Improving cardiovascular health in Asian American patients

Although the Asian American population is the fastest growing racial group in the United States, having more than doubled since 2000, data are limited on the distribution of risk factors for cardiovascular disease among ethnic subgroups. A recent research letter in the Annals of Internal Medicine found significant differences in age-standardized cardiovascular mortality between 2018 to 2023, with Filipino males having the highest rates, followed by Indian males and Filipino females. Notably, Indian American individuals had high mortality associated with heart disease and diabetes, whereas Chinese American individuals had higher mortality from stroke and hypertension-related conditions.

A 2024 American Family Physician editorial by Drs. Asha Shajahan and Saavia Girgla highlighted cardiovascular disparities in people of South Asian ancestry. Earlier risk calculators (Framingham, Pooled Cohort Equations) underestimate cardiovascular risk in South Asians; it is unclear whether the estimates from the newer PREVENT equations have greater accuracy in this population. The authors recommended routinely asking about family histories of premature heart disease and providing culturally informed lifestyle counseling to South Asian patients with insulin resistance (including type 2 diabetes) and metabolic syndrome.

Some national and international studies support lower body mass index (BMI) thresholds for overweight and obesity in Asian American patients. The World Health Organization identified BMIs of 23 and 27.5 kg/m2 as public health action points, corresponding with BMIs of 25 and 30 kg/m2 in non-Asian populations. However, pooling data from all Asian individuals can obscure concerning trends in subpopulations. An analysis of 2012-2023 data from Kaiser Permanente Northern California found that adults 30 to 49 years of age identifying as Native Hawaiian and other Pacific Islander had the highest overall prevalence of obesity; rapid temporal increases in high BMI (>27.5 kg/m2) were also seen among Filipino and other Southeast Asian populations. Oral semaglutide was effective in reducing body weight in a 68-week randomized trial conducted in Japan and Korea (-14.3% change in body weight in the semaglutide group vs -1.3% in the placebo group).

In 2024, the American Heart Association published a scientific statement on the social determinants of cardiovascular health in the Asian American population. Key upstream determinants include “socioeconomic position, immigration and nativity, social and physical environments, food and nutrition access, and health system-level factors,” all potentially modified by interpersonal discrimination and structural racism. The American Heart Association called on the federal government to collect disaggregated data on cardiovascular risk factors and health outcomes in self-identified Asian subgroups and to support research on community-level determinants of poor cardiovascular health to inform primary prevention strategies.

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This post first appeared on the AFP Community Blog.

Oral cancer screening is ineffective; will the USPSTF weigh in?

The U.S. Preventive Services Task Force (USPSTF) normally meets in person three times per year: in March, July, and November. This year, they did meet in March, but their meetings have since been suspended as they await the federal government's reopening and Health and Human Services (HHS) Secretary RFK Jr.'s postponed decision on whether to fire them all. Even if they could meet and vote on new or updated recommendations, their support staff at the Agency for Healthcare Research and Quality (AHRQ) has been gutted, and it isn't clear if the Evidence-Based Practice Centers that AHRQ contracts with to produce systematic evidence reviews are still being funded. Is the USPSTF better off remaining intact but non-functional as opposed to the reconstituted Advisory Committee on Immunization Practices, which is technically operating but has been producing nonsense? I don't know. But while the Task Force's activities remain at a standstill, prevention science is moving on.

One of the last topics I worked on as an AHRQ medical officer was screening for oral cancer. The USPSTF's last recommendation statement, concluding that the evidence was insufficient to determine the effectiveness of an oral screening exam in primary care, is nearly 12 years old. At the time, the only direct evidence was a cluster randomized trial performed in an Indian state with an extremely high incidence of oral cancer due in part to widespread betel quid chewing, and the Task Force reasonably concluded that it wasn't possible to extrapolate the mortality benefit seen in that trial to an American primary care population. In 2023, the USPSTF did a quick search for new evidence and determined that there wasn't enough to warrant updating the previous recommendation. The National Cancer Institute's latest summary of the evidence on oral and nasopharyngeal cancer screening, updated in April 2025, reaches a similar conclusion.

Then, the results of a new study were published. It turns out that Taiwan, where betel quid chewing is also common, launched the world's first national oral cancer screening program in 1999. Screening exams were conducted every two years in all male persons aged 30 and older who chew betel quid and/or smoke, as well as in indigenous males starting at age 18. An observational study of the outcomes associated with this screening program found that despite a 2.4 fold increase in early-stage oral cancer diagnoses, there was little change in late-stage incidence and no reduction in oral cancer mortality from 2004 to 2022. The researchers concluded that oral cancer screening is ineffective.

Taiwan isn't the United States, and if members of the USPSTF have reviewed this study, they may have been tempted to conclude that its results aren't any more applicable to our population than the trial from India. My view is different. If oral cancer screening doesn't work in Taiwan, it isn't likely to work anywhere else, especially in a dysfunctional U.S. health system reliant on opportunistic primary care screening in the absence of a robust public health infrastructure. As cigarette smoking and betel nut use have plummeted in the past two decades, this is likely the best evidence that we will ever have on this topic.

This is a small sample of the studies that the USPSTF and its support team should be reviewing but are likely unable due to irresponsible and damaging decisions being made (or intentionally not made) by HHS department leadership. Here's hoping that the Task Force's limbo ends sometime soon and that they emerge with renewed support and funding - but I'm not holding my breath.

Blood pressure drug combinations, comparisons, and therapeutic intensity

Although blood pressure management is the bread and butter of family medicine, selecting antihypertensive medications is not always straightforward. A 2023 American Family Physician article on initial management of hypertension in adults recommended, “Initial antihypertensive treatment should include an angiotensin-converting enzyme (ACE) inhibitor, an angiotensin receptor blocker (ARB), a long-acting dihydropyridine calcium channel blocker, or a thiazide diuretic.” But how should one choose among drug classes and single vs combination therapy?

Compared with monotherapy, combination antihypertensive drugs have the advantage of reaching blood pressure goals quicker, with similar tolerability. Expert consensus suggests that initial combination therapy is preferred “in patients with systolic blood pressure higher than 160 mm Hg or greater than 20 mm Hg above goal, or with diastolic blood pressure higher than 100 mm Hg or greater than 10 mm Hg above goal.” A 2024 study of US adults taking two classes of antihypertensives found that patients on fixed-dose combinations were 1.78 times more likely to have controlled blood pressure than patients on two separate pills. In June 2025, the US Food and Drug Administration first approved a triple antihypertensive drug, a combination of telmisartan, amlodipine, and indapamide.

Specific antihypertensive classes are indicated for special populations (eg, patients with heart failure, chronic kidney disease, diabetes). A randomized trial of more than 11,000 patients with hypertension at high risk of cardiovascular events found that despite similar blood pressure control, benazepril plus amlodipine was superior to benazepril plus hydrochlorothiazide (number needed to treat [NNT] = 45 to prevent a composite cardiovascular end point over 36 months). In the general hypertensive population, a Cochrane review found that over 5 years, thiazide diuretics have small advantages over calcium channel blockers (NNT = 100 to prevent a cardiovascular event; NNT = 84 to prevent heart failure) and ACE inhibitors (NNT = 167 to prevent one stroke).

Although cholesterol-lowering drugs and doses are classified by intensity, until recently no similar schema was available for antihypertensive drugs. A systematic review and meta-analysis of 484 placebo-controlled trials classified the average systolic blood pressure-lowering effects of 57 monotherapies and 189 combinations as low (< 10 mm Hg), moderate (10-19.9 mm Hg), and high (> 20 mm Hg) intensity. Unsurprisingly, most monotherapies had low efficacy, whereas dual or triple therapies generally produced moderate or high effects. Clinicians can use an online calculator derived from the review to estimate the efficacy of any antihypertensive drug and dose combination depending on the patient’s baseline blood pressure.

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This post first appeared on the AFP Community Blog.

Recent and upcoming presentations and meetings

In September, I traveled to Oxford University for the international Preventing Overdiagnosis conference, where I presented on behalf of a research team that spent several years working to estimate the annual harms of screening colonoscopy overuse in the United States. We concluded that 2.1 million to 3.2 million low-value (unnecessary) screening colonoscopies are performed every year, leading to 9 to 12 thousand preventable cases of severe bleeding or bowel perforation.

Examination Schools, Oxford University

On October 20, I will deliver the cancer screening update lecture at the Temple University Fall Family Medicine Review course. For many years, this live course was delivered in person at a resort conference center in Lancaster, but the virtual format instituted during the pandemic proved so popular that it has continued so that family physicians and other primary care clinicians can join from anywhere in the world. Later that same day, I will lead a study session that allows American Board of Family Medicine Diplomates to complete the Health Counseling and Preventive Care Knowledge Self-Assessment. For readers who are interested, there is still time to register at https://medicine.temple.edu/cme

I've taught in this course since 2012.

Looking ahead, the week before Thanksgiving I will travel to Atlanta for the North American Primary Care Research Group (NAPCRG)'s annual meeting. Although I have never consciously defined myself as a researcher, many of my publications (including the colonoscopy overuse harms study mentioned above) can be classified as such. My relatively new role as the faculty member in charge of resident scholarly activity at the LGH Family Medicine Residency Program has me eager to learn from fellow educators about how to motivate learners to move beyond point-of-care references and artificial intelligence tools for answering clinical questions to designing an original research study or performance improvement project.

Correlation, causation, and Presidential pronouncements on health

The historical track record of major U.S. Presidential pronouncements on health is as abysmal as one might expect given their prior occupations (27 lawyers, zero physicians or medical researchers). In 1971, Richard Nixon famously declared a "war on cancer"; 54 years later, not only is cancer still very much with us, but the Trump administration is now waving the white flag and pulling back on research investments. In 2000, Bill Clinton announced the completion of the Human Genome Project, forecasting that sequencing the human genome would lead to all kinds of breakthroughs in preventing and treating genetic diseases. A quarter-century later, notable progress has been made on many conditions, but genomic insights have yet to transform medicine as initially promised. In 2016, Barack Obama launched the Cancer Moonshot as part of the 21st Century Cures Act, and after his Vice President, Joe Biden, ascended to the Presidency in 2021, he re-committed the U.S. to accelerating progress toward cancer cures. The jury is still out on this one, but the current Health and Human Services Secretary's blanket opposition to mRNA vaccines (including those for cancer) has stacked the deck against it.

So when President Donald Trump made a "major announcement" on autism at the White House earlier this week, the former real estate developer and reality TV show host was following in the ignominious footsteps of his predecessors who, to put it bluntly, should have stayed in their lane. Taking his cue from Robert F. Kennedy, Jr., who for years led a nonprofit organization that opposes routine childhood vaccinations, Trump blamed infant shots and acetaminophen (Tylenol) in pregnancy for the increased prevalence of autism diagnoses in the U.S. and around the world. Dismissing the pain and discomfort that often accompanies being pregnant, he implored women to "tough it out" rather than take a pain reliever that is considered by every major medical organization to be safe in pregnancy. (And yes, there absolutely are downsides to avoiding Tylenol, given the clearly established harms of alternatives for pain and fever.)

I wanted to simply dismiss what Trump said, but after two days of seeing patients and responses on my social media, it's clear that many people are taking him and RFK Jr. quite seriously. To explain why they (and perhaps you) shouldn't be concerned about your child's vaccines or taking Tylenol when needed, join the first-year medical student class in evidence-based medicine that I taught at Georgetown for many years. The question we would examine in our first meeting was: does radiation from cell phone use cause brain tumors? (TL;DR - although there isn't any way to prove without a doubt that cell phones don't cause cancer, most of the evidence suggests that the answer is no.)

But think like a researcher for a moment. How would you study this question? You could do what's called a case-control study and compare the cell phone use of persons with brain tumors to persons without them. (This type of study would have been easier to do in the days before cell phones were ubiquitous; I didn't purchase my first cell phone until 2002.) In addition to asking about ownership, you could ask people to recall how long they spent talking on the phone on average, and which side of their head they pressed it to their ear. (Again, easier to do in the days before hands-free earbuds.) But there's a big problem with this type of study: recall bias. Human beings have a tendency to come up with plausible explanations when bad things happen, and a brain tumor certainly qualifies as a bad thing. Just as a recently administered MMR vaccine is a convenient explanation for the subsequent diagnosis of autism, a cell phone is a convenient explanation for cancer.

So let's say you perform a better type of study, a cohort study where you compare two groups by a more objective measure of cell phone exposure: cell phone subscriptions and number of minutes used each month. Obviously this design poses complications as family and business cell phone plans may not reliably identify who was actually using the phone, even setting aside issues of privacy and phone companies allowing researchers to access granular data. But if you find an association between increased cell phone use and risk for brain tumors, you can feel more confident that it's a true correlation. Similarly, some studies have shown associations between Tylenol use and neurodevelopmental disorders, though others have not.

But it's a huge leap from showing correlation to proving causation. The latter requires systematically eliminating confounding factors that may affect both the exposure and the outcome. For example, perhaps the true correlation is that women carrying pregnancies with children who are genetically predisposed to develop autism are more likely to experience fever-causing infections or musculoskeletal pain. Naturally, they will be more likely to seek fever or pain relief from acetaminophen, making it appear - incorrectly - that exposure to acetaminophen caused the outcome. We do not know if this is happening, as the FDA made clear in its news release.

In the meantime, I am not going to change how I counsel patients about vaccines in childhood or Tylenol in pregnancy. These medications have clear benefits (preventing serious diseases and relieving fever and pain in pregnancy), and the burden of proof rests on proponents of hypothetical negative effects, including Trump and RFK Jr. Finally, I think it's unconscionable for the President to put a "I took Tylenol in pregnancy so maybe I gave my baby autism" guilt trip on mothers without ironclad proof of either correlation or causation.

Are cash benefits for families associated with positive childhood experiences?

In the U.S., state and federal governments employ vast bureaucracies that aim to ensure that only the "deserving" receive public assistance in the form of subsidized health care, food, and housing. 2025 has seen a near-complete reversal of the pandemic policy of keeping people on Medicaid by default; now, states will be required to not only confirm Medicaid eligibility every 6 months, but to verify that certain "able bodied" beneficiaries are enrolled in job training or working at least 80 hours per month. Never mind that Medicaid is only a health care benefit - you can't use it to pay the rent or feed your family - or that work requirements have been unequivocal failures in states that have tried implementing them in the past. The point of this cruel policy isn't to increase employment; it's to save money by removing people from health insurance rolls even if they are working.

What are the effects of financial insecurity on child health? A systematic review in AJPM Focus found that "financial strain was associated with poorer health and well-being and more behavior challenges among children of all ages, poorer academic performance among school-age children, and more depressive symptoms among adolescents." Adverse childhood experiences (ACEs) such as child neglect, abuse, and exposure to violence affect at least one in four American children and are associated with unhealthy behaviors and chronic diseases in adults. As one might expect, these experiences occur more often in neighborhoods with built-in disadvantages such as high concentrations of poverty, pollution, limited green-space, and poor access to healthy food sources. A medical approach to this problem would be to screen patients for ACEs and provide some sort of intervention to counteract the negative effects of childhood trauma. It's unclear if such an approach actually helps, though, and even if it does, the public health professional in me thinks there must be better ways to prevent ACEs in the first place.

A recent cross-sectional study in 4 states (Kansas, Montana, South Carolina, and Wisconsin) turned the concept of ACEs on its head and instead asked more than 20,000 adults if they had experienced one or more of the following positive childhood experiences (PCEs):

1. Adult made you feel safe and protected

2. Felt you belonged in high school

3. Felt supported by friends

4. At least 2 adults took an interest in you

5. Felt your family stood by you

6. Enjoyed community traditions

7. Felt able to talk to your family

Adults who reported higher numbers of PCEs were more likely to have attended postsecondary school, had greater household incomes, were less likely to smoke, and had fewer chronic medical conditions than those reporting lower numbers. So how can our society reduce exposure to ACEs and increase exposure to PCEs? An analysis in the Milbank Quarterly illustrated that state policies that improve economic security are associated with better mental health outcomes in children and adults. More bureaucracies, then? Hardly. Arguably the most effective social policy implemented during the pandemic was the temporary 2021 expansion of the Child Tax Credit, which effectively provided "a near universal, unconditional child cash benefit," reducing child poverty to historically low levels.

Closer to home, since 2022 Philadelphia has experimented with providing no-strings attached cash assistance to low-income families rather than making them wait for inadequate public housing or limited numbers of vouchers to become available. Families (households had to have at least one child under the age of 16) fortunate enough to receive monthly payments ranging from $15 to $2057 (with a median of $1000) have generally applied them toward rent. Not only were households who received cash less likely to be evicted or become homeless, they also had fewer concerns about the quality of their housing.

I attended a conference recently where a presenter half-facetiously, half-seriously, summed up all of the risk factors for developing a chronic health condition as "Don't Be Poor." Our historic societal response to poverty has been to create difficult-to-navigate welfare programs with ever-changing eligibility requirements that help poor people with health care and food and housing but basically force them to stay poor to keep receiving benefits. What if we cut through the red tape and just gave them cash instead? Would fewer ACEs and more PCEs occur, leading to better health for everyone in the long run? It's not the kind of research that the National Institutes for Health will fund any time soon - they're too busy trying to prove that vaccines cause autism - but it's definitely a question worth studying.