?
SPEAKER_00 (17:36):
Yeah, so the AEGI score is called Alternative
Healthy Eating Index.
And essentially, that score inparticular is composed Thank you
so much.
(18:09):
And trans fats and fatty acids.
So just overall a healthy eatingpicture that they then score.
SPEAKER_01 (18:16):
Yeah.
And that's so important becauseit's one of those things that
what I love about this is we canremember those foods.
SPEAKER_00 (18:25):
Yeah, absolutely.
Those are foods that are in ourdiet.
repertoire already, like knowingthat these are the healthy foods
that we want to gravitatetowards in our diet.
SPEAKER_01 (18:35):
So what's nice about that Alternative Healthy Index,
it's not something complicated.
I don't need to memorize thedifferent components.
It's a lot of things that weknow to be important.
Is that right?
SPEAKER_00 (18:50):
Yeah, that's absolutely correct.
People don't need a lot ofhealth literacy or even
experience with diets to knowthat things like fruits,
vegetables, these things thatare emphasized in the diet are
naturally healthy for them.
And so it will be easy to speakto patients about this because
they do have some level ofunderstanding of the basics of
(19:13):
this diet kind of going in.
And I think that's reallyimportant, especially in the
primary care setting, becauseyou don't want to overcomplicate
things too much or it'sdifficult for the patients to
follow and stick to the plan.
So that's the benefit of thesetypes of scoring indices because
they use items that we alreadyknow to be true, emphasizing
(19:35):
fruits and vegetables andminimizing things like alcohol,
trans fats, sugary beverages, orsimple sugars in the diet in
general.
SPEAKER_01 (19:44):
Now, I think this has a lot of clinical
implications for us, both, asyou said in the introduction,
recognizing that diet is thenumber one cause of
non-communicable chronicdiseases, basically of chronic
disease, and then recognizingfrom this study that having a
(20:05):
healthier diet is meaningful.
What do you see?
How does this affect the way youapproach patients?
SPEAKER_00 (20:13):
Yeah, I think it's really important.
And when I learned that diet isthe number one risk factor
modification that we can make, Iwas astounded at that because if
you think about how much timeyou put into your day talking
about smoking cessation forpeople and how much intention
you put behind that, and atleast personally, I'm not doing
(20:36):
the same thing in my practice,my primary care practice in
terms of diet, it's reallyreframed how I think about diet
as a really powerful tool in ourarsenal to help people achieve
healthy aging, and just overallquality of life that right now
I'm leaving largely untouched.
So I think in the future, it'sreally motivated me to use diet
(21:01):
and incorporate diet into mydaily workflow and hopefully be
able to help people at leastestablish early eating habits
that then can carry them throughthe rest of their lives and help
them achieve the type of healthyaging that we're all hoping to
achieve.
SPEAKER_01 (21:17):
I think you're so right, Jessica.
It's interesting.
(21:47):
Have you talked about diet?
And I don't think we're going tosee that as a care gap soon.
I definitely think we should, inour own minds, think of it as a
care gap.
If we have not sat down andtalked in a serious way to our
patients about the benefits of,I'll call it clean eating,
(22:09):
healthy eating, the importanceof fruits, vegetables, whole
grains, nuts, legumes, all thatyou said, and to stay away at
all costs from sugary foods,processed foods, processed
meats, then we aren't trulygiving our patients all that we
can.
I
SPEAKER_00 (22:30):
think that's absolutely true.
And I think for me, movingforward, my goal will be to try
to figure out concrete ways tohelp patients to incorporate
these foods into their diets.
Because I think telling people,fruits and vegetables are
healthy for you is one thingwhich we all already know, but
figuring out a way toincorporate into my practice
(22:53):
tangible goals that the patientscan look to achieve to help move
forward and improve their dietoverall, as well as keeping them
accountable to these diets withgood follow-up visits.
SPEAKER_01 (23:05):
You're so right.
You mentioned to me earlier,Jessica, that if there was a
medicine that we could prescribethat would double the chances of
someone being completely healthyby the time they're 75.
We'd all be trying to prescribeit and we'd figure out ways to
petition insurance companies topay for it.
(23:26):
There isn't such a medicine, butwe can do that with diet.
Dr.
Jessica Steretz, thank you somuch for joining us.
SPEAKER_00 (23:35):
Thank you so much for having me.
SPEAKER_01 (23:37):
for our final discussion this month we're
going to look at two articleswhich further our discussion
about lifestyle medicine both ofthese articles are from the
british journal of sportsmedicine the first article is
titled amount and intensity oftotal daily physical activity
step count and the risk ofincident cancer the second one
(23:59):
is wearable device measuredphysical activity and the
Development of CardiovascularDisease in Cancer Survivors.
Joining us to discuss these twoarticles, I am so pleased to
have on with us Dr.
Bill Callahan, who is anAssociate Director and a
Clinical Assistant Professor ofFamily Medicine in the Family
(24:21):
Medicine Residency Program atJefferson Health Abington.
Welcome, Bill.
Thank you, Neil.
Bill, can you give us somebackground on why they even
thought to look at thesequestions.
Cancer is a big problem, right?
We see a lot of lifestyleassociated cancers in the United
States.
(24:42):
And thankfully, the UK Biobankgave us a ton of data to look at
regarding the development ofcancer in a general population.
So the UK Biobank, just for somebackground, looked at people,
500,000 people starting at theage of 40, and measured in this
population, What would thedevelopment of cancer look like
(25:02):
based on exercise?
That'll be our first study.
And the second, they look at thedevelopment of cardiovascular
disease in those with a historyof cancer, which is important
because we don't really havegreat guidelines on what type of
exercise should people who havealready had cancer be getting.
All of our guidelines areprimarily focused on a general
(25:23):
population.
And so this study really soughtto look at this niche of the
population and should we Whattype of exercise should we be
recommending for them withregard to both the development
of cardiovascular disease aswell as the development of the
second cancer?
So really important questionsthat they sought to answer.
(25:43):
Let's go over the results one ata time, starting with the first
article on the amount andintensity of total physical
activity and the risk ofdeveloping cancer.
What'd they find?
So this article I just love.
So this article looked at 85,000people.
These people were provided anaccelerometer, which they were
(26:04):
on their wrists, a non-dominanthand, which is where most of us
wear wristwatch.
So consider a smartwatch.
And using that data over aperiod of seven days, they
measured both the intensitymeasured in milligravity units
as well as step.
Now, I don't think it'snecessary.
that we go into how to calculateintensity using those specific
(26:28):
units.
But step counts is somethingthat we all hear about all the
time from our patients.
How many steps should I begetting?
So they set as a baseline 5,000steps.
They said that this would beexpected throughout a person's
day.
And that was basically abaseline for someone who's not
getting a ton of exercise.
And what they found was thatanything about the 5,000 was
(26:50):
really helpful.
So for those who got 7,000steps, which is for just
consideration would be about amile of walking and 2,000
additional steps.
They saw a drop in thedevelopment of cancer by about
11%.
Going up to 9,000 steps, 16% and13,000 steps would be a drop in
20%.
Now, importantly, after 9,000steps, what appears linear then
(27:13):
starts to plateau.
And I think that's reallyimportant because our patients
do care about that.
They want to know how many stepscan they get.
And historically, we've heard10,000 steps, but there hasn't
always been great precedent forthat.
So I think this really sets aprecedent for it.
We can say, okay, if you can'tget 10,000 steps, let's aim for
something still better than5,000.
(27:34):
So let's aim for that 7,000,9,000 range.
And that's an impressivedecrease in cancer.
If there was a pill that coulddo that, we'd all be going out
asking our doctors for thatpill.
but you can do that without apill, with exercise.
In our second article, wearabledevice measured physical
(27:55):
activity and the development ofcardiovascular disease in cancer
survivors, what did they find?
This was a great article,really.
So they looked at around justover 6,000 patients.
Again, they also woreaccelerometers and they were
also followed for a week.
These patients, they had ahistory of cancer, but no known
cardiovascular disease.
(28:17):
And what they looked at was thetime that this person was
getting either low intensity ormoderate to vigorous intensity
physical activity.
How was that associated withboth the development of
cardiovascular disease or asecond cancer associated with
physical activity?
And what they set as thebaseline was zero to 75 minutes.
(28:38):
That was going to be consideredsedentary.
And what they found was a linearrelationship that anything above
75 minutes was good and thatThis dropped your rate of both
cardiovascular disease andrecurrence of cancer, as long as
that cancer is associated withphysical activity.
So think like breast, thyroid,GI, skin cancers.
I wrote down some numbers here.
(28:59):
At 150 to 300 minutes a week,they saw a drop between 23% and
up to 27% in a cardiovasculardisease diagnosis, primarily
referring to coronary arterydisease in those.
The So not necessarilysurprising.
Like the general population,more exercise is equating into
less cardiovascular disease andalso less diagnosis of cancer.
(29:21):
But the clear reason I reallylike this study is a lot of
people wear smartwatches and thesmartwatches are excellent at
recording not only things likestep count, but the time that a
person engages in exercise.
And what the smartwatches willdo is that they also will say,
hey, it seems like you'rewalking pretty fast here.
We're going to count that asexercise.
And we can get a great idea fortime that a person is engaging
(29:45):
in this so that even if theyaren't telling us that they're
getting exercise, we can stillsee what their watch is
recording.
And so I think this study does agreat job of that as well.
And so when we put all of thistogether, and just prior to
these two articles, we talked toDr.
Sturitz about the importance ofdiet and healthy diet leading to
(30:07):
a greater chance, asignificantly greater chance, of
healthy aging, being without anysignificant disease at age 70
and even 75.
And now, Bill, you just talkedabout exercise.
What do you think this means forour patients?
I think it means we need to do amuch better job at focusing on
lifestyle, right?
Of course, we need to focus on ahealthier diet.
(30:28):
But I think looking at these twoarticles, I think it's clear
that we need to really focus onexercise.
And I think it's that Walking issomething that most of us can
do.
And when we talk to our patientsand they want to know how much
walking, we can start with justlet's aim for an additional 2000
steps a day on top of whatthey're already getting.
And that seems doable for a lotof us.
That's a wonderful way totranslate this into actionable
(30:52):
knowledge.
Yeah, it's so impressive becauseexercise is in a way the
everything pill.
it improves.
And I think most of us arefamiliar with the fact that it
decreases the likelihood ofdiabetes, decreases the
likelihood of cardiovasculardisease.
I think the fact that itdecreases by over 20% the
(31:13):
likelihood of cancer is notsomething that is in the
forefront of our thinking whenwe talk to patients.
Yet, cancer is in the forefrontof everyone's thinking when they
think about what is it that theyare rate of developing.
So this is incredibly importantinformation.
Yeah, I absolutely agree.
(31:34):
We think of our patients comingin for a physical.
We talk about things like, dothey need mammography?
Do they need colorectal cancerscreening?
Do they need lung cancerscreening?
I think this should be theretoo.
How much exercise are wegetting?
And that exercise does translateinto a decrease in risk of colon
cancer, of breast cancer, ofmelanoma.
I think this is reallyimportant.
(31:55):
That's a great point.
I've always found when I takethe time to discuss exercise,
patients are particularlythankful because they don't
always get that input from uswhen they come to their regular
visits.
Dr.
Bill Callahan, thank you so muchfor joining us and sharing your
thoughts with us today.
(32:15):
Thank you for having me, Neil.
That concludes this month's NACEJournal Club.
What can I say?
Adverse effects of ICS in peoplewith COPD Beneficial effects of
diet on achieving healthy livingto age 75.
The incredibly powerful effectsof exercise in decreasing the
(32:37):
risk of cancer by up to 25%.
That's information we can usewhen we take care of our
patients.
Check out NACE Online forupcoming DME programs with some
of the best faculty in thecountry.
Conversations in Primary Care2025 is on May 10th where our
(32:57):
faculty will give updates onatopic dermatitis, TLP1s,
resistant hypertension, and theOPD.
Till next month, I'm Dr.
Neal Skolnick.
Be well and keep learning.
Welcome to the NACE Journal Club, where we go over
some of the most importantarticles to come out in the
medical literature relevant toprimary care every month.
(00:23):
I'm Dr.
Neal Skolnick.
This month, We have a reallyexciting group of articles,
beginning with an article fromAnnals of Family Medicine that
looks at the adverse effectsfrom inhaled corticosteroids,
that's ICS, used for COPD.
And you're going to be surprisedat these results.
(00:46):
Then an article on optimaldietary patterns for healthy
aging published in NatureMedicine.
And wow.
you're going to find out thatyou might be able to improve the
likelihood substantially ofliving to age 75 completely
(01:07):
healthy just by eating right.
And then a discussion ofphysical activity and how good
physical activity can decreasesubstantially your risk of
developing a number of differenttypes of cancer.
And that was from the BritishJournal of Sports Medicine.
(01:28):
For our first article, we'regoing to discuss an article
published in the Annals ofFamily Medicine titled Adverse
Outcomes Associated with InhaleCorticosteroid Use in
Individuals with COPD.
Joining us to discuss thisarticle is one of the authors,
Dr.
Barbara Yon, who is an adjunctprofessor in the Department of
(01:51):
Family and Community Health,University of Minnesota, and is
the former chief scientificofficer at the COPD Foundation.
She is a clinical researcher.
She's been an author on over 400publications, three books, and
is, I can tell you, an amazingprimary care educator who just
(02:12):
spans detailed knowledge ofspecialty care with our needs as
primary care clinicians.
Barbara, welcome to our podcast.
Thank you for having me joinyou.
Barbara, can you go over thebackground on this issue?
Why did you all choose to studythis?
SPEAKER_02 (02:32):
Certainly.
There's been a lot of attentionin asthma of corticosteroids and
the potential side effects.
and then also COPD.
But most of that attention hasbeen on systemic
corticosteroids, oralprednisone, for example.
But we wanted to see aboutinhaled corticosteroids because
(02:57):
they're used very, very widely.
Almost 60% of the prescriptionsfor first-time COPD diagnosis
include an inhaledcorticosteroid.
And we know the indications forinhaled corticosteroid or ICS
are really limited.
It's only if someone has alsofeatures of asthma like COPD,
(03:22):
asthma overlap syndrome, or ifthey have a high eosinophil
count and have lots ofexacerbations, frequent,
moderate, and severeexacerbations, and they've
failed on lava-lama therapy withdual bronchodilator therapy.
Then there are candidates for
SPEAKER_01 (03:44):
ICS.
And Barbara, it's so importantthat you went over and thank you
for going over it in that detailbecause I think a lot of people
in primary care get confused,frankly, between the treatment
algorithms for asthma where ICSis a foundational therapy and
COPD where it's not.
The details are what you justsaid.
(04:06):
So that Even when people I knowI have taught on this, when I
explain this, people go, butICS, not a big deal.
Well, tell us how you went aheadand looked at that question.
And that's exactly what we
SPEAKER_02 (04:24):
were responding to is people saying it's no big
deal.
So we use this large dark netdata set from multiple health
care systems.
that they use for practiceimprovement.
And it has a lot of primary carepatients in it.
We included everybody over theage of 45.
(04:44):
We had a few exclusion criteria,like being treated actively for
a malignancy or if you had TB.
But otherwise, everybody wasincluded.
And we took two groups.
The prevalence group, those werepeople who had COPD diagnosis,
any time during our period ofobservation, which was actually
(05:08):
almost six years, and people whohad a new diagnosis of COPD
called the inception cohortafter six months.
So we could look at people whohad ongoing therapy with ICS,
people who had new therapy withICS, and people who had no
(05:29):
therapy with ICS with theirCOPD.
And what we did is divide theminto people who had 24 months or
longer ICS exposure, people whohad less than four months,
including no exposure, and wecompared several outcomes, the
kinds of outcomes we care aboutfor corticosteroids like
(05:53):
diabetes, pneumonia, fractures,cataracts, and compared what
happened in the shorter term andthe longer term exposures.
SPEAKER_01 (06:04):
And Barbara, there's no doubt that primary care docs
had input into organizing thisbecause even the way you said
it, you know, outcomes that wecare about is what the way we
like to organize our thinking.
What were the results?
SPEAKER_02 (06:19):
What the results showed is that in the group more
than 24 months, they had clearindications of increased risk
for all of these things.
We use a composite outcome forour primary outcome, and that
was, did you have either newonset diabetes, new cataracts,
(06:42):
new osteoporosis, new fracture,or new pneumonia?
And that was clearly over twoand a half times more common But
then we went on to look at eachof those individually, because
sometimes, you know, when youhave a huge data set, a 1% or
even a 5% increase and you getstatistical significance.
(07:07):
Well, we wanted to show, wasthis really clinically
significant?
And just to give you a couple ofquick examples, the diabetes,
for example, in the long-termprevalence cohort, 13.3%.
5% developed new-onset diabetes,as opposed to short-term, 4%.
(07:28):
So, more than four times asmany.
The osteoporosis was 5 versus3.3.
The fractures, which I think arereally important because, as you
know, hip fractures have highmortality, about 2.8 versus 1.3.
So we're not talking just alittle half a percent or 10%
(07:54):
increase.
We're talking very largeincreases.
And in fact, the number neededto harm was only five.
That means that you only have totreat five people to have one of
these adverse outcomes occuronce.
in a period of 24 to 25 months,starting at 24 months.
SPEAKER_01 (08:18):
Robert, this is such an important set of results, and
thanks for clarifying that it'snot just an increase in relative
risk, but a very importantclinically relevant increase in
absolute risk.
Now, what would you say, beforewe get on to clinical
implications, if one of ourlisteners were to say, but wait
a minute, I thought in theclinical trials that There was
not a big difference in sideeffects between people who got
(08:42):
ICS and those who don't.
They're right.
There wasn't.
But how
SPEAKER_02 (08:45):
long do those clinical trials last?
Most of them last 12 months orless.
It is extremely rare to find,and we couldn't find anything in
the literature, reportingoutcomes longer than 12 months
in those
SPEAKER_01 (09:03):
clinical trials.
So it's really important thatreal-world studies have an
important place in looking atlonger-term implications of
treatment.
What do you see as the clinicalimplications of these results?
SPEAKER_02 (09:17):
Well, I think first we have to realize, you say, oh,
I'm just going to start ICS.
But when you start ICS, italmost never gets stopped.
So you start ICS, and peoplewith COPD don't live just a year
or two.
They live 5, 10, 15, 20 yearswith their condition, and that
(09:38):
could mean that long of an ICSexposure.
So I think the clinicalimplications are you need to do
a risk-benefit assessment.
If these people truly haverecurrent exacerbations,
especially if they're in thehospital, ICS is absolutely
(10:00):
something you want to try andsee if it helps.
But if these people are nothaving exacerbations, and that's
somewhere between 40% and 60% ofpeople with COPD, then realize
that these risks we're talkingabout are significant risks.
They're risks for loss.
(10:21):
They're risks for morbidity.
and their risks for mortality.
And so think about it and helppresent the patient the
understanding of the risks andbenefits of starting that ICS.
SPEAKER_01 (10:36):
Dr.
Barb Rion, I think this is oneof those papers that go on my
list of ones that I will quoteto the residents when we're on
rounds so that they know thiswell.
I want to thank you so much forjoining us.
Thank you for having me.
Our next article was publishedin Nature Medicine and is titled
Optimal Dietary Patterns forHealthy Aging.
(10:59):
Joining us to discuss thisreally important article is
Jessica Sturitz, who is aresident in the Family Medicine
Residency Program at JeffersonHealth Edmonton.
Welcome, Jessica.
Hi, thank you so much.
Jessica, this is such animportant topic because We are
not and should not be just abouttreating disease.
(11:22):
We should also be about helpingpeople stay healthy for as long
as possible.
Can you give us a little bit ofbackground on why they looked at
this?
SPEAKER_00 (11:34):
Absolutely.
As we know in the United States,as well as globally, the
population is aging.
And as part of that, thepopulation as a whole has more
chronic disease burden.
In fact, 80% of older adultshave at least one chronic health
condition.
So it's a population issue thatwe'll be seeing more and more in
(11:57):
all of our offices movingforward.
And as you alluded to, the WHOrecently shifted focus from the
traditional disease-centricapproach to aging to
prioritizing the preservation offunctional ability, preventing
capacity decline, and And ingeneral, just prioritizing
overall health and well-being asa central model for healthy
(12:17):
aging.
So as we're moving towards thismodel, we're thinking about ways
that we can achieve this from aprimary care standpoint.
And diet is actually the firstleading behavioral risk factor
modification fornon-communicable diseases or
mortality burden globally.
In fact, it surpasses tobaccouse in the United States adults.
(12:41):
as behavioral risk factormodification that can make a
substantial impact on adulthealth.
And so this topic of diet inmoving forward in the aging
model, as well as just overallhealth for all individuals, will
become increasingly important, Ithink, as we dive more and more
into the literature and theresearch behind this.
SPEAKER_01 (13:04):
And that's impressive.
And I don't think that most ofus recognize that it's the
leading behavioral risk factorfor non-communicable diseases.
And therefore, it's important.
In many ways, I've seen moreemphasis on healthy aging in the
lay literature.
And this has become somethingthat's out there a lot now than
(13:25):
I have in the medicalliterature.
So it's so important that insome ways, we catch up to where
our patients want to be.
How do they look at the questionof what is an optimal diet that
leads to healthy aging?
SPEAKER_00 (13:41):
Yeah, absolutely.
So they took longitudinalquestionnaire data from these
groups of people, particularlythe Nurses' Health Study and the
Health Professionals' Follow-UpStudy.
And essentially, these werelarge pools of data that were
able to be followed over a longperiod of time, up to 30 years
in some cases.
(14:01):
And the follow-up rate was over90%, so really good retention
data, really important data tobe able to look at.
And essentially, they mailed outquestionnaires to these
participants every four years tomeasure their dietary intake.
And they asked them, howfrequently did you consume these
foods in the past 12 months?
And then based on these nutrientand food intakes, they
(14:23):
calculated, they divided thegroups into eight dietary
pattern scores.
And for each individual, theycalculated their score for each
of the eight dietary patterns.
SPEAKER_01 (14:35):
And...
And they related that to healthyaging.
What did they find?
SPEAKER_00 (14:41):
Yeah.
So essentially, the overarchingfinding of the article is that
long-term adherence to any ofthe dietary patterns is
associated very strongly withhealthy aging.
And they define healthy aging assurviving to the age of 70 years
without the presence of 11 majorchronic diseases and The 11
(15:02):
major chronic diseases wereselected because they are the
primary causes of mortality inthe United States or are
considered to be highlydebilitating.
So they include things likeCOPD, diabetes, MI, things that
you or I would think ofnaturally as participating
strongly in the chronic diseaseburden for people.
SPEAKER_01 (15:22):
Yeah, and it's interesting because when we
think about the patients we see,so many people have one or more
of those diseases.
SPEAKER_00 (15:32):
Absolutely.
Yeah, so essentially, healthyaging is then surviving to the
age of 70 without one of those11 things and no impairment in
cognitive function, physicalfunction, or mental health.
SPEAKER_01 (15:45):
And so what did they find with regard to the
magnitude of effects?
They defined these differenthealthy eating patterns, and
we're going to guess that itmade at least a little bit of
difference.
What was the magnitude ofeffect?
What'd they find?
SPEAKER_00 (15:59):
Yeah.
So essentially, as we talkedabout, they did score eight of
these things.
And all eight, like I hadmentioned before, were
associated with greater odds ofhealthy aging.
But I wanted to highlight one,which was the AHEI.
Essentially, they found that thestatistical analysis gets into
(16:20):
the weeds a little bit, and Idon't think it's salient to this
discussion.
But They compared the topquintile scorers for the AHEI to
the lowest quintile scorers forthe AHEI.
And they found that people inthe top quintile had an 86%
greater odds in achievinghealthy aging using an age
cutoff of 70 years.
(16:42):
And even further than that, 2.24times greater odds when they
increase the age cutoff to 75years.
So if you think about that, 86%is a really high, really strong
number that we're talking about.
SPEAKER_01 (16:56):
And we're talking about things that are common.
So when you see an 86%improvement or up to age 75,
over twofold better odds ofachieving our goal, healthy
aging, when we talk about thatlevel of effect in something
that's very rare, we go, okay,it's important, relative risk,
(17:17):
but not absolute.
This is...
fairly common.
There are a lot of people thatage healthily, fortunately, and
this could enormously increasethe number.
Now, to better understand this,when you talk about that
alternative healthy diet, whatwas it called and what is it?
SPEAKER_00 (17:36):
Yeah, so the AEGI score is called Alternative
Healthy Eating Index.
And essentially, that score inparticular is composed Thank you
so much.
(18:09):
And trans fats and fatty acids.
So just overall a healthy eatingpicture that they then score.
SPEAKER_01 (18:16):
Yeah.
And that's so important becauseit's one of those things that
what I love about this is we canremember those foods.
SPEAKER_00 (18:25):
Yeah, absolutely.
Those are foods that are in ourdiet.
repertoire already, like knowingthat these are the healthy foods
that we want to gravitatetowards in our diet.
SPEAKER_01 (18:35):
So what's nice about that Alternative Healthy Index,
it's not something complicated.
I don't need to memorize thedifferent components.
It's a lot of things that weknow to be important.
Is that right?
SPEAKER_00 (18:50):
Yeah, that's absolutely correct.
People don't need a lot ofhealth literacy or even
experience with diets to knowthat things like fruits,
vegetables, these things thatare emphasized in the diet are
naturally healthy for them.
And so it will be easy to speakto patients about this because
they do have some level ofunderstanding of the basics of
(19:13):
this diet kind of going in.
And I think that's reallyimportant, especially in the
primary care setting, becauseyou don't want to overcomplicate
things too much or it'sdifficult for the patients to
follow and stick to the plan.
So that's the benefit of thesetypes of scoring indices because
they use items that we alreadyknow to be true, emphasizing
(19:35):
fruits and vegetables andminimizing things like alcohol,
trans fats, sugary beverages, orsimple sugars in the diet in
general.
SPEAKER_01 (19:44):
Now, I think this has a lot of clinical
implications for us, both, asyou said in the introduction,
recognizing that diet is thenumber one cause of
non-communicable chronicdiseases, basically of chronic
disease, and then recognizingfrom this study that having a
(20:05):
healthier diet is meaningful.
What do you see?
How does this affect the way youapproach patients?
SPEAKER_00 (20:13):
Yeah, I think it's really important.
And when I learned that diet isthe number one risk factor
modification that we can make, Iwas astounded at that because if
you think about how much timeyou put into your day talking
about smoking cessation forpeople and how much intention
you put behind that, and atleast personally, I'm not doing
(20:36):
the same thing in my practice,my primary care practice in
terms of diet, it's reallyreframed how I think about diet
as a really powerful tool in ourarsenal to help people achieve
healthy aging, and just overallquality of life that right now
I'm leaving largely untouched.
So I think in the future, it'sreally motivated me to use diet
(21:01):
and incorporate diet into mydaily workflow and hopefully be
able to help people at leastestablish early eating habits
that then can carry them throughthe rest of their lives and help
them achieve the type of healthyaging that we're all hoping to
achieve.
SPEAKER_01 (21:17):
I think you're so right, Jessica.
It's interesting.
(21:47):
Have you talked about diet?
And I don't think we're going tosee that as a care gap soon.
I definitely think we should, inour own minds, think of it as a
care gap.
If we have not sat down andtalked in a serious way to our
patients about the benefits of,I'll call it clean eating,
(22:09):
healthy eating, the importanceof fruits, vegetables, whole
grains, nuts, legumes, all thatyou said, and to stay away at
all costs from sugary foods,processed foods, processed
meats, then we aren't trulygiving our patients all that we
can.
I
SPEAKER_00 (22:30):
think that's absolutely true.
And I think for me, movingforward, my goal will be to try
to figure out concrete ways tohelp patients to incorporate
these foods into their diets.
Because I think telling people,fruits and vegetables are
healthy for you is one thingwhich we all already know, but
figuring out a way toincorporate into my practice
(22:53):
tangible goals that the patientscan look to achieve to help move
forward and improve their dietoverall, as well as keeping them
accountable to these diets withgood follow-up visits.
SPEAKER_01 (23:05):
You're so right.
You mentioned to me earlier,Jessica, that if there was a
medicine that we could prescribethat would double the chances of
someone being completely healthyby the time they're 75.
We'd all be trying to prescribeit and we'd figure out ways to
petition insurance companies topay for it.
(23:26):
There isn't such a medicine, butwe can do that with diet.
Dr.
Jessica Steretz, thank you somuch for joining us.
SPEAKER_00 (23:35):
Thank you so much for having me.
SPEAKER_01 (23:37):
for our final discussion this month we're
going to look at two articleswhich further our discussion
about lifestyle medicine both ofthese articles are from the
british journal of sportsmedicine the first article is
titled amount and intensity oftotal daily physical activity
step count and the risk ofincident cancer the second one
(23:59):
is wearable device measuredphysical activity and the
Development of CardiovascularDisease in Cancer Survivors.
Joining us to discuss these twoarticles, I am so pleased to
have on with us Dr.
Bill Callahan, who is anAssociate Director and a
Clinical Assistant Professor ofFamily Medicine in the Family
(24:21):
Medicine Residency Program atJefferson Health Abington.
Welcome, Bill.
Thank you, Neil.
Bill, can you give us somebackground on why they even
thought to look at thesequestions.
Cancer is a big problem, right?
We see a lot of lifestyleassociated cancers in the United
States.
(24:42):
And thankfully, the UK Biobankgave us a ton of data to look at
regarding the development ofcancer in a general population.
So the UK Biobank, just for somebackground, looked at people,
500,000 people starting at theage of 40, and measured in this
population, What would thedevelopment of cancer look like
(25:02):
based on exercise?
That'll be our first study.
And the second, they look at thedevelopment of cardiovascular
disease in those with a historyof cancer, which is important
because we don't really havegreat guidelines on what type of
exercise should people who havealready had cancer be getting.
All of our guidelines areprimarily focused on a general
(25:23):
population.
And so this study really soughtto look at this niche of the
population and should we Whattype of exercise should we be
recommending for them withregard to both the development
of cardiovascular disease aswell as the development of the
second cancer?
So really important questionsthat they sought to answer.
(25:43):
Let's go over the results one ata time, starting with the first
article on the amount andintensity of total physical
activity and the risk ofdeveloping cancer.
What'd they find?
So this article I just love.
So this article looked at 85,000people.
These people were provided anaccelerometer, which they were
(26:04):
on their wrists, a non-dominanthand, which is where most of us
wear wristwatch.
So consider a smartwatch.
And using that data over aperiod of seven days, they
measured both the intensitymeasured in milligravity units
as well as step.
Now, I don't think it'snecessary.
that we go into how to calculateintensity using those specific
(26:28):
units.
But step counts is somethingthat we all hear about all the
time from our patients.
How many steps should I begetting?
So they set as a baseline 5,000steps.
They said that this would beexpected throughout a person's
day.
And that was basically abaseline for someone who's not
getting a ton of exercise.
And what they found was thatanything about the 5,000 was
(26:50):
really helpful.
So for those who got 7,000steps, which is for just
consideration would be about amile of walking and 2,000
additional steps.
They saw a drop in thedevelopment of cancer by about
11%.
Going up to 9,000 steps, 16% and13,000 steps would be a drop in
20%.
Now, importantly, after 9,000steps, what appears linear then
(27:13):
starts to plateau.
And I think that's reallyimportant because our patients
do care about that.
They want to know how many stepscan they get.
And historically, we've heard10,000 steps, but there hasn't
always been great precedent forthat.
So I think this really sets aprecedent for it.
We can say, okay, if you can'tget 10,000 steps, let's aim for
something still better than5,000.
(27:34):
So let's aim for that 7,000,9,000 range.
And that's an impressivedecrease in cancer.
If there was a pill that coulddo that, we'd all be going out
asking our doctors for thatpill.
but you can do that without apill, with exercise.
In our second article, wearabledevice measured physical
(27:55):
activity and the development ofcardiovascular disease in cancer
survivors, what did they find?
This was a great article,really.
So they looked at around justover 6,000 patients.
Again, they also woreaccelerometers and they were
also followed for a week.
These patients, they had ahistory of cancer, but no known
cardiovascular disease.
(28:17):
And what they looked at was thetime that this person was
getting either low intensity ormoderate to vigorous intensity
physical activity.
How was that associated withboth the development of
cardiovascular disease or asecond cancer associated with
physical activity?
And what they set as thebaseline was zero to 75 minutes.
(28:38):
That was going to be consideredsedentary.
And what they found was a linearrelationship that anything above
75 minutes was good and thatThis dropped your rate of both
cardiovascular disease andrecurrence of cancer, as long as
that cancer is associated withphysical activity.
So think like breast, thyroid,GI, skin cancers.
I wrote down some numbers here.
(28:59):
At 150 to 300 minutes a week,they saw a drop between 23% and
up to 27% in a cardiovasculardisease diagnosis, primarily
referring to coronary arterydisease in those.
The So not necessarilysurprising.
Like the general population,more exercise is equating into
less cardiovascular disease andalso less diagnosis of cancer.
(29:21):
But the clear reason I reallylike this study is a lot of
people wear smartwatches and thesmartwatches are excellent at
recording not only things likestep count, but the time that a
person engages in exercise.
And what the smartwatches willdo is that they also will say,
hey, it seems like you'rewalking pretty fast here.
We're going to count that asexercise.
And we can get a great idea fortime that a person is engaging
(29:45):
in this so that even if theyaren't telling us that they're
getting exercise, we can stillsee what their watch is
recording.
And so I think this study does agreat job of that as well.
And so when we put all of thistogether, and just prior to
these two articles, we talked toDr.
Sturitz about the importance ofdiet and healthy diet leading to
(30:07):
a greater chance, asignificantly greater chance, of
healthy aging, being without anysignificant disease at age 70
and even 75.
And now, Bill, you just talkedabout exercise.
What do you think this means forour patients?
I think it means we need to do amuch better job at focusing on
lifestyle, right?
Of course, we need to focus on ahealthier diet.
(30:28):
But I think looking at these twoarticles, I think it's clear
that we need to really focus onexercise.
And I think it's that Walking issomething that most of us can
do.
And when we talk to our patientsand they want to know how much
walking, we can start with justlet's aim for an additional 2000
steps a day on top of whatthey're already getting.
And that seems doable for a lotof us.
That's a wonderful way totranslate this into actionable
(30:52):
knowledge.
Yeah, it's so impressive becauseexercise is in a way the
everything pill.
it improves.
And I think most of us arefamiliar with the fact that it
decreases the likelihood ofdiabetes, decreases the
likelihood of cardiovasculardisease.
I think the fact that itdecreases by over 20% the
(31:13):
likelihood of cancer is notsomething that is in the
forefront of our thinking whenwe talk to patients.
Yet, cancer is in the forefrontof everyone's thinking when they
think about what is it that theyare rate of developing.
So this is incredibly importantinformation.
Yeah, I absolutely agree.
(31:34):
We think of our patients comingin for a physical.
We talk about things like, dothey need mammography?
Do they need colorectal cancerscreening?
Do they need lung cancerscreening?
I think this should be theretoo.
How much exercise are wegetting?
And that exercise does translateinto a decrease in risk of colon
cancer, of breast cancer, ofmelanoma.
I think this is reallyimportant.
(31:55):
That's a great point.
I've always found when I takethe time to discuss exercise,
patients are particularlythankful because they don't
always get that input from uswhen they come to their regular
visits.
Dr.
Bill Callahan, thank you so muchfor joining us and sharing your
thoughts with us today.
(32:15):
Thank you for having me, Neil.
That concludes this month's NACEJournal Club.
What can I say?
Adverse effects of ICS in peoplewith COPD Beneficial effects of
diet on achieving healthy livingto age 75.
The incredibly powerful effectsof exercise in decreasing the
(32:37):
risk of cancer by up to 25%.
That's information we can usewhen we take care of our
patients.
Check out NACE Online forupcoming DME programs with some
of the best faculty in thecountry.
Conversations in Primary Care2025 is on May 10th where our
(32:57):
faculty will give updates onatopic dermatitis, TLP1s,
resistant hypertension, and theOPD.
Till next month, I'm Dr.
Neal Skolnick.
Be well and keep learning.
Popular Podcasts
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com
On Purpose with Jay Shetty
I’m Jay Shetty host of On Purpose the worlds #1 Mental Health podcast and I’m so grateful you found us. I started this podcast 5 years ago to invite you into conversations and workshops that are designed to help make you happier, healthier and more healed. I believe that when you (yes you) feel seen, heard and understood you’re able to deal with relationship struggles, work challenges and life’s ups and downs with more ease and grace. I interview experts, celebrities, thought leaders and athletes so that we can grow our mindset, build better habits and uncover a side of them we’ve never seen before. New episodes every Monday and Friday. Your support means the world to me and I don’t take it for granted — click the follow button and leave a review to help us spread the love with On Purpose. I can’t wait for you to listen to your first or 500th episode!