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.”


Vol.113 May 15, 2014 More “Bad Stuff” For You

May 15, 2014

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“I have a chef who makes sure that I’m getting the right amounts of carbs, proteins and fats
throughout the day to keep me at my max performance level.”
Barry Bonds

My last blog reviewing the movie “FED UP” listed many of the compelling reasons why “added sugar” is bad for you and why food manufacturers keep adding it. Just as I was getting used to looking for the total grams of sugar on processed food labels, some active health food advocates are urging the FDA to declare partially hydrogenated oils (“trans fats”) as bad too. Now I will have to start scanning ingredient lists for that!

These particular “health food advocates” happen to be two scientists from Stanford University and Temple University writing an article in the New England Journal of Medicine (1). This bicoastal duo reports that since 1911 food companies have been adding artificial trans fats to foods to prolong shelf life, improve stability during deep-frying, and enhance taste. Unfortunately, added trans fats alter the balance of good and bad cholesterol in a harmful direction. The CDC estimates that 20,000 coronary events and 7000 deaths per year could be prevented by NOT ADDING trans fats to processed food. Denmark banned it in 2003. New York city banned it in restaurants in 2006, and California did so in 2008.

In 2006 the FDA required food processors to list trans fat as an ingredient, and many manufacturers reduced the amount added to their products to avoid having to declare it as an ingredient. Recently the FDA has proposed a regulation removing trans fats from its “GRAS” category (“Generally Regarded As Safe”) and declaring partially hydrogenated oils (trans fats) as “unsafe” in any food sold in the U.S.

The authors note that “over the past few decades, food-safety concerns have expanded from issues of food borne illness and contamination … to the effects food ingredients have on chronic diseases such as heart disease.” They end their essay optimistically with “regulatory reconsideration of ingredients such as sugar, caffeine, and salt may well be next on the agenda.”

Reeling from this latest disclosure of potentially dangerous things that I unknowingly put into my mouth, I sat back in my recliner with a relaxing glass of red wine only to read in WIRED magazine that wine is not the pure libation that I thought it was! Some of the FDA-approved additives in wine include:

  • sulfur dioxide to kill microbes and prevent oxidation,
  • ammonium salts to revive dying yeast to enhance fermentation,
  • pectic enzymes to improve clarity and color,
  • oak adjuncts (chips, sawdust, or oak “essence”) instead of oak barrel maturing,
  • gum arabic to soften a bitter wine,
  • Velcorin (dimethyl dicarbonate) to kill a half-dozen different bacteria and yeasts,
  • and, of course sugar.

Added sugar  from beet, cane, or corn syrup increases the alcohol content from fermentation. The process is called “Chaptalization”, invented by a Frenchman and illegal in California, Italy, and Australia.

It is simply a wonder that any of us live to be over 65.
I think I’ll just pop open a beer and settle back to read yet another article about how the ills of the elderly are bankrupting our country.
… Or better yet, a martini.
I almost have my physician convinced that gin is “a clear liquid”.

 

References:
1. NEJM 370:19, May 8, 2014, Brownell and Pomeranz)
2. WIRED, April 2014


Vol. 112 May 1, 2014 Sugar is Bad! Oh no, Not Again.

May 1, 2014

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I say “oh, no, not again” because 30 years ago I spent some time in my practice and in the community
defending “bad” sugar against accusations that it caused hyperactivity and attention deficit syndrome.
Research, then and now, has shown that in only about 25% of hyperactive children
eliminating, not the sugar,but the dyes and other additives in sugary foods can reduce their hyperactivity.

 

The film “FED UP” which I just saw in advance of its general release on May 9 makes a compelling argument that the amount of “unaccompanied” sugar (the American Heart Association calls it “added” sugar) that we eat is causing our obesity epidemic. It is narrated by Katie Couric and produced by the producer of “An Inconvenient Truth”.

The film simplifies complex nutritional and biochemistry processes with an easily understood cartoon diagram showing sugar ingested without accompanying fiber or protein being absorbed quickly, traveling directly to the liver where it ignites a burst of insulin that converts the sugar directly into fat. If fiber or protein is ingested along with the sugar this absorption is slowed, less insulin is released, and less fat tissue results. Hence the campaign against super-size sodas in New York City and efforts to ban soda vending machines from our schools. The film points out how detractors try to reframe the soda discussions into terms of “individual liberty vs. an over-reaching government”, rather than that of a serious health issue.

“FED UP” explicitly demands that we demonize sugar the way we have demonized tobacco. “Both are extreme health hazards”.

The average daily consumption of sugar in the U.S. is 84 grams. The American Heart Association recommends 36 grams a day of added sugar. “Processed food” with its high sugar content gets the black mark here as compared to “real food”, which if it has sugar, also has fiber which delays its immediate conversion into fat. The film’s examples of the success, power, and money of the “sugar lobby” and big food corporations are particularly provocative. The film removes all blame from the fat individual and places it squarely on the persistently clever, seductive advertising (particularly to young children) of food processors and distributors. The film’s revelations of the ability of the food and sugar lobbies to resist truthful, transparent labeling and to continue to outmaneuver an amorphous front of three different federal regulatory agencies is compelling .

Fun facts presented by “FED UP” include:

  • When President Reagan cut the school lunch federal subsidy in the 80’s many schools outsourced lunch preparation to fast food suppliers and closed their school kitchen to lower costs. Today 80% of schools in U.S. have their school lunches provided this way (pizza, french fries, cheeseburgers, and sodas – Pizza Hut, MacDonald’s, etc.) Do you know where your schools get their lunches?
  • Promoting student choice of healthy alternatives is an easy, obvious answer to outsourced vendor lunches, but in a school where a healthy alternative is offered a cafeteria worker reports that “only about 25 out of 350 students actually choose it”.
  • Multiple sugar products are often hidden on ingredient labels by use of unfamiliar names.
  • All the fat taken out of milk and other dairy products during the 1980’s rush toward “fat-free” food has been successfully re-marketed as increased cheese products. Many food manufacturers added even more sugar to restore the taste of “reduced fat” foods.
  • Sugar is the ONLY ingredient on the ingredients list that is NOT accompanied with a “percentage of daily requirement” number. This “% number” has been kept off the labels by the sugar lobby. If it were added, we could quickly see that we often exceed our “daily requirement of sugar” about half way through lunch. The film depicts a bowl of corn flakes as actually a bowl of sugar.

A couple of reservations about the film:
1. The film touches only briefly on the genetic contribution to obesity. It explains the two, clearly thin brothers running around in the background of one of the featured fat families, as TOFI (Thin Outside Fat Inside), a recent concept which depends on specialized total body MRI imaging to identify.

2. Its explanation of why the rest of the world is also getting fat is “that we are so good at exporting our ads and processed food to the rest of the world”. I think that is too weak to explain the rise of obesity in countries like Spain, Switzerland, and Korea.

Internatl obesity rates
“FED UP” closes with some specific recommendations and challenges:

  • Reduce sugar intake by 50% by cooking “real” food.
  • Any food with more than 12 listed ingredients is a processed food not a “real” food.
  • Eat fresh, buy local
  • GO SUGAR FREE FOR 10 DAYS. A difficult thing to do because of all the hidden sugar in soups, sauces, catsup, yogurt, and canned foods. A family in the film did do it for 10 days, liked it, extended it, and lost dozens of pounds.
  • Ask your legislators to pass laws requiring the inclusion of “% of daily requirement” for sugar on all labels, just like all the other listed ingredients.

Dare I close with the tag line that this thoughtful, polemic film provides us (U.S.) with “much food for thought”?
.                                     Look for “FED UP” after May 9.


Vol. 104 January 1, 2014 Hubslist’s Blogs of 2013

January 1, 2014

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“Happiness is Not a Warm Gun” – Jan 1, 2013
In half of my lifetime our culture has moved from arguing that sometimes it was “better to not wear a seat belt in case there was a car fire” to having my grandchildren remind me that I shouldn’t start the car until MY seat belt is buckled. No ONE law accomplished that, and it happened despite critics and opposition from big time lobbyists. Why can’t we do the same for gun control?

Ten Ways To Improve Your Health – Jan 15, 2013
 This list, “backed by scientific research”, was complied by AARP.
1.  Throw a Party – Social connections help you live longer.
2.  Adopt a Pet – Exercise it (and you) and count it as another social connection.
3.  Choose Dark Chocolate – An ounce a day keeps the doctor away.
4.  Savor Your Coffee –  Three cups a day keeps Alzheimer’s away.
5. Have a glass of wine or beer – “Guinness is Good For You” One glass a day for women, two for men!
6. Have Sex – There is nothing bad about releasing endorphins. It also counts as aerobic exercise.
7. Listen to Your Favorite Music – A song a day keeps the heart pumping away.
8. Take a Nap –  A nap a day keeps the brain hoarder at bay.
9. Go Outdoors – Go look at the greens, don’t just eat them.
10. Use Soap. regular soap – Antibacterial soaps with triclosan aren’t worth the cost and may not be safe.

The MYTH of Antioxidants – Feb. 1, 2013
A 2007 systematic review of 68 clinical trials concluded that antioxidants do not reduce the risk of death. Certain antioxidants were linked to a 5%  INCREASED risk of death. The American Heart Association and the American Diabetes Association now advise “that people should not take antioxidant supplements except to treat a diagnosed vitamin deficiency”. “The literature is providing growing evidence that these supplements – in particular at high doses –  do not necessarily have the beneficial effects that they have been thought to…We’ve become acutely aware of potential downsides.”

The ATF has no ammunition – Feb. 15, 2013
The Tiahrt Amendment, passed by Congress in 2006, permits gun dealers to destroy gun registration applications within 24 hours of completion so as “to avoid any inadvertent errors from being promulgated” . It placed these prohibitions on the ATF;  the federal agency overseeing firearms

prohibited from establishing a registry of gun owners (imagine no one keeping a registry of car owners)
prohibited from requiring gun dealers to maintain inventories of their wares
prohibited from inspecting any gun dealer’s records more than once a year
prohibited from revealing firearms trace data to anyone other than law enforcement personnel (firearm tracing is done for  firearms used in crimes. One study showed that 57% of guns used in crimes in one state were traced to only 1% of gun dealers.)
prohibited from requiring gun dealers to respond to police inquiries.

 So we may not need any more laws or regulations for gun safety. We could just repeal the one “Tiahrt Amendment”, and let the ATF begin to do its job.

Take a Pill – March 1, 2013
“Something like a third of consumers who’ve seen a drug ad have talked to their doctor about it,” says Julie Donohue, a professor of public health at the University of Pittsburgh who is considered a leading expert on this subject.”About two-thirds of those have asked for a prescription. And the majority of people who ask for a prescription have that request honored.”  Our mantra continues:
“Hey, Doc,
Forget the Mediterranean Diet.
I’m an American.
Give me a pill.”

The New Pope – March 15, 2013
The medical question I have not been able to answer despite my extensive, exhaustive research (at least an hour on Google) is:  Which Pope had the ulnar nerve palsy? The classic hand gesture of the “Papal Blessing” or “Papal Benediction”, despite erudite analysis by reverent writers on the religious symbolism of his hand and fingers, is, in fact, the result of a nerve palsy of the hand. Even the Vatican tourist guides know this.popesign1The Italian bishops were surprised that the Bishop of Milan, Angelo Scola, was not elected, and much to their embarrassment they prematurely released a report that he had been. I, too, was disappointed that Angelo Scola did not get elected. We all could have called him Pope Scola.

Pope Francis Bails Out Obamacare – April 1, 2013
In a solemn Easter Mass Pope Francis dramatically offered the help of the Roman Catholic Church in funding universal health care in the U.S. He noted that because the U.S. is the only civilized Western country without universal health care and is currently having financial problems, it is the Christian thing to do. “Since neither disease nor money is restricted by national boundaries, it makes good sense to protect the rest of the world from the health problems of  the beleaguered U.S. ” The Pope’s plan was immediately dubbed, “Francincare” (pronounced  as “Frankincare” with the Italian hard “c”). At the end of the press conference Pope Francis returned briefly, showed the persistent Papal nerve palsy to the gathering, and closed with a benediction in Italian: “Felice Aprile Ingannare Giorno”, in Spanish: “Felize Abril Enganar Dia”, and finally in English: Happy April Fools Day”.

Patient Centered Medicine – April 15, 2013
PARENT:  So, I should breast feed Leonard for a whole year, but could have started solid foods two months ago?  Most of my friends swear that giving food makes their babies sleep longer at night.
PHYSICIAN: Exclusive breast feeding for 6 months has lots of advantages for the infant. There is no evidence that giving solid foods makes the infant sleep longer at night, but there is probably no harm in starting him on cereal now.
PARENT: Any particular kind of cereal?
PHYSICIAN: A 1994 Swedish study showed that introducing wheat before 6 months of age caused a big spike in gluten allergies and celiac disease, but a more recent one there showed that giving wheat to breast-fed babies at 4 months actually decreased the later occurrence of celiac disease and gluten allergy.
PARENT: So, wheat cereal could be either good or bad at his age? This is very confusing.
PHYSICIAN: Science can be confusing. It often changes its mind as new data is gathered.

Lessons Learned from the Development of Polio Vaccines – May 1, 2013
1. Even in science, what you know is important, but WHO you know can be also.
2. Yesterdays “field trial” is today’s mass immunization campaign, and NOBODY tests drugs or vaccines, whether from mice brains or monkey kidneys, on themselves and their family members anymore!
3. The history of testing vaccines and drugs on impaired or incarcerated populations reminds us again of the necessity for “informed consent”.
4. As more academic institutions seek joint contracts with big pharma to replace reduced NIH support of research (MGH and Sanofi, AztraZenenca, etc.) accusations of being a “commercial scientist” seem moot.
5. Some immigrants can be very smart, focussed, and hard-working, and they can contribute immensely to our country’s health and wealth.
6. Science keeps gathering data and testing hypotheses, so we should not be surprised when its recommendations change.

Medical Marijuana – May 15, 2013
1. Marijuana use before the age of 20 does have structural and functional effects on brain development, primarily but not limited to the frontal lobe. (“The frontal lobe, responsible for impulse control, is the last to develop and the first to go.”)
2. After the age of 20 there is little current evidence that MJ causes any permanent effect on brain function or structure.
3. There are  currently no predictors that will identify an occasional user of MJ as one who will become dependent or addicted to MJ (daily use), but the earlier one starts using marijuana (13 yo.) the more likely brain function will be effected.
4. Despite the “trustworthy karma” of medical marijuana, marijuana prescriptions will result in the dispensing of varied, complex, and inconsistent products.
5.Access to marijuana by middle and high school students in 2013 is now so easy according to both students and researchers that medical marijuana dispensaries will provide little increased access to adolescents.

The three drugs of adolescent choice today, tobacco, alcohol, and marijuana, do share a common denominator in that those who use one of the three drugs by age 13, will use one or more of the others before 18 yr. There is NO evidence that one is the “gateway” to another. In fact, one researcher remarked that the concept of a gateway is more of a myth than a reality. He called development of addiction to one or the other substance as a “shared vulnerability”.

Sunscreen SPF Ratings Escalation – June 1, 2013
This year Consumer Reports states that the according to their tests the maximum effective SPF is now 40. Paying for anything above that is wasted money. Two years ago Consumer Reports tests showed that any sunscreen with a SPF (Sun Protection Factor) over 30 gave no more protection than a 30. They also recommended that year-old sunscreen might have lost some of its effectiveness, so new sunscreen should be bought each year. New FDA regulations require the sunscreen to be labeled with a three-year expiration date.

What Massachusetts Docs Think About Medical Marijuana – June 15, 2013  Common threads in the  118 comments posted were:
1. Does marijuana even belong in the purview of physicians? “Just legalize it and let patients decide whether to use it or not”
2. Most physicians who supported its medical use would do so “in certain circumstances”; implying strongly that physician control over use was assumed by supporters.
3. All camps called for more research to move toward a stronger basis of evidence.

Do You Have Obesity or Are You Just Fat?- July 1, 2013
The House of Delegates of the AMA just voted to designate obesity as a disease. This means that you will no longer “be fat”. You will “have obesity” like you “have diabetes”.  The AMA Scientific Council recommended to retain obesity as “a condition”. A spirited debate about the consequences has begun. I suspect that much of the controversy  is about money. Medicalizing a societal condition will cause more money to be spent on surgery and drugs.  “Insurers will pay more.” The upside of that could be more provider reimbursement for prevention and life style counseling by primary care providers, but surgery and big pharma are usually first in line. Two new anti-obesity drugs (Belvig and Qsymia) came on the market this past year. More than one-third of Americans will instantly be labeled as “ill” and therefore eligible for more medical services.

Sunscreens Are Poisonous? – July 15, 2013
The culprit is oxybenzone  and other similar chemicals in chemical sunscreens first described as “endocrine disruptors”, a code word for “estrogen effect” which directly connects it emotionally to breast cancer, particularly by Dr. Oz.   Oxybenzone is such a common ingredient in skin products that a CDC survey of Americans in 2003 detected it in 97% of urine samples. The link to breast cancer in humans has not been proven. One reassuring fact is that hormones, like all chemicals and unlike radiation, have to reach a certain blood or tissue level to have any significant effect.  An average woman would have to apply 1 and 1/2 quarts of sunscreen to 25% of her body (arms, legs, and face) each year for 277 years to attain the levels of oxybenzone that had uterine effects in lab rats!

Too Much Sun in Vermont?! – August 1  , 2013
I am in a hammock in Vermont reading, much to my surprise, that Vermont, the land of a severely short summer, has one of the highest melanoma rates in the country.  About 29 people per 100,000 in Vermont get diagnosed with melanoma as compared to the national average of 19 per 100,000. Bennington County has the HIGHEST rate of melanoma of any county in the nation, 179% above the national average!

Somezhiemer’s – Sept. 1, 2013
News releases and internet blogs this week are full of buzz about a protein that apparently is related to the memory loss of aging; something I call Somezhiemer’s as opposed to Allzhiemer’s (sic).  In this Columbia University School of Medicine study a deficiency of the protein RbAp48 in a specific part of the brain in both older mice and 8 older humans (both postmortem) was correlated with memory loss ; at least the ability of the mice to remember a water maze pathway.
The good news is that one specific biological cause of memory loss has been discovered, as contrasted with speculation about aluminum, cooper, mercury, zinc, and other environmental agents.The bad news is that us older people will probably not, in our lifetime, be able to take a “RbAp48 pill” each morning, so we don’t misplace our car keys, glasses or …. forget to write an August 15 blog.

Fear of Fever – Sept. 15, 2013
Many parents think that a temperature over 98.6 F is a fever. Most pediatricians consider a temperature of 101 F or higher as a fever, except in infants under 3 months where we pay attention to temperatures over 100 F. Any pediatric practice worth its salt has a handout or a website page describing fever as one of nature’s way to fight infection. Fevers are usually caused by common viruses for which antibiotics are no help, and discomfort from them is relieved easily by simple medicines.
We desire zero risk level in our lives, and a fever, no matter how small or how short in duration, indicates that something may be wrong. Speaking of risks, how can we accept that everyone must remove their shoes at the airport because one person had a bomb in a shoe, but we don’t register gun owners and accept the much greater risks of our kids being shot?

 Obamacare Begins – October 1, 2013
Like the Bible, Obamacare is open to interpretation. Your view of it may depend on your political party rather than your religion. Both are vulnerable to quoting out of context in support of opposing viewpoints. Both have overall, encompassing goals which can often be lost, or at least obscured, by minute details of excess verbiage. Both have, and will continue to have, “unintended consequences” (like the Inquisition and the Crusades) that we mere mortals have to deal with.
Everyone certainly agrees that Obamacare is NOT divinely inspired. Congress has clearly rejected the idea of a central authority (like the Pope, or Donald Berwick, MD as “Czar” of CMS). The Bible is no longer chained in the dark in the back of the church.  Obamacare is now out in public, out in the market place. We shall eventually see how well it meets the needs of our citizens for affordable health care.
By the time the Republicans win the presidency Obamacare will have so many beneficiaries (voters) that they won’t dare to kill it, and they’ll have to rename it. I wonder WWJD?

Flu Vaccination – October 16, 2013
The trivalent vaccine is the most readily available (at both your physician’s office or a retail store) and there is no compelling reason to seek out the quadrivalent vaccine. The vaccine’s effectiveness in preventing the flu depends on which flu strain is circulating in your area. Effectiveness may be as high as 80% in young adults, but is almost always lower in the elderly. A high dose vaccine that allegedly delivers four times the usual prod to your immune system is being marketed for the over 65ers , but it is not recommended since there is no independent study of its success.
In Massachusetts last year there were 5 flu deaths in children under 17 yo.  None of the five had been adequately vaccinated. Two of the five had no pre-existing health problems. Nationally there were 146 pediatric deaths from the flu last year compared to 34 the previous year.  40% of those deaths were in children who were otherwise very healthy.  90% of them were unvaccinated.

Paranoia – Nov. 1, 2013
Former Vice President Dick Cheney recently said during a “60 Minute” interview that he had his cardiologist turn off the wireless function in his implanted pacemaker “in case a terrorist tried to send his heart a fatal shock.” Years later, he saw that scenario played out in an “Homeland” episode. We knew that his DC residency was pixellated in the Google satellite view, and we wondered if he was on the NASA phone surveillance list.  But then, we remembered that he had ordered it.
Polls taken in Boston after the Marathon bombings indicate that more people think that “such attacks are likelier, but fewer live in dread of them.”.”In the United States since 9/11 Islamic terrorism has resulted in the deaths of 37 people. During that same period, ten thousand times that many have been killed by guns wielded by their countrymen or themselves.”

Is It a Strep Throat or Just a Virus Cold? – Nov. 15, 2013
A team of Boston research physicians have recently come up with a potential APP for that! These physicians combined two clinical findings that the patient could recognize with real-time data about the occurrence of positive strep tests in the community in the past 14 days to generate a “Home Score” to tell you if you really need a strep throat test.
There may soon be a home kit for that! Other physician researchers in Boston are ready to test a home-based, patient-administered Rapid Strep Test. A positive home-based RST would be enough to initiate treatment and prevent complications.

The Myth of Multi-Tasking – Dec. 1, 2013
“Multitaskers are terrible at every aspect of multitasking…When we talk to multitaskers they seem to think that they’re great at it and seem totally unfazed and totally able to do more and more and more.” Actually, those who did it the least, did it the best. “We are worried that multitasking may be creating people who are unable to think well or clearly.”
Recent work involved study of the erosion of social and emotional development by the increasing use of social media. “We have to get back to that saying, ‘Look at me when I talk to you’”.

Aspergers or Autism – Dec. 15, 2013
Confusion about these syndromes  increased in the 2000’s as screening tools improved and awareness of the syndromes grew.  The authors of the 2013 Diagnostic and Statistical Manual of Mental Disorders (DSM-5) , the bible of insurance company reimbursement, has attempted to simplify and clarify the situation by lumping all the diagnostic names into one billing code, “Autism Spectrum Disorder” (ASD).
The attempt has not succeeded according to its critics and many practicing physicians.
Parents of Asperger children could lose insurance benefits now tied to that diagnosis. Grant-supported educational and enrichment programs for Asperger’s may dry up. Asperger’s has always been a less terrifying diagnosis than autism.  People with Asperger’s, and probably more important, their parents, don’t want to be labeled with the stigmata of “autistic”. Dan Akroyd and Daryl Hannah  self-proclaimed their Asperger’s in 2013.


Vol. 93 July 1, 2013 “Do You Have Obesity or Are You Just Fat?”

July 1, 2013

hub_2“Obesity is much more like drowning than a disease…We are drowning in calories.”

-David Katz, MD, the Health Care Blog, June 22, 2013

D.

.The House of Delegates of the AMA just voted to designate obesity as a disease. This means that you will no longer “be fat”, you will “have obesity” like you “have diabetes”.  The AMA Scientific Council recommended to retain obesity as “a condition”. A spirited debate about the consequences has begun, but so what?

Proponents claim that disease designation will increase physician attention to the problem and that insurers will pay more. Medicare reimbursement for a disease of obesity could incentivise more “obesity care coordination” which could “widen the range of effective treatment” beyond bariatric surgery (now covered by Medicare) and drug therapy (NOT covered by Medicare).

Opponents point out that the American life expectancy has increased by 12 years since 1970 despite the increase in obesity, that the definition of obesity is ill-defined, that BMI numbers are imprecise (many people with high BMIs are quite healthy), and that designating it as a disease is unlikely to change any outcomes.

My pediatric office computer, and therefore the insurance companies, already let me diagnosis obesity (CPT code #278) just as I can for diabetes (CPT code# 250.0) or drowning (CPT code #E910; the E designates “accidental”). What are the practical differences between a diagnosis and a disease?

I suspect that it is all about money. Medicalizing a societal condition will cause more money to be spent on surgery and drugs.  “Insurers will pay more.” The upside of that could be more provider reimbursement for prevention and life style counseling, but surgery and big pharma are usually first in line. Two new anti-obesity drugs (Belvig and Qsymia) came on the market this past year. More than one-third of Americans will instantly be labeled as “ill” and therefore eligible for more medical services.

Seconding the opinion that money is involved is one investment analysis:

“Increasing efforts to tackle obesity over the coming decades will form an important new investment theme for fund managers…Global obesity is a mega- investment theme for the next 25 years and beyond…”

The definition of obesity and a consensus of its cause(s) remain elusive. Different countries even use different BMI thresholds so international comparisons of obesity percentages are not always accurate. Is obesity caused by genetics, culture, or environment …or all three? Japan and Korea are in the lowest 10 countries of percent obese, BUT their rate of increase of obesity is close to ours, and we are in the top ten. One writer compares obesity with drowning and carbon monoxide poisoning, both results of a “toxic environment”:

“We don’t just wait till the person almost drowns and provide essential resuscitation services. We pass laws regarding pools, fences, life guards, encourage swimming lessons for children, etc. to prevent the drowning condition in the first place.”

The AMA vote has no legal or regulatory weight. It is merely an expression of an opinion, but it shines another spotlight on the problem of increasingly overweight populations, whatever you call it.


Vol. 82 January 15, 2013 A Little Bit of Good News

January 15, 2013

hub_2Imbued with the holiday spirit while writing my January 1 blog, I thought that for my next one I would present  good news only. I am sure that the idea came partly from my mixed feelings while reflecting on gun control so soon after Christmas.

I subscribe to a number of medical journals, two medical review newsletters, several newspapers, keep track of a few medical blogs including the Health Care Blog, read Consumer Reports, Consumer Reports on Health, and generally have my antennae out for medical facts that might be interesting and fun to pass along from any source. I hoped I would have significant good news. Not so. The few items I gleaned were during the first few days of January, and some of them are kind of marginal. It was as if they had been squeezed out by other stories during the holiday season, inserted as filler the next week, only to be overtaken by the usual news items the following weeks.


OVERWEIGHT PEOPLE CAN LIVE LONGER THAN “NORMAL” WEIGHT PEOPLE

People with a BMI (Body Mass Index) of 25 to 29.9 have a slightly LESS risk of dying than “normal” people (BMI under 25).  There is now the thought that a BMI of below 25 might be “too thin”. Obese people (BMI over 35) still have the highest risk of death. The 1912 “perfectly healthy woman” was defined as 5 foot 7 inches and weighing 171 pounds. Her BMI would be 27. As a Cornell graduate myself I got a kick out of that statistic based as it is on measuring 400 Cornell co-eds at the time. My BMI is 30.4 (“overweight”) and so miss the best risk category by just a few decimal points.  I consider this good news. Do you know your BMI?   Boston Globe 1/2/13; JAMA, Blackburn, MD

CHINA CATCHING UP TO U.S. IN OBESITY
The percentage of Chinese adults that are now overweight or obese rose from 25% in 2002 to 39% in 2010. The World Health Organization estimates that 50-57% of Chinese adults will be overweight or obese by 2015. This compares to 69% for U.S. adults. As Chinese wealth increases they are giving up bicycles to buy cars and are enjoying more McDonald’s, Pizza Hut (“a fancy date-night restaurant”), KFC, T.G.I Friday’s, and, of course, millions of cans of Coke. If we could restrict their access to the benefits of coffee (see below) by limiting the number of Starbucks there, we still might win the race for world domination.  Boston Globe 1/6/13; Debra Bruno

ASTHMA INCIDENCE DECREASES BY 50%
The annual incidence of asthma in Boston public housing has dropped from 23% to 13% since 2005. The Public Health Commissioner relates this decrease to a successful program to exterminate roaches and rodents in the housing using LESS pesticide. Given the context that seems to me to be a bit of a reach for “good news”, but I told you pickings were slim.   Boston Globe 1/1/13; Kay Lazan

FDA APPROVES USE OF MARGINPROBE® 
The FDA has approved a new technology already in use in Europe to detect during the breast surgery any cancer cells left in the margins of remaining tissue. Since 20% of lumpectomies for breast lesions result in a second operation at a later date based on pathology reports completed a week after the surgery, this $200 device could prevent some of those second surgeries that cost about $7.000. Breast lumpectomies are increasing in frequency as mastectomy procedures decrease in our efforts in  “breast-conserving surgery”. Boston Globe 1/2/13

MEDICARE PROVIDERS DUCK A 27%  PAYMENT CUT
The “Fiscal Cliff Avoidance” Bill prevented a 27% reduction in payments to Medicare providers for one year. This is good news to beleaguered primary care physicians and to those patients who don’t want them to become even scarcer. The bad news, of course, is that this one year reprieve merely delays once again the time when Congress and the Administration will have to deal in a systematic way with our expensive health care “system”. As another testament to the workings of democracy, or at least of our Congress, this same 2AM bill continued the subsidy for rum manufacturers in Puerto Rico and the U.S. Virgin Islands that offsets their liquor tariff costs.  Boston Globe 1/2/13

HOMICIDE RATE IN BOSTON DROPS FOR THE THIRD YEAR IN A ROW
There were only 58 homicides in Boston this past year. Down from the high of 152 in 1990. The Suffolk County District Attorney called for even stronger gun control laws, but also speculated that the decrease could be due to an aging population (more people over 24 yo., and “older people” apparently kill fewer people), an increasing percentage of immigrants (“they tend to obey the law”), and improved trauma care in the hospitals (people still get shot, but are less likely to die).  Boston Globe 1/1/13; Matt Carroll

TEN WAYS TO IMPROVE YOUR HEALTH
This is good news because I do most of these already. This list, “backed by scientific research”, was complied by AARP.
1.  Throw a Party – Social connections help you live longer.
2.  Adopt a Pet – Excercise it (and you) and count it as another social connection.
3.  Choose Dark Chocolate – An ounce a day keeps the doctor away.
4.  Savor Your Coffee – It appears to lessen chances of diabetes, skin cancer, liver damage, etc. Three cups a day keeps Alzheimer’s away.
5. Have a glass of wine or beer – “Guinness is Good For You” was said a long time ago. One glass a day for women, two for men!
6. Have Sex – There is nothing bad about releasing endorphins. It also counts as aerobic exercise.
7. Listen to Your Favorite Music – Music reduces pain and increases circulation. A song a day keeps the heart pumping away.
8. Take a Nap – A mid-afternoon snooze clears the brain to make room for new stuff. A nap a day keeps the brain hoarder at bay.
9. Go Outdoors – Go look at the greens, don’t just eat them.
10. Use Soap. regular soap – Antibacterial soaps and cleansers with triclosan aren’t worth the cost and the spray kind can trigger asthma. The FDA is researching triclosan safety in humans.


Vol. 55 November 15, 2011 Why is Blue the Color of Child Abuse?

November 15, 2011

The Penn State fans in the stands for the Nebraska football last weekend shed their traditional “all white” dress and showed up in “all blue”. The color guard carried large blue flags. Players tied on blue ribbons. Was this in protest of the firing of the coaches, one of whom was recently arrested for alleged sexual abuse of young boys years ago, or was it in support of the most successful coaching staff in collegiate football, or was it in support of the victims?

According to Wikipedia: A Blue Ribbon Campaign against child abuse originated in the spring of 1989 when Bonnie Finney of Virginia tied a blue ribbon to her car antenna, as tribute to her three-year old grandson, Michael Bubba Dickinson, who died at the hands of his abusive father. The blue color of the ribbon symbolizes the color of bruises. Blue became the symbol of awareness against child abuse.

Blue is also the representative color of 16 other awareness campaigns, including 10 medical conditions from Chronic Fatigue Syndrome (symptoms can mimic depression) to Osteogenesis Imperfecta (eyeballs can have a bluish tint).

Blue, according to many surveys, is the favorite color of a majority of Western hemisphere people. We love blue skies. First prize is always a blue ribbon. There are 18 names of blue in English. We used to affectionately refer to IBM as “Big Blue”.  “One of blue’s essential characteristics in western color symbolism is it doesn’t  make waves, but is calm, pacified, distant, almost neutral.” (1)

Yet, we fear the “dreaded blue screen”, and how did blue get associated with depression and Mondays?

In the days of deep water sailing ships if a Captain or another officer was lost at sea during a voyage the ship would fly blue flags and paint a blue band along the entire hull when arriving in her home port. The 1848 Dictionary of Americanisms by John Russell Bartlett associated blue with “gloomy and severe” especially as applied to Presbyterians! Depressed people actually associate their mood with the color gray.

Blue was not used in any paintings before the 12th century (probably due to the expense and scarcity of the dye) when “out of the blue” the Virgin Mary began to appear in blue clothing, and blue became her color. In the 13th century there were no “blue knights”. Red knights were “evil”; black knights were “important”, not bad; green knights were “youthful and insolent”; and a white knight, of course, was the “good guy”, often the “older protector”. Blue knights didn’t appear in paintings until the 14th century and represented “courageous, faithful, loyal, but secondary figures.”

In 1853 Levi Strauss, stuck with a surplus of canvas meant for tents for the gold rush boys in San Francisco, started making trousers out of canvas imported from Genoa (jeans = canvas from Genoa)) and dyed them with indigo. In 1865 he replaced the stiff canvas with a cotton twill and continued to dye them, so “blue jeans” were created. (1)

Reports of abuse and neglect of children increased 134% from 1980 to 1993 from about 10 in 1000 children to 23 in 1000. 91% of the abuse or neglect was by a parent, a relative,  or a domestic partner of a parent. Since 1993 child abuse and neglect reports have DECREASED about 26%. The largest percentage decrease has been in sexual abuse. This “improvement” may be a true decrease in incidence that could probably reflect the increasing awareness of the problem brought about by blue ribbon campaigns, educational, legislative, and judicial efforts, OR just  decrease in reporting due to fear of the consequences of public stigma and intense media attention on the victims.

If  Dr. David Ludwig from Children’s Hospital is effective in his recent efforts the incidence of child abuse and neglect is about to take a major tick up. He is one of the nation’s leading crusaders against childhood obesity and has suggested that “placement of the severely obese child under protective custody” be considered as an alternative to bariatric surgery. As a research endocrinologist he is alarmed by the rising incidence of childhood obesity and feels it is “a fight that we can not afford to lose”.  (2) Removal of a child to a foster home by the state is authorized by child abuse and neglect laws so any such children would be counted as “abused or neglected”.

The problem, of course, is that a significant part of obesity is biological, if not genetic. Dieting in one study caused an increase in hormones increasing appetite and a decrease in hormones promoting satiety and energy expenditure. (3) Therefore, people who are overweight may be constantly in a hormonal environment that makes them hungry and burn less energy during exercise. (4) Hormones are regulated in part by genes.

Who knows, in the near future we may be talking about a new and different kind of “blue genes.”(5)

Finally, as a gesture toward balance and gender neutrality, I must note with sympathy that Evelyn Lauder, past CEO of Estee Lauder Cosmetics, died this past week at home from ovarian cancer at age 75. In 1992 she and Alexandra Penny, editor of Self Magazine, created the pink ribbon campaign for breast cancer awareness.

References:

1. Blue: The History of a Color, Michael Pastourneau, Princeton University Press, 2001
2. Boston Globe Magazine, October 30, 2011, p.21
3. N Engl J Med 2011 Oct 27; 365:1597, Sumithran, P et al.
4. Journal Watch Pediatrics and Adolescents, Nov. 15, 2011, vol.33, 22; p.180, Anthony Komaroff
5.”Blue Genes”, Nature Neuroscience 8, 701-705, 2005, Stephan Hamann: “Healthy carriers of a gene variant associated with depression have different brains.”


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