Author Archives: Sam - Page 6

Sugar and spice, and salt is not very nice Part I

Posted by on February 19, 2013 Comments Off on Sugar and spice, and salt is not very nice Part I

“No matter how we look at it, the story is the same – there will be huge benefits in reducing sodium,” said Pam Coxson, PhD, a UCSF mathematician and the lead author on the paper who performed one of the three analyses published in Hypertension.

The quotation is an understatement–the studies claim that hundreds of thousands of lives can be saved by less salt. What are the facts?

Let’s start with the Centers for Disease Control and Prevention (CDC):

About 90% of Americans eat more sodium than is recommended for a healthy diet. Too much sodium increases a person’s risk for high blood pressure. High blood pressure often leads to heart disease and stroke. More than 800,000 people die each year from heart disease, stroke and other vascular diseases, costing the nation $273 billion health care dollars in 2010.

The key point is the relationship of sodium to hypertension and cardiovascular events:

About 45 percent of these cardiovascular deaths are attributable to high blood pressure, and numerous medical studies have already demonstrated how reducing dietary salt – the primary source of sodium – can lower blood pressure and reduce the risk of a heart attack or stroke.

The study’s three analyses came up with varying numbers of saved lives, ranging from 250,000 to 1,200,000 over the next decade by reduced sodium intake–they averaged 280,000 to 500,000. We have long known that certain populations are more salt-sensitive and should radically reduce intake. The CDC list below tells that story, but we all should reduce sodium, not merely by not picking up the salt shaker, but by eating more fresh foods and looking at the labels on the processed foods we eat. Salt-sensitive populations

We can all benefit by a reduction in sodium, long before we become part of a vulnerable population. Next time, let’s look at some strategies we can use while waiting for food companies to offer lower sodium alternatives and government action in this domain.

Helpful links for more information about dietary sodium

It’s the children–stupid!!

Posted by on February 14, 2013 Comments Off on It’s the children–stupid!!

If poet William Wordsworth was correct that “The child is father of the man,” then we can expect some really fat men in the coming generation.

Based on data from high school students, the problem is, well, looming large.

Note that even where the trend is not statistically increasing, it is still increasing.

If lifetime habits are formed when we are young, then the target of our efforts should be clear.

Common wisdom is that the schools, from which these data come, are part of the problem and the solution. Because they are often under-funded, they accept money from food companies for placement of vending machines. There is widespread belief that snacks and sugary drinks in those machines are part of the problem of obesity. Some districts have put restrictions on what can be in those machines.

For example, here is a 2005 National Conference of State Legislatures (NCSL) summary

Whether those restrictions are sufficient to mitigate the harm is beyond the scope of this posting.

Then, there is the more basic question of whether the impact of vending machines is real or merely plausible. A study by Penn State researchers found no link between vending machines and obesity, contrary to the expectations of the researchers.

The scope of the problem and the accompanying political debate is well-described in the February 20, 2012 New York Times.

The challenge to our society, shown below, is clear even if the solution remains illusory.

us_obesity_trend_yrbs_91_11

The Role of Obesity in US Mortality

Posted by on February 11, 2013 Comments Off on The Role of Obesity in US Mortality

Recently there was a public debate between a physician and the Governor of New Jersey on the subject of weight. The Governor, pictured below, famously ate a donut on the David Letterman Show, eliciting this: “I’m worried he may have a heart attack. I’m worried he may have a stroke,” former White House physician Connie Mariano, M.D. said in an interview with CNN.
Christie

The media event continued with a press conference at which Governor Christie told the doctor to shut up, and a follow-up phone call in which he put the point more strongly. Nonetheless, he admitted that: “I have been remarkably healthy. My doctor continues to warn me my luck is going to run out relatively soon. So, believe me, it is something that I am very conscious of,”

There were suggestions that the doctor was diagnosing him long-distance, which is generally a breach of medical ethics if not common sense. I take that as political spin–the doctor was simply citing well-known demographic facts. For example, you only need to look at a recent study of the impact of obesity on longevity on 50-year-olds. (Governor Christie is 50 years old)

Researchers at the University of Pennsylvania applying statistical analysis to mortality figures were able to tease out the role of obesity.

In the United States, they concluded, obesity contributes to a loss of 1.5-2.0 years of life to men and women at age 50.

Mortality by country attributable to obesity 2011

That conclusion is even more astounding when you consider that it is an average: many people lose considerably more than 2 years of life because they weigh too much: eating too much and exercising too little.

I confess that I do not like having a President who smokes. I also do not want a President who is morbidly obese. If Governor Christie represents everyman, then everyman needs to exercise more and eat less, beginning with less donuts.

The Casualties Do Not End With The War

Posted by on February 7, 2013 Comments Off on The Casualties Do Not End With The War

We know that casualties do not end with a war, but we don’t often think about it. Unless we are directly affected, the symptoms are invisible to us.

Among the casualties are those who suffer from CMI (Chronic Multisymptom Illness). During the 1991 Gulf War there were 700,000 military personnel in the war theater. About 25-35 percent of them have reported symptoms consistent with CMI.

CMI_IOM_20130201

A Congressionally-mandated, consensus report by the Institute of Medicine Committee on Gulf War and Health lists some of the symptoms, based upon the following working definition:

CMI_Definition_IOM_20130201

Reported symptoms are:

CMI_symptons 20130201

As treatments, the reporting committee considered:

  1. Pharmacological interventions (medications)
  2. Other Biological Interventions (such as electrical brain stimulation)
  3. Cognitive Behavioral Therapy (Individual and Group)
  4. Brief Psychodynamic Therapy (Individual and Group)
  5. Biofeedback
  6. Cognitive Rehabilitation Therapy
  7. Complementary and Alternative Therapies
  8. Exercise

My observation is that the Committee recommendations are guarded and limited because of the absence of unbiased, unambiguous research studies. Use of antidepressants along with cognitive behavioral therapy, as well as symptomatic treatment, such as NSAIDs for pain.

Many of the report recommendations deals with programmatic approaches to the problem by the Veterans Administration as well as teaching clinicians how to deal with patients who have a chronic illness, to be managed not fixed.

As citizens we are obligated to pay the full costs of the wars that we support, not just the military hardware and the salaries of military personnel, but the care of those with casualties. Those casualties may be invisible to us, may be difficult to treat, but the distress they cause is real, and the risks their victims have taken on our behalf are just as real. We are without honor as a people if we do not provide them with treatment for all their wounds, visible and invisible.

The Verdict on US Health: Shorter Lives, Poorer Health Part II

Posted by on February 4, 2013 Comments Off on The Verdict on US Health: Shorter Lives, Poorer Health Part II

Last time we looked at the findings of the consensus report of the Institute of Medicine that concludes that we face shorter lives and poorer health compared to other advanced countries.

The report includes a comparison of deaths among both men and women under 50. I included the chart for men last time, but overlooked the chart for women. My bad.

US-Health-in-Intl-Perspective_women

The top three causes of mortality for men were 1. Non-intentional injuries, 2. Non-communicable diseases, excluding cardio-vascular, and 3. Intentional injuries.

The top three causes of mortality for women were 1. Non-communicable diseases, excluding cardiovascular, 2. Non-intentional injuries, and 3. Perinatal conditions.

Since there is a separate category of maternal conditions for women, the perinatal conditions, which appears for both men and women, obviously refers to risks while being born rather than giving birth.

But the report goes beyond those findings to suggest possible sources of the problem and recommendations for further study.

It is not a simple discussion but a complicated one, filled with the kind of nuance and qualification common to academic work, and conspicuously missing in public discussion.

The Table of Contents gives a taste of the complexity, which suggests that remediation will be equally complex and multi-modal–not as simple as the public and their political representatives might prefer:

4 Public Health and Medical Care Systems, 106
Defining Systems of Care, 107

  1. Question 1: Do Public Health and Medical Care Systems
    Affect Health Outcomes?, 109
  2. Question 2: Are U.S. Health Systems Worse Than
    Those in Other High-Income Countries?, 110
  3. Question 3: Do U.S. Health Systems Explain the
    U.S. Health Disadvantage?, 132
  4. What U.S. Health Systems Cannot Explain, 133
  5. Conclusions, 135

5 Individual Behaviors 138

  1. Tobacco Use, 140
  2. Diet, 144
  3. Physical Inactivity, 147
  4. Alcohol and Other Drug Use, 149
  5. Sexual Practices, 152
  6. Injurious Behaviors, 154
  7. Conclusions, 159

6 Social Factors 161

  1. Question 1: Do Social Factors Matter to Health?, 163
  2. Question 2: Are Adverse Social Factors More
    Prevalent in the United States Than in Other High-Income
    Countries?, 170
  3. Question 3: Do Differences in Social Factors Explain the
    U.S. Health Disadvantage?, 185
  4. Conclusions, 190

7 Physical and Social Environmental Factors 192

  1. Question 1: Do Environmental Factors Matter to Health?, 193
  2. Question 2: Are Environmental Factors Worse in the
    United States Than in Other High-Income Countries?, 199
  3. Question 3: Do Environmental Factors Explain the
    U.S. Health Disadvantage?, 203
  4. Conclusions, 205

8 Policies and Social Values 207

  1. The Role of Public- and Private-Sector Policies, 209
  2. The Role of Institutional Arrangements on
    Policies and Programs, 211
  3. Societal Values, 219
  4. Policies for Children and Families, 225
  5. Spending Priorities, 233
  6. Conclusions, 236

The report notes:
It will also be important for Americans to engage in a thoughtful discussion about what investments and compromises they are willing to make to keep pace with health advances other countries are achieving. Before this can occur, the public must first be informed about the country’s growing health disadvantage, a problem that may come as a surprise to many Americans.

The report summarizes the costs of inaction:

20130108 Costs of Inaction from IOM report

The Verdict on US Health: Shorter Lives, Poorer Health Part I

Posted by on January 31, 2013 Comments Off on The Verdict on US Health: Shorter Lives, Poorer Health Part I

If national defense were a simple matter of military might, the United States would have no concerns. We are clearly the military power of the century–the go-to nation when military power is to be projected.

The premise of this blog is that national defense depends upon more than military power–including economic power and the health of the citizenry. If that premise is correct, we’ve got problems.

As Americans we like to think we have the best of everything including a health care delivery system. That is simply, and demonstrably, not true.

A consensus report of the Institute of Medicine concludes that we face shorter lives and poorer health compared to other advanced countries.

A chart shows part of the problem, deaths before age 50:

US Deaths Before 50 Compared to Peer Countries

The latest report has a table showing the US in 17th place in longevity at birth.

US Life Expectancy at Birth Compared to Peer Countries
We are worse than other countries in 9 areas.

1. infant mortality and low birth weight
2. injuries and homicides
3. adolescent pregnancy and sexually transmitted infections
4. HIV and AIDS
5. drug-related deaths
6. obesity and diabetes
7. heart disease
8. chronic lung disease
9. disability

Next blog will deal with some of the report’s recommendations and conclusions.

The Safety of Our Children: Vaccinations

Posted by on January 28, 2013 Comments Off on The Safety of Our Children: Vaccinations

If there is one aspect of health we care most about, it is that of our children.

We are afraid to do the wrong thing, which might be doing something and might be doing nothing.

Vaccinations are the first major encounter our children have with the health care system.

By major I mean:

Under the recommended plan from the Centers for Disease Control and Prevention, children today are vaccinated against 14 infectious diseases, receiving up to 24 vaccines by their second birthday, and up to five in one office visit.

There has been controversy about the frequency of vaccinations, about the content of vaccines, and about the necessity of the vaccines at all in the absence of the diseases they protect against.

The last reported case of diphtheria in the US occurred in 2003.

The last reported case of polio in the US occurred in 1986.

I do not claim to know the incidence and severity of side effects and reaction to these and other vaccines.

Here is what I know:

  1. When a disease like smallpox was eradicated, the routine vaccination was halted.
  2. The diseases that we are vaccinated against have not been eradicated. We live in a small world: we travel to other countries, and others travel here. HIV/AIDS was brought here on a plane. We do not want to be like the Native Americans, wiped out by diseases from Europe because we were not vaccinated.
  3. The risk and incidence of reactions are minimal compared to the severity of an infectious outbreak.
  4. Science brought us the life-saving vaccines, not hunch or intuition.
  5. The Institute of Medicine of the National Academies has issued a report on childhood immunizations and found:
    1. the childhood immunization schedule is considered one of the most effective and safest public health interventions available to prevent serious disease and death. Furthermore, the committee’s review of the literature did not find high quality evidence supporting safety concerns about the immunization schedule.
    2. The committee’s efforts to identify priorities for recommended research studies did not reveal an evidence base suggesting that the childhood immunization schedule is linked to autoimmune diseases, asthma, hypersensitivity, seizures, child developmental disorders, learning disorders or developmental disorders, or attention deficit or disruptive behavior disorders.
    3. The committee found no significant evidence to imply that the recommended immunization schedule is not safe.

The bottom line: in all of our health care decisions we are playing the odds–life never affords us certainty. The odds favor vaccination according to schedule. Listen to your pediatrician–vaccinate your children.

Violence Prevention and Mental Health

Posted by on January 24, 2013 Comments Off on Violence Prevention and Mental Health

The White House plan to reduce gun violence has substantial mental health provisions:

Children and Young Adults

  1. Project AWARE (Advancing Wellness and Resilience in Education) directed at students in schools
    • Mental health “first aid” training for teachers
    • Referral services for students
  2. Support individuals 16 to 25 outside of and beyond school
  3. School-based violence prevention, including mental health services for trauma and anxiety
  4. Train 5,000 mental health professionals to serve in the schools
  5. Initiate a national conversation to address stigma associated with mental illness

Ensure Mental Health Coverage

  1. Issue final regulations on private health insurance coverage of mental health treatment
  2. Ensure that Medicaid programs are meeting mental health parity requirements

In addition:

  • The $150 million Comprehensive School Safety program will help finance new school resource officers (police) or mental health professionals (psychologists, social workers, counselors).
  • The hiring decisions will be with local school districts.

My Take (this is a blog, isn’t it?)

  1. The problem of obtaining adequate mental health coverage for anyone is a major challenge because:
    1. There is neither a test nor a cure for mental illness, which means that diagnosis is expensive and difficult, and management is expensive and difficult
    2. Mental illness resembles a chronic illness with transitory remission, so there is a temptation to halt treatment during remission and hoard resources to deal with crises.
    3. Nearly all families and individuals, save the super wealthy (think $1 million in annual income), have insufficient resources to address the full spectrum of mental illness symptoms, some of which require residential treatment for long period to be optimally addressed
  2. Large segments of the population continue to provide moral diagnoses rather than accepting a medical diagnosis of mental illness
    1. Depressed people are seen as lazy and unmotivated; bipolar people are seen as lacking discipline
    2. The symptoms are largely invisible and intermittent–mental illness is only partially and rarely someone walking down he street talking to imaginary people.
    3. Consequently, a large part of the public is unwilling to finance the treatment of those seen as slackers.

    Bottom line: the Administration is to be commended for first steps, but any reasonable approach will require billions not millions of dollars

Snacks: the 4th meal of the day

Posted by on January 21, 2013 Comments Off on Snacks: the 4th meal of the day

Let’s say a woman consumes 1500 calories a day to maintain weight and a man consumes 2000. It varies from individual to individual according to your rate of metabolism, your physical activity, your body build, and other variables. More than that–you gain weight.

To lose a pound requires taking in 3500 calories less–or about 500 calories daily to lose a pound in a week.

According the chart below from The Hartman Group, Americans eat 2.3 snacks daily, with chips and soft drinks the most popular.

Consider the math: the chips in the vending machine run 160 calories each. An 8-ounce soft drink can has 97 calories. The calories for that one snack are 160 + 97 = 257. If that is an average snack and there are 2.3 average snacks per day, the total snack calories are: 2.3 x 257 = 591

Of course no one eats an average snack–sometimes we eat less; most of the time we probably eat more to compensate for those in the averages who are not snacking at all.

If you are maintaining weight, cutting out snacks is likely to help you lose a pound a week–assuming you continue to maintain current activity levels while dieting.

If you are gaining weight at a rate of a pound a week, the other three meals may not be the problem.

Clearly, the fourth meal daily can help you lose or gain a pound or more weekly.

snacking-in-america-large

ED use drops when medical practices extend office hours – amednews.com

Posted by on January 17, 2013 Comments Off on ED use drops when medical practices extend office hours – amednews.com

This article from the American Medical Association news service caught my eye because it discusses an issue central to the challenge of providing quality health care at the lowest feasible cost, to individuals and the society: ED use drops when medical practices extend office hours – amednews.com.

With the recent US Presidential election following the passage of the Patient Protection and Affordable Care Act (PPACA) aka “Obamacare,” the issue of access to health care has been prominent.

Access, however, does not merely mean having health insurance, although that is certainly important.

Access also means that the health care provider needs to be open and available. Those of us beyond a certain age can remember when the family doctor made house calls, even in urban and suburban areas.

All of us know that those times are gone, except perhaps in some small, rural communities. Attempts to revive house calls in some areas have not always endured or proved worthwhile.

A study in Health Affairs, 31:12, December 2012 finds that emergency department usage declined 20 percent and unmet medical needs declined over 40 percent when physicians stayed open extended hours.

In the absence of such access, patients go to the nearest hospital emergency room for non-emergency care. The result is a burden on emergency facilities treating more urgent cases as well as an added, and unnecessary burden, on health care insurers. Those costs through higher premiums are passed to the consumer: businesses and individuals.

This study points to a very important lesson: we can improve health care AND lower costs. One important detail is that the practice staying open might mean the availability of a nurse practitioner rather than a physician.

Improving access to health care in a time of fiscal restraint is going to require more innovative use of health care providers, especially nurses, physician assistants, and urgent care facilities. Not only does this study make that clear, but as James King, MD, a family physician in Selmer, TN suggests that practices partner with urgent care facilities in the community that supply after-hours care if the doctors can’t offer these services themselves. “Your patients know to go there, and then the urgent care center knows to get information back to their primary care physician when they’re seen” by their regular office.