Weight Battle

Washington -- With each new insight about asthma, it becomes increasingly clear how much remains unknown. That message was one of the themes at the American Academy of Allergy, Asthma & Immunology's annual meeting.

"Asthma is a diverse, complicated disease with many presentations, outcomes and variability in responses to treatment. It's not just one disease," said William Busse, MD, chair of the Dept. of Medicine at the University of Wisconsin's School of Medicine and Public Health. He was speaking at a news briefing during the meeting held in Washington, D.C., March 13-17.

Coughing, wheezing and shortness of breath are all common factors, but the interplay of allergens and responses to medications varies dramatically. With triggers including cats, cockroaches, stress and obesity, treatments often must be tailored for each patient.

The difficulties doctors and patients face in striking this chord are demonstrated by statistics. For instance, asthma continues to be one of the most common reasons for hospital admission and emergency department care even though most asthma cases can be managed on an outpatient basis, according to research presented by scientists from the federal Agency for Healthcare Research and Quality, and others.

From 2000 to 2005, the number of adults hospitalized with asthma as a secondary condition increased by 113%, the scientists said. From 1997 to 2006, the number of pediatric hospitalizations with asthma noted as a secondary reason rose by about 54%.

Asthma is among the most common reasons for hospital admission and ED care.

Many treatment challenges begin long before a patient lands in an acute situation. Sometimes they start with the illnesses' varying forms of presentation. Although asthma is most commonly recognized in children, it also can begin in adulthood. And asthma among the elderly may be an entirely different disease, as well as one that is hard to diagnose. Its presence among 60-, 70- and 80-year-olds may be mistaken for something else, Dr. Busse said. He also headed the panel that developed the 2007 federal "Guidelines for the Diagnosis and Management of Asthma," which the AMA encourages physicians to follow.

Science continues to offer additional possible underlying causes. Dr. Busse noted that a new, type C rhinovirus, identified about a year ago, seems to play a role in triggering about two-thirds of the asthma attributable to cold viruses. But it's too early in the research to know why.

"Are these new cold viruses more virulent and more likely to cause disease? Or, maybe they have characteristics that lead to airway changes?" he asked.

Steps toward disease control

Although the disease is far from conquered, research presented at the meeting shows progress, said Stanley Szefler, MD, head of pediatric clinical pharmacology at the National Jewish Health hospital system in Denver.

For one thing, asthma mortality has dropped, he noted, and the number of patients incapacitated by medication-induced hypertension, osteoporosis or cataracts has declined.

The number of adults hospitalized with asthma as a secondary condition more than doubled from 2000 to 2005.

But in a less promising finding, researchers at National Jewish Health determined that even families with health insurance and a regular source of care for children often come to emergency departments when they have flare-ups.

Conventional wisdom holds that adequate insurance with access to physicians should lead to successful outpatient asthma control. That was not the case for many of the 153 asthmatic students who completed questionnaires. Fifty-eight percent reported getting care from a physician or other health care professional but said they used emergency department care for treatment regardless.

Dr. Szefler also described research on promising ways to educate children and teens about asthma control. "That's a new opportunity that we have in the schools."

In one effort, Pittsburgh physicians linked basketball camp to asthma education in a pilot study of 21 children age 6 to 12 who all had asthma. A comparison between pre- and post-camp behavior revealed a significant decrease in emergency department visits and physician contacts after the study.

In another pilot study, Chicago physicians sent text messages to teens reminding them to take their medications. At the conclusion of this small, four-student initiative, researchers noted increased adherence to medications.

During a symposium, Peter J. Gergen, MD, MPH, medical officer at the National Institute of Allergy and Infectious Diseases, examined research on children and teens in urban environments and elsewhere.

Cockroaches are the most prevalent allergy source in cities while cats are in the suburbs.

"Asthma morbidity and mortality remain high in the inner city, but biologically the asthma in the city is the same disease we are seeing across the United States," Dr. Gergen said. It also is just as responsive to treatment.

Differences in risk factors play a role, though. For example, cockroaches are the most prevalent inner-city allergens, according to most research, while cats prompt the most allergies in the suburbs, Dr. Gergen said.

The obesity trigger is an even bigger problem in cities where more children are overweight. The psychosocial burden, including stressful life events, also is much higher.

All of these factors affect treatment, Dr. Gergen said, and interventions must be tailored accordingly.

Physicians and their patients soon should hear much more about asthma and its treatment as plans are being developed to better utilize the 2007 guidelines, said Gary Rachelefsky, MD, professor of Allergy and Immunology at the University of California, Los Angeles, Geffen School of Medicine.

The guidelines include several messages: Inhaled corticosteroids are the most effective anti-inflammatory medications for long-term asthma management, and all patients with asthma should have a written action plan. In addition, reviews of disease control should be made at follow-up visits, and subsequent visits should be scheduled regularly to be proactive. Lastly, every patient should have a plan to reduce exposure to allergens at home, school, day care or work.

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Washington -- More than half of the American population is dieting each year, Susan Roberts, PhD, director of the Tufts University Energy Metabolism Laboratory in Boston, told congressional staffers at a recent briefing. And nearly all dieters regain their lost pounds in short order.

In fighting the obesity epidemic that has swept the nation and brought with it soaring levels of diabetes, physicians are being called upon to help patients lose weight. But which diet, if any, can be recommended? Roberts had some advice.

She related her tips at a March 11 briefing sponsored by the Congressional Biomedical Research Caucus. This group provides a forum for members of Congress and their staffs to interact with researchers. The briefing was hosted by the Coalition for the Life Sciences, a Maryland-based alliance of six nonprofit professional organizations that focus on basic biological research.

Not only are extra pounds taking a toll on health, but the diets they inspire are painful to the pocketbook as well, Roberts noted. Consumers are spending an estimated $35 billion a year on weight-loss products and services.

As a first step in determining a solution, Roberts explored how the extra pounds came to settle on the nation's bellies and waists. Since the mid-1970s, the number of calories the average person has consumed each day has increased by about the equivalent of an extra meal, she said. And the two food ingredients that account for most of the added calories are high fructose corn syrup and oil. Flour, cheese, shortening and edible beef tallow each contribute a bit more.

Americans spend around $35 billion a year on weight-loss products and services.

What has not increased is the consumption of beef, seafood, candy, chocolate and chips. Consumption of ice cream and frozen desserts actually fell by 13%.

Boosting the amount of energy burned by the body is a good way to shed extra pounds, but to maintain weight loss, food intake must drop permanently, she said. And no weight-loss program can work overnight, despite advertised claims, Roberts stressed. "Losing significant amounts of fat is a long-term project."

Individuals need to have realistic expectations, she noted. Weight loss of about 1 to 2 pounds per week is the maximum that can be expected.

"There is no magic bullet for belly fat. Energy intake needs to be reduced for a long time to lose weight, and then permanently decreased to keep weight off."

Roberts recommends consuming foods that help satisfy "basic hard-wired biology." For example, hunger is one pressing need that should be satisfied with high-fiber, high-protein foods rather than cookies and chips. The desire for variety can be met with salads, soups and fruit.

Often, "we eat it because it's there," she said, citing a study in which people opted to eat the larger bucket of stale popcorn rather than a smaller amount of freshly popped kernels.

In 2008, the average American consumed the caloric equivalent of one meal a day more than was eaten in the mid-1970s.

Society also needs to get involved. Consumers must take charge of their food environment to make it easier to lose weight, and parents should play a role in the types of food served to their children at school, she advised.

The American Medical Association also has made the effort to combat obesity a priority and has called for societywide involvement that includes schools, public health and medical education.

Additionally, Roberts would like the media to reject advertising for untested diet gimmicks and scientists to continue to research what works best from the biological perspective.

She also recommended a federal junk-food tax. But at least one congressional staffer indicated that was not likely to happen anytime soon.

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Centers for Disease Control and Prevention surveillance data for the week ending March 14 indicate that U.S. flu activity slightly decreased, with 30 states reporting widespread activity -- five fewer than in the previous report, and 18 more with regional activity.

Every year the CDC monitors the influenza virus, focusing on type A strains, H1N1 and H3N2, and type B strains. Since the beginning of the 2008-09 flu season, type A (H1N1) viruses have been dominant. But in recent reporting periods, several regions noted a higher relative proportion of influenza B viruses than at the national level or in other regions.

During the current season, the CDC also detected a significant increase in resistance to flu antivirals in one of the circulating strains.

The flu types and subtypes on this watch list are the viruses that circulate every year, though the proportion of strains is different, explained Nila Dharan, MD, an epidemic intelligence service officer in the CDC's Influenza Division. In addition, the prevalence and proportion can vary during the course of a flu season among communities and even within a specific community, according to CDC materials. These changes in type and subtype affect which antiviral drug will be most useful.

For physicians, this reality can be problematic when it comes to selecting flu antivirals. In an office setting, doctors can be limited as to what information tests will provide about a patient's influenza, Dr. Dharan said. A quick test can confirm the presence of the flu virus and sometimes will be sensitive enough to tell if it is a type A or B. "But that's it," she added.

The U.S. Strategic National Stockpile has 50 million courses of neuraminidase inhibitors to treat flu.

Dr. Dharan also noted, though, that a physician can make a more effective choice by being aware of what strains are circulating in his or her region or even more locally. But still, influenza treatment and chemoprophylaxis with antivirals is no easy proposition.

Two drug classes exist. The newer drugs are the neuraminidase inhibitors -- oseltamivir or Tamiflu and zanamivir or Relenza. The second category, the adamantanes, is made up of amantadine and rimantidine, which is marketed as Flumadine.

To date, 100% of H3N2 viruses have tested resistant to adamantanes. Though all flu strains remain susceptible to zanamivir, this drug has limitations that make it unsuitable for certain categories of patients at very high risk for flu complications. Meanwhile, the adamantanes are not active against type B strains. Emerging resistance to oseltamivir has added to this complexity.

"Before last year, there was very little resistance to oseltamivir among routinely tested viruses -- less than 1%," Dr. Dharan said. But during the 2007-08 flu season, this circumstance changed as resistance to this antiviral reached 12%. During that period, though, H1N1 viruses made up only about 19% of circulating strains. Therefore, the proportion of overall resistance among all influenza viruses tested was not high.

The figures for the 2008-09 season thus far reveal a different picture. Seventy-five percent of circulating strains have been type A and 24% have been type B. Unfortunately, the vast majority of type A viruses are H1N1, and about 98% of H1N1 viruses tested are resistant to oseltamivir.

Experts highlight specific messages from this situation.

100% of H3N2 viruses have tested resistant to adamantanes.

The current resistance situation makes the flu vaccine more important than ever, especially because the vaccine for the 2008-09 season and for that of 2009-10 protects against the strain of H1N1 that is resistant to oseltamivir.

Also, resistance to these antivirals functions differently than that of the usual understanding of antibacterial resistance. Because flu virus is constantly mutating and changing, it is "not necessarily the case that the resistance will persist next year," Dr. Dharan said.

In response to the growing resistance, though, the CDC updated the public health recommendations regarding the selection of antiviral drugs in December 2008. This document directs physicians to use a combination of oseltamivir and rimantadine. Zanamivir also remains an option when appropriate.

Antivirals and the national stockpile

Meanwhile, the current resistance profile warrants attention for reasons far from the day-in, day-out concerns of the exam room. These reasons are related to pandemic preparedness.

"We are watching this very carefully," said Robin Robinson, PhD, director of the Biomedical Advanced Research and Development Authority, which is part of the Dept. of Health and Human Services Office of the Asst. Secretary for Preparedness and Response.

Influenza antivirals have been considered by public health experts to be an important medical countermeasure in the event of a pandemic influenza epidemic. The U.S. Strategic National Stockpile, for instance, houses 50 million treatment courses of the neuraminidase inhibitors. Of this amount, the ratio is 80 to 20, oseltamivir to zanamivir. The stockpile also holds 2.8 million courses of rimantidine.

Officials have been monitoring the resistance situation for at least 18 months, Robinson said, and active deliberation continues. Compared with other countries, the U.S. oseltamivir-zanimivir ratio falls in the middle -- some nations have more oseltimivir, some less. "But no country has made a drastic change yet," he said. A decision about whether to take steps to adjust the stockpile's makeup could occur later this spring.

Robinson also noted that historical data show influenza viruses, even within the H1N1 subtype, can "burn out." In this case, the emergence of the resistant strains has not been driven by exposure to the drugs or, therefore, selective pressure. Instead, it is a natural mutation.

This content was published online only.

As we detailed in our previous installment, More details on moving to a Google account, if you used the MyBrand service at feedburner.com — our service that allows you to use a custom domain with your feed — you must move to a Google account and update your DNS CNAME records by March 16, 2009, or else your MyBrand URLs will return a 404 "page not found" error.

It's important to note that it is not enough to just sign in with a Google account and request to move your account if you use MyBrand. Even if your MyBrand-ed URLs have continued to work after you have completed your move, they will cease to work on March 16, 2009 if you have not changed your DNS CNAME.

If you plan to continue to use MyBrand, you can find detailed instructions for changing your CNAME when you are signed into FeedBurner in the My Account > MyBrand section. If you haven't already moved from feedburner.com to a Google Account, please sign in to your account and follow the guided steps to complete this move. Here's a quick preview of those steps (click to zoom in):

(In the image above, you'll see the phrase {YOUR_CODE} in the instructions. This is replaced by an address that is specific to your Google Account available on the aforementioned MyBrand page; you need to use that address to update MyBrand correctly.)

If you have any questions about this transfer process, please refer to the FeedBurner Help Center entry “Transferring FeedBurner Accounts to Google Accounts FAQ” for additional details.

Many of you have asked for a way to preview ads before they appear in your feed posts. That feature is now available.

The Ad Review Center (ARC) will give you more transparency and control by enabling you to approve or disapprove placement targeted ad creatives before they appear in your posts.

To get started with this tool, please login to your AdSense account. You will find ARC in the ‘Competitive Ad Filter’ section located under the ‘AdSense Setup’ tab. If you are using your AdSense account for other products- content, mobile, or video- please make sure to select the Client-ID starting with ca-feed-pub.

In order to maximize your revenue, we suggest that you keep the default setting to, ‘Run ads immediately.’ This will allow ads to run without delay while still allowing you to login and review the ads at a later time. By selecting the ‘Hold ads’ option, you could potentially decrease your revenue. This option will hold ads from displaying for 24 hours, thus limiting the number of advertisers' driving up your auction price.

You will then have the ability to approve or block a specific ad or advertiser in general. These settings can be changed at any time. Please keep in mind that blocking ads will remove them from the auction and could impact your revenue.

For more information about using the Ad Review Center, please visit our Help Center.

Posted by Barbara Bochner, Google Publisher Solutions Team