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What is the best way to treat older HIV infected patients?

Louis and his poodle, Doodles, on one of their four walks every day
Louis and his poodle, Doodles, on one of their four walks every day

A year ago, HIV patient Louis Zimmerman considered himself sedentary. But thanks to his participation in a CU Anschutz exercise study, he now is able to walk his one-year-old poodle, Doodles, four times a day.

“I’m walking faster with more pep in my step,” says Zimmerman, 66, one of about 50 participants in a study of HIV-infected patients, run by Kristine Erlandson, MD, assistant professor of infectious diseases in the CU School of Medicine, with an adjunct appointment in geriatric medicine.

Kristine Erlandson, MD
Kristine Erlandson, MD

Erlandson, who is board certified in internal medicine and infectious disease, specializes in treating frail and older HIV-infected patients. Affiliated with CU Anschutz since 2008, Erlandson also conducts research studies on patients who have lived decades with HIV.

Erlandson says she became interested in learning about AIDS in high school and was an HIV educator in college. She particularly remembers Ryan White, an Indiana teen who got HIV from a blood transfusion and helped start the movement to stop AIDS discrimination.

“He was a similar age as I was and it stood out for me,” she says.

As for her interest in HIV and aging, she added:  “As a fellow during my infectious diseases training, I was most surprised by the HIV patients who would come into the hospital – they had diseases that should be impacting much older people.”

Erlandson sees commonalities in the challenges of her older HIV patients and hopes her studies will improve lives.

“Most of the people I focus my research on are those diagnosed with HIV back in the late ‘80s or early ‘90s who are now experiencing the long-term side effects of drug therapies that go back 20 or 30 years,” she says.

Zimmerman is a participant in one of Erlandson’s studies that measures how exercise can improve the health of sedentary people ages 50-75. One group is HIV-infected and the other study subjects don’t have HIV. Both groups are in stable health and work out as part of the study for six months at the university’s research gym.

During the study, Zimmerman walked on the treadmill and worked with weights three days a week.  At the end of six months, he says he felt stronger and had more energy. His outcomes are similar to other participants’ experiences, Erlandson says.

“Almost everyone has marked improvements in their strength and endurance,” she says. “And we’ve seen good improvements in basic physical function measures, such as the ability to walk a quarter mile and the speed to rise from a chair.”

A patient’s experience

Louis and Doodles
Louis and Doodles

Doctors diagnosed Zimmerman with HIV and Hepatitis C in 1996 at age 47.

A delivery person for Dolly Madison Bakeries, Zimmerman said he tried to go to work one day and collapsed.

“I couldn’t stand up any longer,” he says. He learned he had pneumocystis pneumonia, an infection fairly common in people with compromised immune systems.

At first, Zimmerman, who had many friends and acquaintances die of AIDS, thought it was a death sentence. But then he started doing research on HIV.

“I didn’t have any information prior to the diagnosis,” he says. “But I started doing research and I’ve kept it up ever since. That’s my job now.”

Zimmerman also has been active in HIV research studies. He’s participated in nine clinical trials since his diagnosis. A tough treatment regimen cured his Hepatitis C, but the early HIV treatments were harder on the body than today’s drug regimens. As a result, he’s suffered neuropathy and had fat loss (lipatrophy) in his face. He also was diagnosed with a rare form of skin cancer that has required 25 radiation treatments.

The work ahead

In addition to her exercise study, Erlandson has also studied the factors that contribute to frailty in HIV patients and how to prevent them. She’s recently started a study in conjunction with the AIDS Clinical Trials Group to look at the effect of statins on physical function in HIV patients.

Erlandson’s hope is that her work will not only help her HIV patients, but that her trainees will have a greater understanding of how to manage HIV and help prevent HIV-associated complications in aging.

“There’s still a lot of research to be done by the next generation of physician scientists,” she says. 

Living a positive life

In the nearly 20 years since Zimmerman was diagnosed with HIV, he says he’s stronger than he realized and he doesn’t give up.

“If I start thinking about anything negative, I get it out of my brain right away,” he says. “Dying is the last thing I think about.”

His advice to fellow HIV patients is to stay positive and build a social network of supportive friends and family.

Zimmerman’s year-old poodle, Doodles, is his constant companion. He laughs as he talks about how she walks on her hind legs like a bear. He says he wants to stay healthy for her.

Says Zimmerman, “A dog lives 15 years, so I have 14 more years to be alive for my puppy.”

Guest Contributor: Kathleen Bohland

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Four generations of one family receive MDs at CU

The line of physicians in the Kenagy-Vance family stretches across states, continents and generations. For centuries, these medical men have guided the health of communities from Switzerland to Pennsylvania to Idaho and beyond.

And most of their skills were acquired in the same place – the University of Colorado School of Medicine (SOM). Four generations of the family received their MDs here. Dr. John Brough (JB) Kenagy started it all when he graduated from the SOM – located in Boulder then – in 1906.

The family’s next two physicians – Drs. Fayre H. Kenagy (class of 1920) and J. Corwin (Corky) Vance (class of 1971) – attended the medical school in Boulder and then the CU Health Sciences Center in Denver. Corky’s father, Edward Pershing Vance, who married Barbara Eloise Kenagy, took a different path: He enjoyed a successful career in natural resource stewardship in the Pacific Northwest. Dr. Karl Kenagy Vance, son of Corky and Karen Vance, extended the family’s black-and-gold legacy into the 21st century by attending medical school at the CU Anschutz Medical Campus from 2005 to 2009.

Fayre Kenagy at Denver General Hospital
Fayre H. Kenagy, center, is pictured at the old Denver General Hospital circa 1917. Fayre was the second member of the Kenagy family to receive his MD from the CU medical school.

Karl applied to about 10 medical schools, but chose CU. “The combination of the high-quality education at the medical school and the lifestyle of being in Colorado factored in,” says the avid cyclist and skier. “Also, it was something I thought would be cool – that I would be the fourth generation of my family to go to the CU School of Medicine.”

Swiss start

The family history of physicians goes back to Bern, Switzerland, where Corky’s sixth great grandfather, Hans Gnage, practiced medicine before fleeing the country over religious persecution of Mennonites. “Family legend has him seeing a patient when the police came to arrest him for draft evasion,” Corky says. “His wife had the policeman sit down to wait for him and offered food and drink, but then sent their son to tell his father to leave the country instead of coming home. His family joined him later.”

Hans arrived in Pennsylvania in 1742 and joined the Amish community, where he resumed work as a physician. It would be several generations later when JB Kenagy, born and raised in a Mennonite community in Ohio, would leave his career as an educator and move from Gunnison to Boulder. After graduating from CU medical school in 1906 he moved to Rupert, Idaho, to practice internal medicine.

His son, Fayre Kenagy, aspired to become a doctor just like his father. He was drafted into World War I but received a deferment to finish his medical degree.

Keeping the CU tradition going

It was Fayre who delivered J. Corwin Vance in August 1945, starting a lifelong bond with the boy who went by the nickname Corky. “I was in awe of my grandfather and wanted to follow in his footsteps. I therefore also attended the CU medical school,” Corky says. “When Karl was born, we named him Karl Kenagy Vance, after his grandfather. He later decided to attend the CU medical school as well, having heard how great it was.”

Drs. Vance sip cappuccinos in Italy
Drs. Corky and Karl Vance take a break from cycling to enjoy cappuccinos during a family vacation in Italy last fall.

The elder Dr. Vance is now retired, but Karl worked with his father during the final year of his practice in Minneapolis. Karl now works with several of Corky’s longtime staff members, though in a different dermatology practice. The Twin Cities are a fitting home for the Vances as twin interests abound in father and son, including a shared love of fine food and wine. When they aren’t pursuing culinary interests, you can find Corky and Karl on their bicycles or in planes traveling the world. Sometimes they’re globetrotting and cycling – as they did on a recent family trip to Italy.

Incidentally, they both met their wives while attending the CU medical school. Corky met Karen while she was a lab technician, and Karl hit it off with Pamela while out on the town with classmates.

Karl and Corky Vance in the CU School of Medicine
On Karl’s graduation day in 2009, Drs. Karl and Corky Vance stand in front of the photos of CU School of Medicine classes of 1919 and 1920 in the SOM. Corky was inspired to pursue medicine by his grandfather, Fayre H. Kenagy, who is pictured in the class of 1920.

Just as Corky was inspired to pursue medicine by his grandfather, Karl looked up to his father, who became the first dermatologist in the Twin Cities to perform Mohs surgery – a micrographic procedure that removes skin cancers. “He found it rewarding. Growing up around medicine, you get an understanding of the process, the responsibilities and the ups and downs of it,” Karl says. “Mostly, it’s a fulfilling career because it’s a daily opportunity to help people.”

Camaraderie with CU classmates

Excellence in clinical care

“If you want to get clinically grounded, the CU School of Medicine is as good as any,” says Dr. Corky Vance, who attended the SOM from 1967 to 1971. “I got to see acute and emergency care at Denver General, and at University Hospital I got to see the rare cases you heard about from your professors. We also went out to the Fitzsimons Army Hospital (as it was known then) and saw cases and procedures that you were going to see in your own practice. There was a real advantage to having that much exposure to clinical practice.”

The retired physician says the SOM is even better since moving to the CU Anschutz Medical Campus. “Having everything together – with the hospitals on campus, as well as the VA – it really makes it even easier to get clinical exposure.”

Unlike the camaraderie he enjoyed at CU Anschutz, Karl struggled to connect with his pre-med classmates as an undergraduate at Stanford University. But he excelled in chemical engineering, and it wasn’t long before he connected that discipline to his burgeoning interest in wine. After graduating from Stanford, he became an assistant wine maker in Northern California and Australia. A few years later, however, he realized that winemaking couldn’t quite match the fulfillment of medicine.

At CU Anschutz, Karl loved his classmates – “It was hard to find people who weren’t into skiing and biking,” he says. And he was influenced by Dr. J. Ramsey Mellette, the faculty member who trained him on Mohs surgery. Back in the 1970s when Corky first performed Mohs, it was a new and innovative procedure. “Now, this procedure is pretty widespread,” Karl says. “I like it because of the precision in which we take the cancer out, and I enjoy the creativity involved in the reconstruction (of the tissue).”

Mohs is usually performed on a patient’s face, so the reconstruction of the skin requires utmost precision to minimize scarring.

Finding a mentor in the SOM

Corky was inspired to pursue dermatology by Dr. Robert Goltz, who in the late 1960s served as head of the Dermatology Department in the medical school. Corky so enjoyed Goltz’s teaching that he took the professor’s early-morning class on public health. “Dr. Goltz noticed that I was a hard worker, that I liked dermatology and was good at it,” Corky says. “I was good at visual learning, and that’s why dermatology appealed to me. You have to be able to memorize what rashes and other conditions on the skin look like.”

Goltz proved to be the catalyst for Corky’s career in Minnesota. Goltz, who had just accepted a job as chair of dermatology at the University of Minnesota, suggested Corky pursue his residency in the Land of Lakes.

Drs. Vance at CU medical school graduation
Drs. Karl and Corky Vance at Karl’s graduation from the CU School of Medicine in 2009.

Now, as Corky and Karen settle into retirement, they watch their progeny carry on the Kenagy-Vance caregiver tradition. Karl has established his own thriving practice in Minneapolis, while his sister Chardonnay, who attended medical school at Wake Forest University, is a family practice doctor. The life in medicine has made for a full, satisfying ride for the elder Vances – and a lasting family legacy that’s anchored in CU’s SOM.

“The most important thing is your job,” Corky says. “If you have a miserable job, you’ll be miserable wherever you are. If you have a rewarding job – as we are lucky enough to have – you’ll be happy.”

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Study: Light-intensity activities may play role in maintaining weight loss

Light-intensity activities such as washing the dishes, making the bed, and walking the dog may play a significant role in helping people maintain weight loss, according to a study by researchers at the Colorado School of Public Health (ColoradoSPH) and the University of Colorado Anschutz Health and Wellness Center.

The researchers noted that moderate-to-vigorous physical activity has been shown to strongly correlate with long-term weight-loss maintenance, but few studies have examined patterns of light-intensity activity and sedentary behavior in people who successfully keep the pounds off.

Woman walking a dog in the city
Simple light-intensity activities such as walking the dog could play a significant role in helping maintain weight loss.

“We conducted the study to better understand whether patterns of light-intensity activity and sedentary behavior were different in those who were successfully maintaining a weight loss compared to those who are not,” said Danielle Ostendorf, a CU Anschutz doctoral student in epidemiology who worked on the study.

Three groups of participants

In the National Institute of Health (NIH)-funded study (Principle Investigator Victoria A. Catenacci, MD), subjects wore a small, lightweight activity monitor (activPALTM, PAL Technologies LTD, Glasgow, Scotland) for seven days as they went about their normal activities. Participants were drawn from three groups:

  • weight-loss maintainers (individuals who had lost at least 30 pounds and were maintaining that weight loss for at least two years);
  • controls of normal body weight (matched to the current Body Mass Index (BMI) of the weight-loss maintainers);
  • controls with overweight/obesity (matched to the pre-weight-loss BMI of the maintainers).

Data from the 90 healthy adults in their mid-40s was collected and analyzed at the Center, with all three groups having a similar number of participants and distribution of age and sex. In a study such as this, it is critical to have groups with similar age and sex make-up, as physical activity varies by both age and sex.

Catenacci, a Department of Medicine faculty member in endocrinology, was lead author of the abstract. Ostendorf presented the abstract’s findings at the recent annual American Public Health Association conference in Denver.

Surprising results

“We had hypothesized that the weight-loss maintainers would be significantly different than the other two groups in terms of sedentary behavior and light activity,” Ostendorf said. “What was surprising was that the weight-loss maintainers and normal weight controls were similar in terms of their overall sedentary time and their time spent doing light activity, but differed dramatically from the controls with overweight/obesity in these parameters.”

Fitness room at University of Colorado Anschutz Health and Wellness Center
A woman works out on a treadmill at the University of Colorado Anschutz Health and Wellness Center.

The weight-loss maintainers and normal weight controls spent 4.8 hours (290 minutes) and 4.7 hours (281 minutes) a day doing light-intensity activity, respectively, while they were sedentary for 9.9 hours (596 minutes) and 10.3 hours (617 minutes) a day. The overweight/obese control arm spent 3.9 hours (234 minutes) a day in light-intensity activity and 10.9 hours (654 minutes) a day being sedentary. Compared to the controls with overweight/obesity, weight-loss maintainers and normal weight controls were doing about one hour more of light activity and one hour less of sedentary time each day.

Top student abstract

Danielle Ostendorf won the “Outstanding Student Research in Physical Activity” award at the recent American Public Health Association conference in Denver. It was selected among the top three student abstracts at the October conference.

Consistent with other studies, weight-loss maintainers also engaged in more exercise than controls of both types. Weight-loss maintainers spent 38.8 minutes a day doing moderate-to-vigorous exercise (accumulated in sustained bouts of 10 minute or more) compared to 16.7 minutes a day for the normal control group and just nine minutes a day for the controls with overweight/obesity.

Citing U.S. Office of Disease Prevention and Health Promotion (ODPHP) guidelines, Ostendorf said moderate-to-vigorous exercise is emphasized when it comes to maintaining weight loss. For example, the ODPHP recommends that weight-loss maintainers do 300 minutes of moderate-intensity aerobic activity (such as brisk walking, jogging, or swimming laps) each week compared to the 150 minutes of comparable activity for people in a normal weight range.

Benefits of light-intensity activities

The 300-minute guideline can be intimidating for people who are trying to maintain their weight loss, especially for those who struggle to exercise in a moderate to vigorous manner, Ostendorf said. “The fact that people may benefit from increasing light-intensity activities like doing household chores or taking the dog for a walk is encouraging information,” she said. “However, future weight loss interventions need to test whether increasing light-intensity activities can help people maintain weight loss.”

As part of her dissertation, Ostendorf plans to test the 300 minutes of moderate-intensity exercise guideline for weight-loss maintenance. She wonders if a lower amount of moderate-intensity activity, when coupled with less time being sedentary and more time doing light-intensity activity, would be just as effective in maintaining weight loss.

Track at the University of Colorado Anschutz Health and Wellness Center
A woman runs the track at the University of Colorado Anschutz Health and Wellness Center.

The potential exists, Ostendorf believes, to incorporate both reduced sedentary behavior and increased light-intensity activity into the ODPHP maintenance guidelines. “This would lead to future weight-loss interventions that people can do at the workplace, or at home because it involves physical activity that doesn’t require people to get their heart rate up, which can be uncomfortable for some people,” she said.

Not typically examined

Light-intensity activity is typically not examined in weight-loss maintenance studies because it’s more difficult to monitor than heart-pumping moderate-to-vigorous exercise. “Light-intensity activity is like walking in a grocery store – it’s movement, but it’s not really getting the heart rate up,” Ostendorf said.

She said workplace interventions, such as standing at your desk and taking more frequent breaks from sitting, can be beneficial to help break up dangerous sedentary behaviors. These easy-to-implement interventions would be helpful for health care professionals as they consult with patients about how to keep shed pounds from coming back.

“Understanding how people maintain weight loss is really important,” Ostendorf said. “If we can have an impact on helping people maintain their weight loss then we can help prevent chronic disease and early mortality. Excess weight is connected to so many disease pathways.”

 

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Student’s study for state health department links heroin, opioid abuse

Lindsey Kato takes the opioid epidemic personally — the Colorado School of Public Health (ColoradoSPH) alumna has lost eight friends to heroin overdoses. She said most of those friends began abusing prescription opioid painkillers such as Vicodin and OxyContin in high school. Then they graduated to heroin, an even more lethal and addictive opioid.

Kato grew up in Juneau, Alaska, a community hit hard by opioid abuse and a surge in heroin use. “I still continue to lose friends,” said Kato, who in December received her Master of Public Health degree. “I want to understand how did I end up here, and how did my friends end up there.”

CU Anschutz fights the opioid epidemic

This is the second in a series of articles that examines how University of Colorado Anschutz Medical Campus faculty and students are finding ways to solve the opioid epidemic.

For Kato, “here” meant the University of Colorado Anschutz Medical Campus, where she studied epidemiology. That led to a job with the Colorado Department of Public Health and Environment (CDPHE). In May 2016 and while still a student, she began working as the department’s heroin strategies coordinator. The job helps bridge the public health and law enforcement communities, which in the past have not always seen eye-to-eye on how to deal with addiction.

Kato’s responsibilities included collecting all the data about arrests for heroin or opioid possession and distribution that Colorado law enforcement agencies could provide. She also studied the progression from prescription medications to street drugs, leading a project that conducted surveys in nine Denver-area methadone clinics. The CDPHE will publish the survey findings next month in a report titled “Heroin in Colorado.”

Lindsey Kato
Colorado School of Public Health graduate Lindsey Kato, MPH

Kato’s work is an example of how CU Anschutz faculty, students and alumni help fight opioid abuse. Epidemiologists in the ColoradoSPH study demographic trends and social impacts in the hopes of helping individuals, families, communities and government officials come to grips with the epidemic. Other researchers at CU Anschutz study alternative pain treatments, develop continuing education programs for rural doctors and integrate databases used by doctors, dentists and pharmacists.

Understanding prescription opioids’ connection to heroin

The State of Colorado considers opioid and prescription drug abuse a public health crisis, and it relies heavily on CU Anschutz to coordinate the response, with the university providing the Colorado Consortium for Prescription Drug Abuse Prevention’s director and the chairs of many of its work groups.

The state has become especially concerned about the link between opioid abuse and heroin, said Robert Valuck, PhD, RPh, a professor at the Skaggs School of Pharmacy and Pharmaceutical Sciences and expert in opioid abuse. Valuck coordinates the consortium.

In 2015, 160 people in Colorado died of heroin overdoses, up from 37 in 2000 and 91 people in 2012, according to the state health department.

The idea that painkillers prescribed by a doctor or dentist could lead to heroin addiction surprises people, Valuck said. Some think it might be harmless to share meds with family members in pain or keep unused pills in the medicine cabinets. But that can lead to disaster — according to national statistics, about 69 percent of opioid abusers started that way.

The connection between the two epidemics seems to make sense. Heroin is in the same family of drugs as prescription opioids, and the nervous system reacts to them in similar ways. They share harsh withdrawal symptoms that cause people to become violently ill. Addicts become desperate to prevent withdrawal, Valuck said, and some will begin buying pills from drug dealers to avoid the pain.

“People who go through withdrawal say they would rather die than go through that again,” Valuck said.

Anecdotal evidence from law enforcement officers and health care providers supports the connection between the epidemics. But government officials and public health experts developing strategies for combatting the epidemic needed better data. One of Kato’s tasks for the state health department was to collect data about why and how people became addicted to heroin.

“We had a hunch about the connection between prescription drug abuse and heroin,” Kato said. “We wanted solid evidence, and we wanted to understand heroin abuse from the perspective of people who have experienced heroin addiction.”

Researching in methadone clinics

Heroin and opioid abuse in Colorado

 

160 people died of heroin overdoses in 2015

 

37 died of overdoses in 2000

 

70 percent of recovering heroin users abused prescription opioids

 

329 people died from misusing prescription opioids in 2015

To conduct the study, Kato and five ColoradoSPH students interviewed patients in nine methadone clinics around Denver. The clinics help patients recover by distributing methadone, which mitigates opioid withdrawal. The medication itself is a long-acting opioid, but unlike heroin or prescription opioids, it does not get users high. Patients receive their doses at clinics, and doctors supervise their treatment.

Kato and the team administered an in-person survey with 46 questions. They asked the clinics’ clients about their backgrounds and why they began using drugs. Kato also sought to find what recovering addicts thought about their treatment and what helps them stay sober.

Interviewers often started at 5 a.m. to meet people who went to the clinic before work. They conducted 713 surveys in 25 days.

What Kato found shocked her, especially what she saw during her first visit to a clinic.

“We couldn’t tell who was a client from who worked there,” Kato said. “Society paints a certain picture of addiction, we think of particular demographic, and that’s the stigma around methadone clinics. But it was so diverse — there were people in suits who looked like they could be professors, classmates or even your grandmother.”

Kato also found that about half of the recovering patients had college educations, more than a third were employed, and the majority rented or owned homes. The data confirmed what Kato saw happen to her friends. About 70 percent of the clients cited prescription pain medication use as one of the main reasons for transitioning to heroin.

Their stories shared certain traits—sometimes people got hooked as kids, sneaking a family member’s meds. Some became dependent on legitimately prescribed painkillers for a medical problem. When doctors stopped prescribing, they would borrow or steal pills from friends or family.

At that point, Kato found prescription drug abusers reached a crossroads. Some sought treatment, while others turned to drug dealers. Some of the latter were able to limit their addictions to prescription medications. Others couldn’t and tried heroin.

Someone in this situation isn’t necessarily trying to find a better high, Valuck said. Heroin is cheaper and easier to find on the drug market than prescription meds, and he said it is not uncommon for people to sell their prescription medication and use the money to buy heroin.

Creating a unified response

Controversy still lingers around methadone. Doctors and public health experts consider methadone a legitimate and effective treatment. Valuck said giving patients carefully managed doses that decrease over a few years has proven safer and more effective than making them quit cold turkey.

“We couldn’t tell who was a client from who worked there…. They could be professors, classmates or even your grandmother.”

Law enforcement officers historically have not been involved in drug treatment, Kato said. She believes that police see the crimes committed by drug addicts and often identify with victims affected by these crimes, rather than identifying or empathizing with the individuals experiencing addiction.

The difference in perception shows the different approaches between those who see drug abuse as a criminal matter or a medical issue. Kato plans to spend her career working to bring the sides together to help coordinate an effective response. Already, she’s seeing attitudes change among leaders in the law enforcement community.

“They have come to terms with knowing they’re not going to solely arrest their way out of this problem,” Kato said.  “They are actively seeking to understand the process of addiction and how they can be involved in a public health approach.”

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Research investigates role of protein in obesity

Obesity in Latin America is increasingly concentrated among women of low socioeconomic status, but surprisingly little is known about what such women eat or how their diets compare to others.

protein sources

Yet in a study published recently in the American Journal of Human Biology, researchers at the CU Anschutz Medical Campus, in collaboration with colleagues at CU Boulder and the University of Costa Rica, tested an explanation for greater obesity among these women: limited access to dietary protein leads them to consume a lower proportion of protein in the diet, driving higher calorie intake and obesity.

The study, “Using the protein leverage hypothesis to understand socioeconomic variation in obesity,” examined elements of the protein leverage hypothesis in a sample of Costa Rican women.

“Studies conducted in a laboratory setting show that when people eat a diet with a lower proportion of protein, they tend to consume more calories,” said lead author Traci Bekelman, a post-doctoral fellow in pediatrics at the CU School of Medicine. “We tested out this relationship between protein and calories in a real world setting in order to provide insight into rising obesity among the poor in Latin America.”

According to the report, the majority of research on the dietary causes of obesity has focused on carbohydrates and fats. This study suggests that explanations for obesity, especially among populations with limited access to food, should not overlook the potential role of protein.

The protein leverage hypothesis predicts that protein intake is more tightly regulated by the body than intake of other macronutrients. If one does not eat enough protein, in grams, to achieve the body’s intake target, an appetite for protein drives individuals to keep eating and could result in excess calorie intake and obesity.

Consistent with expectations, researchers found that obesity was higher and the proportion of protein in the diet was lower among low socioeconomic status women compared to others. They also found an association between the proportion of protein in the diet and total calorie intake. As the proportion of protein in the diet increased, total calorie intake decreased.

Researchers also looked at the relationship between the proportion of protein in the diet and calorie intake within different socioeconomic groups. They expected that the relationship would be strongest for women of low socioeconomic status because the protein leverage hypothesis should be most relevant to populations on low protein diets, but they found this relationship to be strongest for women of middle- and high-socioeconomic status. They found no relationship among women of low socioeconomic status.

“One possible explanation for this unexpected finding is that women of low socioeconomic status cannot afford to continue eating until they reach the body’s protein intake target,” Bekelman said.

According to the report, researchers were surprised to find that over half the women in the full sample did not meet their protein requirements, revealing a potential public health issue, especially because the protein deficit is among women of childbearing age.

The cross-sectional study used a random sample of 135 women from San José whom researchers placed into one of three socioeconomic categories. Researchers interviewed the participants over a nine-month period to collect information on their body mass index and what they ate and drank.

The study should not be interpreted as a causal link between protein intake and obesity and had a number limitations related to study design. The report recommends that further research on the protein leverage hypothesis should include studies that measure energy balance by simultaneously collecting data on energy intake, energy expenditure and body weight.

At CU Anschutz, scientists engage in high-profile academic studies resulting in discoveries that contribute new information about the nature and treatment of disease to the rest of the world.

 

 

 

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School of Dental Medicine, CU Anschutz take lead fighting opioid epidemic

Pills
More Coloradans have died from overdoses of opioids such as hydrocodone, oxycodone and fentanyl since 2011 than have been killed in homicides.

Helping patients cope with severe pain is a priority for dentists and physicians, but the opioid epidemic requires health-care practitioners to face a balancing act. Prescription opioids such as Vicodin, Percocet and OxyContin are powerful painkillers that provide real relief. However, they can be addictive, and misuse can have devastating and even deadly consequences. Every year since 2011, more Coloradans have died of opioid overdoses than have died in homicides.

CU Anschutz fights the opioid epidemic

This is the first in a series of articles that examines how University of Colorado Anschutz Medical Campus faculty and students are finding ways to solve the opioid epidemic.

Dentists, including oral and maxillofacial surgeons, are on the front lines of the epidemic, writing about 12 percent of all prescriptions for immediate-release opioids. Individually and as a profession, they have to strike the right balance between managing pain and preventing abuse. Now, the University of Colorado School of Dental Medicine (SDM) is coming to their aid.

“We’re taking opioid abuse very seriously and doing whatever we can to address the problem,” said Michael Henry, DDS, PhD. Henry is the school’s associate dean for academic affairs, and he has spent his career training dentists and studying orofacial pain.

Henry and his colleagues at the School of Dental Medicine are just some of the researchers at the CU Anschutz Medical Campus fighting the opioid epidemic. CU Anschutz faculty members and students evaluate public health options, find new ways to track prescriptions and direct Colorado’s major public education campaign. The state relies heavily on CU Anschutz to coordinate the response to the crisis, with the university providing the Colorado Consortium for Prescription Drug Abuse Prevention’s director and the chairs of many of its work groups.

At the SDM, faculty look for alternatives to opioids, develop new prescribing standards and create new curriculums. Their work already has shown results that benefit dentists, physicians and patients.

Searching for and finding new approaches

Dentists want to start by finding effective pain relievers that will not cause addiction or dependence. That effort is paying off and leading to surprising findings, Henry said. One is that a combination of acetaminophen, which is the active ingredient in Tylenol, and ibuprofen, which is in Advil, can be more effective than opioids in the management of post-operative and procedural dental pain. Under the guidance of their dentists, recovering patients can take the combination of over-the-counter medicines longer without having to worry about getting hooked and can avoid common opioid side effects such as nausea and constipation.

Dr. Michael Henry
Michael Henry, DDS, PhD, is associate dean of the School of Dental Medicine.

The SDM wants the dental community and patients to know that kind of new information.

“We’re really trying to get that message out,” Henry said. “The data is pretty strong that that’s a very, very potent combination.”

The school has developed guidelines about the best medications to prescribe depending on the type of pain, along with recommended dosages.

Better guidelines are important because opioids will continue to have a place in pain management, Henry said. While it is still appropriate to prescribe opioids after some dental surgical procedures where severe post-operative pain is expected, researchers are carefully evaluating the specific number of opioid-containing tablets that are prescribed. Improving best practices can help dentists identify when opioids are appropriate and help them do what’s best for patients.

Opioid abuse by the numbers

329 people died in Colorado from misusing prescription opioids in 2015

 

224,000 Coloradans misuse prescription drugs each year

 

Colorado ranks 15th in the nation for opioid abuse—down from second in 2011

“We have to be concerned about opioid addiction, but we have to consider that in light of providing patients with proper pain management,” Henry said.

Through continuing education programs for current dentists, the school will share that protocol, as well as best practices for discussing pain and opioids with patients. The next course is on Feb. 25, and Henry will teach it along with Rachael Rzasa-Lynn, MD, who is director of the Interventional Pain Clinic in the School of Medicine, and Robert Valuck, PhD, RPh, who is the director of the Skaggs School of Pharmacy and Pharmaceutical SciencesCenter for Pharmaceutical Outcomes Research and an opioid abuse expert.

Improving patients’ knowledge about painkillers

Henry said it is not enough for dentists to understand the latest research and best practices. Patients also need to be educated, and that includes helping them overcome misconceptions about painkillers.

Patients often assume that after a procedure they will be prescribed Percocet, Vicodin or a similar medication—after all, they’ve heard those are the most powerful. There also is the perception that if a medication needs a prescription, it must be better than what is available over-the-counter.

That perception is not true, Henry said, but it is difficult for dentists to change patient expectations. Patients could doubt their treatment, which has negative consequences for pain management.

“Patient expectation is our biggest challenge,” Henry said. “So much of pain relief is based on the expectation of the patient. The expectation of pain relief can actually activate brain regions that contribute to analgesia. If they are expecting that medicine to be effective, it has a greater chance of being effective. That’s basic pain science.”

Meanwhile, institutions such as the SDM and organizations such as the American Dental Association continue pain management education and work to combat the epidemic.

“Every week I see new concerns regarding the role that dentists play in opioid abuse,” Henry said. “This is at the forefront of dentistry.”

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WWII vet receives hero’s welcome at Heroes Clinic

Charles Walters doesn’t consider himself a hero, but the moment he enters the University of Colorado School of Dental Medicine the retired Naval Captain and World War II veteran receives a hero’s welcome from the clinicians who will repair his chipped tooth.

Walters is greeted by Heidi Tyrrell, RDH, assistant director and clinical instructor in the dental school’s Heroes Clinic, who cheerfully tells him his care will be free of charge. Tyrrell says it’s a small gesture of gratitude to someone who so honorably served our country.

“The Dean of our School of Dental Medicine, Dr. Denise Kassebaum, insists (on the free care), and I couldn’t agree more,” she says to Walters. “It’s such an extraordinary honor for us to take care of someone like you. The fact that you not only served in World War II but re-upped and served in the Korean War – there are no words to express how much I admire and respect you.”

Charles Walters and Olga Hamilton at Heroes Clinic
Charles Walters, a WWII and Korean War veteran, shows his chipped tooth to student provider Olga Hamilton at the Heroes Clinic in the CU School of Dental Medicine.

Walters, a widower who lives on his own, is visibly touched by the news, noting that he gets by on a modest fixed income – Social Security and his Navy retirement. In addition to his wartime service, Walters spent 32 years in the Naval Reserve.

The Southern California native enlisted in the Navy immediately after the bombing of Pearl Harbor and served in the Pacific Theater of WWII. Instead of being dispatched to a Destroyer, which was his hope, Walters was assigned to Naval communications intelligence where he served on a team that deciphered Japanese transmissions. “It was exciting work, breaking the enemy’s coded messages,” he says.

Walters returns the gratitude to the CU clinicians – the Heroes Clinic is staffed by faculty and fourth-year students – and says, “I appreciate what you’re doing – there’s nothing that’s too good for the service people, and I mean that primarily for the people who fought – and still are fighting – in battles.”

‘All dental specialties under one roof’

The Heroes Clinic launched in August 2014 thanks to a $1 million grant from Delta Dental of Colorado. The program originated to provide free dental care to student veterans enrolled at CU Denver and CU Anschutz. They are an underserved population as most veterans do not quality for or receive coverage for dental care when they leave the military. The Heroes Clinic fills this gap by providing dental services which supplement health care provided through the Veteran’s Administration.

Veteran receives dental care at CU Heroes Clinic
Heroes Clinic patient Charles Walters has a chipped tooth treated by Dr. Doug Wilson, a dental school faculty member and Air Force veteran, and student provider Olga Hamilton.

Delta Dental kicked in another $1 million grant in 2015, allowing the program to also serve student veterans on CU’s Boulder and Colorado Springs campuses. In 2016, the Heroes Clinic expanded again to serve student veterans from the Community College of Aurora, Metropolitan State University of Denver and Emily Griffith Technical College. That year, the clinic also added “pathway” programs: Pathway 1 provides dental care to veterans served through the Bill Daniels Veteran Services Center, which helps link homeless veterans to jobs, while Pathway 2 provides dental services to low-income veterans.

“It’s the greatest joy to talk to these vets. It’s a privilege to help such a deserving population.” – Heidi Tyrrell, clinic assistant director

Now, the Heroes Clinic is looking to expand care to even more veterans, and the dental school has the faculty and students ready to serve. “Our faculty is amazing. We have all the different dental specialties under one roof,” Tyrrell says. “And Delta Dental loves what we’re doing; they love the stories they get every quarter about veterans and what we’ve done for them.”

Heroes Clinic a ‘godsend’

Since 2015, the Heroes Clinic has served more than 500 veterans, including Walters, who is making his first visit as a Pathway 2 recipient.

Sitting in the next patient chair over, Micah Marmaro, one of the first Heroes Clinic adherents, gets prepped for a tooth crown. Marmaro, who served in the Marines for four years, calls the clinic an “incredible” service. He needed some fillings replaced two years ago, but lacked dental coverage. “I was quoted $5,000 or $6,000 to get the work done, and as a student that’s not easy to pay for,” he says. “It was either have it done or continue to have pain in my teeth. It was a godsend this came along.”

Micah Marmaro is a Heroes Clinic patient
Micah Marmaro is one of the original patients at the Heroes Clinic. He served in the Marines for four years.

He’s been to the Heroes Clinic multiple times since that first visit. “Overall,” Marmaro says, “it’s fantastic to be able to come in and get the level of care you get here.”

Meanwhile, Walters’ chipped tooth gets examined by Olga Hamilton, a fourth-year dental student, and then repaired by Dr. Doug Wilson, a dental school faculty member and retired Air Force Colonel.

Walters happily chats with both providers, while Tyrrell beams at the sight of this 92-year-old enjoying this long-overdue visit to the dental clinic.

“It’s the greatest joy of my job to talk to these vets, and Mr. Walters is so amazing. He’s like a hot fudge sundae with peanuts, caramel and a cherry on top – the whole nine yards,” she says. “The big thing is the extraordinary gift from Delta Dental. It’s such a privilege to help such a deserving population.”

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Our students don chefs’ hats to further their education

Students from the Culinary Medicine/Culinary Dentistry present a meal they prepared
Students from the Culinary Medicine/Dental Medicine present a meal they prepared

On a recent Friday, Gabriela Andrade, a second-year dental student from the CU Anschutz School of Dental Medicine (SDM), was putting the finishing touches on a group project. She stacked sandwiches on a platter, and her group lined up to explain to their instructors and classmates about an extra ingredient they added to the hummus: chipotle peppers.

Because of a program funded by Delta Dental of Colorado to support interdisciplinary education among health professionals, called the Frontier Center, the classmates, 17 CU dental and medical students, join culinary nutrition chefs side-by-side each week in a Culinary Medicine/Dental Medicine elective course. The class is a venture of the School of Medicine (SOM), the SDM and the College of Culinary Arts at Johnson & Wales University (JWU). Every Friday the students gather in JWU’s production kitchen to talk about and taste food—for academic credit.

As Andrade’s group described how the peppers contributed a pleasing heat and flavor, as well as added nutritional benefits, their instructor chimed in with suggestions for ingredient substitutions. Then the class heard the words they had been waiting for all afternoon: “let’s eat.”

Gabriela Andrade, a School of Dental Medicine student, practices her knife skills
Gabriela Andrade, a School of Dental Medicine student, practices her knife skills

An interdisciplinary education in nutrition

The class, which will meet for eight Fridays, consists of a two-hour discussion and quiz on nutrition, followed by hands-on training in cooking techniques, including knife skills, working with fresh produce, and making healthful substitutions in recipes. Students work in small groups to produce different parts of a complete meal: appetizers, salads and a main course. Clinical nutrition students from JWU are on hand to provide guidance and experience.

Tamanna Tiwari, a clinical instructor at the School of Dental Medicine
Tamanna Tiwari, a clinical instructor at the School of Dental Medicine

The interdisciplinary focus of the course is one of its primary benefits, according to Tamanna Tiwari, MPH, MS, BDS, a clinical instructor at the SDM. “As the first School of Dental Medicine to offer an elective for Culinary Dentistry, we are adding to our innovative, interdisciplinary curriculum,” she said. “Our dental students work as a team with medical students. They take ownership of projects together.”

The course aims to fill a gap in medical education by providing students with the latest research on clinical nutrition and instruction on how to communicate lessons about nutrition to their future patients. “Diet has a huge effect on the whole person,” said Mark Deutchman, PhD, SOM professor. “This class fills in a knowledge gap. It will make our students better practitioners and help them to address all aspects of a patient’s health.”

Adding tools to their toolkits

For medical student Nick Stephanus, the class is an opportunity to add more tools to his toolkit. “In primary care, many illnesses are chronic, and can be managed by careful monitoring of one’s diet,” he said. “This class teaches us how to give good advice to future patients, so that physicians can say more than just ‘manage your calorie intake.’”

Mark Deutchman, professor at the School of Medicine
Mark Deutchman, professor at the School of Medicine

Andrade, too, plans to use the skills she gains in the class to help her future dental patients. “I plan to work with Hispanic populations and with patients with a lower socio-economic status,” she said. “They may not have had a lot of education about nutrition, and this class will help me to better communicate tips for a healthier lifestyle and oral health.”

Although the Culinary Medicine/Dental Medicine course focuses on skills that students can use to help their future patients, the class agrees that they are already benefiting by taking their work home. The skills they are learning have allowed them to cook meals that are more nutritious for themselves. They’ve also cultivated camaraderie with the nutrition students from JWU, who will go on to work in the medical field as dietitians and clinical researchers.

“The JWU students enjoy the interchange of information with CU,” said Marleen Swanson, RD, the department chair of the JWU Culinary Nutrition program. “They glean a better understanding of the medical world through case studies that they review with CU students.”

School of Medicine students like Nick Stephanus learn cooking skills and how to communicate nutrition tips to their patients
School of Medicine students like Nick Stephanus learn cooking skills and how to communicate nutrition tips to their patients

Following their taste buds

With a growing awareness of the important role nutrition plays in preventive care, and the lack of nutrition education in medical and dental schools across the country, the Culinary Medicine/Dental Medicine course will make a significant contribution to medical education. The interdisciplinary approach at CU Anschutz, along with the partnership with JWU, are producing medical and dental professionals who are knowledgeable and enthusiastic about healthy eating.

For good reason. The smells wafting from the kitchen classroom every Friday are mouthwatering, and the energy in the room is contagious. Both Andrade and Stephanus look forward to the class each week. “Cooking is an experiment,” Andrade said. “I’m learning as I go, but I’m also following my taste buds.”

 

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Study finds an association between proximity to oil and gas development and childhood leukemia

Young Coloradans diagnosed with acute lymphocytic leukemia are more likely to live in areas of high-density oil and gas development compared to young Coloradans diagnosed with other types of cancer, according to researchers at the Colorado School of Public Health at CU Anschutz. The researchers observed no association between non-Hodgkin’s lymphoma and high-density oil and gas development.

Dr. Lisa McKenzie
Dr. Lisa McKenzie

“Over 378,000 Coloradans and millions of Americans currently live within a mile of at least one oil and gas well, and petroleum development continues to expand into residential areas,” said lead investigator Dr. Lisa McKenzie, assistant research professor at the Colorado School of Public Health. “The findings from our registry-based case control study indicate that young Coloradans diagnosed with one type of childhood leukemia are more likely to live in the densest areas of oil and gas sites. More comprehensive research that can address our study’s limitations is needed to understand and explain these results.”

Funded by the CU Cancer Center and published today in the journal PLOS ONE, the study shows children and young adults between the ages of 5 and 24 with acute lymphocytic leukemia were 4.3 times more likely to live in the densest area of active oil and gas wells than those with other cancers. The study focused on rural areas and towns in 57 Colorado counties and excluded urban areas of more than 50,000 people.

According to the report, U.S. oil and gas development has grown rapidly over the past 15 years and this industrial activity has the potential to emit toxic substances into air and water, including carcinogens like benzene.

According to current research, over 15 million Americans now live within 1.6 kilometers (1 mile) of oil and gas development. There are hundreds of oil and gas wells within one mile of a home in Colorado’s most intensive areas of oil and gas development. The study indicates that people living in areas of oil and gas development may be at an increased risk for health effects, including cancers, resultant from such industrial exposures.

The report concludes that future research should incorporate information on oil and gas development activities and production levels, as well as levels of specific pollutants of interest like benzene, near homes, schools and day care centers. It recommends such research consider specific ages and residential histories, compare cases to controls without cancer and address other potential confounders and environmental stressors.

Data for the study was obtained from the Colorado Central Cancer Registry and the Colorado Oil and Gas Information System. The study included 743 young Coloradans aged 0-24 years living in rural Colorado and diagnosed with cancer between 2001 and 2013.

Researchers used information from the Colorado Oil and Gas Information System to build a geocoded dataset with coordinates of all oil and gas wells in rural Colorado and determined dates for when each well was active.

Geocoded residential addresses of cancer patients at the time of diagnosis were linked to active well locations in the year of diagnosis and active well locations in each of the 10 years preceding the cancer diagnosis. They then took the inverse of each distance and summed the inverse distances to calculate inverse distance weighted oil and gas well counts within a 16.1 km radius of each participant’s residence at cancer diagnosis for each of the 10 years prior to the date of the cancer diagnosis. The inverse distance weighted well count method gives greater weight to the wells nearer the home. Age, race, gender, income, elevation of residence and year of cancer diagnosis all were considered in the analysis.

The study was limited by the low occurrence of leukemia and non-Hodgkin lymphoma in rural Colorado, lack of specific age at cancer diagnosis and the fact that all study participants had been diagnosed with cancer. The study also was limited by the lack of information on specific activities at the well sites, place of residence before cancer diagnosis, other sources of pollution around the residence and individual characteristics such as common infections and family history of cancer.

The other study authors are William Allshouse, Tim Byers, Berrin Serdar and John Adgate of the Colorado School of Public Health at CU Anschutz and Edward Bedrick of the College of Public Health at the University of Arizona.

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Alice Deanda celebrates 50th anniversary with CU

Alice Deanda, program assistant in the Department of Pathology, began working at University of Colorado Hospital (UCH) in 1966 and was honored for her years of work with the University of Colorado on Feb. 4.

“When I started working we used typewriters, carbon paper and mimeograph machines to make copies,” Deanda said. Sometimes she would have to walk the paperwork to another department, which was one of her favorite parts of the job. While her workplace has gone through drastic changes with the introduction of technology such as the computer and UCH’s 2007 move from Ninth Avenue to the CU Anschutz Medical Campus, her personal life also changed when she took over as her mother’s primary caregiver.

Alice Deanda and Gary Brown of CU Anschutz

Alice Deanda with Gary Brown, a colleague in the Department of Pathology. Photos courtesy of Lisa Litzenberger.

Deanda retired from her position in the Department of Pediatrics Section of Infectious Diseases in 2000 but continued to work part time after that. She began working in the Department of Pathology in the CU School of Medicine in 2008.

“I’ve always liked working at the university. I’ve never thought about going to work anyplace else,” she said. “As long as I can walk into work, I’m coming in. And I’m 75.” She also enjoys the 20-mile drive to work and has never found it difficult.

Praise from colleagues

Deanda’s coworkers all have overwhelmingly positive things to say about her.

“Alice is remarkable for her reliability, expertise and professionalism,” said Ann Thor, MD, chair of the Department of Pathology. “She is a joy to work with. We have enjoyed knowing her large family as well.”

Deanda’s supervisor, Matt Bilby, assistant administrator for the Department of Pathology, first met Alice when he began as a student worker in the Office of Grants and Contracts in 1990 and was later responsible for connecting Deanda to the Department of Pathology.

Alice Deanda at CU Anschutz

Alice Deanda is joined by colleagues for her 50th anniversary celebration at CU Anschutz.

“When I first started here as a student worker it was a very close-knit community,” Bilby said. “In the time she has worked for pathology and me, that same sense of community has always continued.”

“I like to brag that I’ve been around for 16 years in the Department of Pathology, but it doesn’t even come close to touching the amount of time Alice has worked for (the university),” Bilby said.

Deanda found that it was difficult to get a promotion early in her career within a single department. “I kind of kept moving with the increase — let’s put it that way. If I could get an increase, I moved. Or, if I couldn’t get one, I moved.”

In the last 50 years, Deanda has worked with many people and has seen coworkers come and go. She has been with the Department of Pathology longer than any other single department and is quick to make impressions on co-workers new to the workplace.

“I’ve only known Alice for the last couple of months, but she’s a very warm and welcoming person,” said Rose Segawa, accounting manager. “I really enjoy working with her. We got along right away.”

Adapts to many changes

Deanda takes care of her mother, who is 93 years old and has dementia. Her sister, Josie Ponce, acts as a caregiver during the two days Deanda works at CU Anschutz. Other family members often fill in when necessary or to provide a break.

“In 2011 I moved my mother in with me because she wasn’t eating and couldn’t take care of herself anymore. She didn’t have dementia at the time,” Deanda said.

Shortly after the move, her mother broke both hips. “From then on,” Deanda said, “her mind started to go, where she doesn’t remember who people are, but physically she is very healthy.”

“The thing that I really appreciate, especially with this department, is that they are flexible in letting me work when I can. If my sister can’t come to the house to take care of my mother, I can’t come to work,” Deanda said.

Deanda’s time spent at work are “the only 16 hours of her life that she isn’t taking care of her mother,” Segawa said. “I commend her to be able to adapt to all the changes CU has gone through.”

Deanda said she is a “real Colorado native” and wouldn’t choose to live anywhere else. When she isn’t working, she enjoys cooking from scratch and spending time with her family, particularly on special occasions like Thanksgiving and New Year’s Eve. She also enjoys shoveling her own walkway when it snows.

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