Category Archives: Morbidity - Page 3

Calcium: Friend or foe? Part I

Posted by on March 4, 2013 Comments Off on Calcium: Friend or foe? Part I

As I approached a certain age, my doctor said, “Oh, are you taking calcium supplements?” And, I asked him, “Isn’t arterial plaque calcified cholesterol? Is it really a good idea to flood my arteries with calcium?” He is a thoughtful person. “Maybe not,” he said, upon reflection.

The main therapeutic use of calcium supplements is to ward off osteoporosis. We are beginning to live longer than our bones were intended, and we are trying to avoid turning into boneless amoebae before we die. Knowing from childhood that “calcium builds strong bones,” we thought calcium supplements made perfect sense.

Calcium Source: news@Jama

I felt really validated when studies came out showing calcium to be a cardiac risk. The most recent was published online a month ago. The NIH AARP Diet and Health Study found a higher risk of cardiovascular events in men taking supplementary calcium. Why the risk did not appear to be elevated for women is a subject for further study.

Similar findings have been reported in the British Medical Journal: Heart and Education in Heart.
Calcium supplements: bad for the heart?
Heart 2012;98:12 895-896
As well as in other European studies:
2011_BMJ_Heart_Calcium

Where are those calories are coming from?

Posted by on February 28, 2013 Comments Off on Where are those calories are coming from?

Hint: it’s fast food. A recent Centers for Disease Control and Prevention (CDC) study found that over a 3-year period 11.3 percent of calories came from fast food.

That surprises no one. There were, however, two interesting points made:

First, while adults have decreased their intake of fast food, consumption by youth has increased. As consumption of fast food declines with age, it is not clear to me whether the decline is true progress or related to the aging of the population.

The second takeaway from the study is more intriguing, as shown in the following summary of study findings:

CDC_NatHealthSurveyNutrition_201302

I have highlighted the finding at the bottom of the graphic.

When it comes to fast food: the more you eat, the more you gain; the more you gain, the more you eat.

If someone told you that the more heroin, opium, etc. you consume the more you want, you would not be surprised.

Are you as surprised as I am to find a study that shows the same is true of fast food?

Since we regulate addictive drugs, there is an argument to be made that addictive substances consumed as food could be regulated as well. I do not know what that regulation should consist of, only that we have a tradition of regulating addictive substances, assuming that the individual is incapable of self-regulation in the face of addiction.

As is frequently the case, the questions that arise are more intriguing and clear than the answers.

Source: NCHS Data Brief ■ No. 114 ■ February 2013

If soft drink consumption is dropping, why are we getting fatter?

Posted by on February 25, 2013 Comments Off on If soft drink consumption is dropping, why are we getting fatter?

I saw an article from Reuters by Silvia Antonioli, and the subject excited me: Analysis: Health-conscious Americans hurt aluminum can market.

Wow–consumption of sugary drinks in aluminum cans is declining as Americans switch to bottle water and iced tea. The article is well-written, but it is a news article not a scholarly study.

So, I thought: Maybe it is absolutely correct, but:

  1. Americans might have health concerns about aluminum cans and be switching to larger (16.9 oz and 20 oz) soft drink bottles.
  2. Consumption of aluminum cans may have declined because of recession and economic uncertainty, not health concerns.
  3. The decline in consumption of aluminum cans might be diet sodas or beer or even juice not soft drinks

    4. The Can Manufacturers Institute (CMI) publishes data on production of cans, but the latest data are proprietary, sold, and probably more available to a Reuters reporter. The following graphic confirms the decline in cans for carbonated soft drinks and increase in alcoholic beverage cans 2008-2010.

    MetalCans 2008_2010

    Source: CMI 2010 Annual Report

    Looking at a longer period (1970-2005), aluminum can production for soft drinks peaked in 1998 and for beer in 1990.

    Can Production 1970-2005

    An excerpt from a white paper by Ibis World confirms the points in the Reuters article:

    IBISWorld on Canned Soft Drinks

    I came to the thesis of the Reuters article as a skeptic, but now tend to be more accepting. That conversion leaves a more pressing mystery: if soft drink consumption is really dropping, why are we not dropping pounds as well?

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

Posted by on February 21, 2013 Comments Off on Sugar and spice, and salt is not very nice Part II

Last time we looked at the danger of dietary sodium, likely to shorten the lives of a million Americans. If knowledge is power, then here is some power for you:

Let’s start simple, with the major sources of dietary sodium from the CDC.
CDC Sources of Sodium

Unless we make our own bread (a fun thing to do with a bread maker, not as much fun by hand), we have little control over the amount of salt in bread. We can look for low-sodium alternatives or we can wait for government action. By the way, the government has been regulating bread for a long time, in Europe before the founding of this country and since the 17th century by colonies/states such as Massachusetts. Since 1941 the US government has been mandating nutritional additives to bread, including folic acid, iron, and other nutrients. Regulating sodium content is not even a stretch.

Take a look at this graphic from the CDC–sodium can be reduced by half in nearly identical sandwiches with a bit of care in choosing ingredients:

Low Sodium Sandwich

Reducing sodium in our diets is one of those simple things we can do to improve our health. Doing the easy thing is sometimes better than the difficult. 2 Kings 5:13

Here is some further reading on dietary sodium:

UCSF Low Sodium Guidelines
CDC Sodium Tip Sheet
Medline Plus: Dietary Sodium

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 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.

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