The Doctor Weighs In

By Dov Michaeli MD, Ph.D

I remember a wonderful lecture at UCSF, about 30 years ago, by Dr. Dennis Burkitt, on “Diseases of Civilization”. Dr. Burkitt was a missionary doctor in the bush in what at the time was Rhodesia (today’s Zimbabwe ). He was also an extraordinarily astute clinical observer (he was the first to describe a hitherto unknown cancer, aptly called Burkitt’s lymphoma). At the end of the lecture somebody asked whether Africans in the bush, being free of modern world stress, are healthier. Dr. Burkitt retorted that wondering every night whether that was the night the lion was going to have you for lunch is hardly an anxiety-free thought. The message was that stress recognizes no boundaries of geography, education, income, sex or national origin.

What is stress?

To paraphrase Potter Stewart, a supreme court justice who grappled with the definition of pornography: “I know it when I see it”. But there is a more ‘scientific’ definition: Psychological stress occurs when an individual perceives that environmental demands tax or exceed his or her adaptive capacity”. Interestingly, an elaboration of this definition includes two elements: high psychological demands coupled with low decision latitude. In other words, stress as we commonly understand it, high and unrelenting demand, is not enough. It is the lack of control, the feeling of helplessness, which tips the scale to the feeling of stress.

Can psychological stress cause disease?

I have to admit: being a firm believer in the physical causes of disease, I was highly skeptical. I readily admitted that stress could exacerbate disease; I have seen countless cases of acute asthma attacks or acute MI precipitated by acute psychological stress. But chronic, low intensity stress? I wanted to see hard evidence.

The title of a recent article, and an accompanying commentary in the JAMA, “Job Strain and Risk of acute Recurrent Coronary Heart Disease Events”, tweaked my curiosity. The authors followed 206 patients who have had an MI, for a period of 2.5 years following their initial episode. After statistically adjusting for 26 potentially confounding factors (smoking history, hypertension, high LDL etc.) they concluded that job strain increased the risk of recurrent coronary heart disease or CHD by 100%!

How can it happen?

There are many theories, but the most plausible and the best documented is the stress hormone theory. We have two systems that get activated during stress: the HPA (hypothalamic-pituitary- adrenocortical axis) and the SAM (sympathetic- adrenal- medullary) systems. HPA secretes cortisol, SAM secretes epinephrine aka adrenaline. Both are known as stress hormones.

 If stress is so common in life, how is it that evolution allowed the hormonal response to stress to be so deleterious? And the answer is: it didn’t. Besides facilitating the fight or flight response, they increase innate immunity, our first line of defense against pathological invaders, and decrease the inflammatory response. But all this is true for acute stress (e.g. the lion is coming at you). Chronic stress is something quite different. For reasons yet unknown, chronic stress causes a decrease of the immune response and an increase of the inflammatory response—exactly the opposite effects of acute stress. Whatever the reasons may be—the effect is destructive. As an example: coronary heart disease is basically an inflammatory process, and chronic stress aids and abets it. Furthermore, macrophages, which are white blood cells that are central to the formation of a coronary plaque, were recently discovered to secrete their own adrenaline, adding insult to injury.

Does a low dose of NSAID (non-steroidal anti inflammatory drugs) to prevent CHD make sense now?

What other diseases are associated with stress?

Depression is the most obvious one. To cite some compelling statistics: approximately 20-25% of persons who experience major stressful events develop depression. And when a cohort of depressed persons was examined, it was found that 50-80% have had a major “life event” in the preceding 3-6 months. To close the loop: most depressed individuals suffer from a depressed immune response and from chronic, low grade inflammation. Based on this we still cannot conclude that there is a cause and effect relationship here; but it is an intriguing correlation nontheless.

HIV/AIDS has also been suggested to progress faster, even when taking anti HIV medications, if the patient is under chronic stress. Again, one shouldn’t be surprised if the explanation will turn out to be a depressed immune response.

In Conclusion

On the biological level, this is yet another demonstration of the mind-body relationship. In fact, a whole field of research called psychoneuroimmunology (I know, it’s a mouthful, but if you break it up to its component words, psycho-neuro-immunology, it makes sense) is thriving and is uncovering new connections between brain, mind and immune response on an almost daily basis.

On the clinical level, the strengthening evidence of the effect of stress on health and disease suggests new modalities and approaches to treatment.

What is most intriguing and potentially far-reaching, are the societal consequences. Now that we accrue more and more evidence on the effects of stress on health, it would make economic sense to pay attention to the work environment. An enlightened manager would insist on stress reduction in the workplace in order to increase productivity. Conversely, could a company be found liable if an employee is subjected to an abusive supervisor and suffers a heart attack? The medical evidence is already here.

Dov Michaeli MD, Ph.D is in the biotech industry.

by Pat Salber, MD

When's the last time you seriously looked at the vending machines at work?  When you looked, what did you see?  I found candy bars, cookies (including the notorious transfat-laden Oreos), and grease chips (as opposed to "sun chips"). 

The first few times that I got the mid-day munchies at my new job, I made several trips to the break room searching for something to eat from the company's vending machine.  Nope, I said to myself, you can't buy corn chips, Oreos, or snickers--a dry, stale sweet roll is just not the way to use any of those precious 1200-1300 calories per day.  Come on now, isn't there anything remotely healthy or real in this machine?? - Apparently not. 

Back and forth I go, office to vending machine; vending machine to office.  Finally, the hunger pangs make the decision for me.  I will buy the least unhealthy thing in the machine - salted, greasy, (and stale) peanuts.  The little bag of "baddies" that I purchase for 65 cents is ingested in less than 2 minutes.

So, what to do?  As the brand-spanking new Chief Medical Officer of a Health Insurance Company, I know I need to do something.  But exactly what to do gets catalyzed at a health care conference I attended recently.  I chaired a panel on the integration of disease management and disability management, sponsored by Presagia, a leader in software to support this type of integration. 

One of the speakers on the panel, Bruce Goya, Universitywide Coordinator of Employee Support Programs at the University of California - a major employer in the state -gave a presentation in which he emphasized the importance of creating a culture of health in the workplace.  The light bulb in my head went on - big time. 

This is the answer to the vending maching problem at work.  Improving the vending machine selections in my workplace is not just about messing with people's snack choices, rather it is part and parcel of CREATING A CULTURE OF HEALTH.  A Culture of Health, I love it.

So, dear readers, here is a practical question.  If you got to choose what to put in your workplace vending machines to offer your fellow employees a healthy alternative to the usual vending machine fare....what would you choose?  Sunchips?  Protein bars?  Unsalted almonds?

Send me your suggestions.  I may not be able to change your company's culture of health, but you can help me change mine.

Brian Klepper

This week TDWI is delighted to take our turn hosting Health Care Wonk Review, a collection that highlights some of health policy's best observers. The quality of these 14 posts is very high, and well worth your time.

As HWR has gained visibility and popularity, the number of submissions has risen. We couldn't publish them all, so chose the ones we thought were must-reads across industry sectors. (Apologies to those we didn't include this time.)

Before we begin, a quick announcement. Envision Solutions, LLC and Trusted.MD Network have launched the second annual global survey of healthcare bloggers.  The companies are producing this poll to shed additional light on why people blog about health-related subjects.  Click on the link to learn about and take the survey.  The study will close on October 15.

Now onto the show!

Physician Temper Tantrums. Over at Managed Care Matters, Joe Paduda picks a scab and elicits a (deliciously) minor furor. He argues that when payors use the results of claims data analysis to encourage patients to see better performing doctors, they are well within their rights as purchasers. He also notes (and I agree) that when doctors reject out-of-hand claims data as inherently flawed and inappropriate to provide quality analysis, they may not appreciate the progress in the available tools and methods, and may be simply defensive. Actually, he says "their actions look more childish than professional from here." A provocative piece.

No Docs in This Box. Retail medical clinics are popping up all over as an inexpensive alternative to a full-blown practice or the ER. Traditional providers are crying foul, but InsureBlog's Bob Vineyard suggests this is the pot calling the kettle black.

Abusing The Orphan Drug Law To Rip Off Customers. In a damning indictment of a drug company's business practices, David Williams at the Health Business Blog discusses Questcor Pharmaceuticals announcement about “a new strategy and business model for H.P. Acthar Gel(R).”

What Are The Real Savings In Medical Tourism. MedTripInfo's Michael Horowitz analyzes the probable total savings for a hip replacement obtained overseas. They're substantial.

Medical Justice League of America. The Sentinel Effect's Richard Eskow describes a new group that provides "gag order" forms to dissuade patients from reviewing their docs online, and also promises to "relentlessly" fight med mal lawsuits." The situation he relates would be hilarious if it weren't so lopsided and scary.

Make Sure Your Online SaaS Vendors Are Appliance Capable. The Healthcare IT Guy, Shahid Shah, provides sage advice on why you should not depend on "software in a cloud" without a backup plan. With big outages from Microsoft, Skype, eBay, and PayPal recently making headlines, it is wise to make sure you're protected. A fascinating and smart look at the pitfalls and realities of letting other companies be responsible for your mission-critical IT functions.

What The Lumenati Are Saying May Surprise You.  The ever-entertaining Matthew Holt is making the final dash toward hosting the Health 2.0 conference, where the discussion will focus on a significant portion of market-based reform, and the players will be none of the usual suspects. Meanwhile, back at The Health Care Blog, he ticks off some surprisingly lucid health care insights from the most unexpected sources.

Mitt Romney's Health Plan - A Foot In Each Canoe.  Over at Health Care Policy and Marketplace Review, Bob Laszewski wryly observes that conservative Presidential candidate Mitt Romney would like to have it both ways. He gloats over the Massachusetts reform he helped to engineer while assuring his political base that it wouldn't work elsewhere. (It's also not yet clear that it is going to work in Massachusetts.) It's a delightful bit of political dissonance, seen through the clarity of Bob's highly polished health policy lens.

BiPolar Diagnosis in Children: Another Epidemic? Here at The Doctor Weighs In, the erudite Dov Michaeli recounts a recent review article from the Archives of General Psychiatry. Between 1994-1995 and 2002-2003, an 8 year period, the rate of bi-polar diagnoses in children increased 40 fold! He lists a range of possible explanations for the epidemic, but settles, gloomily and cynically, on money. By explicating an immense but relatively obscure problem, he lays bare a pervasive trend that's corroding our health system. A must read!

Conflicted View on the Pitfalls of Government-Sponsored Comparative Effectiveness Research. In a withering analysis, Roy Poses at Healthcare Renewal rebuts a recent commentary by WSJ Editorial darling Scott Gottlieb. Dr. Gottlieb disparaged government-sponsored research as biased against costly drugs, while ignoring similar and more odious flaws in private sector research practices. AND Dr. Gottlieb conveniently neglects to disclose that he's associated with the biotechnology sector. Superb.

To Hell and Beyond: Dave Holland's Terrible Story. At Workers' Comp Insider, Julie Ferguson points to a particularly gruesome work-related accident by way of reminding us that these incidents are still all too common. Julie's perspective is particularly poignant, because it is also a reminder that what lies beneath the day-to-day work  of the people who write for and read this review is the vital goal of preventing and managing the suffering that is too often a part of life.

Katrina: Two Years Later Are Health Systems Better Prepared?  On the second anniversary of Hurricane Katrina, NewsHour correspondent Tom Bearden asks a coastal area provider if the health systems are now better prepared. The short answer is "No," according to the  interview excerpted by Jane Hiebert-White on Health Affairs Blog.

Cookbook Medicine Saves Lives.   A pretty good cook (I can vouch for her!) as well as a physician, The Doctor Weighs In's Pat Salber relates the substance of a July 23 article in the Archives of Internal Medicine. She describes a new heart failure guideline that improves outcomes when followed by clinicians, and details the range and depths of those improvements. She concludes with a quote from  the lead author, telling us that if these protocols were followed in hospitals across the country, they would result in 40,000 fewer deaths and 1.4 million fewer hospital days annually. Keeping in mind that this is just one condition in the vast complex of health care, it is a deeply compelling point.

Reform's Tougher Problem. I've been a bedouin lately, wandering from oasis to oasis, grateful for the chance to publish on Pat Salber's The Doctor Weighs In, Bob Laszewski's Health Care Policy and Marketplace Review, and on Matthew Holt's Health Care Blog. This post, placed on Matt's site, summarizes what I've learned working for several years on the reform problem. I now believe that meaningful change can only occur through the leadership of the non-health care business community, the one group with more power and influence than the financially conflicted health care sector. Non-health care's business leaders will pursue this effort, not because they care about health care or social justice, but because health care's impending instability will threaten the stability of their own econonic environments.

Thanks again to Health Wonk Review for letting us host, and thank you for stopping by.

I am in Houston. This is not to point a finger at Houston, but merely to point out how our environment is anti-fit and pro-fat. Be prepared. This is a rant, but I will be brief.

I am staying at a very nice Hyatt Hotel. I am on the second floor. I can’t find the stairs to walk up and down between the ground level and my room. Why? Because there aren’t any...at least that is what the woman at the reception desk tells me. She says, “There aren’t any stairs for guests, but the elevators are safe in the case of an emergency.” She looked astonished when I explain that my question is a health question, not a safety question. Apparently, she hasn’t had a lot of guests asking how they can walk up and down the stairs to get from point A to point B.

While I am on the topic of using stairs, instead of the elevator, to go up or down one floor, let me tell you that my current workplace has secure access to the staircase (a safety issue). I finally figured out that my security badge will allow me to get back into the offices if I use the steps (although it took a while, asking a number of different people to determine that). So, today, I took the stairs. They are bare concrete, stained with something brown. They are ugly, in fact, a little creepy. The unspoken message is, only use these stairs if you really, really have to escape from the building in case of emergency.

After work tonight, I parked my car at the hotel and walked to The Galleria -- one of the best shopping centers in the world. But crossing the main street from the hotel to the mall was, frankly. scary. It took forever for the light to signal that a pedestrian could cross. Cars going straight, turning right, turning left, and going fast to wherever they were going. Clearly, pedestrians crossing the street are not a priority in this neighborhood, and, in fact, this action may be hazardous to the health of the brave walker who tries to get to the Galleria on foot.

I wonder why this is the case, but then I noticed that no one else is walking. Ah, now I get it, if there are no pedestrians, why bother to time the signals to help walkers get across the street safely? The unspoken message is that I should have driven the two blocks to the mall, paid to park, and then driven two blocks back to the hotel. This is what the “environment” supports.

Hey folks, why do we have to go to a gym to walk on a treadmill or use a stairmaster in order to move our body parts? Why can’t we get some exercise during our day-to-day activities at work and after work?

I suggest you pay attention to the details of your everyday environment. Is your community designed to make it easy and pleasant to walk or ride you bike from one place to another? Or is it designed to get you and keep you in your cars? Does your workplace encourage body movement and healthy eating or does it have built in barriers to physical activity and healthy eating.

For those of you who have to fly on planes a lot for work (does anyone really do it for pleasure anymore?), ask yourself, what do the airlines want you to do on those 3, 4 or 5 hour flights. Do their procedures keep you trapped in your tiny rented space for hours on end, or do they make it easy to stand up and walk in the aisles?

If this type of stuff bothers you and if you would like to see real health care reform, then I suggest you become a LHE (a local health environmentalist). Let’s not quibble about the name -- if environmentalist sounds too liberal or green for your tastes, then suggest another name, but not another approach. Remember that obesity and physical unfitness are politically agnostic. Liberals get fat, libertarians get fat, and conservatives get fat. Red or blue, Republican or Democrat, we all can benefit from an environmental focus on fitness.

If you want to live in a healthy community, live in a healthy home space and work in a physical environment that promotes your health, then get out of your car and onto your feet and agitate, really agitate, for structural changes in your environment that support fitness.

Pat Salber, MD, MBA

If you are like many Americans, you spend more of your “awake” time at work than you do at home. At home, I can control my environment. I don’t keep calorie dense foods in the house. I read food labels and use a food scale to help me determine portion sizes. I have a personal trainer who comes to my house five days a week – rain or shine, whether I am in the mood or not. And, I have my husband – a guy who is religious about good nutrition and physical fitness – to serve as my live-in health coach.

But, at heart, I am weak. I love, love, love to eat, eat, eat. I eat when I am stressed out and I eat when I am relaxed. Eating right does not come naturally to me. I have to work at it. I do like to exercise, but when I get busy, it is usually the first thing to fall off of my “to do” list.

Sometimes, I spend long periods of time working out of my home. During those times, I am physically fit. Sometimes, I travel to work long hours in remote workplaces. What I have learned is this type of work-life makes me fat. Let me give you some recent examples:

• I travel to a different time zone to work on a fascinating and challenging assignment. The flight is delayed. I am hungry. I am in the Continental Airlines lounge. They have cheese and crackers. So, I eat cheese -- lots of it. Why, because it is there.
• My flight is delayed. I arrive at the hotel after 11 pm and, guess what, I am hungry again. There is nothing to eat at 11 pm except what is in the mini-bar. Hmmm. What’s there? A container of cashews and a container of peanuts. I choose the cashews. It is only after I have shoveled many dozens of the tasty nuts into my mouth that I read the label: 90 calories per portion - a portion is 5 (that’s right 5) cashews. OMG
• I give myself permission not to work out on the first travel day, after all I can only get 7 hours of sleep and I need eight hours minimum to feel even remotely human.
• I have 30 minutes to get ready in the morning. I ordered oatmeal – pretty healthy? But it came with (and I ate) milk and brown sugar.
• Now, I am at the office. It is 11 am. It is too early for lunch, but I am hungry. So, I go to the vending machine. Here are my choices:
• The top two rows are various types of potato and corn chips
• The next couple of rows are cookies and sweet rolls.
• At the bottom are some corn nuts (I love corn nuts), and some candy bars.

Really?

• Ok, I am good. I didn’t get anything from the vending machine…do I get any points for that? Probably not because the company has arranged a “potato bar” for lunch. The potato was, no question, the biggest Idaho potato I have ever seen in my life—this was a potato on steroids or maybe it was genetically engineered to be humongous. I bet it weighed 2 pounds. The toppings were all in trays. They included huge mounds of butter and sour cream (not low cal, low fat). There were also containers of (the most delicious) shredded beef, Tex-Mex beans, and shredded cheese. And, just in case you couldn’t ingest enough carbs via the potatoes and toppings, there was also a bowl of potato chips and dip. Now, I must admit there was a bowl of raw veggies. It was sitting on a counter behind the table with the potato bar.
• I would like to use the stairs to go to meetings on different floors, but there is a sign by the staircase warning that you can’t exit the stairwell once you have entered it except on level one….some sort of security thing (definitely not a health thing).  Maybe there is a way around this, but I am too busy to find out.
• It’s close to 7 pm when I leave work. I am tired and I am hungry. I call room service. Do I need to tell you the rest of the story?

Sound familiar?  If so, I am not surprised.  The typical American workplace is not designed to keep us healthy. Our workplaces and our work habits are making us fat:

• We work obscenely long hours
• We have long commutes
• We are surrounded in the workplace by high energy density foods
• We have no time to exercise – before, during or after work
• Doesn’t matter because we are too tired to exercise anyway
• We have workplaces that are designed to help us avoid any type of physical activity (except for our typing fingers – mine, by the way, are quite thin)
• When we fly across time zones for work, we have an excuse to eat more and exercise less – we are tired and the airlines treat us like cattle – which, by the way, also eat too much and exercise too little.

There are better scenarios our there. In a post to follow, I will explore the concept of a workplace that is healthy by design. This is a workplace where it is easier to walk up the stairs than take the elevator.  There are apples and carrots in the vending machine instead of candy bars and potato chips.  In this type of workplace, "work-life balance" is an expectation, not a slogan.

Lest you think it is too expensive or too inefficient for American companies to have a healthy work place, let me remind you that those of us susceptible to developing diabetes, heart disease and other related conditions when we get fat and out of shape will cost you a ton of money.  We are a part of the reason why your health insurance costs are so high. And you know what that does to the bottom line.

Perhaps a little less productivity, a little less stress, and a little more work-related body movement might be cheaper in the long run. Think about it.

Pat Salber, MD, MBA