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Internal Medicine News


VO L .

38, N O.


The Leading Independent Newspaper for the Internist—Since 1968

M AY 15, 2005

Newspaper for the Internist—Since 1968 M AY 15, 2005 “Knowledge is necessary but not sufficient for

“Knowledge is necessary but not sufficient for change,” said Dr. Vincenza Snow, ACP’s director of clinical programs, with Dr. Alan C. Moses, vice president of medical affairs for Novo Nordisk.

ACP Effort Targets U.S. Diabetes Care


San Francisco Bureau

— American College of Physicians and the American College of Physicians Foundation have be- gun a major 3-year initiative to improve diabetes care in the Unit- ed States. The initiative, announced at a press briefing during the annual meeting of the ACP, is aimed not only at physicians, but also at the entire diabetes management team, including subspecialists, physician assistants, diabetes ed- ucators, nurses, office staff, and the patients themselves. Of the 18.2 million Americans with diabetes, 5.2 million are un- diagnosed, according to informa- tion distributed at the briefing. Novo Nordisk, the Denmark- based pharmaceutical company that first commercialized insulin, has funded the initiative with an unrestricted educational grant of $9.27 million. “We believe this intensive 3- year project, combining an em- phasis on highest standards of care, measurable goals for prac- tice in office settings, and re- search, can dramatically improve diabetes care,” Charles K. Fran- cis, M.D., president of the ACP said in a prepared statement an- nouncing the initiative.




Some of the educational pro- grams and materials will be avail- able to the medical profession in general, while others will be lim- ited to ACP members. Vincenza Snow, M.D., the ACP’s director of clinical pro- grams, said that the project has three goals: to increase physician awareness of high-quality diabetes care and the gap between current practice and acceptable standards, to provide proven educational in- terventions for improving care to the entire diabetes team, and to recognize physicians and physi-

See Diabetes Care page 6

I N S I D E Shedding Light On Parkinson’s Radioligand tracers may help identify


I N S I D E Shedding Light On Parkinson’s Radioligand tracers may help identify affected
I N S I D E Shedding Light On Parkinson’s Radioligand tracers may help identify affected
Shedding Light On Parkinson’s

Shedding Light On Parkinson’s

Radioligand tracers may help identify affected patients.

Radioligand tracers may help identify affected patients.



Drugs, Pregnancy, And Lactation

Drugs, Pregnancy, And Lactation

Column debuts with a look at asthma medications.

Column debuts with a look at asthma medications.



Column debuts with a look at asthma medications. PAGE 30 Bent Out of Shape Be on
Column debuts with a look at asthma medications. PAGE 30 Bent Out of Shape Be on

Bent Out of Shape

Bent Out of Shape

Be on the lookout for joint hypermobility syndrome.

Be on the lookout for joint hypermobility syndrome.













Top 10 Diagnoses by Internists in 2004

Hypertension Diabetes mellitus Hyperlipidemia Hypercholesterolemia Routine medical exam Depressive disorder Esophageal disorder Hypothyroidism Asthma Allergic rhinitis

15.6% 6.5% 6.0% 2.5% 2.3% 2.1% 2.0% 1.9% 1.6% 1.5%

Note: Based on projected nationwide data from a monthly survey of about 360 internists. Source: Verispan

Statins May Lower Risk of Advanced Prostate Cancer

No link was found for localized disease.


San Francisco Bureau

A NAHEIM , C ALIF. — Choles- terol-lowering drugs, particularly statins, appear to be associated with a greatly reduced risk of ad- vanced prostate cancer, according to a large, prospective, observa- tional study presented at the an- nual meeting of the American Association for Cancer Research. “Men who used cholesterol- lowering drugs had about half the risk of advanced prostate can- cer,” as those who did not, said Elizabeth A. Platz, Sc.D., the lead author of the study, which was conducted as part of the Health Professionals Follow-Up Study, an ongoing cohort study that be-

gan in 1986 at the Harvard School of Public Health, Boston. “When we limited advanced prostate cancer to just those cas- es that were metastatic or fatal, men who used cholesterol-low- ering drugs had a third of the risk of metastatic and fatal dis- ease,” Dr. Platz of Johns Hop- kins University, Baltimore, said at a press briefing. The study followed 34,438 male health professionals (in- cluding dentists and veterinari- ans) who were free of prostate cancer in 1990, when their ages ranged between 44 and 79 years. They completed health ques- tionnaires every 2 years through 2000 to report the use of choles-

See Prostate Cancer page 2

Report Conveys Scope of Substance Abuse Problem


San Diego Bureau

A bout half of children in America—nearly 36 million

of them—live in homes where a parent or other adult uses tobac- co, drinks heavily, or uses illicit drugs.

That’s one of the sobering facts contained in “Family Mat- ters: Substance Abuse and the American Family,” an 81-page white paper produced by the Na- tional Center on Addiction and Substance Abuse (CASA) at Co- lumbia University, New York. The report “underscores the

magnitude of our national prob- lem with substance abuse, David Fassler, M.D., a child and adoles- cent psychiatrist who practices in Burlington, Vt., told this news- paper. “It clearly outlines the risk factors and demonstrates the dra- matic impact on children of growing up in a family environ- ment where they are exposed to substance abuse.” The CASA report includes these findings:

Thirteen percent of children under age 18 live with a parent or other adult who uses illicit drugs. Twenty-four percent of chil-

See Substance Abuse page 31






May 15, 2005

Initiative Seeks Better Outcomes

Diabetes Care from page 1

cian practices that improve the care of pa- tients with diabetes. “Knowledge is necessary but not suffi- cient for change,” Dr. Snow said, noting that all internists have extensive training in diabetes care. “It’s not necessarily that our members don’t know what to do. We need to empower them to do that in their real-life practices. What has been shown is that multifaceted and multi-intervention educational programs are what works. You have to hit people over the head many,

mented and that they don’t disappear once the intervention goes away.” The initiative was inaugurated at the ACP annual meeting with a diabetes track consisting of 16 workshops and courses. This track will be a feature of future an- nual meetings, and clinical skills modules will be offered at local chapter meetings. Other parts of the program will be in- troduced at a rapid pace, Dr. Snow said. For example, enhanced diabetes informa- tion will become part of the ACP’s Web-

source (PIER); the medical knowledge self- assessment program (MKSAP); and the college’s Web site ( Versions of MKSAP will be developed for nonphysician members of the diabetes management team. And ACP will develop a self-management tool kit to help patients become working partners with their health care providers in diabetes care. These materials, available in both English and Spanish, will include versions intend- ed for patients whose literacy is at the third- or fourth-grade level. Additionally, ACP will develop a Web portal collecting all of its diabetes infor- mation in one place, offering clinical de-

“Beating diabetes is our passion, not just our business,” said Alan C. Moses, M.D., vice president of medical affairs for Novo Nordisk. “We try to distinguish ourselves from other companies by acting in accor- dance with our triple-bottom-line principle, [which] emphasizes a commitment not only to the economic success of the busi- ness, but just as importantly, to environ-

mental soundness and social responsibility.” The initiative will include a research component that will assess measurable outcomes as the project progresses. “I hope that 3 years from now we’ll be here again talking about the positive results of the project and the real changes that have occurred in diabetes care,” Dr. Francis

many times in many different ways to make sure that new things are imple-

based point-of-care decision support tool, Physicians’ Information and Education Re-

cision support, CME credit, and the latest research in diabetes care.



Revamped Federal Food Pyramid Draws Mixed Reviews


Chicago Bureau

E xperts are applauding the in-

clusion of exercise in the na-

tion’s revamped food pyra-

mid guide, but they also question the value of a national dietary icon that lacks details and requires the use of a computer to interpret. The new “My Pyramid” replaces the familiar horizontal configura- tion of the 1992 Food Guide Pyra- mid with six vertical color wedges that represent the five food groups and oils, and adds a staircase to symbolize the importance of phys- ical activity. Instead of one pyramid, there are now 12 different versions. They contain 23 general recommenda- tions and 18 specific suggestions for the elderly, children, and other special populations. Consumers can obtain personal- ized dietary and exercise recom- mendations by plugging in their age, gender, and physical activity

can obtain personal- ized dietary and exercise recom- mendations by plugging in their age, gender, and


“Recommending people eat that much oil I think may exacerbate obesity rather than help reduce it,” Dr. Ornish said. “On the one hand, they’re asking people to ex- ercise more, but then if they’re going to be eating that many calo- ries from fat, it’s going to be hard to control the number of calories as requested.” Emphasizing a balance between food and physical activity is a step in the right direction, but the new pyramid may not be able to help teach that concept in the clinical setting, according to Monica Myk- lebust, M.D., director of Integra- tive Medicine clinical services at the University of Michigan, Ann Arbor. Even after an electronic session with their physician, it will be chal- lenging for patients to carry the necessary information in their heads and apply it in a restaurant, Dr. Myklebust said. Her own Healing Foods Pyramid ( clinical) includes such images, and

The 12 available versions of the new food pyramid represent 23 general recommendations and

levels to either the “My Pyramid Plan” or “My Pyramid Tracker” features on the U.S. Department of

Agriculture’s Web site (

18 specific suggestions for the elderly, children, and other special populations.

dairy consumption increases blood levels of insulin-like growth factor-1 (IGF-1), which has been related to a num- ber of cancers, he said. A statement by the Center for Science in the Public In- terest also called the new pyramid a “missed opportu- nity” because one has to go to a Web site for details. It chided the government for bending “over backward to avoid upsetting any particular commodity group or food company by not showing any food that Americans should eat less of.” The inclusion of oils in the pyramid for the first time is a step in the right direction, but the recommendations do not distinguish among them, according to Dean Or- nish, M.D., clinical professor of medicine, University of California, San Francisco. The pyramid guidelines advise adults who consume 2,000 calories a day to consume the equivalent of about 6 teaspoons (or 2 tablespoons) of oil daily, with most of it coming from fish, nuts, and vegetable oils. Solid fats like butter, stick margarine, shortening, and lard should be limited. Canola oil and fish oil are high in omega-3 fatty acids, but olive oil and corn oil have almost none, Dr. Ornish said. Secondly, each tablespoon of oil is equivalent to about 28-30 g of fat, and fats are the densest form of calo- ries. Only about 3 g of fish oil or flax oil is needed to pro- vide the necessary omega-3 fatty acids.

“It’s as basic


as sophisticated as you want it to be,”

Secretary Mike Johanns said at a press briefing sponsored by the USDA. Although printed materials will be available this fall in English and Spanish, the Web site is the centerpiece of the new program. The Web site includes a “For Profes- sionals” section, which provides information to help pa- tients apply the new guidelines. Leading physicians and other parties who spoke with this newspaper expressed concern regarding the new program. “It’s a lost opportunity to convey information about healthy food choices to the American public,” said Wal- ter Willett, M.D., chair of the department of nutrition at Harvard University, Boston. “It’s good that it does em- phasize physical activity, but the pyramid itself gives no information about what people should be using sparing- ly and what they should be emphasizing in their diet.” Not everyone uses the Internet, and even if they have access, it takes quite a bit of motivation to look up the information, he said. A new recommendation that adults should consume up to the equivalent of three glasses of milk daily represents a “radical change” in the adult diet, said Dr. Willett, not- ing that most men consume only about one-half glass of milk per day. Moreover, there is definitive proof that high

has water as its foundation, followed by a variety of fruits and vegetables, then grains and legumes. There are separate categories for herbs, monounsaturated fats, organic dairy, lean meats, and wild fish. “All of this reflects the recent data that we need to be eating in a plant-based manner,” Dr. Myklebust said. “Such recommendations help to prevent and treat dia- betes, obesity, heart disease, chronic pain, mood disor- ders—the list goes on and on. [The USDA] uses the term

plant based, but I don’t feel there was enough emphasis

on it.” The food pyramid was never meant to serve as a treat- ment algorithm, observed Scott M. Grundy, M.D., who has served on several federal dietary guideline committees. The question about the new pyramid is whether it fol- lows the guidelines established by the “Dietary Guidelines for Americans 2005” document, which when released in January were the strongest ever put forth by the govern- ment, Dr. Grundy said. The 70-page scientific document is accessible on the Web site, along with links to a variety of topics such as coronary heart disease, federal nutrition assistance pro- grams, and food labeling. “You have to work with it,” said Dr. Grundy, director of the Center for Human Nutrition, University of Texas Southwestern Medical Center at Dallas. “It’s not some- thing that just strikes you in the face like the old pyramid, but I’m not sure how effective that was either.”


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