Vol. 110 September 15, 2014 Recent Updates From Around the World

September 15, 2014

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“Some believe in eating anything, while the weak only eat vegetables.
Those who eat must not despise those who abstain,
and those who abstain must not pass judgement on those who eat.”
Romans 14:2-3

This biblical citation has nothing to do with this week’s contents, but I was so surprised to hear it read in a church service,  and I want to preserve it to use in my defense when my children try to push lima beans, brussels sprouts, and quinoa on to my plate. Plus, I don’t think that it should be only the fundamentalists who quote the bible out of context to support their biases.

My favorite grace, of course, is the Robert Burns grace reproduced here in English (absent the Scottish dialect which really makes it poetic):

Some have meat and cannot eat,
And some would eat, but want it:
But we have meat, and we can eat,
And so let the Lord be “thanket”.

High Dose Flu Vaccine, Hype or Truth?

A study of 32,000 people over 65 years of age during 2011-13 showed that the “high dose” flu vaccine in that age group provided more protection than the standard dose. 1.9% (301) of the standard dose vaccinees got the flu while “only” 1.4% (228) of the high dose vaccinees did. Both vaccines had the same percentage of adverse side effects (9%).

The study’s conclusion was that high dose vaccine is 24% more efficacious, but to me these small numbers hardly justify the high-energy, hyped-up TV ads telling me to “Ask your doctor for the high dose flu vaccine!” AND the authors also remind us that any flu vaccine works best if it matches this year’s flu viruses. That is not always the case. Each year’s flu vaccine is developed from last year’s virus.

Bottom line: get a flu shot, any flu shot.

Too Much Salt Does Kill People, But Not So Much in the U.S.

In a huge, multi-year study funded by the Bill and Melinda Gates Foundation daily salt consumption was determined for 74% of the world’s adult population! The data taken from previously published surveys, 24-hr urine collection reports, and dietary intake studies was fed into a computer (Bill Gates, of course, but the authors added a disclaimer that the “funder had no role in this study or report”). The computer kicked out an average daily salt consumption by age, sex, and year for 187 countries.

The average worldwide salt consumption was about 4 grams per day, twice the amount recommended by the World Health Organization (2 grams per day). 181 of the 187 nations exceeded the WHO recommendation. The computer model went on to estimate that 2 out of 5 premature deaths (under 70 yo.) were attributed to salt consumption above 2 grams a day. The Institute of Medicine has stated that there is little evidence that reducing salt consumption below 2.3 grams a day reduces cardiovascular events. There is even some evidence that a low salt intake (under 1.5 grams a day) can increase your cardiovascular risk!

The good news, for us, is that the  U.S. and Canada have one of the lowest salt consumption rates, but still over the 2 grams threshold. The highest salt consumption associated mortality rates were in Central Asia, Central, and Eastern Europe,  Only Australia and New Zealand had lower CV mortality rates attributed to salt consumption than the U.S. and Canada (again, they beat us!).

Bottom line: If you’re worried about your future cardiovascular events try a 2 gram a day salt diet for a few days. Then very slowly, add a little bit more  salt each day until the food tastes good again.

From the “Duh Department”

Norwegians who have large, complex, or multiple non-cancerous polyps removed from their intestine by colonoscopy have a slightly higher death rate from colon cancer within 10 years than those people with small, single “low-risk” non-cancerous polyps. (3)

People in low income countries have lower risk factors for cardiovascular deaths, but have much higher death rates from heart attacks than middle- and high-income countries (Also true for “deaths from any cause”).(4)

References:
1. NEJM August 14, 2014 vol. 137, no. 7, pg. 635
2. Ibid; pg. 624 and 677 Editorial
3. NEJM August 28, 2014 vol. 371, no. 9, pg.799 and 860 Editorial
4. Ibid; pg. 818


Vol. 109 September 1, 2014 Today’s Buzzword is “HARM REDUCTION”

September 1, 2014

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Harm reduction is a policy of encouraging and supporting an individual
to take incremental actions to reduce the potential harm of high-risk behaviors
which a person can’t or won’t stop.

 

 

The American Heart Association (AHA) last week reiterated its concern about the negative health effects of e-cigarettes (electronic cigarettes that deliver vaporized nicotine only), but cautiously noted that it considered e-cigarettes as an acceptable “last resort” for those who can’t stop smoking after using nicotine patches and other medications . This is the most recent example of a “harm reduction” strategy.

Aruni Bhatnagar, Professor of Medicine at the University of Louisville in Kentucky and the lead author of the AHA’s statement, wrote: “If someone refuses to quit, we’re not opposed to them switching from conventional to e-cigarettes…Don’t use them indefinitely. Set a quit date for quitting conventional, e-cigarettes and everything else.”

There is scant evidence that using e-cigarettes help people to stop smoking, but e-cigarettes do not deliver tars and other carcinogenic chemicals to the lungs. Hence, smoking an e-cigarette can reduce harm. The American Cancer Society jury is still out.

The “harm reduction” strategy, identified in the 1980‘s, began to really be promoted as an alternative to abstinence around 2000. It was initially focussed on psychoactive drug abuse, but was later expanded to include alcohol and all substance abuse. Its strategies are also incorporated into adolescent sex education, HIV prevention, and homeless health programs. Tactics include school-based distribution of condoms, community needle exchange programs, methadone maintenance, housing without sobriety for the homeless, and, in some countries, heroin dispensing clinics and clean injection facilities.

The DARE (Drug Abuse Resistance Education), or “just say no”, program was that was based on a zero tolerance principle, and it was not effective in reducing drug abuse.

Critics of the harm reduction strategy claim that such an approach can “normalize” the risky behavior that society wants to change. They think harm reduction policy can raise an expectation that such risky behavior is acceptable and even “expected”, particularly for adolescents.

Proponents of harm reduction quote extensive literature that shows that it is “inexpensive, evidence-based, and effective” . The designated driver awareness policy is an excellent example of a successful harm reduction tactic. It is one factor in the reduction of teen age car accidents and deaths. A few years ago the homeless health center with which I am associated stopped requiring alcohol abstinence, sobriety, on the part of a client prior to being placed in transitional housing. Its rates for successful stable housing, subsequent employment, and duration of sobriety increased among those clients.

 MYTH
Harm reduction is opposed to abstinence and therefore conflicts with traditional substance abuse treatment.
Harm reduction encourages drug use.
Harm reduction permits harmful behavior and maintains an “anything goes” attitude.

FACT
Harm reduction is not at odds with abstinence; instead, it includes it as one possible goal across a continuum of possibilities.
Harm reduction is neither for nor against drug use. It does not seek to stop drug use, unless individuals make that their goal.
Harm reduction focuses on supporting people’s efforts to reduce the harms created by drug use or other risky behaviors.
Harm reduction neither condones nor condemns any behavior. Instead, it evaluates the consequences of behaviors and tries to reduce the harms that those behaviors        pose for individuals, families and communities.

Despite all the scientific evidence, it is sometimes hard to fully embrace the concept of “harm reduction” emotionally. I sometimes feel that small moral tug of “whatever happened to right and wrong”. After all, the Ten Commandments say “Thou shall not commit adultery”; not “Try very hard not to commit adultery and, at least, don’t cause an unwanted pregnancy”. But, many studies  show that harm reduction strategies can benefit the individual, the family, and the community. We will be hearing a lot more about it, so we should get used to it.


Vol. 108 August 15, 2014 “Big” Marijuana?

August 15, 2014

hubWhat will be the future impact of marijuana use?

A recent article in the New England Journal of Medicine suggests very plausibly
that the history of tobacco use tells us how the marijuana industry might develop.

 


“The tobacco industry has provided a detailed road map for marijuana:

  • deny addiction potential,
  • downplay known adverse health effects,
  • create as large a market as possible as quickly as possible,
  • and protect the market through lobbying, campaign contributions, and other advocacy efforts.”

Marijuana (MJ) IS LESS addictive than tobacco. Presently about 9% of MJ users meet the criteria for dependence as compared to 32% for tobacco users. But, recent studies show that heavy MJ use by an adolescent can lead to structural brain changes and subsequent dependency as an adult. All researchers agree that MJ use in those under 21 years can be harmful and should not be permitted. Most agree that MJ is NO more a gateway drug than alcohol and tobacco are.

MJ’s effect on cognitive functioning IS LESS than alcohol, but it can slow reaction time. Effects of MJ are independent of blood or urine levels. There is no breathalyzer test for MJ. DUI standards for MJ do not exist. (see Buzzfeed video, “Drunk vs. Stoned”)

We now accept that smoking tobacco is a major cause of death. To our knowledge no one has ever died of marijuana. Since it is inhaled it can cause lung damage, but it doesn’t cause cancer. Sensitive to the concern about damage caused by inhaled MJ, sellers are already pushing vaporizers and edible products. A rumored joint venture between a medical MJ vendor and an e-cigarette manufacturer apparently sent stock prices soaring.

MJ is cited often for its useful effects for cancer and AIDS patients, and those benefits are real. There is very little evidence that MJ “reduces anxiety”. Such claims imply that “a little reduction of anxiety” will, of course, make your work and life easier and users will be more successful. Can’t you just envision the ad campaigns for “cool”, “mellow”, and “helpful MJ”?

Cigarettes started out as a “roll your own” process used by a small portion of the population in the 1880’s. By 1950 half of our population used tobacco, mostly cigarette smoking. As the process of making cigarettes was industrialized, 120,000 cigarettes a day were rolled and packaged by machines. Advertising and marketing soon expanded the use of cigarettes to the general population with special targets of women and the young. Cigarettes were made “more mellow” and had additives to speed absorption and “enhance taste”. Increasing the potency of MJ is already well under way and literally has free rein, since there is no standardization of MJ products. Competitive sellers boast of their product’s enhanced potency and use it as a marketing tool.

As the tobacco industry grew, so did the smoking lobbies and corporations that resisted regulation of tobacco products or distribution of the scientific studies of tobacco effects. The National Cannabis Industry Association with 450 business members and offices in Washington, D.C. and Denver already exists.  The strength and power of the tobacco lobby prevented us for 50 years from accepting cigarette smoking as a public health problem. Unlike cigarettes, MJ also has the internet that provides direct, and directed, advertising to the public; a fantastically effective and profitable way to sell a product as proven by our pharmaceutical companies.

Anyone that does not believe that MJ will become a major business need only look at the competitive scramble for permits in states newly allowing medical marijuana dispensing ; a fierce competition despite ambiguity of Federal vs. state law compatibility, as well as hefty application and annual permit fees.

“The free-market approach to tobacco clearly failed to protect the public’s welfare and the common good: in spite of recent federal regulation, tobacco use remains the leading cause of death in the U.S.” The author calls for “collaboration among the FDA, NIH, SAMHSA (Substance Abuse and Mental Health Services Administration) , the National Highway Traffic Safety Administration, and other agencies” to “understand the harms and forecast the effects of industrialization” of MJ. In light of the ineffectiveness of multiple governmental agencies in “collaborating” to ensure proper, transparent food labeling and enhance the public health, one can’t be too optimistic about government’s effectiveness in influencing the manufacture, selling, and use of MJ in the future.

References:
1. NEJM 371:5 July 31, 2014 “Big Marijuana – Lessons From Big Tobacco”, Richter and Levy
2. Institute of Medicine, Marijuana and Health, 1982
3. Institute of Medicine, Marijuana and Medicine – Assessing the Science 1997


Vol. 107 July 15, 2014 Update on Sunscreens

July 15, 2014

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“Consumers continue to [erroneously] perceive high-SPF sunscreens as more effective than lower ones.”
– Consumer Reports, July 2014

 

My last blog on sunscreens a year ago was largely based on a testing of products by Consumer Reports. So is this one.

1. The FDA does NOT test sunscreen products before they are put on sale.
The FDA does require manufacturers to meet certain standards in order to label their product with these three terms:
“SPF  number “- level of protection from UVB rays that cause sunburn
“broad spectrum” – also protects against UVA rays that can increase skin aging
“water-resistant” – claims protection for 80 minutes after immersion
In 2011 the FDA requested more data from manufacturers about sunscreen sprays and is currently evaluating it.

2. Any SPF over 30 provides little more protection, and will cost you more.
SPF 15 = 93% protection
SPF 30 = 97% protection
SPF 50 = 98% protection
SPF 100 = 99% protection

3. Sunscreen for kids is a marketing gimmick.
Though half of parents who use sunscreen on their children think that sunscreen for kids is “safer” and “gentler”, that is simply NOT true. The FDA makes no distinction in standards for children’s sunscreens and the ingredients of most “children’s” sunscreens are identical to and are present in the same concentration as regular sunscreen. Some may  be reformulated to be “tear-free” or “sting-free”, but that is the only difference.

4. Use more of it, and earlier than you think.
Apply the sunscreen at least 15 minutes before exposure because the chemicals take that long to interact before providing protection. Apply at least an ounce (2 tablespoons or one shot glass full) to cover your face and body adequately.  Reapply every 2 hours.

5. “Natural” sunscreens are no safer nor more effective than “chemical” ones.
There are no effective “natural” sunscreens, however defined, on the market. Zinc oxide and titanium oxide are natural minerals, but if used in their natural (unprocessed) state your zinc oxide covered nose would be black and covered with lead! Sunscreen lotions with zinc oxide and titanium oxide NANOPARTICLES are clear, neither black nor white, but nanoparticles still have their safety critics. “Natural” sunscreens, often labeled as “mineral” rather than “chemical”, can also clump and lose uniformity of SPF.

6. The jury (NIH and the FDA) is still out on the safety of nanoparticles in sunscreens, but the risk appears to be very small.
Nanoparticles do not penetrate skin cells and actually provide very good protection against the effects of the sun, but the potentials effects of inhalation (powders) or ingestion (lip balm) have generated some caution. Nanoparticles have long been used in a whole variety of cosmetics, combine with cells in very tiny amounts, and are approved in sunscreens in Europe. According to the Environmental Working Group, a watch-dog  organization that has been monitoring the use of  nanoparticles in cosmetics for years, “Nanoparticles are a lower hazard than most sunscreen ingredients approved for the U.S. market.”

7. Sunscreen sprays are not recommended.
Correct spray patterns are key for good protection, even spraying the same area twice is recommended, and it is not a good thing to breathe in the spray. The best way to use a spray is to spray it in your hand and then apply it, so why bother with a spray? The FDA is investigating the potential risks of spray sunscreens; like standing too close to a grill after you have sprayed and getting burned when the propellant ignites.

A selected list of products (not all recommended) Consumer Reports tested: (7 of 24 tested products were “recommended”)
(scores are result of UVB and UVA protection measured by wave length and effects of a soak in the tub for 80 minutes: 100 is the maximum)

Up and Up  Sport Spray (Target)           SPF 50     $0.80 per ounce    score: 90 Rec.
Coppertone Water Babies                        SPF 50     $1.38 per ounce     score: 81 Rec.
Equate Ultra Protection (Walmart)      SPF 50      $0.56 per ounce    score: 80 Rec.
No-Ad Sport                                                SPF 50      $0.63 per ounce    score: 69
Up and Up Kids (Target)                         SPF 50      $0.64 per ounce    score: 39
Banana Boat Kids                                     SPF 50      $1.25 per ounce     score: 16

References:
1. Consumer Reports, July 2014, “The Truth About Sunscreens”.


Vol. 106 July 1, 2014 Whas’up with Obamacare?

July 1, 2014

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My nomination to the
“Understatement Hall of Fame”

“I think that probably no one fully anticipated when you have a law
that phases in over time how much confusion that creates for a lot of people.”

- Health and Human Services Secretary Kathleen Sebelius, April 8, 2013

The news media (and a lot of republicans) have not been ranting or raving about Obamacare lately. They seem to be preoccupied with Immigration laws, Tea Party challengers in Congressional primaries, and Hilary’s uptick in her campaign (aka “book tour”). I thought it might be helpful to look at “where Obamacare is at”.

82 out of 87 provisions are in effect
Of the 87 provisions in the Affordable Care Act signed March 3, 2010 (over 4 years ago!) 82 are in effect in today. Granted there have been some postponements in deadlines for enforcement and some delays in implementation of certain sections, but overall Obamacare is apparently plugging along very well. Only 3 additional provisions are slated to go into effect for 2015 to 2018. Kaiser Foundation has an interactive website to track each provision and its implementation status if you really want to know all the details.

27 states have decided to expand their Medicaid coverage
The ACA offers federal reimbursement for 100% of the initial years cost to states expanding coverage by raising the income level of eligibility for Medicaid. The federal subsidy to the states who expand coverage will gradually decrease each year, but the maximum cost to the state will be 10% by 2020.Medicaid ACA status by state
Three more states are openly discussing the move and 29 are not moving at all.

Enrollment targets continue to be met.
As of April 2014  13.5 million individuals have been determined to be eligible to enroll (“buy health insurance”) in a “marketplace plan” (either state-created or federally run) 8.5 million individuals or two-thirds of these could be eligible for financial assistance in the form of an advanced tax credit for their health insurance purchase. 8.1 million individuals of the 13.5 million total eligible have actually selected a plan. However, no premiums have actually been billed or paid just yet.

ACOs are blossoming nationwide, particularly in the northeast corridor.
Creation of Accountable Care Organizations (ACOs) which incentivize health care providers (physicians, hospitals, and other members of the health care team) to band together to provide patient care more efficiently (“less costly”) and with improved quality. It is a lynch pin of Obamacare. According to the Levitt Partners (yes, creation of the ACOs legal entities has become another guarantor of lawyers’ retirement funds), a total 626 ACOs covering 20 million patients, or 17% of the U.S. population, now exist. Most of these individuals have purchased commercial health insurance policies (another reminder of the boon of ACA to health insurance companies)  AND most patients don’t even know that they are now in an ACO. About 2/3 of the U.S. population lives in localities with ACOs mostly concentrated in the Northeast, 40% of the general population have access to at least two ACOs, and 10% of Medicare patients are patients of an ACO.

MSSP participating ACOs
As of May 2014 about one-half of the ACOs (338) are participating in the Medicare Shared Savings Program (MSSP) covering 5 million patients in 47 states, DC, and PR. In the MSSP the ACO that “saves money” by reducing costs without compromising defined quality standards gets to keep some of that money for its providers. This is usually called “risk sharing”, and though dismissed initially as “managed care in different clothes”  reluctant providers have clearly jumped on the bandwagon. In May of 2012 the first report  period identified 27 MSSP ACOs. There are different levels of risk to ACO providers so “when you see one ACO you have seen just one ACO”. About 50% of ACOs include hospitals as members. Preliminary data about ACO performance is currently mixed, and credible  data about which models will work the best is still unavailable.

What about the cost of ACA?
Of course, increased access of individuals to effective health insurance is going to cost money. In April of this year the non-partisan Congressional Budget Office (CBO) working with the Joint Committee on Taxation REDUCED their estimate of the cost of ACA in 2014 by $5 billion (from the $36 billion originally estimated). The estimated cost over 2015-2024 wa REDUCED by $104 billion (of $1,400 billion total originally estimated).CBO est. cost of Obamacare

 

Billions of Dollars, by Fiscal Year graph

 Wrap Up Of  Whas’up with Obamacare
“First, all major parts of the ACA except the individual mandate are popular — including the insurance-market reforms, the subsidies to make insurance affordable, closure of the drug-benefit “doughnut hole,” and the incentives for most employers to provide affordable insurance as a fringe benefit. Second, lawmakers who support repeal will not want to snatch insurance coverage from an estimated 37 million people who will be insured thanks to the ACA in 2017. Third, repeal would cut into the sales and profits of health care providers and suppliers of all stripes.”  (1)

The Supreme Court ruled that the individual mandate penalizing people (via their annual tax return) who don’t purchase some form of health insurance was constitutional because the court considered it  “a tax, not a fine”. Justice Robert’s unexpected vote in favor of the ruling prompted Jay Leno to quip,”The Obamacare ruling makes Roberts the first Republican to favor an insurance law with an individual mandate since, well, Mitt Romney.”

1. “Here to Stay- Beyond the Rough Launch of the ACA”,  HJ Aaron, NEJM, June 12, 2014

 

 

 


Vol. 115 June 15, 2014 Sometimes a picture IS worth a thousand words.

June 15, 2014

 

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THE LAST OF MY “FOOD BLOGS” FOR A WHILE.

After blogs about the evils of excess added sugar, added trans fats, the obfuscation of ingredient lists, and manipulative marketing by food manufacturers  I find it easy and appropriate to finish up this series with pictures that capture more than I can write.

 

Food cartoons1

 

Some churches have come up with the ultimate answer to WWJD?  Gluten-free communion wafers!!

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Food cartoons2

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Wouldn’t it be great if parents were as paranoid about gun deaths – 500 children per year – as we are about peanut allergy deaths – 150 children and adults per year.

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Food cartoons3

As a pediatrician with 45 years of experience and a grandfather, I think that the moment depicted here is much more important in the long run for the child than reading the % of trans fat or sugar content in the ingredients list.

 


Vol. 114 June 1, 2014 Much Ado About Nothing

June 1, 2014

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“[In response to] an announcement from another U.S. infant formula manufacturer
about its plans to decrease the caloric density of some of its formula to 19 kcal/fl. oz,
Mead Johnson Nutrition (MUN) would like to assure youthat we have
NO plans to modify the density of our formulas from 20kcal/fl oz to 19 kcal/fl oz.”
-Mead Johnson news bulletin to pediatricians, April 1, 2014

 

My last two blogs discussed the evils of added sugar documented by the movie “Fed Up” and the possibility of an FDA ban of added trans fats in manufactured foods.  Both describe politically correct responses to the growing awareness of U.S. and global obesity rates and prevalence. We are urged to become ingredient list readers and to “buy healthier” as a defense against food corporations’ slick advertising and successful lobbying against transparent ingredient lists.

Abbott is the latest food corporation to claim to save us all from the scourge of infant obesity, all by reducing its Similac calories by  1 kcal/fl. oz.   Mead Johnson’s (Enfamil) rebuttal warns that reducing the formula calories means that infants would need to consume 1.5 more ounces per day to “meet their daily energy requirements during the first six months.”  All my kids have left more than that on their bibs  and chins every day, or as Stephen Colbert might say,  “Give me a f&*king break!”

Abbott’s stated reason for the formula change, already labeled by Abbott as “Innovative”, is to help decrease excessive infant weight gain by matching its formula content more closely to breast milk. In my increasingly skeptical (cynical) view Similac is merely adding new marketing buzz words to the current debate about what makes obese infants and do they become obese adults?

It is hard for me to get too excited about minimal formula calorie changes when I remember that one can of Coke, Pepsi, or Sprite contains more sugar than  100% of the total daily requirement of sugar as defined by the American Heart Association (36 g).  Mayor Bloomberg’s campaign against the super-size soda which contains 128g of sugar and the efforts to remove soda vending machines from schools even make some sense. One kcal/fl oz. or 1.5 more ounces of formula a day certainly pales by comparison on the spectrum of “sublime to ridiculous”.

One of the perks of being a pediatrician is being reminded daily about the flexibility, innate wisdom, and versatility of infants and toddlers. In a two-page  news announcement peppered with scientific journal citations the American Academy of Pediatrics Committee on Nutrition notes that ” the number of formulas choices have increased and the selection process is more complicated”.  It concludes in one of its more common-sense statements that “infants appear to eat to satisfy energy needs and will compensate for low food energy density … by increasing food intake.” Duh? More importantly,  “Neither parents nor pediatricians should assume that newer and more expensive products have health benefits for infants.”


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