Depression leads to internal fat in 70-somethings

CHICAGO – Older people who are depressed are much more likely to develop a dangerous type of internal body fat — the kind that can lead to diabetes and heart disease — than people who are not depressed, a disturbing new study found.

The connection goes beyond obesity and suggests some biological link between a person's mental state and fat that collects around the internal organs, scientists said.

"For the depressed public, it should be another reason to take one's symptoms seriously and look for treatment," said study co-author Stephen Kritchevsky, director of the Sticht Center on Aging at Wake Forest University in Winston-Salem, N.C.

People with depression were twice as likely as others to gain visceral fat — the kind that surrounds internal organs and often shows up as belly fat. It raises the risk for heart disease and diabetes.

Previous research has linked depression with those same health problems. Some researchers believe depression triggers high levels of the stress hormone cortisol, which promotes visceral fat. The cortisol connection may explain the findings, Kritchevsky said.

The research, published in Monday's Archives of General Psychiatry, is the first large study to track people over time to see if those with depression were more likely to gain weight. Mostly federally funded, the study used data from 2,088 people in the ongoing Health, Aging and Body Composition study. That project is following healthy older Americans to find out how changes in bone, fat and lean body mass affect health.

The participants, all in their 70s, were recruited in and around Memphis, Tenn., and Pittsburgh in 1997 and 1998 and were followed for five years. Researchers screened for symptoms of depression at the start of the study and again at four follow-up visits.

They measured visceral fat with CT scans. They calculated body mass index, body fat percentage, waist size and the distance between the back and the biggest part of the belly.

There were 84 people with depression symptoms at the start of the study. They gained, on average, 9 square centimeters of visceral fat. In contrast, the 2,004 people who weren't depressed lost visceral fat — on average, 7 square centimeters.

That variation "could mean the difference between developing a cardiovascular disease or not," said lead author Nicole Vogelzangs of VU University Medical Center in Amsterdam, the Netherlands, in an e-mail.

Both groups, depressed and non-depressed, were overweight on average at the start of the study, with approximately the same average body mass index. When the researchers took into account other risk factors for obesity, including the depressed group's higher visceral fat levels in the beginning, they still found a connection between depression and visceral fat gain.

They also found a similar link to visceral fat gain in people with recurring depression over the years. Adjusting for antidepressant use didn't change the findings either.

Researchers didn't make adjustments for poor eating habits, but they found no link between depression and BMI or body fat percentage.

"Since such an increase in overall obesity was not clearly found, we believe a biological explanation is more likely" than poor diet, Vogelzangs said.

The researchers did find hints of a depression link with waist circumference and the back-to-belly measurement — two other gauges of visceral fat.

That suggests depression has a specific tie with fat gained around the organs in the abdomen. The good news is visceral fat is easier to lose than subcutaneous fat, Kritchevsky said.

Dr. David Baron of Philadelphia's Temple University School of Medicine praised the study, although he wanted to know more about the participants' family history of obesity. The connection between brain and body makes sense, he said.

"Depression is a physical illness," Baron said. "Maybe we should be even more aggressive in treating depression in this age group, whether through medication or talk therapy."

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On the Net: Archives of General Psychiatry: http://archpsyc.ama-assn.org/

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Asthma inhalers to go 'green' on Dec. 31

WASHINGTON – Last warning: Asthma inhalers go "green" on Dec. 31, forcing patients still using the old-fashioned kind to make a pricey and even confusing switch. The medicine inside these rescue inhalers — the albuterol that quickly opens airways during an asthma attack — isn't changing. But the chemicals used to puff that drug into your lungs are.

No more chlorofluorocarbons, or CFCs, that damage Earth's protective ozone layer. By year's end, all albuterol inhalers must be powered by the more eco-friendly chemical HFA, or hydrofluoroalkane.

The down side: The new inhalers cost more, $30 to $60 compared to as little as $5 or $10 for the disappearing generic CFC inhalers.

And patients face a learning curve. HFA inhalers must be used differently than the old-fashioned kind. The medicine feels and tastes different, sometimes alarming new users despite doctors' assurances that it works just as well.

"There's still significant confusion," says Dr. Harvey Leo of the University of Michigan's C.S. Mott Children's Hospital. "Patients will tell you, 'I don't feel the puff anymore.'"

Calls from parents unsure how to use the new inhalers, or even what they are, have increased in the past two months as more drugstores run out of CFC-powered inhalers and automatically switch people who'd been expecting a mere refill, he adds.

The change shouldn't be a surprise. The Food and Drug Administration has long warned it was coming, and lung specialists have spent the past year easing many of the nation's 20 million asthma patients — as well as millions of emphysema sufferers who also use albuterol to ease breathing — into it.

But industry figures show that in mid-November, 20 percent of all albuterol prescriptions still were being filled with CFC versions.

Some patients may purposefully be buying up cheaper CFC inhalers before the sales ban. But many patients don't see a lung specialist, or their prescription may not expire until next year so they haven't been seen recently enough to be told.

Reaching the last fraction "is, as you can imagine, a very difficult task," says Dr. Bidrul Chowdhury, FDA's pulmonary drugs chief. "How to get to somebody who is not tuned in?"

The CFC-free options: GlaxoSmithKline's Ventolin HFA, Schering Plough's Proventil HFA and Teva Specialty Pharmaceuticals' ProAir HFA all contain albuterol. Also, Sepracor's Xopenex HFA contains the similar medication levalbuterol.

Albuterol inhalers are for emergencies, for quick relief of wheezing. Patients also need daily medication to control their asthma and prevent flare-ups. Someone who's using the albuterol inhaler more than a few times a month isn't well-controlled, and his or her doctor needs to determine why, stresses Dr. Paul Greenberger of Northwestern University, president-elect of the American Academy of Allergy, Asthma & Immunology.

Here's the rub: Recent research suggests only one in five children has their asthma under good control; no one knows how many adults do.

The last to go CFC-free will be the poor and uninsured whose asthma is less likely to be controlled, says Leo, who researches that issue at Michigan's Center for Managing Chronic Disease.

Albuterol manufacturers are providing free samples and posting coupons on their Web sites.

Still, specialists worry that some patients will try to save money with a decades-old nonprescription inhaler that contains a different drug, epinephrine, best known by the brand name Primatene Mist — inhalers that also contain ozone-harming CFCs. National asthma guidelines argue against such self-treatment as too risky and less effective than albuterol. The government will allow sale of those over-the-counter inhalers until December 2011 as manufacturers reformulate.

Leo has another concern: Only one of the new inhalers counts doses used. He's monitoring emergency-room statistics to see if cost-conscious patients trying to squeeze out last drops wind up using empty inhalers.

What do patients need to know as they switch?

_Expect a softer puff instead of the CFC version's cold blast of air in the back of the throat.

"They are getting their medicine," says Dr. David Rosenstreich of New York's Montefiore Medical Center. "They have to get used to it and be aware that it's working."

_The new inhalers clog more often because HFA makes the drug stickier. Clean the hole weekly, following the instructions unique to each brand.

_Never get the whole device wet.

The FDA says there's plenty of supply; it gave manufacturers several years to ramp up before the ban.

But don't wait until the last minute. When Eric Stoermer of Ann Arbor, Mich., made the switch in August, he waited a week for a new inhaler for his 11-year-old son Ethan. Their drugstore was temporarily out of stock.

"I ended up having to hunt around on an emergency basis," Stoermer says. "This is a bad thing to run out of."

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EDITOR's NOTE — Lauran Neergaard covers health and medical issues for The Associated Press in Washington.

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Some doctors may give up vaccines because of cost

ATLANTA – About one in 10 doctors who vaccinate privately insured children are considering dropping that service largely because they are losing money when they do it, according to a new survey.

A second survey revealed startling differences between what doctors pay for vaccines and what private health insurers reimburse: For example, one in 10 doctors lost money on one recommended infant vaccine, but others made almost $40 per dose on the same shot.

The survey was revealing even to some doctors. "Many physicians really weren't aware and that they were getting reimbursed so little," said Dr. Gary Freed of the University of Michigan, a co-author of both articles published in the December issue of the journal Pediatrics.

The studies are the first to attach numbers to doctors' long-simmering complaints that they are only breaking even — or even losing money — when they give shots.

"It's a pleasure to see a real study to show we're not just making this up," said Dr. Herschel Lessin, a pediatrician in Hopewell Junction, N.Y. who said his practice's spending on vaccines has more than doubled from 2006 to 2007.

Experts say there's no evidence that significant numbers of doctors are quitting the vaccination business yet because of financial concerns.

But health officials are worried. Reimbursement concerns were behind an exodus of doctors from vaccine programs in the 1980s, which contributed to a terrible resurgence of measles in 1989-91 that caused 11,000 hospitalizations and 123 deaths.

This year, U.S. measles cases rose to the highest level in more than a decade, mainly because some parents are opting out of getting their kids vaccinated.

Health officials fear that problem, along with doctor's economic concerns, could set the stage for bigger outbreaks in the future.

"This is a very important wake-up call," said Dr. Lance Rodewald of the U.S. Centers for Disease Control and Prevention, referring to the two new studies.

The first study was based on a mail-in survey last year of nearly 1,300 pediatricians and family physicians; nearly 800 responded.

About half said they had delayed buying at least one vaccine because of the cost. Roughly one in five said they felt strongly that reimbursement for the purchase and administration of vaccines was not adequate.

The second survey asked doctors what they paid for vaccines and how much they were reimbursed by private insurers. It was answered by 76 doctors in five states, representing about 20 percent of those asked to participate. Many contracts prevent doctors from talking about their spending and reimbursement for vaccinations, Freed said.

One example of the disparity was a vaccine that protects against pneumococcal disease. The per-dose difference ranged from a $40 profit to an $11 loss. A chickenpox vaccine netted some doctors $35 but cost others nearly $30 per dose.

The survey examined the cost of the vaccines and the expense of storage and related medical supplies. But it didn't look at administrative fees and staff time.

The studies did not look at the 50 percent or more of vaccinations paid for by government, which generally provides free vaccines to doctors and covers administrative fees.

In New York state, some doctors actually do better financially with the government vaccine program than they do on the private market, with the government's administrative fee double or triple what some private insurers pay. But some business-savvy doctors can still make at least a small profit on vaccines in the private market, said Lessin, who is vice president of a 24-physician pediatric practice.

Most pediatricians are likely to keep giving vaccinations to kids, partly because of altruism and partly because giving shots drives business. "For us to give up vaccines would hurt our core business because that's why kids come in," Lessin said.

But family practice doctors — who are not as dependent on vaccinations for patients — may decide the shots are too much of a financial headache, he added.

Indeed, the new studies reflected that schism: Overall 11 percent of physicians have seriously considered stopping vaccinations for privately insured patients. But 21 percent of family doctors felt that way, compared with just 5 percent of pediatricians.

The financial problem has been getting worse in recent years, as more vaccines have come on the market, experts say. Some have been unusually expensive, including Gardasil, a vaccine for girls against cervical cancer which is given in three doses over six months and is priced at about $375 for the series.

A government advisory panel studying the financial burden of vaccines is expected to submit proposals for changes in reimbursement practices to federal health officials next year.

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On the Net:

Pediatrics: http://pediatrics.aappublications.org/

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