Green Space and Mortality; Do Supplements Prevent Health Risks?

TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.

This week’s topics include Medicaid expansion and suicide; long COVID and the Delta versus Omicron variants; green areas and mortality; and multivitamins, supplements, cardiovascular disease, and cancer.

Program notes:

0:47 Omicron and Delta and long COVID

1:50 Self-reported symptom studies

2:50 Lots more since more people are getting infected

3:08 State Medicaid expansion and suicide in adults

4:10 Difference might be linked to increased access to mental healthcare

5:10 Men at higher risk

6:00 USPSTF and supplements and minerals

7:00 May increase risk of cancer

8:00 Only a big longitudinal study will define

9:00 What do you say to a patient?

9:25 Green space and mortality

10:25 All-cause mortality in those 65 and older

11:25 For recreational activity?

12:34 End

Transcript:

Elizabeth Tracey: Is Medicaid expansion associated with reduced rates of suicide?

Rick Lange, MD: The risk of long COVID with adults on the Omicron variants of the virus.

Elizabeth: Does increase in green space in urban areas affect mortality?

Rick: And do multivitamins and supplements prevent cancer and heart disease?

Elizabeth: That’s what we’re talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.

Rick: I’m Rick Lange, president of Texas Tech University Health Sciences Center in El Paso, where I’m also dean of the Paul L. Foster School of Medicine.

Elizabeth: Rick, let us turn right to this notion of, wow, is it better to get Omicron? That’s in The Lancet.

Rick: Prior to November 2021, the Delta variant was the predominant virus. Beginning in December of 2021 through March of 2022, the Omicron variant was really the most prevalent. Many of these individuals who got either Delta or Omicron had been vaccinated. What’s the risk of developing long COVID symptoms in individuals who have been vaccinated, but subsequently became infected with either Delta or the Omicron variant? Is the Omicron variant more likely to give you COVID symptoms? We know that compared to the earlier Delta variant that the Omicron is more infectious. However, usually the symptoms are milder.

What these investigators attempted to do by examining individuals that had been infected after vaccination with the Delta or Omicron is to determine whether the incidence of long COVID symptoms was the same. They looked at over 56,000 adults who were likely infected with the Omicron and then they compared those to over 41,000 individuals in the U.K. that had gotten infected with the Delta variant because they were infected prior to November of 2021.

These were self-reported symptom studies — this is an app on the phone — and what they discovered is that among the Omicron cases 4.5% experienced long COVID symptoms — symptoms present more than 4 weeks after the infection, whereas with the Delta, it was about twice that — it was 10.8%.

Now, they looked at the various times people have been vaccinated. Was it in the previous 3 months, or 3 to 6 months, or more than 6 months afterwards? It didn’t matter when the person had been vaccinated. The Omicron variant was associated with fewer long COVID symptoms than the Delta variant.

Elizabeth: This is all really interesting. Of course, there are a lot of factors that could play a role in this. We have gotten a lot better, for example, at managing a lot of the symptoms, and also there are other things that have been changing about it too. I’m just wondering, really, what could explain this?

Rick: Elizabeth, I think it has to do with the viral variants. Even though it’s less likely with the Omicron because there were more people infected, long COVID symptoms increased from 1.3 million in January of 2022 to 1.7 million just 2 months later.

Elizabeth: We’re going to still be seeing a whole lot more of long COVID irrespective of which one we get infected with.

Rick: Right, and this is just individuals in the United Kingdom.

Elizabeth: More to come, of course.

Let’s turn to JAMA Network Open. This is in some respects a good news study and this is the association of State Medicaid expansion status with rates of suicide among U.S. adults. We know that unfortunately with the pandemic has also come this increase in suicide and in suicidality, lots and lots of increase in mental illness, and especially among younger people, unfortunately.

This study takes a look at U.S. individuals aged 20 to 64 years. It’s a cross-sectional study and it associates state-level mortality rates with Medicaid status and whether there was the expansion of Medicaid in the respective state in which someone was living.

During this time period, there were 550,000+ deaths by suicide. The vast majority of them occurred in white individuals, almost 90%, and about 78% in males. There were smaller increases in the suicide rate after the 2014 increased Medicaid expansion.

The state level analysis absolutely reflected that that was the case, and the authors speculate that this difference might be linked to increased access to mental healthcare when Medicaid is in place. It sounds like an important potential factor for helping to stem this tide of suicidality.

Rick: There are a couple things that concern me about this. Even though the ACA [Affordable Care Act] increased the number of people insured, what happened is many of those that were insured had very high deductibles. Whether these individuals had increased access to mental healthcare really isn’t ascertained in this particular study.

I’m also surprised with the fact that it is only associated with the decreased risk of suicide in whites — not in Blacks, by the way, and also not in individuals between the ages of 45 to 64 years old. There is a very small group — that is, whites between the ages of 20 and 29. What do you think about that?

Elizabeth: I think it’s also maybe a reflection of who is willing to go and have mental healthcare services. We know that historically there has been this propensity to turn away from that for men — who we already know are at higher risk of suicide and suicidality — and as they age also.

Rick: Maybe due to hesitancy to actually get care. I would suggest that there are other things that contribute to this: unemployment, lack of housing, and social stresses. Although this is an interesting association, I’m not sure that it proves that increased access to Medicaid actually decreased suicide rate, especially in those groups we have talked about,

Elizabeth: I’m going to accept that, but I’m also going to say that I for one would like to see increased access to this because I think that a lot of these folks are classically underserved populations and there is no question that we need more mental healthcare services.

Rick: Elizabeth, I agree with you. There is no question that we need to increase access.

Speaking about access, let’s talk about access to vitamins and supplements. This is an update from the United States Preventive Services Task Force (USPSTF) that in 2014 examined whether supplements or minerals could help prevent the two major causes of death in America: heart disease, which accounts for at least 30% of all deaths, and then cancer, which accounts for about 20% of all deaths.

It’s really interesting, because 52% of U.S. adults report using at least one dietary supplement and 31% use a multivitamin mineral supplement. The question is, what are they doing it for? Presumably it’s for the benefits. These minerals, supplements, are known to be antioxidants and anti-inflammatory. Both cancer and heart disease are related to inflammation. One would assume that by taking these supplements one could decrease the risk of cancer and heart disease.

They looked at over 84 studies examining whether in fact multivitamins or minerals could reduce the rate of cancer and cardiovascular mortality. Here is what they found out. They recommended against the use of beta-carotene or vitamin E. They felt that there was really good data that especially with beta-carotene, at least in smokers, it actually increases the risk of cancer. With vitamin E, the data are very clear that it’s really of no benefit at all.

Now, what about the other, either individual supplements or multivitamins? They concluded with moderate certainty the data is insufficient. They can’t tell, so there is really sitting on the fence about this.

Elizabeth: Well, let’s just talk about the staggering amount of money people spend on these things.

Rick: All right, $50 billion in a single year. That’s in 2021. By the way, the companies that make these spend $900 million on advertising. One of the things that I’m concerned about is there are many things we know are beneficial. We have talked about smoking cessation, physical activity, diet, sleep, and a number of different things that we know are beneficial for preventing heart disease or cancer. I think it diverts our attention from strategies that we know are beneficial. What are your thoughts?

Elizabeth: I think that also the other thing that’s clear is that what we need is a super longitudinal study where a whole population takes a bunch of supplements and then a whole population doesn’t — otherwise, they appear to be much the same — and then really analyzing what is the impact of the supplements and vitamins on people. We are just not going to get that kind of data.

I think the other thing that we have talked about so many times is the healthy user effect, where people who are taking vitamins and supplements are also more likely not to smoke, to engage in physical activity, and all the other constellation of things that could be helpful.

Rick: Yeah, I agree. Now, one of the things that I failed to make clear at the beginning is this study applies to community-dwelling, non-pregnant adults. It does not apply to children. It doesn’t apply to persons who are pregnant or may become pregnant, because we know that the use of folic acid there is really important in terms of preventing neural tube defects, and iron can be beneficial as well. When we say supplements aren’t beneficial, we are talking about just the general community, not specific populations.

Elizabeth: Would you sort of sum this up by saying, if you were talking to a patient who said to you, “Look, I really like taking these supplements,” what would you say? Would you say, “Well, if it makes you feel better, go ahead. But the data don’t support that you’re really achieving anything with it”?

Rick: I would first of all make sure they are not taking beta-carotene or vitamin E. I would say the same thing you did, “There is really not any data. But let’s talk about your diet and see how you’re doing, and your physical activity, and are you smoking,” and let’s kind of redirect our attention there.

Elizabeth: Okay.

Finally, we are going to turn to a journal we have never talked about before, Frontiers in Public Health. This is a study that takes a look at the association — again, we are looking at an association — between increasing greenness in urban areas on all-cause mortality in the past two decades. If you take a look at epidemiologic literature, we find that greenness has a protective effect on mortality through various direct and indirect pathways. This is the authors’ hypothesis.

They conducted a nationwide quantitative health impact assessment to assess the predicted reduction in mortality associated with an increase in greenness across two decades, 2000 to 2010 and then in 2019.

They used this really interesting exposure-response function — that’s a satellite imagery data set that’s available — and publicly available, county-level mortality data from the CDC. They looked at all-cause mortality for people aged 65 and older in 35 of the most populated metropolitan areas in the U.S.

By doing these calculations, they estimated that just about 35,000 in some cases plus all-cause deaths could have been reduced in 2000, 2010, and 2019, with a local increase in green vegetation by 0.1 unit across the most populated metropolitan areas.

Rick: As you alluded to, they took satellite pictures, ascertained how green areas were, and then compared them over a 20-year period. It’s a really interesting hypothesis because the greenness doesn’t necessarily imply, for example, space that we use. It doesn’t imply parks or more recreation; it just means it’s greener. It could be they planted a tree somewhere. It could be that there are crops or something else.

I agree with you it’s an interesting study. In some ways, I think all of us would agree that the greener things are, the better things are in terms of decreasing pollution. If there is increased green space for recreation activity, physical space, that’s great as well. I’m not sure that I take these numbers home to the bank, but I do think that the way they approached the study was very interesting.

Elizabeth: This new factor I was completely unfamiliar with, the normalized difference vegetation index (NDVI). Of course, the authors also speculate that there is one factor that you’ve already mentioned about the green space that could have been important. The other thing was the difference in the air quality as a result of vegetation and that the respiratory pathway might have been the thing that was impacted.

Rick: Obviously, just making someplace greener isn’t helpful if you don’t have access to healthcare, healthy foods, or physical activity. It’s not just planting a tree or making it greener. It’s really the entire picture of how do you make a geographic region healthier for an entire population.

Elizabeth: And something at least I’m glad people are thinking about.

That’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.

Rick: I’m Rick Lange. Y’all listen up and make healthy choices.