VOLUME CXXVI ISSUE 9 • INDIANAPOLIS, INDIANA SEPTEMBER 2019 BULLETIN editorial pg 12 A Public Health Approach to Gun Control by RICHARD D. FELDMAN, MD IMS Board Member, Family Physician, Former Indiana State Health Commissioner Permit 593 Permit Indianapolis, IN Indianapolis, PAID Indianapolis, IN 46204 IN Indianapolis, U.S. Postage U.S. 125 West Market Street, Suite 300 Suite Street, Market West 125 Presorted Std. Presorted Indianapolis Medical Society Medical Indianapolis VOLUME CXXVI • ISSUE 9 INDIANAPOLIS, INDIANA TABLE OF CONTENTS BULLETIN IN THIS ISSUE OFFICIAL MONTHLY PUBLICATION OF THE SPECIAL FEATURES Indianapolis Medical Society President’s Page .......................................04 125 West Market Street, Suite 300 Indianapolis, IN 46204 “The all-cause mortality rate among participants who consumed 2 or more glasses per day of total soft drinks was higher than that ph: 317-639-3406 www.indymedicalsociety.org among participants who consumed less than 1 glass per month.” Editorial: Childhood Sex Abuse .............................06 President CHRISTOPHER D. BOJRAB Special Feature: 2019 Sachem Recepient ....................08 President-Elect ERIC E. TIBESAR Editorial: A Public Health Approach to Gun Control ............12 Board Chair LINDA FEIWELL ABELS ANNOUNCEMENTS Editor/Executive Vice President MORGAN E. 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BOJRAB, MD The Beverage Wars and the Sick-User Effect ecently at a meeting, I had an exchange with a respected colleague about the potential risks as- sociated with sodas and products sweetened with Rsugar substitutes. He expressed concern about these potential risks which was contrary to my under- standing of the topic. It prompted me to spend some time doing a review of some of the more recent data. There has been more interest again in this topic lately due to a recent article in JAMA Internal Medicine pub- lished September 3, 2019 titled Association Between ened drinks and deaths from digestive diseases with Soft Drink Consumption and Mortality in 10 European a hazard ratio of 1.59 (95% CI 1.1.24-2.05). A significant Countries by Amy Mulee, PhD, Dora Romaguera, PhD, difference in mortality rates were not observed for Jonathan Pearson-Stuttard, BMMCh, et. al. This was cancer or neurodegenerative diseases. an observational study looking at over 520,000 sub- jects from 10 countries in Europe The confidence intervals of evaluating the consumption of most of the outcomes are sugar-sweetened and artificial- “I believe that if we consider what largely overlapping, so it ly sweetened soft drinks and is hard to draw solid con- all-cause mortality between 1992 we have learned about these pos- clusions. Also, the study and 2000. They looked at total sible differences as mentioned did not look at 2 or more mortality and cause-specific mor- above, we should explore these glasses consumed per day tality. Of the total group, over new hypotheses both vigorously vs. 1 or less glasses con- 450,000 were included in the and rigorously. To be sure, there sumed per day, but rather study (86.7%) with an average are some fascinating findings 1 or less glasses consumed age of 50.8 years (roughly 71% per MONTH. I would have female and 29% male). early on, but they are still early and almost exclusively limited to been interested to see what animal studies at this point.” many would consider to be The mean follow-up period was an “average” consumption 16.4 years during which time of around 2 glasses per day, there were just under 41,693 deaths. The all-cause a very low consumption of mortality rate among participants who consumed less than 1 glass per month (both of which they did) 2 or more glasses per day of total soft drinks was but then also a very high consumption group (perhaps higher than that among participants who consumed those individuals consuming on average 6 or more per less than 1 glass per month. The hazard ratio for total day?). soft drinks was 1.17 (95% CI 1.11-1.22), sugar-sweetened drinks was 1.08 (95% CI 1.01-1.16), and artificially sweet- The study did attempt to adjust for the role of BMI as ened drinks was 1.26 (95% CI 1.16-1.35). Subgroup anal- the degree of adiposity could be a confounding vari- ysis showed a positive association between artificially able in many ways, but the results were unchanged sweetened soft drinks and deaths from circulatory with or without BMI adjustment. (in a separate review diseases with a hazard ratio of 1.52 ((95% CI 1.30-1.78), of related articles, 3 of 7 studies pointed to a possible as well as a positive association between sugar-sweet- IMS BULLETIN • SEPTEMBER 2019 PAGE 4 THE PRESIDENT’S PAGE CHRISTOPHER D. BOJRAB, MD increase in hepatic lipogenesis associated with the use of fructose and 4 of 7 studies pointed to possible increases in insulin resistance associated with the use of fructose). (J Hepatol. 2018 May; 68(5): 1063–1075.) Complicating this type of observational study is the fact that people who are overweight and who are at greater risk of cardiovascular disease are more likely to avoid sugar-sweetened drinks, so while this may strengthen the association, it does not speak to the degree of causation. This is an example of the sick-us- er effect. This is also seen in the association between the use of a daily multivitamin and an increased risk of mortality (people who are sick or recently diag- nosed with a potentially life-threatening illness are gradually declined over the course of observation more likely to take multivitamins than are the gener- following NNS consumption. The glycemic impact of al public). NNS consumption did not differ by type of NNS but to some extent varied by participants’ age, body weight, and diabetic status.” And concluded, “NNS consump- Other reviews of the association between artificial tion was not found to elevate blood glucose level. sweeteners or low calorie sweeteners (AS/LCS) and Future studies are warranted to assess the health im- sugar have pointed to similar associations, but have plications of frequent and chronic NNS consumption also pointed out that the use of these AS/LCS may and elucidate the underlying biological mechanisms.” be more likely the result of these other health issues (Eur J Clin Nutr. 2018 Jun;72(6):796-804. doi: 10.1038/ rather than the cause. s41430-018-0170-6. Epub 2018 May 15.) There have been some animal (rat and mice) studies As a side note, doing a little reading for this article that have suggested a correlation between the use of dramatically pointed out the ways in which there are AS/LCS and weight gain, but many of these studies often times difference between theory, basic bench used what appear to be unrealistically high levels/ science, animal studies, and human studies. It made amounts of AS/LCS compared to what would be seen me think of some of the information coming out re- in actual dietary consumption. To be sure, the ani- garding the impact of our gut microbiome on a vari- mal data is a good reason to address the question in ety of health concerns (obesity, diabetes, autoimmune human studies, which has been done. Larger scale disease, autism, depression, etc.). I believe that if we reviews of the impact of AS/LCS have found that consider what we have learned about these possible “Low-calorie sweeteners provide a means to reduce differences as mentioned above, we should explore energy density while largely preserving food or bev- these new hypotheses both vigorously and rigorously.