Category Archives: Sources - Page 2

The latest in DME: an umbrella

Posted by on March 25, 2013 Comments Off on The latest in DME: an umbrella

When my wife moved to the States from Singapore, she was amazed to find that the umbrellas sold did not list their UV protection. Singapore is 137 km or 85 miles from the equator, and light skin is valued in Chinese culture. So protection from the aging and darkening effect of the sun’s rays has strong cultural underpinnings–unlike the US where there seems to be a tanning salon in every strip mall.

Normally we don’t think of an umbrella as DME (Durable Medical Equipment). However, if DME is home medical equipment you need for your health, then using an umbrella to prevent melanoma seems to qualify. As reported in JAMA Dermatology The researchers Josette R. McMichael, MD, Emir Veledar, PhD, and Suephy C. Chen, MD, MS of Emory University performed a simple, but well-designed experiment: they invited friends to join them in a parking lot, took 3 ultra-violet radiation (UVR) readings, and then opened umbrellas the friends had brought, taking two UVR readings, 1 cm from the individual, and 1 cm from the edge of the umbrella as shown:

Umbrella_uvr_measurement_20130304

There was wide variety in protection among the 22 umbrellas tested, ranging from a white totes® (77%) to a silver Coolibar® (99%). Fourteen were black in color.

Some of the numbers: Umbrella_findings_20130314

As is apparent in the account, the two readings (close and far) were highly correlated. The following scatterplot shows that as the values of each of the two readings are on the axes. The lowest reading shows the greatest protection, so umbrella 6 is the Coolibar®.

Umbrella_uvr_emory_20130304

As the earth warms, we can expect disturbances in the atmosphere that increase our exposure to UVR. Borrowing the style of the 19th century, carrying umbrellas, especially those designed to screen UVR, may be the best we can do.

Bad News for Boomers: Our Parents Were Healthier

Posted by on March 14, 2013 Comments Off on Bad News for Boomers: Our Parents Were Healthier

As Americans we believe in progress, in a better tomorrow, sometimes with a bump in the road or a hiccough, but always a better tomorrow.

The data are in (March 4,2013 edition of JAMA Internal Medicine), and it ain’t happening for boomers. Blood pressure, cholesterol, diabetes, and obesity–all greater than the previous generation.

Boomer_Parent_Comparison_JAMAinternalmed_20130304
Source: The Status of Baby Boomers’ Health in the United States The Healthiest Generation?
Dana E. King, MD, MS; Eric Matheson, MD, MS; Svetlana Chirina, MPH; Anoop Shankar, MD, PhD, MPH; Jordan Broman-Fulks
JAMA Intern Med. 2013;173(5):385-386

Although longevity has risen during the twenty-year gap between the two groups, every other indicator of health, except smoking, has become less favorable. And the pattern is clear.

At the top of the following chart are general measures of health. Then, we can see that lifestyle factors have declined leading to the trends in the last section: declining indicators of cardiovascular health.

We can’t choose to be healthy or not: what we can do is make healthy choices by changing the lifestyle factors.

We are choosing illness at great expense to ourselves, both financially and in quality of life, while continuing to endure longer and sicker lives instead of enjoying healthier lives.

Boomer_Parent_Extract_Comparison

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

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.

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.

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