Category Archives: Population - Page 2

Salt: Connecting the Dots

Posted by on March 11, 2013 Comments Off on Salt: Connecting the Dots

Some number of millenia ago our evolutionary forebears crawled out of the sea, carrying its salt flowing through their veins to ours. In the right amount, salt is not only good for us but essential to life.

That is not the same, however, as dumping salt on our food before tasting it or eating processed dinners, from the supermarket or from the nearest fast food franchise.

Most of us have long known that salt increases hypertension among salt-sensitive individuals.

Two sets of studies have come out, one widely publicized, the other well below the radar, that add concerns about excess salt consumption.

Researchers publishing in a recent issue of Nature have linked salt consumption to auto-immune disorders such as multiple sclerosis, psoriasis, ankylosing spondylitis, and rheumatoid arthritis. Unless you have a $200 annual subscription to Nature, you may wish to google “salt autoimmune” to read descriptions of the studies. Or, you may wish to simply click on these links to Medical News Today or The Huffington Post.

So, what are the dots to be connected? That’s where the second study comes in, the one with little publicity.

A presentation at the 2013 American Academy of Dermatology annual meeting in March found that individuals with psoriasis were more likely to have metabolic syndrome. They found that 30 percent of the psoriasis children had metabolic syndrome symptoms compared to the non-psoriasis group. There were not significant differences in Body-Mass Index (BMI), c-reactive protein, or endothelial cells

A 2012 study in South India found a higher incidence of metabolic syndrome among those with psoriasis. In this case:

Patients were diagnosed with MetS for having three or more South Asian Modified National Cholesterol Education Program Adult Treatment Panel III criteria: abdominal obesity (waist circumference ≥90 cm for men, ≥80 cm for women); blood pressure, >130/85 mm Hg; fasting blood glucose, ≥100 mg/dL; hypertriglyceridemia, >150 mg/dL; or low HDL (<40 mg/dL for men, <50 mg/dL for women).

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

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 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.

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.

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