Metabolic Syndrome

FP WINTER 2020

MISSOURI FAMILY PHYSICIAN VOLUME 39, ISSUE 1

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FP N A I C S Y H P Y L I M FA I R U O S I M

EXECUTIVE COMMISSION BOARD CHAIR Sarah Cole, DO, FAAFP (St. Louis) PRESIDENT Jamie Ulbrich, MD, FAAFP (Marshall) PRESIDENT-ELECT John Paulson, DO, PhD, FAAFP (Joplin) VICE PRESIDENT John Burroughs, MD (Liberty) SECRETARY/TREASURER Lisa Mayes, DO (Macon)

BOARD OF DIRECTORS DISTRICT 1 DIRECTOR Arihant Jain, MD (Cameron)

ALTERNATE Jared Dirks, MD (Kansas City) DISTRICT 2 DIRECTOR Brooks Beal, DO (Kirksville)

ALTERNATE Vacant DISTRICT 3 DIRECTOR Emily Doucette, MD, FAAFP (St. Louis)

DIRECTOR Kara Mayes, MD (St. Louis)

ALTERNATE Dawn Davis, MD (St. Louis) DISTRICT 4 DIRECTOR Jennifer Scheer, MD, FAAFP (Gerald)

ALTERNATE Kristin Weidle, MD (Washington) DISTRICT 5 DIRECTOR Natalie Long, MD (Columbia)

ALTERNATE Amanda Shipp, MD (Versailles) DISTRICT 6 DIRECTOR David Pulliam, DO, FAAFP (Higginsville)

ALTERNATE Carrie Peecher, DO (Marshall) DISTRICT 7 DIRECTOR Wael Mourad, MD, FAAFP (Kansas City)

DIRECTOR Afsheen Patel, MD (Kansas City)

ALTERNATE Beth Rosemergey, DO, FAAFP (Kansas City) DISTRICT 8 DIRECTOR Kurt Bravata, MD (Buffalo)

ALTERNATE Vacant DISTRICT 9 DIRECTOR Patricia Benoist, MD, FAAFP (Houston)

ALTERNATE Vacant DISTRICT 10 DIRECTOR Vicki Roberts, MD, FAAFP (Cape Girardeau)

ALTERNATE Gordon Jones, MD (Sikeston) DIRECTOR AT LARGE Jacob Shepherd, MD (Grain Valley)

RESIDENT DIRECTORS Misty Todd, MD, UMC John Heafner, MD, SLU (Alternate)

STUDENT DIRECTORS Morgan Dresvyannikov, UMKC Noah Brown, UMKC (Alternate)

AAFP DELEGATES Todd Shaffer, MD, MBA, FAAFP, Delegate Keith Ratcliff, MD, FAAFP, Delegate Kate Lichtenberg, DO, MPH, FAAFP, Alternate Delegate Peter Koopman, MD, FAAFP, Alternate Delegate

MAFP STAFF EXECUTIVE DIRECTOR Kathy Pabst, MBA, CAE The information contained in Missouri Family Physician is for informational purposes only. The Missouri Academy of Family Physicians assumes no liability or responsibility for any inaccurate, delayed, or incomplete information, nor for any actions taken in reliance thereon.

The information contained has been provided by the individual/ organization stated. The opinions expressed in each article are the opinions of its author(s) and do not necessarily reflect the opinion of MAFP. Therefore, Missouri Family Physician carries no respsonsibility for the opinion expressed thereon.

Missouri Academy of Family Physicians, 722 West High Street Jefferson City, MO 65101 p. 573.635.0830 • f. 573.635.0148 Website: mo-afp.org • Email: office@mo-afp.org

CONTENTS

6 METABOLIC SYNDROME: REDUCING THE RISKS OF C ARDIOVASCULAR DISEASE

4 A Letter from the Chair Opening remarks

8 Exercise in Medicine

A review of the guidelines for Americans

11 Using Medications to Treat Obesity 12 To Give or Not to Give?

Aspirin Use for Primary Prevention of Cardiovascular Disease

16 Cosmetic Surgery-Metabolic Health is More Than Skin Deep 18 Fasting:Thoughts and FAQ 20 MAFP Submits Resolutions for 2019 Congress of Delegate 24 MAFP President Reflection Congress of Delegates, Philadelphia

26 2020 Legislative Session Begins Here's what you need to know

27 GME Information Meeting Held at Research Family Medicine Residency Program, Kansas City 28 Family Physicians Gather for the 28th Annual Fall Conference 30 Members in the News Recognizing our colleagues

34 References

MARK YOUR CALENDAR MAFP Advocacy Day February 17-18, 2020 Capitol Plaza Hotel, Jefferson City MAFP Show Me Family Medicine Conference and Resident/Student Transition Session June 12-13, 2020 Margaritaville Lake Resort, Osage Beach

MAFP 28th Annual Fall Conference & KSA Working Group November 12-14, 2020 Big Cedar Lodge - Ridgedale, MO MAFP Advocacy Day March 1-2, 2021 Capitol Plaza Hotel Jefferson City

AAFP Family Medicine Experience (FMX) October 14-18, 2020 Hyatt Regency, Chicago, IL MO-AFP.ORG 3

A LETTER FROM THE CHAIR

A

Sarah Cole, DO, FAAFP Board Chair

s we enter the new year, some of our legislators on issues surrounding access to health patients may be regretting caloric care (particularly in underserved areas), health care overindulgence over the holidays or costs, scope of prescription medications and more. resolving to effect lifestyle changes to improve their health. Missouri Academy of While it can feel unsettling or inconvenient to Family Physician’s first volume of 2020 magazine “close up shop” for Advocacy Day, your presence provides Missouri’s family physicians with in Jefferson City can have long-lasting effects knowledge and tools to support their patients’ that reach far beyond the four walls of your New Year’s resolutions to lose weight, exercise clinic! To register, go to https://www.mo-afp.org/ more, reduce risk of cardiovascular disease (CVD) advocacy/advocacy-day/. Got a medical student and improve overall well-being! From evolving or resident rotating with you that day? Bring recommendations on the use of aspirin as primary them along! Students and residents are eligible prevention of CVD to increasing confidence for complimentary lodging to attend. Can’t attend in prescribing anti-obesity medications, our contributing Family physicians will play an important authors offer valuable evidence and insight and I thank them for role over the coming months, sharing their time, wisdom and energy!

expertise with legislators on issues surrounding access to health care (particularly in underserved areas), health care costs, scope of prescription medications and more.

As we advocate for changes at the level of our individual patients, I am mindful that family physicians champion change at the public policy level too.

Resolve to improve health care statewide by saving the date for 2020’s MAFP Advocacy Day in Jefferson City, MO, set for Tuesday, February 18th. Legislative bills are being pre-filed at this time. Family physicians will play an important role over the coming months, sharing expertise with

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in person? Contact kpabst@mo-afp.org about our Speak Out portal to contact your legislator via virtual advocacy outreach!

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EXERCISE IS MEDICINE

A REVIEW OF THE GUIDELINES FOR AMERICANS

I Halden D. Nielsen, OMS IV

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Andi Selby, DO, MS

n November 2018, the United States Department of Health and Human Services (HHS) released the second edition of the Physical Activity Guidelines for Americans, a decade after the first edition. In the interim, new evidence about additional benefits of physical activity on health has come to light.

The second edition builds upon what was already known, provides new information that can change the way physicians discuss physical activity with their patients, and can motivate patients to be more physically active by taking small steps.

Some health benefits have been known for many years, but some have been discovered more recently and are new to the 2018 Physical Activity Guidelines. Regular physical activity in adults and older adults has been shown to reduce the risk of all-cause mortality, cardiovascular disease mortality, cardiovascular disease, hypertension, type 2 diabetes, adverse blood lipid profile, and various cancers including breast, colon, bladder, endometrium, esophagus, kidney, lung, and stomach1. Physical activity also has many positive benefits on the mind, including improved cognition, reduced risk of dementia and Alzheimer’s disease, reduced anxiety and risk of depression, and improved sleep1. Benefits on weight are also seen, including slowed or reduced weight gain, weight loss, and prevention of regaining weight after an

adolescents also benefit from physical activity, as it improves bone health, weight status, cardiovascular and muscular fitness, cardiometabolic health, cognition, and reduces the risk of depression1.

Pregnant women do not miss out on the benefits of physical activity, with positive effects including a reduced risk of excessive weight gain, postpartum depression, and gestational diabetes1. Generally, even in those with chronic disease who are seen most frequently in the office, we see that physical activity decreases the risk of all-cause mortality and disease-specific mortality1.

The 2018 physical activity recommendations are the same as they were a decade ago. For adults, at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic physical activity per week are recommended. These are the same recommendations for older adults, adults with disabilities, and adults with chronic health conditions, as health and circumstances permit.

Pregnant women are recommended to get at least 150 minutes of moderate-intensity aerobic activity per week, and children and adolescents should spend 60 minutes per day doing moderate- or vigorous-intensity physical activity, with most of that being aerobic. This continues to be a challenge for our country to meet these guidelines, as nearly 80% of adults in the United States do not meet the recommended amount of physical activity1.

We see that physical activity decreases the risk of all-cause mortality and disease-specific mortality. initial weight loss1. Family physicians have known to recommend regular physical activity for years to improve physical function and bone health. It has also been shown to lower the risk of falling and fall-related injuries in older adults1. Children and

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While a majority of Americans do not meet recommended physical activity guidelines, some of this may stem from a lack of understanding. Many patients become instantly discouraged at the mention of the word “exercise.”

Their thoughts immediately jump to the hassle of a gym membership or miserably spending hours on a treadmill. For some patients, this type of exercise

may work perfectly well. However, it is important for physicians to help patients understand that the guidelines put out by the HHS are not based on exercise alone, but on physical activity, of which exercise is a subcategory.

Being clear about the differences and overlap of physical activity and exercise may make all the difference for some. Patients should feel inclined to be physically active in whichever ways are enjoyable to them, or in ways in which they are reasonably able. This may take the form of riding bicycles with a spouse, gardening, playing basketball in a city league, working a job in manual labor, or enjoying a jog with friends. Adults are more likely to engage in physical activity and maintain it over long periods of time when doing something they personally enjoy and when they participate with others where mutual encouragement can happen.

not count. With the new recommendations, we can confidently tell patients that every effort makes a difference. Instead of just being a cliché catchphrase, “something is better than nothing” is now backed by scientific evidence. This realization can empower patients to take small steps and eventually progress to a point where they are able to meet recommended guidelines which seem daunting at first.

One of the most crucial updates in the 2018 version is elimination of the recommendation that moderateto-vigorous physical activity needs Another important section Enough evidence to be done in periods of at least 10 included in the updated guidelines minutes in order to have any health has been gathered is the topic of physical inactivity benefit. Enough evidence has been and sedentary behavior. No specific to conclude that gathered to conclude that health recommendation is given regarding health benefits begin sedentary behavior in the 2018 benefits begin to accrue at any duration of physical activity1. This is guidelines, but the HHS outlines to accrue at any a seemingly small breakthrough, but some health risks associated with duration of physical being physically inactive, while one that has the potential to change the entire mindset of physicians and activity also outlining some interventions patients alike. Previously, a mental that are likely to be beneficial. barrier was in place that discouraged Having become a hot topic in the small steps towards the goal of increasing physical last decade, studies show that sedentary behavior activity. It was easy to think that small efforts did is linked to increased risk of all-cause mortality,

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In an age of smartphone apps, fitness trackers, and smartwatches, patients have many methods of keeping themselves accountable.

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cardiovascular disease mortality, cardiovascular disease, type 2 diabetes, and several cancers including colon, lung, and endometrium1. The HHS suggests that replacing sedentary behavior with light-intensity physical activity would most likely bring about benefits for health. Reducing the amount of sedentary behavior in day-to-day life is an issue for which most people can find solutions. In an age of smartphone apps, fitness trackers, and smartwatches, patients have many methods of keeping themselves accountable. This market spreads into more than just handheld devices, with innovations such as standing desks and balance ball chairs coming into play, and under-desk inventions such as leg swings, pedal exercisers, and sitting steppers making a strong presence in the battle against inactivity. These should be encouraged, but patients should also understand that many things can be done without any cost. For some, the answer may include taking the stairs instead of the elevator, parking further away, walking to the furthest restroom, or taking a lap around the building. Small changes in lifestyle can accumulate into large benefits.

What is standing in the way of American adults from engaging in regular physical activity? For some, a lack of education. For others, a lack of motivation. And it is possible that by providing proper education, motivation may automatically rise. Family physicians hold a unique position to be able to address these deficits. Backed by evidence-based guidelines, there is now the ability to dispel misunderstandings that small efforts to be more physically active are insignificant. Indeed, “there is no threshold that must be exceeded before benefits begin to occur.”1. It is hard to argue with statistics and robust research, and in a day of skyrocketing medical costs, this provides hope. The understanding that something really is better than nothing is a gateway for patients to a healthier and happier life.

References are found on page 34

USING MEDICATIONS TO TREAT OBESITY

T

he American Medical Association (AMA) first recognized obesity as a disease in June 2013 with the simple resolved statement, “Our AMA recognizes obesity as a disease state with multiple pathophysiological aspects requiring a range of interventions to advance obesity treatment and prevention.” There is a spectrum of treatment options for obesity, including caloric restriction, physical activity, nutritional counseling, pharmacotherapy and bariatric surgery.

The most recent National Health and Nutrition Examination Survey data estimates that 39.6% of American adults (age 20+ years) have obesity.1 Use of anti-obesity medication (AOM) increases the likelihood of greater than 10% body weight loss from baseline. Guidelines from many groups support pharmacologic treatment with antiobesity medications for patients with obesity, including the National Institutes of Health, American Heart Association/American College of Cardiology, and the Endocrine Society. Despite these recommendations, AOM an underutilized resource. A recent review of medication use among a cohort of 2.2 million adults across eight large health-care organizations found that only 1.3% of eligible patients filled a prescription for an AOM over a six-year period.2 Since 2012, four new medications have been approved by the Food and Drug Administration (FDA) for the long-term treatment of obesity: 1.

2.

3.

4.

topiramate/phentermine, lorcaserin, naltrexone/bupropion, and liraglutide.

There is no maximum length of treatment for these newer anti-obesity medications. Side effects, teratogenicity and drug-drug interactions can vary, necessitating a shared decision-making approach when discussing AOM with patients.

One study showed that AOM prescribed by a physician was a less common method of attempting weight loss than over-the-counter herbs, supplements, and medicines.3 These other supplements are less likely to be effective and more likely to cause negative side-effects when compared with FDA-approved medications for obesity, an important point to share with patients.

It is also important to be able to discuss bariatric surgery as an option for patients with obesity. Bariatric surgery is typically recommended for patients with a BMI above 40 kg/m2, or a BMI 35-40 kg/m2 with comorbidities related to obesity. This is a safe and effective procedure, with a mortality rate around 0.1%.

Family physicians all have patients affected by obesity and should be competent in prescribing medication to treat this condition.

Given the prevalence of obesity in this country, it is impractical to rely on endocrinologists or obesity medicine specialists to treat our patients.

Consider attending a conference or online course to learn more about treating obesity, and start discussing medication as an option for patients with obesity. Sometimes discussing a patient’s weight can be intimidating for physicians, but many great resources exist to help start this conversation. One excellent source is the STOP Obesity Alliance www.whyweightguide.org.

Kara Mayes, MD Board-certified Family Physician Diplomate of the American Board of Obesity Medicine

References are found on page 34

These medications are approved for use in patients with a body mass index (BMI) of 30 kg/m2 or above. They are also approved for use in patients with a BMI between 27 and 30 kg/m2 with one or more obesity-related comorbidity.

They are all recommended to be used in conjunction with healthy lifestyle changes, including increased physical activity and decreased caloric intake.

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TO GIVE OR NOT TO GIVE? ASPIRIN USE FOR PRIMARY PREVENTION OF CARDIOVASCULAR DISEASE

C Michael Selby, MD Kansas City University of Medicine and Biosciences Joplin, MO

ardiovascular disease (CVD) primarily includes coronary heart disease (CHD), cerebrovascular disease, peripheral arterial disease, and atherosclerosis of the thoracic and abdominal aorta. CVD is the leading cause of death in the United States.1 In 2016, CVD accounted for over 840,000 deaths in the U.S. Fortunately, the death rate from CVD is declining.1 Between 2006 and 2016, the overall deaths from CVD had decreased by 18.6%, and the overall deaths specifically from CHD had decreased by 31.8%.1 While the mortality has improved, the financial burden of CVD remains enormous. The annual total cost of CVD in the U.S. is estimated at $351.2 billion dollars.1 Given the mortality and cost associated with CVD, prevention of CVD is essential and should be a focus of every primary care provider.

For secondary CVD prevention, long-term aspirin use has a clear role in decreasing CVD morbidity and mortality in patients with known CVD.2 However, its role in primary prevention of CVD is not as clear or well established despite widespread historical use for primary prevention for decades. In fact, three recent randomized controlled trials published in 2018 have called into question the use of aspirin for the primary prevention of CVD.2

1)

The ARRIVE trial, a double-blind randomized controlled trial in the Lancet, studied the use of aspirin in primary prevention of CVD in patients with a moderate estimated risk of CVD based upon specific risk factors. Over 12,000 patients were randomized to receive either enteric-coated aspirin 100 mg daily or placebo tablets. The primary endpoint was a composite outcome of first occurrence of cardiovascular death, myocardial infarction, unstable angina, stroke, or transient ischemic attack.3 Patients were followed for a median of 5 years. The

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primary endpoint occurred in only 269 (4.29%) patients in the aspirin group versus 281 (4.48%) patients in the placebo group (hazard ratio [HR] 0.96; 95% confidence interval (CI), 0.81–1.13; p=0.6038).3 Gastrointestinal bleeding occurred in only 61 (0.97%) patients in the aspirin group versus 29 (0.46%) in the placebo group (HR 2.11; 95% CI, 1.36–3.28; p=0.0007).3 However, most of the associated gastrointestinal bleeding was noted to be mild.3 Thus, this trial did not show any significant benefit in using low-dose aspirin for primary prevention of CVD in patients with moderate risk of CVD and revealed some harm in the form of gastrointestinal bleeding, albeit mild.

2)

The ASCEND trial, a randomized controlled trial published in the New England Journal of Medicine, studied the use of aspirin in primary prevention of CVD in diabetic patients without known CVD. Over 15,000 patients were randomized to receive either enteric-coated aspirin 100 mg daily or placebo tablets. The primary endpoint was a composite outcome of the first serious vascular event (i.e., myocardial infarction, stroke or transient ischemic attack, or death from any vascular cause, excluding any confirmed intracranial hemorrhage).4 Patients were followed for a mean of 7.4 years. The primary endpoint occurred in 658 (8.5%) patients in the aspirin group versus 743 (9.6%) patients in the placebo group (HR, 0.88; 95% CI, 0.79 to 0.97; p=0.01).4 However, major bleeding events occurred in 315 (4.1%) patients in the aspirin group versus 245 patients (3.2%) in the placebo group (rate ratio, 1.29; 95% CI, 1.09 to 1.52; p=0.003).4 The vast majority of the bleeding events included gastrointestinal bleeding (41.3%) or other extracranial bleeding.4 Thus, the trial did show a significant benefit in using aspirin

for primary prevention of CVD in diabetic patients, but this benefit was offset by the risk of major bleeding.2, 4

3)

The ASPREE trial, published in the New England Journal of Medicine, is a randomized controlled trial studying the use of aspirin in primary prevention of CVD in healthy community-dwelling older patients (≥70 years) with no known CVD. Over 19,000 patients were randomized to receive either enteric-coated aspirin 100 mg daily or placebo tablets. The primary endpoint was a composite end point of death, dementia, or persistent physical disability among older adults.5 The secondary endpoints were major bleeding and a composite endpoint of CVD (i.e. fatal CHD, nonfatal myocardial infarction, fatal or nonfatal stroke).6 Patients were followed for a median of 4.7 years. The primary endpoint occurred in 21.5 per 1000 patient-years in the aspirin group versus 21.2 per 1000 patient-years in the placebo group (HR, 1.01; 95% CI, 0.92–1.11; p=0.79).5 The major bleeding rate was higher in the aspirin group (3.8%) than in the placebo group (2.8%); [HR, 1.38; 95% CI, 1.18 to 1.62; p<0.001].5 The CVD rate was 10.7 events per 1000 patient-years in the aspirin group and 11.3 events per 1000 patient-years in the placebo group (HR, 0.95; 95% CI, 0.83 to 1.08).6 Thus, aspirin did not increase disability-free survival or decrease CVD events in healthy community-dwelling older adults without CVD and was associated with more major bleeding events.

Additional analysis of the ASPREE study found that the risk of death from any cause was 12.7 events per 1000 person-years in the aspirin group and 11.1 events per 1000 person-years in the placebo group (HR, 1.14; 95% CI], 1.01 to 1.29).7 Interestingly, cancer was the main reason for the increased mortality in the aspirin group despite evidence that aspirin may lower the incidence of some cancers like colorectal cancer.8, 9 Of note, the authors suggested caution in interpreting these results given that previous studies are not consistent with these findings.7

Finally, a large meta-analysis which included the above three randomized trials was published in European Society of Cardiology in 2019. This

meta-analysis involved > 157,000 patients from 11 total randomized trials assessing the role of aspirin in primary prevention of CVD in patients without CVD. At a mean follow-up of 6.6 years, the incidence of all-cause mortality was similar between the aspirin group (4.6%) and control group (4.7%) with a relative risk [RR] of 0.98 (95% CI, 0.93-1.02, p= 0.30, I2 = 0%).10 The incidence of major bleeding was higher in the aspirin group (1.8%) than control group (1.2%) with a RR of 1.47 (95% CI, 1.31-1.65; p< 0.0001, I2 = 31%).10 Thus, there was no clear benefit of aspirin in primary prevention of CVD; however, there was an increased risk of major bleeding.

At this time, there is substantial evidence suggesting no or only limited benefit of aspirin in the primary prevention of CVD with possible harm in the form of bleeding. However, criticisms of these recent studies call into question these two conclusions. Some have argued that entericcoated aspirin decreases the bioavailability of aspirin and that the use of other formulations, particularly in diabetic patients, might have revealed a benefit of aspirin in the primary prevention of CVD.2 Others have suggested twice daily dosing of aspirin is associated with enhanced platelet inhibition compared to once daily aspirin use, particularly in diabetic patients.2 Finally, there are conflicting guideline recommendations on the use of low-dose aspirin for primary prevention of CVD from various medical organizations which only leads to further confusion for the primary care provider.2 Thus, it is imperative that family physicians review the risk and benefits of low-dose aspirin for primary prevention of CVD with a shared decisionmaking approach. Authors of one recent article suggested that low-dose aspirin could be given to patients with all of the following criteria: • age between 40-70 years, • higher risk of CVD due to multiple risk factors, • low risk of bleeding, • awareness of the limited data to suggest benefit of aspirin in primary prevention, and • desire to prevent CVD.2 Ultimately, further studies will be needed to address the criticisms of these recent studies and hopefully answer the question, “To give or not to give?”

References are found on page 34 MO-AFP.ORG 13

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COSMETIC SURGERYMETABOLIC HEALTH IS MORE THAN SKIN DEEP

C

osmetic surgery is a booming business. As a family physician in rural Missouri, I don’t get a lot of questions about it, but I certainly get more now than I did when I first went into practice. It will often come up when I am talking to patients about weight loss, especially in the context of improving their overall health. Not a day goes by that I don’t see a diabetic, hypertensive, or obese patient in my clinic. When it comes to females, the question usually comes up as, “So do you know anything about this new CoolSculpting procedure? Does it really work?” With men, the question is typically, “Hey, Doc, can’t I just go to some plastic surgeon and get this belly cut off?” Both situations take me down a pathway of patient counseling about which, until reviewing for this article, I was admittedly not well educated. My standard response was that no surgery could replace hard work and dedication, and if one wasn’t in the right mindset about getting their health in check, nothing would work. When it comes to metabolic health, we must see adipose tissue as an endocrine organ. Understanding how adipose tissue functions in metabolism, all the different “adipokines” that are released and suppressed, and how cosmetic surgery affects those pathways, allows us to better understand why (or why not) metabolic health is more than skin deep.

With regards to adipose tissue, there are three kinds: white, brown, and a lesser known, still under investigation, beige. White adipose tissue can be broadly categorized into two components: subcutaneous and visceral. Subcutaneous white adipose tissue is external. It is what we see. Its main function is to store lipids, mainly triglycerides, as well as provide insulation and protection to our bodies. Subcutaneous white adipose tissue can congregate in various parts of the body, most notably centrally around the abdomen.

Visceral white adipose tissue is just like it sounds—it surrounds the internal organs, mainly in the abdomen. Excess of this type of tissue can lead to more sinister sequelae.

Brown adipose tissue is present at birth.

Highly active metabolically, brown adipose tissue is thermogenic, not only providing insulation, but creating heat at the same time.

As we grow, this mitochondria-rich tissue transforms into white adipose tissue.

The third kind of adipose tissue is beige adipose tissue. Not much is known about this tissue, but scientists are currently studying its origins and effects. It is thought to arise from white adipose tissue but retains some of its thermogenic properties like brown adipose tissue. Although it is good to know that this type of tissue exists, the availability of evidence regarding this adipose tissue limits its presence and relevance to this particular article.

Katie Dias, DO FAAFP, Mosaic Family Care, Albany

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Because of its effects on metabolic health, we will focus on white adipose tissue. When it comes to distribution of this fat, gender matters. In both genders, up to the point of adulthood, distribution in the limbs and abdomen is fairly similar. Once women reach adulthood, though, adipose tissue tends to concentrate in the abdominal and hip area and continue throughout life. In men, this shift happens, but tends to level out in the sixth decade of life. No matter the gender, as we age, visceral adipose tissue increases.

White adipose tissue, as stated above, is metabolically active, whether in the subcutaneous tissue or around the viscera. The fat secretes various inflammatory and anti-inflammatory substances, known as adipokines, that initiate cascades of endocrine effects. These cytokines include: adiponectin, adipsin, angiotensinogen, apelin, ASP, HGF, IGF1, interleukin-10, interleukin-6, leptin, MCP-1, PAI-1, resistin, Sfrp5, tecidual factor, tumor necrosis factor-alpha, VEGF, and visfatin.

These adipokines are present more so in visceral fat compared to subcutaneous.

Let’s focus on just a few of these substances in more detail. Leptin plays a crucial role in subcutaneous white adipose tissue. When adipocytes secrete leptin, they signal to the body that it is satiated, therefore decreasing appetite.

Fat stores are adequate, and the body can stop increasing its stores. Tumor necrosis factor-alpha (TNF-α) stimulates lipolysis, or breakdown of fat. It revs up metabolism and decreases insulin sensitivity.

HDL. Weight loss is a hallmark recommendation in the treatment of metabolic syndrome. Is there a quick fix? Liposuction is a cosmetic procedure that involves introduction of a probe into the subcutaneous space, injecting lidocaine and saline, and suctioning fat from the space, resulting in smaller circumferential measurements and weight loss. Sure, the cosmetic results might be gratifying, but what metabolic changes happen in the remaining adipose tissue? Furthermore, do our measurable criteria for metabolic syndrome improve? Should we recommend liposuction as an adjunctive therapy for our patients with metabolic syndrome?

Several studies exist in both animal and human models looking at the cellular effects of liposuction on metabolic parameters. One important point to remember is that liposuction removes only subcutaneous white adipose tissue, not visceral adipose tissue. In a 2004 study, Klein, et al, studied effects of large volume (>4 liters of aspirate) liposuction in obese women without glucose intolerance as well as in women with type 2 diabetes mellitus. They found that at 90 days post-op, leptin levels decreased, and there was no significant change in insulin sensitivity, fasting blood glucose, TNF-α, interleukin-6, lipid profile, or blood pressure.

It has been furthermore hypothesized that the removal of leptin-producing adipocytes creates a feedback loop where the hypothalamus, in leptin’s absence, stimulates hunger and limits energy use, lowering metabolism and promoting weight gain.

Large volume liposuction was studied in a 2014 meta-analysis by Boriani, et, al. In obese women with no other chronic medical issues, fasting plasma insulin was reduced but improvement in other metabolic parameters was inconsistent. A 2017 systematic review by Sailon, et al, echoed these findings.

A 2015 meta-analysis conducted by Seretis, et al, looked at metabolic parameters in women receiving

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Cosmetic surgery can be considered as an adjunctive treatment option for metabolic syndrome.

The interleukins 10 and 6 have antagonistic roles.

Interleukin-10 is anti-inflammatory. It acts to suppress TNF-α production. Interleukin-6 is proinflammatory, working in tandem with TNF-α.

Metabolic syndrome includes a constellation of findings, such as obesity, hypertension, hyperglycemia, hypertriglyceridemia, and low

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abdominal lipectomy. This meta-analysis did include liposuction, as well as abdominoplasty, which we refer to commonly as a “tummy tuck” procedure.

They found that neither procedure caused significant change in triglycerides, HDL, insulin sensitivity, or glucose levels. They did find that, when comparing abdominoplasty to diet, those women who underwent abdominoplasty had lower waist-hip ratio, interleukin-6 levels, and TNF-α levels at 8 weeks post-procedure. Several of these analyses were limited due to lack of long-term follow-up.

Robles-Cervantes, et al, looked at longer term effects, studying the effects of liposuction vs. diet over the course of 6 months. They focused on the adipokines leptin and TNF-α. In a group of obese females, none of whom had diabetes or other conditions affecting insulin sensitivity, they found no differences in metabolic labs at the end of the 6 months. Furthermore, they found that TNF-α did not show a significant change at the 6-month mark. Leptin initially decreased, but after one month began trending upward again. There was a significant decrease in appetite in those women who underwent liposuction that persisted to the end of the study. Interestingly, there was a significant drop in TNF-α levels in the diet only group.

Surgical breast reduction, or mammaplasty, has been studied as a means to improve metabolic parameters in women. Vinci, et al, studied reduction mammaplasty and its effects on blood glucose and HDL cholesterol. White adipose tissue makes up the majority of breast tissue in women with larger breast size. They found that at 40 days postreduction, HDL improved a mean of 4.41 points, and Glucose improved by 5.22 points. Mild changes, but statistically significant, nonetheless.

Cryolipolysis, or “CoolSculpting” is a newer procedure that uses cooling techniques to breakdown adipose tissue, resulting in loss of adipose tissue from the treated area. This noninvasive procedure is gaining popularity among men and women looking to quickly and effectively remove fat from unwanted areas. I found one case report on this procedure, and, in contrast to nearly all the other articles I reviewed, this report focused on a male patient and his testosterone levels. This obese gentleman with low testosterone

levels underwent 13 cryolipolysis treatments in 11 months. After just 6 months of treatments, his free testosterone level went from a low of 7.6 initially to a normal level of 13.7. It was felt that by removing pro-inflammatory adipose tissue, his insulin sensitivity improved, therefore contributing to his improved testosterone level. As a result of the treatments, he lost 7 pounds.

While there are some positive outcomes with regard to metabolic parameters in these studies, it is obvious that more research needs to be done.

Conflicting methods of lab collection, measurement of actual adipose tissue, and interpretation of the outcomes themselves limit the reliability of the data. Furthermore, there is a definite gender bias in the literature, with the majority of studies being conducted on female subjects. The data also lacks in long term follow-up. Most importantly, with the interpretation of any data, patient oriented outcomes must be sought, not just improvement in numeric values.

What can be taken away from this literature is the fact that cosmetic surgery can be considered as an adjunctive treatment option for metabolic syndrome. When it comes to insulin sensitivity and lipids, surgical intervention can be helpful. To improve leptin and TNF-α, though, it’s hard to beat good old-fashioned diet and exercise.

References are found on page 34

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FASTING: THOUGHTS AND FAQ

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ith the prevalence of metabolic disease, there are very few office visits in a day where I do not talk about diet and exercise with patients. I have discovered that one of the most consistent knowledge gaps in my medical education was providing advice to patients about timing of food intake. All I had was the common wisdom of “breakfast is the most important meal of the day” and to eat 3 meals. My knowledge of diet could be reduced to “eat more fruits and vegetables and eat fewer calories.” When it comes to providing any informed opinion regarding timing, I was at a loss.

The Question and Answers below will provide you with guidance for these discussions with your patients.

What are the metabolic effects of fasting and what are the clinical ramifications?

Fasting has marked metabolic effects that are separate from reduced calories (2). One is increased utilization of fatty acids and production of ketones. This metabolic change has been shown to be harmful to cancer cells (4). The same ketone production also shows increased neuroplasticity. Depending on the fasting regimen selected, one could reduce their blood glucose from 30 to 60%. Fasting also decreases leptin (associated with pro inflammatory states) and increases ghrelin and adiponectin, both of which are associated with increased insulin sensitivity. Most studies show weight loss to weight neutral effects with improved glucose control with mixed changes in lipids (5). From a practical stand point, most reviews are complicated by different definitions of fasting and different study populations. Also, most studies look at short-term outcomes from weeks to month time frames, which makes it difficult to give long-term recommendations about maintaining a fasting program throughout the year for health benefits.

How did we get here in terms of meal timing?

Breakfast first became common in mediaeval Europe with set schedules for laborers to nearly universal during the industrial revolution. Contrast this to the 18

MISSOURI FAMILY PHYSICIAN JANUARY-MARCH 2020

hunter-gatherer society, where food availability dictated when it was consumed (2). The classic American farmer’s breakfast of cured meats and flapjacks became increasing popular in 1800s which also led to the rise of dyspepsia. To counter this, Dr. John Harvey Kellogg eventually developed Corn Flakes® for a more healthy breakfast option, giving rise to cereal companies and the cultural importance of breakfast to the American food landscape (1).

How do different religious groups practice fasting?

Fasting has long been a component of many cultures and has no clear-cut definition. It varies from complete abstention from food and water to food restrictions. Here are a few ways different cultures practice fasting: BUDDHISM: Monks as part of precepts do not eat past noon. Lay practitioners may practice various forms of fasting at retreats.

CHRISTIANITY: Varies between denominations.

Varies from 2 small meals in a day to 24-hour fasts either throughout the year or only during Lent.

Hinduism: Varies widely. Most common is 24hour fasts one day a week.

ISLAM: Fasting during Ramadan is the 3rd of 5 pillars of Islam. 29 to 30 days of abstaining from food, liquids, smoking, and engaging sexual relations. Exceptions are for the ill, those traveling, elderly, pregnant, breastfeeding, diabetic, or menstruating. Fasting occurs from sunrise to sunset with altered schedules for areas with extreme night/day length differences.

JUDAISM: Yom Kippur is the most observed with abstaining from all food and drink from sundown to nightfall of the next day (~25 hours).

How are therapeutic fasts structured?

There are three possible components to a therapeutic fasting regimen. First is caloric

restriction. Second is time-restricted eating, which consists of reducing the amount of time in the day in which eating calories is allowed.

Third is number of days of fasting. The benefits of different fasts have included improvements in blood pressure control, glycemic control, and weight.

Complete alternate day fast: Eating regular meals one day and then complete calorie fast the next day.

5:2 diet : 5 days regular meals with 2 days of severe calorie restriction (20 to 25% of required calories)

Hareesh Gadde, DO, Truman Medical Center Kansas City

Time restricted fasting- calories are only allowed to be ingested within a 6-8 hour interval.

What are some best practices for diabetics and fasting?

Most of the studies on this subject have been done in countries with high Muslim populations and Ramadan. For secular fasting studies most of the studies include healthy, obese, or noninsulin dependent diabetics.

For insulin dependent diabetics, I evaluated them based on the 2010 guidelines (“Recommendations for Management of Diabetes During Ramadan”) to see if they would be a suitable candidate. This is a must read for anyone who has patients who are Muslim diabetics. This guideline also has useful tips for altering medication regimens to people who may eat in a similar fashion to a Ramadan fast. Often the most usable dietary recommendation that is usable is timerestricted eating. I use anywhere from 12 to 16 hours of fasting depending on his/her glycemic control and insulin/medication regimen so that meals are appropriately timed with the effects of the therapeutic regimen. I find that even if a patient has difficulty fasting, it becomes a useful discussion point for discussion on the relationship with food.

References are found on page 34

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MISSOURI FAMILY PHYSICIAN JANUARY-MARCH 2020

MAFP SUBMITS RESOLUTIONS FOR 2019 CONGRESS OF DELEGATE

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he MAFP Delegation to this year’s Congress of Delegates was comprised of Delegates Keith Ratcliff, MD, FAAFP, and Todd Shaffer, MD, MBA, FAAFP, and Alternate Delegates Kate Lichtenberg, DO, MPH, FAAFP, and Peter Koopman, MD, FAAFP. Over the three days of deliberation, the Congress considered more than 90 resolutions which were divided between five reference committees. The Committee on Organization and Finance was assigned 17 Resolutions, the Committee on Practice Enhancement considered 8 Resolutions, the Committee on Advocacy worked with 20 Resolutions, the Committee on Education perfected 12 Resolutions. The Committee on Health of the Public and Science worked well into the early morning hours to discuss 27 Resolutions, 17 of which dealt with the topic of abortion. Kate Lichtenberg, DO, FAAFP, served on the Reference Committee on Practice Enhancement, and Todd Shaffer, MD, MBA, FAAFP, served as chair of the Reference Committee on Health of the Public and Science.

Keith Ratcliff, MD, FAAFP

MAFP submitted two resolutions to the Congress this year. The first, Resolution 201 titled Survey AAFP Members on Legislative and Regulatory Issues, was assigned to the Reference Committee on Organization and Finance. We have noted over the years that the COD sometimes considers very specific issues during deliberations, but the AAFP does not really have data to know our members opinions on these issues. Similar to the Member Survey that the MAFP Board uses to help guide our positions, we felt that the AAFP Board should develop similar data so that the decisions made by the Board would consider the opinions of the membership. Testimony at the Reference Committee was surprisingly negative on this issue as many constituencies felt that having this data would encourage the AAFP Board to minimize their specific interests. The MAFP position is that we have elected a very diverse and compassionate AAFP Board that has the wisdom to use data in an MO-AFP.ORG 21

appropriate manner to represent all member interests. But our opinion was not shared by the reference committee, and this Resolution was not adopted.

The second resolution proposed by your MAFP, Resolution 505 Eliminating Barriers in Rural Communities for Cardiac Rehabilitation, sought to bring cardiac rehabilitation (CR) services to more communities by asking the CMS to alter the rules concerning physician supervision. Many years ago, CMS had written a Rule that all CR programs must operate under the direct supervision of a physician which means that a physician must have “immediate availability to furnish assistance and direction throughout the performance of the procedure.” While probably necessary when first written decades ago when resuscitation science was in its infancy, this rule effectively prevented smaller hospitals from enacting CR programs because of the expense associated with the salary required for direct supervision by a physician. In the current modern model of resuscitation with many team members skilled in ACLS, and the advancement of AED equipment,

the MAFP felt that this rule provided a barrier to many of our patients who could benefit from having a CR program in their local community. The Reference Committee on Advocacy improved the language we had proposed by removing the word “rural” and by asking for the rule to be modified to allow for the general supervision of a physician which means “the service is performed under the supervisory practitioner’s overall direction and control but his or her presence is not required during the performance of the procedure.” The Reference Committee brought back a Substitute Resolution 505 which was unanimously approved by the Congress and reads as follows: RESOLVED, That the American Academy of Family Physicians (AAFP) request the Centers for Medicare and Medicaid Services, National Coverage Determination for Cardiac Rehabilitation Programs rules be modified to allow for cardiac rehabilitation programs to operate with the general supervision of a physician when an Automated External Defibrillator (AED) is immediately available, and the patient is attended by nursing staff currently trained in Basic Life Support and AED use.

Overall this was a very fruitful COD, and Resolution 201 was the first that your Delegation has “lost” in the last few years. We look forward to representing the MAFP in Chicago next year, and hope that many of our members will be able to come and support our candidate for MAFP Board of Directors, Todd Shaffer, AKA “Show-Me Shaffer, a Champion for Family Medicine”.

Resolution Actions Overview The Congress supported a resolution on the Interstate Medical Licensure Compact. The compact is an agreement that allows licensed physicians to practice across state lines if they meet certain eligibility requirements. Other resolutions addressed health care claims data (too many payers and employers have been exempted from the process), include generic drugs in health plan formularies, make screening colonoscopies free of co-insurance and deductibles, and to support the right of physicians to organize and collectively bargain.

Other resolutions addressed the American Board of Family Medicine's Family Medicine Certification Longitudinal Assessment and that this assessment was inconsistent with the final report of the American Board of Medical Specialties' Continuing Board Certification: Vision for the Future Commission. The final version of the resolution expressed its concern that the ABFM's Todd Shaffer, MD, FAAFP chaired the FMCLA is the only alternative to Reference Committee on Health of the the one-day certification exam Public and Science and asked that the Academy

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DELEGATES:

Keith Ratcliff, MD, FAAFP

Todd Shaffer, MD, MBA, FAAFP

urge the ABFM to offer a longitudinal self-assessment process (similar to that used by the American Board of Obstetrics and Gynecology) and that this process satisfy the cognitive component of ABFM's continuing certification requirement. Substitute resolutions passed related to privileging, credentialing, scope of practice and use of acupuncture to treat chronic pain, and one that called on the AAFP to engage with the AARP to educate them about the role of family physicians in providing quality and costeffective patient care.

Another substitute resolution passed that asked the AAFP to collaborate with The Joint Commission (www. jointcommission.org) and other organizations to create policy that would have hospitals remove undue barriers and restriction of privileges to hospitals and intensive care units for qualified family physicians who practice hospital medicine. The Congress supported the creation of a policy against health insurance company privileging of physicians based solely on their hospital privileges and hospital credentials.

It was time to vote In addition to hearings, AAFP’s new leadership was elected and Gary LeRoy, MD, Dayton, Ohio, was installed as AAFP's president. Dr. LeRoy spoke to MAFP members during the 2018 Show Me Family Medicine Conference where he gave an AAFP update and presented a session on primary care opthamology. “People outside of our specialty of family medicine define us. We must not accept the term "provider." We did not go to provider school. We went to medical school. We chose the specialty of family medicine.”

Ada Stewart, MD, of Columbia, SC, was elected AAFP president-elect. Others elected or chosen by acclamation for the following positions are Speaker of the Congress -- Alan Schwartzstein, MD, of Oregon, WI Vice Speaker -- Russell Kohl, MD, of Stilwell, KS

ALTERNATE DELEGATES:

Peter Koopman, MD, FAAFP

Kate Lichtenberg, MD, FAAFP

Directors -- Andrew Carroll, MD, of Chandler, AZ; Steven Furr, MD, of Jackson, AL; and Margot Savoy, MD, MPH, of Newark, DE. New physician Board member -- Brent Sugimoto, MD, MPH, of Richmond, CA Resident Board member -- Kelly Thibert, DO, MPH, of Columbus, OH Student Board member -- Margaret Miller, of Johnson City, TN Town Hall Meeting is Standing Room Only Before the Congress of Delegates began, AAFP leadership held a Town Hall meeting and the topics of discussion were on administrative burden including documentation, prior authorization, etc. And, Doug Henley, MD, AAFP Executive Vice President, engaged in a discussion on artificial intelligence to simplify some of the administrative burden challenges family physicians face. Mike Munger, MD, FAAFP, AAFP Past President, highlighted positive elements of the 2020 Medicare physician fee schedule that CMS proposed in late July, including a 12% increase in payment for evaluation and management codes and simplified billing and coding requirements for E/M services.

Many questions were related to single-payer models.

AAFP's current policy adopted last year has positioned AAFP for potential changes. Retaining full scope of practice concerns around pediatric care was discussed that it may be primarily offered by pediatrics instead of family physicians. This is an access to care issue in the rural area where most children are seen by their family physician.

Lastly, workforce was a hot topic and members were encouraged to precept medical students so they can see family medicine first hand, in order to counter some of the less than positive guidance from medical schools. And we can’t forget the need for more residency slots for family medicine, particularly in rural and underserved areas.

Information in this article was obtained from AAFP.org.

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MAFP PRESIDENT REFLECTION CONGRESS OF DELEGATES, PHILADELPHIA

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Jamie Ulbrich, MD, FAAFP, Ulbrich Family Medicine Marshall, MO

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s I sat in the airport terminal in Philadelphia on my way back to Missouri, I reflected on my experience at the 2019 Congress of Delegates (COD). My first reflections were “Wow!” and “What an experience!”.

The Missouri delegation met on Sunday to review both surveys that went out to every Missouri Academy member as well as the survey sent to your board after resolutions were submitted for consideration to the COD. A lot of discussion centered around all the resolutions felt to be pertinent to our membership. After much discussion and review, the delegation came up with a position on each resolution.

One of my primary observations was that after the American Academy put out its priorities last spring, such as reducing administrative burden, addressing burnout, improving revenue, and addressing workforce issues, which I presented at the summer conference, many resolutions centered around ethical and moral issues that were divisive and polarizing to our academy.

In fact, it was hard to find resolutions that

MISSOURI FAMILY PHYSICIAN JANUARY-MARCH 2020

addressed the above mentioned “legislative priorities”.

We had anticipated this and asked our membership to weigh in; the poll showed that opinions were split evenly on most issues that were morally divisive, such as abortion. With this in mind, your delegates went to the “table” with these results with the hope of achieving neutrality given our state’s survey results.

The next morning, I had the opportunity to provide testimony in support of a resolution to not have insurance payments linked to hospital privileges. This was my first time to “offer support” on a resolution. It was eventually sent on to the COD and by consent was approved.

I then attended a chapter president’s luncheon where the Missouri Academy of Family Physicians was presented an award for our work opposing Assistant Physician legislation in our state (see photo below). Our gratitude goes to all the membership that provided testimony in opposition to this legislation, along with our advocacy committee, lobbyists, and last but probably most importantly, our executive director, Kathy Pabst.

The rest of the afternoon was spent listening to testimony in a reference committee hearing about several resolutions dealing with abortion. The testimony was very passionate on both sides of the issue.

That evening, we had an opportunity to meet with president elect and board member candidates for the AAFP. It was opportunity to ask the candidates any question that you wanted. My observation was that there were really no bad candidates but rather all candidates seem to have their political opinions well-rehearsed and were able to articulate them well when asked.

The next day all the reference committees presented their recommendations to the COD to discuss further and have a vote.

Nothing seemed too controversial and most resolutions passed by consent until the abortion resolutions were introduced. After

some discussion, a substitute resolution for neutrality was submitted. The COD then proceeded to explode into much heated debate with passionate testimony given again on both sides. Then a “suspension of rules” was given by the Speaker of the COD. The original resolution was then successfully passed without allowing the substitute resolution on neutrality to be debated or discussed. If I could have taken a selfie about that time, you would have been seen with “a deer in the headlights look.” I was stunned!

In the end, there was really no change to AAFP policy on abortion and that is either good or bad depending on which side of the aisle you are on.

We then went to dinner that evening to discuss all the Board candidates as well as the president and president elect candidates. Everyone weighed in on who they felt would be the best person to fill the positions and gave reasons for their decision. In the end, there was consensus on who the Missouri delegation would vote for.

The next day, the election results were announced and are included in the COD article in this issue of the magazine.

All and all, my experience at the COD was positive. However, I was surprised that many of the legislative priorities announced by leadership did not make it to the COD in the form of resolutions. I was disappointed in the number of resolutions submitted that were politically polarizing. The AAFP has so many important issues that we can find common ground on to be fighting for at the national level, but we debated issues that

seemed to create more division than commonality. That was disheartening.

To provide some balance to the abortion issue, a MIG (membership interest group) was formed by members who are passionate about protecting life and who are in opposition to abortion. There appears to be a very strong MIG that is in support of abortion so hopefully going forward this group will be able to provide balance to some of the morally divisive issues as they come up next year.

In summary, the MAFP received a “Leadership in State Government Advocacy Award”. Two resolutions were introduced to COD by the MAFP. The first was Resolution #201, Survey Membership on Legislative and Regulatory Issues. It was referred to Reference Committee on Organization and Finance.

It was voted to “Not Adopt”. This recommendation was carried as a consent agenda item at COD. The second, Resolution #505, Eliminating Barriers in Rural Communities for Cardiac Rehab, was adopted after being referred to the Reference Committee on Advocacy with the AAFP requesting CMS/National Coverage Determination for Cardiac Rehabilitation Programs rules to be modified to allow cardiac rehab programs in rural communities to operate without direct supervision of a physician when an AED is immediately available and nursing staff is trained in BLS and AED use.

I would like to thank the MAFP for giving me the opportunity to attend, participate and represent the MAFP as your President at this important event.

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2020 LEGISLATIVE SESSION BEGINS HERE'S WHAT YOU NEED TO KNOW

Volunteer to Present Testimony

House and Senate committees of interest to MAFP hold hearings on Tuesdays, Wednesdays, and Thursdays during session. Priority committees are House Health and Mental Health Committee, House Professional Registration and Licensing, Senate Health and Pensions, and Senate Professional Registration.

We need you to represent Missouri family physicians and present testimony at these hearings. With a usual 48-72 hours’ notice, Kathy Pabst will work with you to prepare your testimony and provide tips for a successful experience. Your voice is important and legislators need to hear from you. Contact Kathy at kpabst@mo-afp.org.

Weekly Legislative Updates

MAFP members began receiving weekly legislative updates on January 3, 2020. These reports include the status of MAFP priority bills and calls to action if we need you to reach out to your legislators. New in 2020, MAFP will utilize a Speak Out portal for you to easily and conveniently send a prepared message to your elected leaders.

Preceptor Tax Credit Legislation Introduced

Representative Jon Patterson (R-30), Lee’s Summit, is sponsoring a bill prepared by the Missouri Academy of Family Physicians, to establish a preceptor tax credit for primary care physicians and physician assistants. In collaboration with the Missouri Healthcare Workforce Coalition (MHWC), the legislation HB2036 was approved by both the MHWC and the MAFP this past fall.

The purpose of the tax credit is to strengthen primary care training. Currently, Colorado, Maryland, Georgia, and Hawaii have passed similar legislation. This bill would provide a $1,000 tax credit to primary care physicians who precept medical students. Primary care is defined as family medicine, internal medicine, pediatrics, psychiatry, or OB/Gyn. The preceptorship must consist of 120 hours (for one or more students) and the preceptor is eligible for up to 3 tax credits. This program is limited to a total of 200 preceptor tax credits for a total of $200,000 per year. Funding will be generated from a license fee increase of $7 per license for physicians and $3 for physician assistants. For more specific details, contact the MAFP office.

2020 LEGISLATIVE SESSION IMPORTANT DATES TO REMEMBER December 1, 2019 January 8, 2020 March 23-27, 2020 May 15, 2020

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Bill filing opens Session convenes Legislative Spring Break Last day for bills to be considered

MISSOURI FAMILY PHYSICIAN JANUARY-MARCH 2020

May 15, 2020 May 30, 2020 July 14, 2020 August 28, 2020 September 16, 2020

Last day to pass bills Session adjourns Governor’s approval by Effective date of laws Veto session

GME INFORMATION MEETING HELD AT RESEARCH FAMILY MEDICINE RESIDENCY PROGRAM, KANSAS CITY

Kavitha Arabindoo, MD, Research Family Medicine Residency, shares information about the economic impact of family physicians and workforce issues.

Legislators participated in a clinic tour at the Goppert-Trinity Family Care Clinic.

T

he MAFP and Research Family Medicine Residency Program hosted an informational meeting with three Kansas City legislators on December 16, 2019 (yes, during the first major snow this winter!). The purpose of this meeting was to inform the elected leaders on the importance of graduate medical education and the need to increase primary care residency slots.

Kavitha Arabindoo, MD, stated that “this informational interaction is imperative to educate our legislators on why graduate medical education is a crucial stepping stone to producing independent and well-trained family physicians.

Family physicians are uniquely qualified to care for patients from birth to end of life, and play a critical role in ensuring that our citizens in urban, rural and underserved areas receive the care that they deserve.” She continued, “It is time for the state of Missouri to invest in retaining Missouri medical students by

Brent Hrabik, MD, shares why GME is important to rural areas

enabling them to complete their residency training here and practice in Missouri. Evidence has shown that close to half of family medicine resident graduates tend to stay within the state that they trained in. It would hence help to increase our residency slots for primary care physician training.”

This sentiment was reiterated in the session on the state of family medicine in Missouri, the economic impact of a family physician, and a panel discussion on why graduate medical education is important. Residency faculty, medical school staff, and physicians in the Kansas City area presented these sessions.

A similar meeting is being planned in St. Louis during the summer of 2020. If you are interested in hosting a meeting with your legislators, please reach out to Kathy Pabst and she will provide you with a general outline and assist with the arrangements.

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FAMILY PHYSICIANS GATHER FOR THE 28TH ANNUAL FALL CONFERENCE

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he beautiful hills of the Ozarks drew over 175 family physicians in November to attend the 28th Annual Fall Conference at Big Cedar Lodge MO. A time for rejuvenation and education, the three-day conference was a blend of continuing medical education by eight experts on important topics for family physicians, and “fun”draising for the Family Health Foundation of Missouri.

Two full days of CME sessions were offered and covered topics on sexual health, fetal surgery for congenital anomalies, physician burnout, managing migraines, rheumatoid arthritis, medical literature review, pain management, diabetes and heart failure, and dermatology. These topics clearly represent the broad spectrum of care family physicians provide their patients.

A KSA on the Well Child was held on Sunday.

Family medicine residents and medical students gathered for a luncheon to plan next year’s Transition Conference for Family Medicine residents and students. They provided new ideas and concepts on how to improve the overall structure of the meeting. Underwater bowling (not really, but it looked like it) was a fun team-building activity that wrapped up their day.

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MISSOURI FAMILY PHYSICIAN JANUARY-MARCH 2020

The Family Health Foundation of Missouri held three “fun”draising activities to support the Tar Wars© program, support residents and students in developing their leadership skills, and medical student externships.

We raised over $4,100 through a wine pull, silent auction, raffle, and reception. Attendees’ skills were challenged as they played kiddy golf and corn-hole toss. The wine pull drew 38 donations from board members and exhibitors.

Two special bottles had $100 gift cards – but the wine was not quite so special. Four baskets were part of the silent auction and garnered interest from those interested in spending time at Margaritaville Lake Resort in Osage Beach, or Chateau on the Lake Resort in Branson. Other baskets included Missouri wine and a gift card, and a children’s books and toys basket. The 50/50 raffle raised a total of $2,110 and Bridget Gruender, MD, Columbia was the winner of $1,055.

Thank you to all who participated by donating wine, attending the reception, purchased raffle tickets, or bid on the silent auction items. We need your continued support so the Foundation can continue its mission to advance Missouri family physicians.

Thank You To Our Exhibitors And Conference Sponsors.

Your support enables this conference to continue to be affordable and of value to family physicians.

Diamond Sponsor

SSM Health (this includes a ½ page ad)

Conference Sponsor

Direct Primary Care Clinics, Osage Beach

Family Health "Foundation of Missouri "Fun"draiser Sponsor Compass Health Network

Exhibitors Alexion Pharmaceuticals Anthem Blue Cross AstraZeneca

Missouri Telehealth Network MoDocs

Babylon Health

National Diabetes Prevention Program

Barnes Jewish Hospital

Novartis

Bristol-Myers Squibb

Novo Nordisk

Citizens Memorial Hospital

Path Group

Compass Health Network

PDRx Pharmaceuticals, Inc.

CoxHealth

Primaris

Crossroads Hospice Charitable Foundation

SoutheastHEALTH

Docs Who Care

SSM Health

Exact Sciences/Cologuard

SSM Health Saint Louis University

Home State Health

Teva Pharmaceuticals, Inc.

CALL FOR PRESENTATIONS

Kansas City Southwest Clinical Society

U.S. Army Medicine Civilian Corps

Are you a subject matter expert in a specialty within family medicine? Share your knowledge by presenting at a future MAFP conference. We need your expertise to present relevant topics for your colleagues. Call or email the MAFP office today to be included in the 2020 lineup.

Telephone: (573) 635-0830 or office@mo-afp.org.

Mercy Clinic

US Army Medical Recruiting

Missouri Athletic Trainers Association Missouri Health Professional Placement Services

MEMBERS IN THE NEWS Barbe to Lead World Medical Association

David Barbe, MD, of Mountain Grove, has been elected president-elect of the World Medical Association (WMA).

Delegates from more than 100 countries elected him during their annual convention in the eastern European city of Tbilisi, Georgia. Dr. Barbe will serve one year as president-elect and will be inaugurated as president of the WMA in October 2020 during the annual meeting in Córdoba, Spain.

Dr. Barbe has been a family physician in Mountain Grove for 36 years. In addition, he has held leadership roles with Mercy, the Missouri State Medical Association and as the recent past president of the American Medical Association.

While Dr. Barbe didn’t set out to lead health care discussions on an international level, he did want to improve care for more than just the patients in his hometown. “If I sit in my office in Mountain Grove, I can care for about 3,000 patients and my community,” he said. “I wanted to help more people than that, so I got involved on a state level, then nationally. It’s so gratifying to think that in this role, I’ll be able to help improve patient care around the world.”

The WMA, which has an official relationship with the World Health Organization, is an international organization representing more than nine million physicians. Its members include 114 national medication associations. For the past three years, Dr. Barbe has been one of the three delegates from the AMA to the WMA.

Paulson Admitted to AACOM 2019-2020 Class of OHPF Fellows John Paulson, DO, PhD, FAAFP, has be admitted to the American Association of Colleges of Osteopathic Medicine (AACOM) Osteopathic Health Policy Fellowship (OHPF) class of 2019-2020: The OHPF is a national program designed to prepare emerging leaders in the osteopathic profession to engage in health policy discussions, analysis, and formulation. Alumni of the program have served as policy advisers in public and private forums to the profession, legislators at the local and national levels, diverse health institutions, and other health leadership groups.

Paulson will attend ten weekend sessions and perform extensive work outside of these sessions that enhances his ability to evaluate, articulate, and formulate concise and objective assessments of health policy issues. Fellows further complete two health policy issue analysis briefs and present them to their colleagues and other leaders in policy issues. A strong mentor network provides research, writing, and editorial support.

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MISSOURI FAMILY PHYSICIAN JANUARY-MARCH 2019

DO YOU HAVE NEWS TO SHARE?

Email it to office@mo-afp.org for review.

We love to hear from our members!

Todd Shaffer, MD, MBA, FAAFP Announces Campaign

Todd Darian Shaffer MD, MBA has announced his candidacy for election to the AAFP Board of Directors.

He is a Past President and Chairman of the Board of the Missouri Academy of Family Physicians. He Served on the Association of Family Medicine Residency Directors Board of Directors for 7 years- also serving as its president and Chair. He was also Chairman of the Council of Academic Family Medicine. He Todd Darian Shaffer MD proudly served for the 15 years as the Program Director of a 42 resident, 3 fellowship, combined AOA/MD residency program with an integrated MBA in Physician Healthcare Leadership in a University Family Medicine Residency Program providing care in a Safety Net Community Hospital. He is a core leader in the UMKC - Department of Family Medicine, medical staff of our teaching hospital, state family medicine association, and other community organizations. He has helped lead the residency and department with innovations to EHR, asynchronous adult learning, and improved patient satisfaction through patient centered care. He initiated a rural immersion expansion program supported by an $1.92 million dollar grant from HRSA that he authored. He has had the opportunity to be identified as a key leader in their hospital administration and to have the opportunity to work on many task forces for strategic planning from the local level through to the AAFP Working Party, AAFP Commission on Insurance and Finance, AAFP Commission on Continuing Professional Development and AFMRD Leadership. He advanced to full Professor of Medicine in July 2008 at the University of Missouri-Kansas City and was recognized by his alma mater (Mizzou) by being inducted into Alpha Omega Alpha. He is one of a handful of physicians in the country who has graduated from a Physician Healthcare Leadership MBA program. 2020 is his 36th year in the University of Missouri System. AAFP Congress of Delegates will elect new board members October 12-14, 2020, in Chicago.

Pabst Serves on Missouri Immunization Coalition In early 2019, key stakeholders interested in improving the immunization rates in Missouri gathered in Jefferson City to discuss the formation of a coalition to achieve this goal. Over the last 6 months, these stakeholders have met to develop goals and objectives, and adopted bylaws. It is currently in the legal process of forming a non-profit organization which includes electing board members. Kathy Pabst, MBA, CAE, MAFP Executive Director, will serve a two-year term as treasurer of this coalition. Kathy applied for and received an AAFP Foundation, Family Medicine Philanthropic Consortium grant to help establish a web presence and a communications campaign for this group.

Kate Lichtenberg, DO, FAAFP, St. Louis, also serves on this coalition.

UMC Faculty Featured in Podcast Laura Morris, MD, MPH, and Alex Fink, MD, University of Missouri Columbia, were featured in the AAFP’s October AFP podcast. Their Help Desk Answer on thickened feeds for infants with gastroesophageal reflux will also be published in the American Family Physician magazine.

MAFP Announces Reorganization The 2019-2020 MAFP Strategic Plan that was passed by the Board of Directors in November, 2018, and published in the January-March, 2019 Missouri Family Physician magazine, includes aggressive tactics in public relations and communications. When reviewing the current staff job descriptions, it was decided that they needed to be updated to reflect our Strategic Plan. The MAFP is currently searching for an Assistant Executive Director and a Member Communications and Engagement Coordinator.

With this change, look for enhanced communications and expanded outreach efforts in Missouri.

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MU SCHOOL OF MEDICINE PARTNERS WITH MISSOURI BOARD OF HEALING ARTS TO COLLECT PHYSICIAN WORKFOR CE DATA

IT’S TIME TO PAY YOUR DUES

The Missouri Board of Healing Arts and the MU School of Medicine are collaborating to collect workforce data to better understand Missouri’s physician workforce in Missouri. Physicians receive a link to the survey when completing their license renewal. The survey link is also available below. The portal to renew physician licenses is open until January 31, 2020.

Thank you for your past membership in the American Academy and Missouri Academy of Family Physicians. We appreciate your support of our efforts to promote family medicine in Missouri. If you haven’t paid your dues, it is easy by clicking https://nf.aafp.org/myacademy/ memberdues/checkmydues and pay online.

The survey results will be used in conjunction with other health care workforce data to inform local and state policymakers, public and private health care providers, and health care workforce training programs to better meet Missourians’ health care needs and to ensure the best possible outcomes for Missouri’s population health.

You ask, what have we done for you lately?

We have:

“This project is a decade-long collaboration of the Missouri Healthcare Workforce Advisory Group to plan, develop and implement a system to collect data to benefit Missourians,” said Kathleen Quinn, PhD, associate dean for rural health.

“We’re monitoring trends and developing training programs to understand our state’s distribution of health care professionals and meet the needs of local communities.”

• Offered over 25 hours of CME • Worked with 163 state representatives and 34 senators and testified at many committee hearings • Reviewed 1,864 bills and tracked over 100 bills impacting family physicians during the 2019 legislative session • Met with our U.S. Senators and Congressmen/women • Supported federal regulations increasing physician reimbursement • Funded residents and student’s leadership opportunities through conference attendance and externships • Reached over 900 4th and 5th graders through the TarWars© program • Received three AAFP grants: o Health equity o Transition Conference for FM Residents and Students o Missouri Immunization Coalition • Received the Leadership in State Government Advocacy Award • Collaborated with other medical professional organizations on issues of common interest • Founding organizer and member of the Missouri Immunization Coalition • Spoke to Family Medicine Interest Groups and residency programs on the importance of engagement in organized medicine • And the list goes on

We are here for you…

can we count on your support to continue and expand our efforts?

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MISSOURI FAMILY PHYSICIAN JANUARY-MARCH 2019

Please use this link to access the survey: https://missouri. qualtrics.com/jfe/form/SV_50gEEUSPgnf48lL. If you have any issues with the survey please contact Jill Lucht, Survey Administrator, at luchtj@health.missouri.edu.

MAFP REPRESENTED ON RADIOLOGIC TECHNICIAN LICENSURE TASK FORCE During the 2019 legislative session, SB 514 was passed which created the Joint Task Force on Radiologic Licensure and MAFP was specifically mentioned to have representation on this task force. On Wednesday, December 4, the joint task force held its first meeting. Douglas Crase, MD, of Texas County Memorial Hospital volunteered to serve as the MAFP representative given his past experience as a radiology tech. Brian Bernskoetter, MAFP legislative consultant, also attended the initial meeting which covered a host of topics on the issue including exemptions, scope of licensure, workforce management issues, and testing for certification. The next meeting will take place December 20 which is after this magazine has gone to print.

Look for an update on this issue in the Show Me State Update. A final report is due before the start of the legislative session which is January 8, 2020.

ABFM: IMPORTANT ANNOUNCEMENT REGARDING FAMILY MEDICINE CERTIFICATION EXAM The American Board of Family Medicine announced in November that potential candidates for the 2020 administration of the one-day exam (for those who choose this option) that starting with the April 2020 one-day examination, ABFM will no longer offer content-specific modules as part of the one-day exam. This decision was made due to the overwhelming initial popularity of the Family Medicine Certification Longitudinal Assessment (FMCLA) pilot, and the percentage of eligible Diplomates in their tenth year of certification who chose to take the one-day examination in 2019 dropped below 25%. Given the shift in physicians participating in the one-day examination, the ABFM’s analysis indicated that only two out of the seven modules offered – Ambulatory Family Medicine and Maternity Care – will have a sufficient number of participants to allow for reliable scoring. Therefore, going forward, the exam will consist of four sections with 75 questions each and the number of items will reduce from 320 questions to 300 questions. Examinees will have the same amount of time per question as on previous exams.

This decision builds on trends the ABFM has followed over several years. In 2016, the ABFM Board of Directors elected to drop from two modules to one module for the one-day examination, based on psychometric data that showed no advantage with respect to exam pass rates.

And in 2019, the Child & Adolescent Medicine module was removed from the one-day examination due to having too few responses to those questions to reliably score them on future exams. Our ongoing evaluation of examinee performance confirms that this planned elimination of modules as part of the one-day examination would not disadvantage candidates with respect to pass/fail rates. If you have questions about the changes in the one-day examination, please contact the ABFM Support Center at 877-223-7437 or help@theabfm.org.

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REFERENCES: Pages 8-10

1. U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans, 2nd edition. Washington, DC: U.S. Department of Health and Human Services; 2018.

Page 11

1 Hales CM. Fryar CD. Carroll MD. Freedman DS. Ogden CL. Trends in obesity and severe obesity prevalence in US youth and adults by sex and age, 2007-2008 to 2015-2016. JAMA 2018;319:1723-1725.

2 Saxon DR, et al. Antiobesity medication use in 2.2 million adults across eight large health care organizations: 20092015. Obesity 2019;27:1975-1981.

3 Nicklas JM, Huskey KW, Davis RB, Wee CC. Successful weight loss among obese US adults. Am J Prev Med. 2012;42:481– 485.

Page 12-13:

1. Benjamin EJ, Muntner P, Alonso A, et al. Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association. Circulation. 2019;139(10):e56-e528.

2. Marquis-Gravel G, Roe MT, Harrington RA, et al. Revisiting the Role of Aspirin for the Primary Prevention of Cardiovascular Disease. Circulation. 2019;140(13):1115-1124.

3. Gaziano JM, Brotons C, Coppolecchia R, et al. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial. Lancet.

2018;392(10152):1036-1046.

4. Group ASC, Bowman L, Mafham M, et al. Effects of Aspirin for Primary Prevention in Persons with Diabetes Mellitus. N Engl J Med. 2018;379(16):1529-1539.

5. McNeil JJ, Woods RL, Nelson MR, et al. Effect of Aspirin on Disability-free Survival in the Healthy Elderly. N Engl J Med. 2018;379(16):1499-1508.

6. McNeil JJ, Wolfe R, Woods RL, et al. Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly. N Engl J Med. 2018;379(16):1509-1518.

7. McNeil JJ, Nelson MR, Woods RL, et al. Effect of Aspirin on All-Cause Mortality in the Healthy Elderly. N Engl J Med. 2018;379(16):1519-1528.

8. Cole BF, Logan RF, Halabi S, et al. Aspirin for the chemoprevention of colorectal adenomas: meta-analysis of the randomized trials. J Natl Cancer Inst. 2009;101(4):256266.

9. Rothwell PM, Fowkes FG, Belch JF, et al. Effect of daily aspirin on long-term risk of death due to cancer: analysis of individual patient data from randomised trials. Lancet.

2011;377(9759):31-41.

10. Mahmoud AN, Gad MM, Elgendy AY, et al. Efficacy and safety

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of aspirin for primary prevention of cardiovascular events: a meta-analysis and trial sequential analysis of randomized controlled trials. Eur Heart J. 2019;40(7):607-617.

Pages 14-17

Boriani, F. e. (2014). Metabolic Effects of Large-Volume Liposuction for Obese Healthy Women: A Meta-Analysis of Fasting Insulin Levels. Aesthetic Plastic Surgery, 1050-1056.

Hamdy, O. e. (2006). Metabolic Obesity: The Paradox Between Visceral and Subcutaneous Fat. Current Diabetes Reviews, 367-373.

Klein, S. M. (2004). Absence of an Effect of Liposuction on Insulin Action and Risk Factors for Coronary Heart Disease. The New England Journal of Medicine, 2549-57.

Marcadenti, A. e. (2015). Different Adipose Tissue Depots: Metabolic Implications and Effects of Surgical Removal.

Endocrinologia y Nutricion, 458-464.

Pinney, S. e. (2018). Effects of Cryolipolysis on Testosterone.

Dermatologic Surgery, 142-143.

Robles-Cervantes, J. A. (2007). Behavior of Insulin Sensitivity and Its Relation to Leptin and Tumor Necrosis Factor-Alpha in Obese Women Undergoing Liposuction: 6-Month Follow-up.

Obesity Surgery, 1242-1247.

Sailon, A. e. (2017). Influence of Large-Volume Liposuction on Metabolic and Cardiovascular Health. Annals of Plastic Surgery, 623-630.

Seretis, K. e. (2015). The Effects of Abdominal Lipectomy in Metabolic Syndrome Components and Insulin Sensitivity in Females: A Systematic Review and Meta-analysis.

Metabolism, 1640-1649.

Vinci, V. e. (2016). Metabolic Implications of Surgical Fat Removal. Annals of Plastic Surgery, 700-704.

Pages 18-19

1. https://www.theatlantic.com/business/archive/2016/06/ how-marketers-invented-the-modern-version-ofbreakfast/487130/ 2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4250148/ 3. Carroll A., Three Squares: The Invention of the American Meal.

Basic Books; 2013. Page 192 4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3941741/ 5. Annu. Rev. Nutr. 2017. 37:371–93 6. Sutton EF, Beyl R, Early KS, Cefalu WT, Ravussin E, Peterson CM. Early Time-Restricted Feeding Improves Insulin Sensitivity, Blood Pressure, and Oxidative Stress Even without Weight Loss in Men with Prediabetes. Cell Metabolism [Internet]. 2018 Jun 5 [cited 2019 Dec 9];27(6):1212-1221. e3. Available from: http://www.sciencedirect.com/science/ article/pii/S1550413118302535

Missouri Academy of Family Physicians 722 West High Street Jefferson City, MO 65101

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