Author Archives: Sam - Page 7

Flu season: where statistics and anecdote meet

Posted by on January 14, 2013 Comments Off on Flu season: where statistics and anecdote meet

No missing that it is flu season. Like hurricanes in Florida, fires in California, and tornadoes in Oklahoma, either the media reminds us or our friends do.

Massachusetts just declared a flu emergency. The Centers for Disease Control and Prevention (CDC) map showing that there are widespread flu cases in 41 states is on all the news media websites and news reports. And the flu deaths have just surpassed the 1 of 14 deaths threshold to officially be called an epidemic.

There seem to be a lot of people with the flu or flu-like symptoms, which seems strange. The flu vaccine is not something new. It is readily available, far more cheaply than getting the flu is. If you are an hourly worker, it costs the equivalent of 1-2 hours of work, but the flu costs you 8 hours of work.

I think there are four reasons why there is so much flu.

1. Many people do not get the flu shot even when it is available for free, as in many workplaces. There is magical thinking involved. The vaccine is dangerous, they think, or, “it will make me get the flu.” Often there is a fear of needles.

Comparing vaccination rates from November to the previous year, they are about the same: less than 3 out of 8 people. By March of last year, less than 1 out of 2 individuals had been vaccinated. Trends from November to March are likely to be similar this year.

Flu_vaccinations2012
The next two reasons are a bit more complicated.

This table shows the reports of testing of flu strains around the country totaling over 9,000 tests with slightly less than a third positive. There are about 4 times as many Type A as Type B positive tests. Of course, many people with the flu do not get tested. They may call their doctor, who either prescribes an anti-viral or tells them it is too late, that they should drink plenty of liquids, and look for the signs of pneumonia.

Flu_week52_1

So, the next reason is:

2. People contract a virus that is not influenza.

The next image shows tests done at the CDC for different strains. The sample is much smaller, about a seventh of the previous number of positive tests. Note that strains of both Type A and Type B influenza were identified. About a fourth are Type B.

Flu_week52_2

And here are the strains in the 2012-2013 vaccine:

On February 23, 2012 the WHO recommended that the Northern Hemisphere’s 2012-2013 seasonal influenza vaccine be made from the following three vaccine viruses:
an A/California/7/2009 (H1N1)pdm09-like virus;
an A/Victoria/361/2011 (H3N2)-like virus;
a B/Wisconsin/1/2010-like virus (from the B/Yamagata lineage of viruses).

Note the absence of B/Victoria lineage from the vaccine, so the final reason:

3. People contract an influenza virus for which they have not been vaccinated–even though they received this year’s flu vaccine. There has been talk of a vaccine with four strains (quadri-valent) rather than the current three strains (tri-valent), but none yet operational in the US.

4. Even those who get the flu shot do not get perfect immunity. Immunity depends on the weakened or killed virus stimulating the production of antibodies. Everyone’s immune system is different, and those with weaker responses get less protection. Indeed, older folks get a strengthened vaccine now, so that aged immune systems can be stimulated to trigger an adequate response. Also, the antibodies stimulated tend to stay concentrated in the bloodstream, not the lining of the lungs where the virus enters.

Conclusion: The flu virus is inconvenient at best and deadly at worst. You may not get adequate protection from the vaccine, but you get zero protection without it. And get the pneumonia vaccine as well, if you haven’t already: real good chance of a secondary infection if you get the flu and haven’t gotten the pneumonia vaccine.

Are the troops healthier than before?

Posted by on January 10, 2013 Comments Off on Are the troops healthier than before?

Military troops are healthier than before with less arterial plaque than previous studies showed. So says a study published in the Journal of the American Medical Association

Whether our military is healthier is an important question, going to the heart of the reason for this blog. The study also makes clear how difficult answering that question is.

The study compares arterial plaque from autopsies of US soldiers in Iraq to the findings from similar studies on soldiers in the Vietnam and Korean conflicts.

The implicit assumption is that deceased soldiers are a random sample of the larger military population, or at least that deceased soldiers from different wars are comparable samples.

For example, the sampling is quite different in the 3 conflicts, with a larger number and larger percentage of deceased soldiers available to the Iraq War study than from the earlier conflicts, which had much higher number of combat deaths.

Table 3 JAMA 20121226

The authors, as in all good science, do an admirable job of listing in the Comments section all the possible variables unaccounted for. Probably the most striking change between the earlier and current study subjects is that in earlier wars tobacco consumption was encouraged, while by the time of the latest conflict the military had successfully lowered smoking rates within the ranks. That rate is over 30% while the civilian rate is closer to 20%.

In addition, both military and civilian populations have profited from the availability of statin drugs. The military may have improved arterial health today, but that health may be better, the same, or worse than civilian equivalents. I cannot help but assume that the Army still produces bacon for breakfast nearly every morning by baking it in its own grease per this recipe, under Note.

Even with the limitations that the authors list, the study provides an intriguing look at disease across demographic categories.

Table 1 JAMA 20121226

It appears that older more sedentary occupations, ranks, services are all likely to show greater evidence of arterial plaque.

For example, the Marines show the least while the Air Force shows the most. Higher ranks show more plaque. Higher educational levels show more plaque, as education is a likely correlate of rank, implying more sedentary activity and perhaps greater age.

Policy, Politics, and Guns. Oh my!

Posted by on January 7, 2013 Comments Off on Policy, Politics, and Guns. Oh my!

No solutions here. Just some clarifications of a complicated subject.

1. While we have a constitutional right to “bear arms,” there is no obligation to do so.

Some people need guns. Most of us don’t. If you are a hunter (and not a bow hunter), you need a rifle or shotgun when you are hunting, but you can lock it up soundly the rest of the time.

For most people the use of a gun for self-defense is illusory—you aren’t going to get to the gun before someone gets to you.

Criminals often get guns by stealing them from licensed owners—so your gun is making lots of people unsafe.

Your gun is much more likely to be used for a suicide or discharged accidentally than for self-protection.

2. The constitutional right is not unlimited. The First Amendment is not unlimited: child pornography is not protected speech. The Second Amendment is not unlimited.

    a. There are prohibitions on owning automatic weapons and sawed-off shotguns.

    b. There is no protection for magazines with 30 rounds.

    c. The recent Heller case establishing a personal right was a 5-4 decision. Such decisions are often reversed when there is an absence of a national consensus.

3. There is no historical evidence that personally-owned guns have maintained freedom. There is clear evidence that they are the source of death from homicides, suicides, and accidents.

If we take a fantasy trip to an authoritarian United States of the future—several lifetimes from now, we will find that the U.S. military outguns any opposition, so in that fantasy world, only defections with weapons would have any impact on regime change.

In the present, civilian weapons are used to kill other civilians.

4. Personal automobiles are no more likely to be taken away than firearms, yet vehicles are registered, require proof of proficiency to operate, and require liability insurance.

The idea that anyone is taking away the firearms of the US civilian population is an excellent marketing ploy that has been successfully implemented several times in the past half century: someone suggests that there will be gun control as a first step to confiscation, and gun owners rush to the store to get more.

I do not claim to have answers to the problem of more than 30 thousand deaths from firearms annually.

However, I assert that in a democratic society we have the means to address the problem—and the obligation. We can do so with minimal inconvenience to anyone who wishes to legally own a firearm for hunting, target-shooting, or self-defense, while making it prohibitively inconvenient for individuals who wish to shoot school children.

Firearm Trends Leave Me Clueless

Posted by on January 4, 2013 Comments Off on Firearm Trends Leave Me Clueless

One of the more interesting aspects of firearm mortality is the trend over the past 15-20 years. Beginning in 1994 the rate of mortality began to drop. That was the year that the assault weapon ban passed. Note that the rate of firearm deaths was close to the rate for deaths in motor vehicle accidents.

Injury Deaths 1979_2007

The rate of firearm deaths dropped from 1993 to 1999 and has remained level since then. The rate of death from motor vehicle accidents has dropped, but not as steeply.

The rate of death from poisonings has nearly tripled. What is that all about?

It might be thought that the assault weapons ban brought down the death rate, but that is not likely. The chart below compares 1993 to 2004, showing that the rate for suicide with firearms dropped about the same as the rate for homicides. I may be mistaken, but assault weapons are not the weapon of choice for suicide. Something else must have been happening in those ten years, or until 1999, at least. I don’t know what it was, but it would be nice to replicate it.

Firearms 1993_2004

When events like the Newtown massacre dominate the airwaves, we would like to act to prevent the next one. I think we should act to prevent the next one. However, the data demonstrate how difficult it is to decide what will work. An effective policy does not have to solve the problem by ending all future incidents: it just has to demonstrate a substantial change in a positive direction. That will be challenge enough.

I really don’t want to write about guns . . .

Posted by on December 27, 2012 Comments Off on I really don’t want to write about guns . . .

Everyone has opinions on the subject, and few are indifferent.

The opinions are strongly held, not preferences. And everyone has recited the top 5 arguments for or against societal action, according to one’s opinion.

But how can anyone seriously write about health care in the United States without considering the impact of firearms?

I know that I am not interested in becoming one more activist in the debate—there are plenty of those on both sides. I also know that no opinion on any subject is without dissenters, including whether the sun will rise tomorrow morning.

Knowing that, I plan to point out some facts that might be generally agreed upon, no matter where one’s opinions lie.

First, firearm deaths are a public health concern. In 2010 there were 2,468,435 deaths in the United States from all causes, of which 31,328 were related to firearms. Deaths from firearms were 1.27 percent of all deaths, or one of every 78.8 deaths.

For purposes of comparison, there were 35,332 deaths from motor vehicle accidents that year, or 1.43 percent of all deaths, and one out of every 69.9 deaths. Source: National Vital Statistics Report, October 12, 2012, Centers for Disease Control and Prevention

Second, while the rate of death from firearms has been steady for the past ten or more years at about 10.2 per 100,000 of population, it is not equally distributed among age groups.

The risk of homicide by firearm is greatest between ages 18 and 44, while the risk of suicide rises with age through life.

Firearm Deaths by age and intent, 2001-2009

More to follow, reluctantly.

If you don’t think this is a matter of national defense

Posted by on December 20, 2012 Comments Off on If you don’t think this is a matter of national defense

Well, the Department of Defense does.

During the period 1998-2010, discharges from the US Armed Forces for obesity have risen at a rate that should concern all of us.

Presumably, the military problem reflects the similar civilian problem; however, we expect soldiers to be more physically fit than civilians.

In this inter-service rivalry no one is winning:

AFHSC_obesitypct_201101

The entire report: Diagnoses of Overweight/Obesity, Active Component, U.S. Armed Forces, 1998-
2010

Fat old people have a problem. Fat old people are a problem.

Posted by on December 17, 2012 Comments Off on Fat old people have a problem. Fat old people are a problem.

Bette Davis famously said, “Old age is no place for sissies.” Growing old is challenge enough, so is being obese—but put them together and . . . .

Among the challenges:

1. Accelerated cognitive decline. A recent study found that cognitive decline was accelerated among the obese with any two of the four abnormalities:
a. High triglycerides or use of lipid-lowering medications
b. High low-density lipoproteins (LDL)
c. Elevated blood pressure or use of blood pressure medications
d. Elevated blood glucose

A 2009 Nursing World article added the following life-threatening illnesses:

2. Cardiovascular Disease. Over 80 percent of older Americans dies from this disease. Obesity seems to exacerbate the inflammatory process that underlies it.

3. Gallbladder Disease. Obesity is believed to effect a decrease in bile salts and increase in cholesterol.

4. Cancer. The evidence that obesity is a risk factor for cancer, particularly breast cancer, is growing.

5. Diabetes. Even relatively small weight gains can provoke a genetic tendency toward diabetes, so much the worse for the large weight gains that result in obesity.

As well as the nonfatal ailments:

6. Respiratory Problems. Lungs decrease in size, and the chest wall becomes heavier.

7. Arthritis and Osteo-arthritis. While arthritis is a general challenge for older adults, obesity puts weight on the knee and hip joints, resulting in damage to cartilage.

8. Skin conditions. Perspiration and friction can lead to persistent skin conditions.

The necessary emotional and financial burden of caring for the aged in our society, as well we should, is inflated by the unnecessary burdens of avoidable disease and disability. As we address the health needs of our population, we must lessen the burden of the aged on our society, not by decreasing available benefits but by decreasing needs. That goal requires improving health before and during old age.

Further reading:
Obesity Among Older Americans
National Blueprint: Increasing Physical Activity Among Adults Age 50 and Over
Effect of Obesity on Falls, Injury, and Disability

What to do about fat kids?

Posted by on December 14, 2012 Comments Off on What to do about fat kids?

Obese children tend to become obese adults.

Obese adults tend to get high blood pressure, diabetes, chronic back pain, heart attacks and strokes.

Some researchers in an article published in the August 13, 2012 edition of Pediatrics have a partial answer.

Competitive foods are those sold outside of the Federal meal program. The conclusion from the Full Report:

Laws that regulate competitive food nutrition content may
reduce adolescent BMI change if they are comprehensive, contain strong
language, and are enacted across grade levels. Pediatrics 2012;130:437–
444

What this means is that researchers have found something our state legislators and local school boards can do to slow the public health crisis of obesity among children.

But there is a problem—you knew that, right? Many school districts depend on the sales of snacks and sugary drinks to supplement the local school budget. Even if the wealthiest school districts could afford to remove the snack and drink machines, the poorer districts would face a Hobson’s choice: accept the machines and health risks or reject them at the expense of education.

Many states have been dealing with how to equitably share revenue among different school districts, allowing some redistribution of revenue in favor of the poorer districts without being confiscatory toward the wealthier districts. What is “equitable” is a highly charged political debate.

Even with the political caveat, it is reassuring to learn there may be things we can do, even without Federal intervention, to reverse the public health epidemic of obesity and its consequences.

There was a time when FAT City was something good.

Posted by on December 12, 2012 Comments Off on There was a time when FAT City was something good.

No more.

We are FAT City. It is bad. It is getting worse. Here’s what it looks like geographically:

Map of Obesity in the USA 2011

The map shows the problem in 2011, but it does not show the growth of the problem over time. Exploring that growth is part of the search for the cause and the solution.

If being overweight were just an aesthetic choice, no one would care. If being overweight were totally beyond the control of individuals, we would simply live with it as we do other things beyond our control, such as the limits of our life span.

But, the problem of obesity has an impact on our entire society and is at least in part modifiable. It makes finding soldiers who can pass basic physical exams scarcer than would otherwise be the case, and it puts a burden our health care system, both payers and providers, particularly public programs such as Medicare and Medicaid.

While we will want to consider diabetes, heart disease, and cancer, as well as other preventable causes of death and disability, in discussing the health of our nation, they are affected profoundly and substantially by the prevalence of obesity in the society. There are a considerable number of obesity-related illnesses,
and they impact our health, our longevity, our national budget, and our family budgets.

So, initially I may be writing a bit more about obesity than other health challenges, but we will get to them as well in the fullness of time.

What the health is this blog about anyway?

Posted by on December 10, 2012 Comments Off on What the health is this blog about anyway?

Murray Feshbach, Vladimir Treml, Barbara Anderson, Brian Silver

Who are these guys?

In the 1970’s and 1980’s these scholars documented the declining life expectancy in the Soviet Union. Ten to twenty years before its demise, they demonstrated that the USSR was drinking itself to death.

In the US we are eating ourselves into history’s dumpster—unless we stop the trends.

Obesity leads to diabetes, heart disease, back problems, cancer, and others. We are having an epidemic of obesity. It is a big problem. It is not the only problem—just a big one.

As our belt sizes grow, the health care needs of the baby boomers will grow beyond our ability to meet them. There will be neither enough dollars nor enough people to take care of those with chronic illness.

The problem is too big for a simple solution, like the latest diet or routine liposuction. The consequences are too great for the luxury of magical thinking—if we don’t think about it, it will go away. It won’t, as anyone who has tried to lose 10 pounds surely knows.

In order to manage, if not solve a problem, we need to:

1. Agree there is a problem
2. Define precisely what the problem is
3. Determine what tools we have to meet the problem
4. Agree on the best tools or remedies to use
5. Apply all appropriate remedies to reduce the uncertainty of the outcome

While this challenge is less dramatic than those we regularly see headlining news stories, it is my belief that it is the most serious threat to our nation. As such, it must be a national priority and must be addressed at the national, regional, state, local and personal levels, by both governmental and non-governmental organizations, including private businesses.

It is the purpose of this blog to address the American health crisis in the context of the five points of problem-solving mentioned, including the evidence of the problem, possible causes of the problem, and actions we might take. I plan to provide links to the latest research as well as the initiatives of others.

Let’s get started: Background of the Problem