Lack of Health Insurance and Decline in Overall Health In Late Middle Age

Clinical Briefs
By Louis Kuritzky, MD

It is intuitive that uninsured Americans would use fewer healthcare services. Whether insurance status is related to overall health in late middle age is little studied. As many as 1 in 6 persons age 55-64 are uninsured in the United States. Baker and colleagues examined the health status of persons included in the Florida Health and Retirement Survey Database (n = 9824) as observed over a 4-year time period. Over the study period, 79.6% were continuously insured, 10.9% intermittently insured, and 9.5% continuously uninsured. Uninsured persons were 2-2.5 times more likely to report a major decline in overall health, more heavily weighted among those continuously uninsured. New difficulties with mobility (eg, walking or stair-climbing) were also more common in uninsured individuals.

The deleterious effects of uninsured status were not related to gender, ethnicity, or income, but better baseline health was associated with greater risk for major decline in health status among the uninsured. The number of persons uninsured over age 55 is increasing. The observation that uninsured status increases the likelihood of negative health outcomes is concerning. 

Baker DW, et al. N Engl J Med. 2001; 345:1106-1112.

Long-Term Weight Loss with Sibutramine

The burgeoning epidemic of obesity and its consequences shows no signs of diminution. Currently available pharmacotherapy tools have enjoyed only modest use in the clinical setting. Long-term trials are necessary to convince the physician and patient populations that pharmacotherapy of obesity is meritorious. This 1-year trial of obese adults (BMI > 30) used sibutramine 15 mg on a daily continuous or daily intermittent schedule vs. placebo. The intermittent schedule used a 7-week hiatus of pharmacotherapy after each 3-month segment, based upon the observation that weight reductions tend to slow after this interval.

Subsequent to the 4-week run-in period, at 1 year patients on treatment lost a mean of 4% of their body weight (continuous regimen) and 3.5% on the intermittent schedule, both of which results were significantly greater than placebo. Although sibutramine has been reported to be associated with changes in blood pressure, no blood pressure changes were seen during the study period in this population. Sibutramine is effective in long-term (1 year) management of obesity.

Wirth A, Krause J. JAMA. 2001;286: 1331-1339.

Prediction of All-Cause and Cardiovascular Mortality in Elderly People from One Low Serum Thyrotropin Result

Subclinical hyperthyroidism (SCH) is defined as a subnormal TSH level accompanied by normal levels of T4 and T3; as is implied in the name designation, persons must also be free of symptoms of hyperthyroidism. The pathologic consequences (or lack therof) have been thus far ill-defined. Parle and colleagues evaluated the impact of SCH upon mortality in a large population (n = 1191) of persons older than age 60 followed for up to 10 years (mean follow-up, 8.2 years). Of the study population, 6% fulfilled diagnostic criteria for SCH.

All-cause mortality was significantly increased at years 2, 3, 4, and 5 after study entry for those with SCH, mostly due to an increased risk of death from circulatory diseases. Earlier reports have indicated an increased risk of atrial fibrillation in persons with SCH. Parle et al suggest that persistently low TSH levels in asymptomatic persons with normal levels of T4 and T3 are indicative of increased mortality risk; whether reducing T4 or T3 levels to a point where TSH is normalized will reduce risk of mortality is not yet known.

Parle JV, et al Lancet. 2001;358:861-865.