POP THIS QUESTION TO IMPROVE MEDICATION ADHERENCE

In recent years, there has been an increased focus on rising medication prices within the United States. In addition to the actual cost of purchasing medicines, costs associated with suboptimal medication regimens, including poor adherence, are substantial. In 2016, the yearly cost of morbidity and mortality relating to nonoptimized medication was $528.4 billion, which equalled 16% of total US healthcare expenditures for that year.^[1] Cost-related nonadherence has been associated with higher death rates for individuals with cardiovascular disease, diabetes and hypertension, highlighting the need for increased prescription affordability across the United States.^[2] In this article, Dr Caroline Sloan shares her insights on addressing rising medication costs with patients.

How often do you talk with patients about how to lower their out-of-pocket costs for medical care? For most clinicians, the answer is: not often enough. But having those conversations can improve medication adherence and strengthen the patient-clinician relationship, according to panelists at the Society of General Internal Medicine (SGIM) 2023 Annual Meeting.

The inverse association between out-of-pocket expenditures and fidelity to prescriptions is clear.  One in 5 Americans said cost prevented them from adhering to medication regimens, according to a new study in JAMA Network Open.^[3]

The researchers surveyed more than 2000 men and women, 40.4% of whom were at least aged 75 or older. They found that nearly 90% of respondents said they would not be uncomfortable being asked about drug costs before a visit with a physician. A similar share (89.5%) said they would welcome the use by their physician of a real-time tool to determine the cost of their medication.^[3]

But the survey results contained a note of warning for clinicians: A significant number of respondents said they would be "extremely" upset if the cost of their medication exceeded the estimate from the pricing tool. And many also said they would be "moderately" or "extremely" angry if their physician used a pricing tool but failed to share the results with them.^[3]

"Real-time benefit tools may support medication cost conversations and cost-conscious prescribing, and patients are enthusiastic about their use," the authors write. "However, if disclosed prices are inaccurate, there is potential for harm through loss of confidence in the physician and nonadherence to prescribed medications."

While having conversations about cost can be difficult for both clinicians and patients, studies have shown that patients who discuss cost concerns with their doctors feel as if they have stronger relationships as a result. Clinicians often avoid conversations about out-of-pocket expenses because they don't know specific price information, they lack solutions to address cost, or they are uncomfortable bringing up the issue.^[4]

One member of the audience at the SGIM meeting recalled a patient who worked in a warehouse for a large company. The man, who had type 2 diabetes, had medical insurance, but even with insurance, insulin was going to cost him $150 per month. He struggled to afford the necessary treatment. "He looked at me and said, 'What do they want me to do? Do they want me to actually not be able to work for them and not manage my diabetes?' " The clinician said he offered empathy in the moment but felt he could do little else.

Panelists acknowledged that clinicians are crunched on time when seeing patients, but being willing to initiate conversations about cost with patients and to offer resources can help patients get necessary treatment.

Start the Conversation

Panel member Caroline Sloan, MD, an assistant professor of medicine at Duke University School of Medicine, in Durham, North Carolina, said making patients aware that you know cost can make a big difference.

The American College of Physicians advises clinicians to ask patients whether they are worried about the cost of care and to not assume which patients may have concerns. The conversation could be started like this: "I'd like to discuss any concerns you might have about the cost of your healthcare." Normalize the concern by making it more general and reassure your patient that your goal is to get them the best care. Say something like, "I've heard from many patients the cost of medications or tests is becoming hard to manage."^[5]

Once a patient's concerns are clear, you can direct them to resources for assistance in reducing their costs. Sloan said she knows clinicians don't have time to understand every insurance plan and other issues related to cost. "But at least know to ask about costs," she said. "Practice, practice, practice. It feels awkward at first, but it gets easier every time."

INTERNET USE A MODIFIABLE DEMENTIA RISK FACTOR IN OLDER ADULTS?

More than 55 million people across the world are living with dementia, and 10 million new cases are diagnosed each year.^[6] In parallel, the world’s aging population is growing and the internet is enabling people to receive and deliver information conveniently via the internet.^[7] However, the long-term implications of internet usage among older adults, particularly its impact on cognition, is poorly understood.^[8]

In a new study, investigators followed over 18,000 older individuals and found that regular internet use was associated with about a 50% reduction in dementia risk compared with their counterparts who did not use the internet regularly. It found that self-reported, regular internet use, but not overuse, in older adults is linked to a lower dementia risk.^[8]

Researchers also found that longer duration of regular internet use was associated with a reduced risk of dementia, although excessive daily internet usage appeared to adversely affect dementia risk.

"Online engagement can develop and maintain cognitive reserve — resiliency against physiological damage to the brain — and increased cognitive reserve can, in turn, compensate for brain aging and reduce the risk of dementia," study investigator Gawon Cho, a doctoral candidate at New York University School of Global Public Health, New York City, told Medscape Medical News.

The study was published online May 3 in the Journal of the American Geriatrics Society.^[8]

Unexamined Benefits

Prior research has shown that older adult internet users have "better overall cognitive performance, verbal reasoning, and memory," compared with nonusers, the authors note. However, since this body of research consists of cross-sectional analyses and longitudinal studies with brief follow-up periods, the long-term cognitive benefits of internet usage remain "unexamined."

In addition, despite "extensive evidence of a disproportionately high burden of dementia in people of color, individuals without higher education, and adults who experienced other socioeconomic hardships, little is known about whether the internet has exacerbated population-level disparities in cognitive health," the investigators add.

Another question concerns whether excessive internet usage may actually be detrimental to neurocognitive outcomes. However, "existing evidence on the adverse effects of internet usage is concentrated in younger populations whose brains are still undergoing maturation." Cho said the motivation for the study was the lack of longitudinal studies on this topic, especially those with sufficient follow-up periods. In addition, she said, there is insufficient evidence about how changes in internet usage in older age are associated with prospective dementia risk.

For the study, investigators turned to participants in the Health and Retirement Study, an ongoing longitudinal survey of a nationally representative sample of US-based older adults (age ≥ 50 years). All participants (n = 18,154; 47.36% male; median age, 55.17 years) were dementia-free, community-dwelling older adults who completed a 2002 baseline cognitive assessment and were asked about internet usage every 2 years thereafter.^[8]

Participants were followed from 2002 to 2018 for a maximum of 17.1 years (median, 7.9 years), which is the longest follow-up period to date. Of the total sample, 64.76% were regular internet users. The study's primary outcome was incident dementia, based on performance on the Modified Telephone Interview for Cognitive Status (TICS-M), which was administered every 2 years. The exposure examined in the study was cumulative internet usage in late adulthood, defined as "the number of biennial waves where participants used the internet regularly during the first 3 waves."^[8]

In addition, participants were asked how many hours they spent using the internet during the past week for activities other than viewing television shows or movies. The researchers also investigated whether the link between internet usage and dementia risk varied by educational attainment, race-ethnicity, sex, and generational cohort. Covariates included baseline TICS-M score, health, age, household income, marital status, and region of residence.^[8]

U-Shaped Curve

Over half of the sample (52.96%) showed no changes in internet use from baseline during the study period, while one fifth (20.54%) did show changes in use. Investigators found a robust link between internet usage and lower dementia risk (cause-specific hazard ratio [csHR], 0.57 [95% CI: 0.46, 0.71]) — a finding that remained even after adjusting for self-selection into baseline usage (csHR, 0.54 [0.41, 0.72]) and signs of cognitive decline at baseline (csHR, 0.62 [0.46, 0.85]).^[8]

Each additional wave of regular internet usage was associated with a 21% decrease in the risk of dementia [95% CI: 13%, 29%], wherein additional regular periods were associated with reduced dementia risk (csHR, 0.80 [95% CI: 0.68, 0.95]). "The difference in risk between regular and non-regular users did not vary by educational attainment, race-ethnicity, sex, and generation," the investigators note.^[8]

A U-shaped association was found between daily hours of online engagement, wherein the lowest risk was observed in those with 0.1 to 2 hours of usage (compared with 0 hours of usage). The risk increased in a "monotonic fashion" after 2 hours, with 6.1 to 8 hours of usage showing the highest risk. This finding was not considered statistically significant, but the "consistent U-shaped trend offers a preliminary suggestion that excessive online engagement may have adverse cognitive effects on older adults," the investigators note.^[8]

"Among older adults, regular internet users may experience a lower risk of dementia compared to non‐regular users, and longer periods of regular internet usage in late adulthood may help reduce the risks of subsequent dementia incidence," said Cho. "Nonetheless, using the internet excessively daily may negatively affect the risk of dementia in older adults."

Bidirectional Relationship?

Commenting for Medscape Medical News, Claire Sexton, DPhil, Alzheimer's Association senior director of scientific programs and outreach, noted that some risk factors for Alzheimer's or other dementias can't be changed, while others are modifiable, "either at a personal or a population level." She called the current research "important" because it "identifies a potentially modifiable factor that may influence dementia risk."

However, cautioned Sexton, who was not involved with the study, the findings cannot establish cause and effect. In fact, the relationship may be bidirectional. "It may be that regular internet usage is associated with increased cognitive stimulation, and in turn reduced risk of dementia; or it may be that individuals with lower risk of dementia are more likely to engage in regular internet usage," she said. Thus, "interventional studies are able to shed more light on causation."

EMOTIONAL EATING ISN'T ALL EMOTIONAL

Obesity is a chronic, treatable disease that is associated with numerous health complications.^[9] The Centers for Disease Control and Prevention reported that from 2017 to March 2020, the prevalence of adult obesity exceeded 40% in the United States.^[10] Furthermore, obesity was prevalent among 19.7% of children and adolescents during the same time period.^[11] In this article, Dr Sylvia Gonsahn-Bollie describes the experience of a patient living with obesity.

"Food gives me 'hugs,'" Ms S* said as her eyes lit up. Finally, after weeks of working together, she could articulate her complex relationship with food. She had been struggling to explain why she continued to eat when she was full or consumed foods she knew wouldn't help her health.

Like millions of people struggling with their weight or the disease of obesity, Ms S had tried multiple diets and programs but continued to return to unhelpful eating patterns. Ms S was an emotional eater, and the pandemic only worsened her emotional eating. As a single professional forced to work from home during the pandemic, she became lonely. She went from working in a busy downtown office, training for half-marathons, and teaching live workout sessions to being alone daily. Her only "real" human interaction was when she ordered daily delivery meals of her favorite comfort foods. As a person with type 2 diabetes, she knew that her delivery habit was wrecking her health, but willpower wasn't enough to make her stop. Her psychologist referred her to our virtual integrative obesity practice to help her lose weight and find long-term solutions. Ms S admitted that she knew what she was doing as an emotional eater. But like many emotional eaters, she didn't know why or how to switch from emotional eating to eating based on her biological hunger signals. As a trained obesity expert and recovering emotional eater of 8 years, personally and professionally I can appreciate the challenges of emotional eating and how it can sabotage even the best weight loss plan. In this article, I will share facts and feelings that drive emotional eating. I aim to empower clinicians seeking to help patients with emotional eating.

Fact: Emotional Eating Isn't All Emotional

It's important not to dismiss emotional eating as all emotion driven. Recall that hunger is hormonally regulated. There are 2 main hunger pathways: the homeostatic pathway and the hedonic pathway. The homeostatic pathway is our biological hunger pathway and is driven by the need for energy in calories. Conversely, hedonic eating is pleasure-driven and uses emotional stimuli to "bypass" the physical hunger/satisfaction signals. Emotional eating falls under the hedonic pathway. As clinicians, the first step in helping a patient struggling with emotional eating is empathetically listening, then assessing for any physiologic causes.

Several factors can disrupt physiologic appetite regulation, such as sleep disturbances; high stress levels; and many medical conditions, including but not limited to obesity, diabetes, and polycystic ovarian syndrome. Such factors as insulin resistance and inflammation are a common link in these conditions. Both contribute to the pathophysiology of the changes in appetite and can influence other hormones that lead to reduced satisfaction after eating. Furthermore, mental health conditions may disrupt levels of neurotransmitters such as serotonin and dopamine, which can also cause appetite changes.

These settings of physiologically disrupted appetite can trigger hedonic eating. But the relationship is complex. For example, one way to research hedonic eating is by using the Power of Food Scale. Functional magnetic resonance imaging (MRI) studies show that people with higher Power of Food Scale readings have more brain activity in the visual cortex when they see highly palatable foods.^[12] While more studies are needed to better understand the clinical implications of this finding, it's yet another indicator that "emotional" eating isn't all emotional. It's also physiologic.

Feelings: Patterns, Personality, Places, Psychological Factors

Physiology only explains part of emotional eating. Like Ms S, emotional eaters have strong emotional connections to food and behavior patterns. Often, physiologic cues have been coupled with psychological habits. For example, menses is a common physiologic trigger for stress-eating for many of my patients. Studies have shown that in addition to iron levels changing during menses, calcium, magnesium, and phosphorous levels also change.^[13] Emotionally, the discomfort of "that time of the month" can lead to solace in comfort foods such as chocolate in different forms. But this isn't surprising, as cacao and its derivative, chocolate, are rich in iron and other minerals. The chocolate is actually addressing a physical and emotional need. It can be helpful to point out this association to your patients. Suggest choosing a lower-sugar form of chocolate, such as dark chocolate, or even trying cacao nibs, while addressing any emotions.

But physiologic conditions and patterns aren't the only emotional eating triggers. Places and psychological conditions can also trigger emotional eating.

Places and people. Celebrations, vacations, proximity to certain restaurants, exposure to food marketing, and major life shifts can lead to increased hedonic eating. Helping patients recognize this connection opens the door to advance preparation for these situations.

Psychological conditions can be connected to emotional eating. It's important to screen for mental health conditions and past traumas. For example, emotional eating could be a symptom of binge eating disorder, major depression, or generalized anxiety disorder. Childhood trauma is associated with disordered eating.^[14] The adverse childhood events quiz can be used clinically.^[15]

Emotional eating can lead to feelings of guilt, shame, and negative self-talk. It's helpful to offer patients reassurance and encourage self-compassion. After all, it's natural to eat. The goal isn't to stop eating but to eat on the basis of physiologic needs.

Putting It Together: Addressing the Facts and Feelings of Emotional Eating

1. Treat biological causes that impact physiologic hunger and trigger emotional eating.

2. Triggers: Address patterns, places/people, psychological events.

3. Transition to non-food rewards; the key to emotional eating is eating. While healthier substitutes can be a short-term solution for improving eating behaviors, ultimately, helping patients find non-food ways to address emotions is invaluable.

4. Stress management:^[16] Offer your patients ways to decrease stress levels through mindfulness and other techniques.^[17]

5. Professional support: Creating a multidisciplinary team is helpful, given the complexity of emotional eating. In addition to the primary care physician/clinician, other team members may include:

• Psychologist
• Psychiatrist
• Emotional Freedom Technique (EFT)^[17] coach and/or certified wellness coaches
• Obesity specialist

Back to Ms S

Ms S is doing well. We started her on a glucagon-like peptide-1 (GLP-1) agonist to address her underlying insulin resistance. Together we've found creative ways to satisfy her loneliness, such as volunteering and teaching virtual workout classes. Her emotional eating has decreased by over 60% and we continue to discover new strategies to address her emotional eating triggers.

Conclusion

Despite being common, the impact of emotional eating is often minimized. With no DSM-5 criteria or ICD-11 code, it's easy to dismiss emotional eating clinically. However, emotional eating is common,^[18] and associated with weight gain. In light of the obesity epidemic,^[10] this significance can't be overlooked. Thankfully we have ground-breaking medications to address the homeostatic hunger pathway and physiologic drivers of emotional eating, but they're not a substitute for addressing the psychosocial components of emotional eating. As clinicians, we can have a meaningful impact on our patients' lives beyond writing a prescription.

* Name/initial changed for privacy.

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