Tag Archives: Prevention

Why I hope to live until I die

Posted by on September 28, 2014 Comments Off on Why I hope to live until I die

Seventy-five years is all I want to live. I want to celebrate my life while I am still in my prime. My daughters and dear friends will continue to try to convince me that I am wrong and can live a valuable life much longer. And I retain the right to change my mind and offer a vigorous and reasoned defense of living as long as possible. That, after all, would mean still being creative after 75.

So wrote Ezekiel J. Emanuel, director of the Clinical Bioethics Department at the U.S. National Institutes of Health and head of the Department of Medical Ethics & Health Policy at the University of Pennsylvania, in the Atlantic magazine of September 17, 2014.

He argues that:

  1. He will have lived a complete life by then.
  2. Increased life expectancy has been accompanied by increased disease, accompanied by physical and mental disability.
  3. If we change our goals to match our ages, we still burden our children and alter their memories of us as decrepit rather than vibrant.
  4. “But 75 defines a clear point in time: for me, 2032. It removes the fuzziness of trying to live as long as possible.”

He concludes that certain medical tests and interventions that the larger population would consider quite normal should be ruled out after age 65, after age 70, after age 75.

It is a thoughtful and provocative essay that has attracted a lot of attention, presumably to the satisfaction of publisher and author. It could be that he wished to attract an audience, or it could be that as a bioethicist, he wished to begin a national conversation about end-of-life issues, rather than to be taken at face value. I would not question the sincerity of Dr. Emmanuel, nor would I question his education, which surpasses my own. I question his wisdom.

First, his choice of 75 is by his own admission arbitrary. Why not 74 or 76? Why not 79 or 81? Choosing an arbitrary age, or arbitrary criterion for anything, is a logical one-size-fits all or Procrustean standard. Such standards assume a homogeneity of population that does not exist, and Dr. Emmanuel presents counter-examples and outliers himself.

He further claims that a country that achieves life expectancy of 75 for both men and women need no longer concern itself with further life-lengthening efforts. This is a statistical fallacy. He does not state which life expectancy.

Our life expectancies change as we age. Much of the life expectancy quoted is at birth, including the risks of infant mortality. Life expectancy at age 18 is much different. Furthermore, life expectancy at age 70 is considerably higher, as there is a heightened risk of mortality in the fifties and sixties, with those reaching their seventies enjoying a much longer expectancy. On top of that, those are averages that say nothing about the experience of any one individual, and we live life as individuals not as averages, except for those rare individuals with precisely 2.4 children.

Second, when he points to the increase in disability and disease in extended old age, those figures apply to the general population, including the obese we see among us. They may not apply to those who climb Mt. Kilimanjaro in their fifties, as has Dr. Ezekiel.

Third, he is concerned about burdening his children, but he may prove to be a greater burden on his children by refusing available medical interventions than had he accepted them. A person with atrial fibrillation who has a pacemaker is less likely to experience a debilitating stroke than someone who refuses medical treatment. The only difference is that the stroke disability occurs in the person’s seventies rather than their eighties. That doesn’t sound the ethical high road to me.

Fourth, it is ironic that Dr. Ezekiel in pointing out the “spiritual and existential” reasons for his position to be rejected overlooks the religious drive behind his position: the desire for certainty in the face of life’s ambiguity. That drive motivates most religious belief in the same way that desiring to die at a fixed age “removes the fuzziness of trying to live as long as possible.”

Fifth, it could be that as a physician on record as opposing active euthanasia and recognizing that people do have disabilities that radically degrade their quality of life at an increasing rate with age; he is left with the only alternative being a form of very passive self-euthanasia, which he describes in other terms in the essay.

Now, the essay is replete with disclaimers that Dr. Ezekiel is not trying to convince us nor does he think it unethical to conclude otherwise and so forth. In short, he is restricting his conclusion to a population of one that we cannot know as well as he does. If that were truly so, the essay need not be published anywhere but a diary. So, I find the disclaimers to be disingenuous.

At the outset, I challenged Dr. Ezekiel’s wisdom but not his sincerity. I did so on two grounds.

First, in academic research, with which any physician is familiar, it is a cardinal rule to state what you know, what you don’t know, and what should be the next steps. My impression is that Dr. Ezekiel confuses what he knows with what he doesn’t know. Among the things he doesn’t know, not because he is not intelligent and knowledgeable, but because he is not omniscient are:

  1. What the outcomes of two personal time lines would be, one being the refusal of interventions and the other being the acceptance of interventions.
  2. What medical advances will occur in the next fifteen years to address some of his concerns about disability accompanying expanded life expectancy.

Have we not all wondered at some time, what if we had married person A instead of person B, what if we had taken job A rather than job B, visited country A rather than country B, and an almost infinite number of similar questions that are summarized in Robert Frost’s The Road Not Taken? And the power of the poem lies in our understanding that we simply cannot see the path that disappears in the underbrush, nor can Dr. Ezekiel.

In the field of economics, everyone becomes familiar with work of Thomas Malthus, who predicted widespread war and famine accompanying population growth. It may still happen, but it has not happened yet because Malthus was unable to take into account the impact of technological advance. The same technological advance that has helped us lengthen our lives by declining infant mortality and more hopeful outcomes to heart disease and cancer may yet address the disabilities accompanying aging. What I know is that at my age (67) I can walk 5 miles easily and 10 miles less easily whereas my parents’ generation could not at my age. I carry two stents in my heart, which have no lengthened my life but improved its quality such that I can climb a hill without feeling faint. Such qualitative improvements from technology should not be overlooked.

Second, the ancient Greeks had a word that survives in our studies of their literature and ours, hubris, an excessive pride or self-confidence. And, to me that is the lack of wisdom in an otherwise well-written, thoughtful essay. We have come a long way as a species. With luck and wisdom that we do not always demonstrate, we will have a long way to go. Part of that wisdom is a certain humility that I found lacking in the essay. Even about ourselves we know less than we pretend to know. A person contemplating his death at 75 does not know he will not be hit by a car at 60 or suffer a heart attack or learn he has pancreatic cancer. By the same token, there are imponderables on the other side of 75 as well, good and bad, desired and feared. A person cannot plan that way, but the humility of admitting those possibilities should come through in this essay.

Many years ago I lived in the backyard converted garage of an older couple in Miami, Florida. They had an old dog. One day, the man about 70 years old was musing about how the dog was arthritic, had trouble walking and could not climb up on his lap, and how perhaps it was time to put him down. It gives me pause and a needed dose of humility in thinking about such things to recall that the dog outlived the man.

Addiction: Twenty-first Century Style

Posted by on November 19, 2013 Comments Off on Addiction: Twenty-first Century Style

Technology is wonderful, ever moving forward. Now that cigarettes and other tobacco products have been thoroughly discredited as nothing more than a dirty 20th Century addiction, the purveyors of nicotine addiction have developed the e-cigarette for the 21st.

None of that harmful tar. None of that distasteful, annoying smoke. Just pure pleasure, as innocent as sucking a straw.

The Food and Drug Administration (FDA) is not convinced and is expected to issue regulations shortly.

E-cigarettes are a battery-powered device, about the size of a cigarette, that heats a nicotine-laced liquid into a vapor to be inhaled.

First, the FDA will not be able to regulate e-cigarettes as medical devices. That was decided by the DC Court of Appeals in Sottera, Inc v. FDA at the end of 2010. That means that restrictions will be similar to tobacco products rather than to nicotine patches.

Second, there will be considerable debate about the relative safety of e-cigarettes. While it is true that the tar and smoke is missing, it is unclear what the effects of the vapor components are both or the “vaper” and those around him.

A 2012 study at the University of Perugia (Italy) concluded:

The e-cigarette seems to give some advantages when used instead of the conventional cigarette, but studies are still scanty: it could help smokers to cope with some of the rituals associated with smoking gestures and to reduce or eliminate tobacco consumption avoiding passive smoking. However, the e-cigarette causes exposure to different chemicals compared with conventional cigarettes and thus there is a need for risk evaluation for both e-cigarettes and passive steam exposure in smokers and non smokers.

In August, 2013 respected researcher Igor Burstyn of the Drexel University School of Public Health issued a study financed by The Consumer Advocates for Smoke-free Alternatives Association (CASAA), an advocacy organization of the e-cigarette industry. Burstyn’s work and presentation is rigorous, but it is a technical study, not the peer-reviewed journal article considered the gold standard among researchers. While finding that the contaminants are generally safe, Burstyn:

  1. does not evaluate the risk of nicotine exposure to the person “vaping.”
  2. notes the difference in standards between exposure to a willing user and more stringent standards for an unwilling bystander.

Burstyn report

This approach to secondhand vapors provides a legal and philosophical foundation for applying existing tobacco regulation to the newer nicotine delivery systems.

Third, the e-cigarette industry is following the lead of the tobacco industry in its advertising. Note the remarkable parallels in Cigarette Flashbacks, a presentation by three Democratic members of the House Energy and Commerce Committee.

Fourth, there is widespread concern about the marketing and increased consumption of e-cigarettes by teenagers. Ninety percent of adult smokers had begun smoking in their teen years. The issue is well summarized by Health.Howstuffworks.com Flavoring the vapor with chocolate, caramel, strawberry, and bubble gum suggests a conscious attempt to lure youth into early addiction for later profits. Similar concerns have been expressed about the flavorings in hookah smoking as well. The Centers for Disease Control and Prevention recently issued a report on the percentages of teenagers using flavored tobacco products, nearly half of the consumption is flavored.

In the Jewish tradition, consumption of dairy and meat products together is forbidden. Technically, it would be permitted to have soy cheese on a hamburger, but the rabbis have forbidden that as well, because the appearance of violation by believers might encourage others to violate the prohibition.

It is clear that the appearance of smoking cigarettes should be treated no differently than the consumption of cigarettes. The difference between suggesting “Reach for a Lucky instead of a sweet,” and “E-cigarettes have no tar or smoke,” is minimal.

The FDA should treat e-cigarettes as tobacco products, and the several states should follow the examples of Utah, North Dakota, New Jersey, Arkansas, and the District of Columbia in banning indoor use in public places. Additionally, sales to minors should be banned as well as Internet sales since age-verification is not possible on line. In short, we need to bring these products under the same regulations as their tobacco cousins–NOW.

Getting your teeth into health care

Posted by on October 27, 2013 Comments Off on Getting your teeth into health care

We all know the reasons for going to the dentist regularly:

  1. Early detection (cavities, gum disease, oral cancer, bruxism)
  2. Checking existing fillings for structural weakness or peripheral decay
  3. Review of oral health practices

These are dental reasons, but there are other reasons as well.

The relationship between dental health and other medical health is not a new concept, with studies going back to the 1980’s. For example, the statistical relationship between heart attacks and poor dental health was noted in a 1989 Finnish study.

Managed care organizations have a strong financial incentive to lower health care costs. Healthier members have lower medical costs, so improving the health of members is an attractive alternative to cutting benefits in order to lower costs.

Aetna has been a leader in “Dental-Medical Integration” (DMI) as an approach to that end.

A study in 2006 found significant relationships between treatment for gum disease ( a proxy for having gum disease) and higher medical costs for cardiovascular, cerebrovascular, and diabetic conditions, heart, stroke, and diabetes, respectively.

In 2009, Aetna reported considerable success in getting dental care for at risk members:

In 2008, nearly 67,000 medically at-risk members sought dental care after being enrolled in Aetna’s Dental Medical Integration program. At-risk members are identified as those with diabetes, heart disease and pregnant women who have not seen a dentist in 12 months or more.

A 2011 University of Pennsylvania study in collaboration with Cigna Dental established lower medical costs two years after periodontal (gum) treatment:

2011_UPa_Dental

Earlier this month Aetna reported:

  • Lowered their medical claim costs by an average of 17 percent
  • Improved diabetes control by 45 percent
  • Used 42 percent less major and basic dental services
  • Required 3.5 percent fewer hospital admissions year-over-year compared to a 5.4 percent increase for non-members

With the caveat that the Aetna programmed targeted individuals with particular diagnoses who had not seen a dentist in a year, we are nonetheless facing an important question:

Is it time to end the division between dental and medical insurance, treating health care for the mouth as a medical specialty like others, and dentists as medical specialists like others?

Learning about fat people

Posted by on September 16, 2013 Comments Off on Learning about fat people

When I was growing up, I had a first cousin who was morbidly obese, long before the efforts of the rest of the country to catch up with her. Her failure, and it was considered a failure, to lose weight was seen as evidence of a moral failing, a lack of willpower, only slightly less pejorative than the sin of gluttony in earlier times. There was some vague talk that she might have some hormonal imbalance, but it was clear that all around her considered her problem to be predominantly one of willpower.

Both alternative and scientific medicine have taken a recent interest in gastro-intestinal (GI) flora, or “gut bacteria.” The alternative medicine folks have favored “probiotic” supplements and yogurts fortified with bacteria. The probiotic movement began with Nobel laureate Elie Metchnikoff, known as the “father of probiotics,” who believed that longevity of rural Bulgarians and Georgians could be attributed to their consumption of fermented milk products.
Metchnikoff

Consideration of the impact of GI flora on diarrhea is not really new–a half century ago I can recall being given lacto-bacillus pills to counter the gastric distress resulting from penicillin. It is the potential impact of bacteria on obesity that is notable in the current focus. Recently National Public Radio (NPR) interviewed Jeffrey Gordon, a microbiologist and director of the Center of Genome Science and Systems Biology at the Washington University School of Medicine in St. Louis.

While I hope you will either listen to the embedded audio clip (about 12 minutes) or read the interview transcript, the short version is that there the research shows a recursive feedback loop between how the bacteria impact our appetite and how what we eat impacts the bacteria that are in our intestines. By eating the right or “lean” foods, we encourage the bacteria that help us maintain our weights at a healthy level. Now, there has been some experimentation with fecal transplants, having a similar aim, but that does not seem to be for everyone–particularly those of us who would be grossed out by the very idea. Eventually, we will probably have probiotics, which, combined with proper diet (they need to be fed or cultivated in our gut), can be delivered to our intestines in pill form, or at least a suppository rather than a fecal transplant.

Over time my cousin became estranged from nearly everyone in the family and died a few years ago, not having been seen by any family members in decades. Waxing philosophically, I cannot help but wonder how different my cousin’s life might have been had she been born a half-century or better a century later. And, I wonder how different my father’s life might have been had he survived his first heart attack and lived to see statin drugs.

It seems that much of our survival depends upon living just long enough for technology to address a mortal weakness in our genome. Nonetheless, it is encouraging to note that promising approaches to obesity may make it seem like nothing more interesting than a historical healthcare statistical blip rather than the crisis it appears to be as we live with it and address it.

Three research pieces with a lot of heart

Posted by on September 10, 2013 Comments Off on Three research pieces with a lot of heart

Often the most heartening news comes from health research. The past couple of weeks have revealed three worthy of note. All three involve prevention measures, two before a heart attack, and one after.

First, the US Centers for Disease Control and Prevention estimate that 200,000 deaths from heart attacks can be avoided annually. The preventable deaths are concentrated in three areas.

The first area is age, where preventable deaths are concentrated in the 45-64 age cohort.
Preventable deaths by age

The second area is race, where African-American men are at the highest risk of preventable death, 143 out of 100,000.

Preventable deaths by race

Finally, the deaths are concentrated geographically in the South-Central Region.
Preventable deaths by region

Second, a study from Britain and India, published in the Journal of the American Medical Association (JAMA) found that a single pill or “polypill” with fixed doses of aspirin, anti-hypertensive, and cholesterol-lowering drugs was statistically more effective than offering separate prescriptions. While physicians point out that this approach limits flexibility, greater variation of dosage combinations in polypills is a promising approach.

Polypill study

Third, a study in JAMA Internal Medicine found that even after a heart attack, better diet, as measured with Alternative Healthy Eating Index (AHEI 2010), resulted in lowered mortality.

The good news is that either before, or failing that, after a heart attack, the good practices of medication adherence and reduction of risk factors such as poor diet, can improve our survival as individuals. Furthermore, we can move the needle in a better direction by focusing our educational and interventional efforts on those under 65, African-American, residing in the South-Central United States.

Vaccination–Now and Then

Posted by on August 26, 2013 Comments Off on Vaccination–Now and Then

Smallpox was long one of the scourges of humanity, killing millions throughout history. Early attempts were made to combat it through “variolation,”inoculation with the scabs of the disease. Such efforts began at least a thousand years ago in China. ChineseVaccination

Without images to guide us, it is easy to think of smallpox as chickenpox that kills. Not exactly. Besides the fact that smallpox does not concentrate on the torso, the number of pustules seems much more severe to my eye. Here is a child in Bangladesh in 1973 with smallpox. This is what we no longer fear because of vaccination:

Child_with_Smallpox_Bangladesh

Vaccination is relatively new in human history–the United States of America is older. Just before and after 1800 Edward Jenner, noticing the apparent immunity to smallpox of milk maids, experimented with inoculation using the relatively benign disease cowpox to which they had been exposed. It was not until 1840 that the British government routinely provided the means for inoculation, as the medical establishment had been slow to accept Jenner’s findings.

Nonetheless, the disease that killed an estimated 400,000 Europeans annually at the time of Jenner’s discovery, was still able to kill several hundred million in the 20th century.

The last documented case of smallpox occurred in Somalia in 1977. By 1980 the World Health Organisation (WHO) was able to declare smallpox eradicated. Consequently, routine smallpox vaccination was discontinued in the 1980’s as the statistical danger from the vaccination (14 to 52 per million per the CDC) exceeded the danger of the disease.

I would prefer to be able to present a time series of smallpox cases, but have been unable to locate one this week. Failing that, here is the impact of vaccination in the US on numerous diseases during the 20th Century, worth considering when someone questions the value of vaccination.
Vaccination_US_thru1998

Celebrity and science: the vaccination controversy

Posted by on August 19, 2013 Comments Off on Celebrity and science: the vaccination controversy

Bill Maher is witty and funny–particularly if you are not politically or religiously conservative.

However, the closest he will get to being a virologist is when a video clip of him goes viral.

In 2009 he provoked a controversy by tweeting that anyone who got a flu shot was an idiot. In a blog post on November 15, 2009 he backed off a bit, but defended himself by:

  1. I’m a comedian
  2. I tweeted it, didn’t say it on my show.
  3. Saying there are questionable things about vaccines.
  4. Endorsing a group opposing vaccinations.

It was a non-apology worthy of a Washington official. The truth is that while Bill Maher is neither an authority nor an expert on vaccines, he has influence based upon his celebrity. And, as a result, he can influence many people who should get vaccinated but are undecided, as can any other celebrity. After all, who likes hypodermic needles except for the rare needle freak? We all want some cover for deciding to avoid needles.

We may all be grateful that celebrities are not the go-to experts on health care for most parents; however, a 2011 University of Michigan study found that 1 out of 50 parents rely on celebrities a lot for information, and that 1 out of 4 rely on celebrities some.

MichiganVaccineSurvey2011

One of the sources that Maher cited was the National Vaccine Information Center (NVIC). It is reasonable that individuals who have suffered side effects from vaccines or any other medication might band together to ask that there be full disclosure on the risks as well as every effort to promote safety. Unfortunately, NVIC goes a step forward, suggesting that vaccination is a matter of preference rather than necessity. It is a bit like receiving a full glass of water and obsessing about the emptiness between the top of the water and the lip of the glass.

A key paragraph in their statement of purpose:

This traditional paternalistic medical model is increasingly being rejected by today’s more educated health care consumers and, along with this challenge, is also an historic challenge to the supremacy of the allopathic medical model as the only means of maintaining health and preventing disease. The movement toward a more diversified, multi-dimensional model health care system is a phenomenon occurring not only in the United States but in many technologically advanced countries.

In short, it is a rejection of science in favor of some other belief system for medical care. The United States makes ample allowance for alternative belief systems; however, alternative behaviors are circumscribed. If you wish religion taught in the schools, you must attend a parochial school, not a public one. Similarly, if you want to attend a public school, then a vaccination prerequisite is reasonable, particularly when you have private alternatives, including home schooling available. Even that stretches the limits, because unvaccinated people lower the safety of everyone. Since vaccines are not 100 percent perfect (and what is in this world?) we depend on an adequate percentage of vaccinated people to prevent an epidemic among those who are only partially protected by vaccines against communicable diseases such as polio, diphtheria, and influenza.

This is “herd immunity,” or:

Indirect protection against disease that results from a sufficient number of individuals in a community having immunity to that disease. With enough immune individuals, the transmission of a disease can be reduced, thus limiting the potential for any one individual to be exposed to it. Herd immunity does not apply to diseases, such as tetanus, that are not spread via person-to-person contact.


One of the best and simplest ways to lower healthcare costs and to improve public health is to increase our rates of vaccination. Consider this: do businesses pay for flu vaccinations because they are loving and generous, or because it will lower absenteeism and paid time off?

All That Jab – one more reason to vaccinate

Posted by on August 12, 2013 Comments Off on All That Jab – one more reason to vaccinate

Those who look toward the scientific for explanations know that only UFOs and and political assassinations attract more conspiracy theories than vaccines do.

The challenge of conspiracy theorists is similar to the challenge of mental illness–no amount of evidence contrary to a deeply held view is sufficient or dissuasive. Astute observations are followed by non-sequitur conclusions, or either-or alternatives with no room for gray in between the black and white alternatives.

Nonetheless there is heartening new evidence that influenza vaccines are benign for pregnant women–or as Reuters put it:

Pregnant women who get flu shots are at no greater risk for complications like high blood pressure, urinary tract infection or gestational diabetes, according to a new U.S. study.

The study of Inactivated Influenza Vaccine During Pregnancy and Risks for Adverse Obstetric Events, which will appear in the September issue of Obstetrics & Gynecology found In this large cohort, influenza vaccination during pregnancy was not associated with increased risks for medically attended adverse obstetric events.

Often such studies are handicapped by small sample bias, not enough people studied to draw a strong conclusion, even if statistically significant. Not the case here, as the authors report that their study group was 74,292 vaccinated females matched on age, site, and pregnancy start date with 144,597 unvaccinated females.

One might ask, “Why bother? So, I get the flu while pregnant–one more nuisance.” The same article in Reuters Health addressed that question:

For a pregnant woman, contracting the flu is “really dangerous,” according to Dr. Laura E. Riley, medical director of labor and delivery at Massachusetts General Hospital in Boston.
Pregnant women with the flu are at greater risk of death, respiratory disease requiring hospitalization and premature labor and delivery, Riley told Reuters Health.
The risk-benefit ratio was already clear, she said, but collecting new safety data is always good.

On the positive side, the benefits of vaccination accrue not only to the mother but to the baby:

“Flu shots protect pregnant women, their unborn babies, and even protect the baby after birth,” Kharbanda said.[lead author Dr. Elyse Kharbanda of Health Partners Institute for Education and Research in Minneapolis, Minnesota]
Babies don’t receive vaccines until six months of age, so they are vulnerable to catching the flu in the first six months of life, he said. But previous studies have found that some of the protection passes across the placenta to the baby and can help shield them from flu after birth.
“What mother doesn’t want to do that?” Schaffner said [ Dr. William Schaffner, chair of the department of preventive medicine at Vanderbilt University Medical School in Nashville, Tennessee]. “There should be no hesitation for women getting the vaccine.”

There is no reason for a pregnant woman not to get vaccinated against the flu; there is every reason to avoid possible consequences of not getting vaccinated; and, if not for you, then for the benefit of your baby, who does not need the flu while getting used to living outside the womb.

The things we already know–but don’t often do

Posted by on July 15, 2013 Comments Off on The things we already know–but don’t often do

There is the old Middle Eastern story of the one who journeyed East in search of wisdom. He came upon a stone where he read, “Turn me over.”
He picked up the stone and read on the underside: Why do you seek new knowledge when you do not use that which you already have?

A recently reported Swedish study that followed 71,000 individuals over a 13-year period found that consuming less than five daily servings of fruits and vegetables was associated with higher mortality and shorter survival periods. Those eating one serving of fruit daily lived 19 months longer on average, while those eating 3 servings of vegetables lived 32 months longer.

Now by itself, this is not very surprising. We know that heavy meat consumption is linked to colorectal cancer, particularly in combination with genetic mutations, as described in a recent issue of Smithsonian Magazine. So, the possibility that a different diet would be protective, even by contrast, makes some sense.

Fornaciari subsequently analyzed bone collagen of King Ferrante and other Aragonese nobles, revealing a diet extremely reliant on red meat; this finding may correlate with Ferrante’s cancer. Red meat is widely recognized as an agent that increases risk for mutation of the K-ras gene and subsequent colorectal cancer. (As an example of Ferrante’s carnivorous preferences, a wedding banquet held at his court in 1487 featured, among 15 courses, beef and veal heads covered in their skins, roast ram in a sour cherry broth, roast piglet in vinegar broth and a range of salami, hams, livers, giblets and offal.)

In a similar vein, one out of three Americans suffers from hypertension (high blood pressure), a major risk factor for serious cardiovascular events such as stroke and heart attack. A recent study in JAMA showed that 18 months after the beginning of a study in which the experimental group did home blood pressure monitoring along with pharmacist case management, 71.8 percent had controlled blood pressure compared to the control group with usual care at 57.1 percent.

It would be easier if we had pills that would lower our body weight or a vaccination against high blood pressure. We don’t. But we have knowledge that we are not using: walk more, eat less processed foods and more whole grains, vegetables, and fruits, monitor blood pressure and pulse regularly. No, it is not magic–just the best that we can do.

Illusion and Health

Posted by on June 24, 2013 Comments Off on Illusion and Health

A recent University of Texas study about the gap between perception of adequate exercise and optimal diet and the reality of an individual’s regime sent me googling.

I remembered a similar meme about body image. My memory was that men do not see how fat they are, and women imagine themselves fat when they are not, leading to anorexia.

Here are a few of them, and there are no doubt more:

Those studies raised an important question: how do reality and perception diverge when it comes to health?

So, let’s look at the University of Texas study from the Journal of Women’s Health, entitled Lifestyle and Cancer Prevention in Women: Knowledge, Perceptions, and Compliance with Recommended Guidelines.

Among those who believed that good diet and physical activity prevented cancer, the study found discrepancies (I have color-coded them) between what they believed they were doing and were actually doing as shown in the following table:

Women's Perceptions JWH 20130610

It can be seen that while 85 percent believe they are consuming a healthy diet, only 8.5 percent are eating an adequate amount of fruits and vegetables. While 73.1 percent reported engaging in physical activity to prevent cancer, only 31.5 percent were active enough to have a positive impact.

The study found that the significant predictors of the discrepancy were education, and to a lesser extent race-ethnicity independent of education. While the authors speculate about the reasons for those findings, they are clear and unambiguous about the implications, which I quote at length with the footnotes removed:

This finding has important public health implications. The first implication is that women in the current study reported understanding that engaging in regular physical activity and eating a healthy diet are important behaviors for cancer prevention. Thus, media campaigns and targeted public health messages should focus on the importance of specific frequencies and durations of recommended behaviors (i.e., 5 a Day for Better Health), and place less emphasis on the general importance of health behaviors. This may help attenuate the “underdosing” observed in the current study. Current public health efforts are focusing on making community-wide changes to reduce obesity and improve health.19 These efforts may be enhanced by promoting awareness of potential discrepancies between perceptions of behavior and actual behavior and by highlighting practical ways to integrate specific cancer prevention behaviors into daily life at adequate levels. Furthermore, they should consider the imbalance between educational resources for healthy eating and physical activity and barriers to these behaviors (i.e., society encourages the overconsumption of unhealthy food; low access to fresh produce and places to exercise safely sometimes exists). Given that women often serve as “gatekeepers” of health behavior within their families, efforts to address these discrepancies among women may ultimately have a positive downstream effect on men and children. Because dietary habits are often solidified in childhood, the discrepancies observed in this study could potentially set children up for a lifetime of poor health behaviors. These findings add to the body of existing literature indicating that although health-relevant knowledge and attitudes are generally positively associated with the practice health behaviors, the associations are only modest.

Results further indicated that the observed discrepancies for diet and physical activity were significantly more common among women with less education and among members of racial/ethnic minority groups. This is consistent with a large body of research supporting a social gradient in health (i.e., lower socioeconomic position and minority status are associated with poorer health behaviors and poorer health outcomes). One explanation for this is differential exposure to obesogenic environments. That is, individuals with low socioeconomic status and racial/ethnic minorities have less access to healthier foods such as fruits and vegetables due to higher cost and lower access to grocery stores that carry fresh produce. They also have fewer safe places to engage in physical activity. These women may be particularly vulnerable to perceiving that they are engaging in specific diet and physical activity behaviors to help prevent cancer. However, they may lack the opportunity to fully engage in preventive behaviors, thus failing to engage in such behaviors with sufficient frequency and duration to reduce their cancer risk. Such women may need to be specifically targeted for intervention and may benefit from tailored messages and interventions regarding diet and physical activity.

Do we not all know friends and family and clients who believe they are eating well and exercising adequately, but do not understand why their weight keeps rising, with the attendant complications? Our challenge as a society is not only to find ways of addressing the health problems that are undermining our economy and personal functioning that underpin our nation, but to communicate those findings in a way that is unambiguous and specific. The challenge of communicating the findings of a solution to the public health issues may be even more daunting than isolating those causes.