The Doctor Weighs In

by Pat Salber, MD

I wonder if we will ever know how many American kids got pregnant or contracted sexually transmitted diseases (STDs) because of a decade of a failed national health policy: abstinence-only programs. Thankfully, we seem to be regaining our senses and will once again resort to science to guide public health policy related to sex education.

This positive development is discussed in some detail in the May 7, 2008 issue of JAMA  (Vol. 299, No. 17, p. 2013-15). Here is a brief summary:

In 2007, Mathematica Policy, Inc., a nonpartisan research firm (oh, how sad it is that it must be pointed out that a research firm is nonpartisan) published the results of its controlled trial of abstinence-only programs. For its study, Mathematica surveyed more than 2000 elementary and middle school students who were followed into high school. 60% of these young people were in programs identified by abstinence-only proponents as “ideal programs,” 40% were controls – in other words, a best case vs worst case scenario.

The conclusion: The abstinence-only programs “had absolutely no measurable impact on initiation rates [first time sex], age of first intercourse, number of partners, number of pregnancies, births, or STDs.” In other words, not one of the major hoped for outcomes of these programs was obtained. Hmmm. Once again, it seems hormones have trumped the best intentions of some wishful thinkers. Lest you think the “dose” of the programs was not intensive enough, the study points out that “in some of these cases, kids sat through 3 years of mandatory abstinence-only classes.

At long last, medical organizations are once again talking about the need to have REAL (science-based) sex education, as opposed to programs driven by ideology. The Society for Adolescent Medicine (http://www.adolescenthealth.org/) states that “abstinence-only as a basis for health policy and programs should be abandoned.” The American Psychological Association, the AMA, the National Association of School Psychologists, the American Academy of Pediatrics, and the American Public Health Association have all criticized abstinence-only approaches. Thank heavens. Our kids need a great big dose of reality when it comes to sex: and it is this - sexual desire is a powerful driver of young (and old) people’s behaviors. Hey, y’all, don’t you remember what it was like when you were teens? We are finally acknowledging that it is better to know what you can do to protect yourself from the life-long consequences of unprotected sex instead of muddling through ignorant of the facts of life – so to speak.

One of the most interesting aspects of the JAMA article is a comparison of US approaches to sex education compared to what happens in the Netherlands. The JAMA article states that the US has one of the highest rates of teen pregnancy in the Western world and the Netherlands has one of the lowest.

Abstinence-only programs are not part of Dutch public health policy. In the Netherlands, adolescent girls can get birth control pills confidentially and those aged 16 or older have access to government subsidized clinics where they can get abortions without parental consent. Despite, or perhaps because of, these progressive policies, the teen pregnancy and abortions rates in the Netherlands are among the lowest in the world.

In a study comparing parental attitudes about teenage sexuality in the US vs the Netherlands, researcher Amy Schalet , PhD, interviewed parents of teens in both countries. She found dramatic differences in attitudes. US parents worried about their teens getting carried away by emotions they “mistake for love.” Dutch parents believed their children could fall in love, pace their sexual development and, (lordy, lordy), use contraceptives when they (the teens) deem themselves ready for intercourse.

In the US, the government spent the last decade behaving like a strict surrogate parent to our teens: controlling information about alternatives to abstinence, making it hard for comprehensive sex education programs to get funded, and substituting religious ideology for science. Thank heavens, that we are finally moving on and that we are ready, once again, to base our public health programs on science, real, honest to goodness science. Whoopee!

By Pat Salber

When I was a practicing Emergency Physician, I always used to volunteer to work Super Bowl Sunday. Two reasons: 1) I could care less about football, and 2) It is the one day of the year when no one, and I mean no one, comes to the ER. Whole families on their second week of a cold show up on Christmas Eve. Folks drop by to have their skin rashes checked out on Thanksgiving Day. New Years Eve and New Years Day – busy, busy, busy. But Super Bowl Sunday, while the Super Bowl is on, is dead quiet.

If you talk to emergency physicians, they all have stories about the guy who got chest pain during the first quarter, but held out, sweating and breathing hard, until the game was over. By the time this fellow actually showed up in the ED, his heart muscle had been starved for oxygen for quite some time and the damage was worse than it would have been if he had shut off the TV and dialed 911.

Turns out, according to a study presented at last year’s American College of Emergency Physicians’ 37^th annual scientific session, that some guys (and it is mostly guys), do delay seeking emergency care if they are watching a game. Dr. David Jerrard of the University of Maryland Medical Center in Baltimore and colleagues tracked ER visits over a three year period during and immediately after 800 postseason professional football games, major league baseball games, or Division l college football or basketball games. They found that on the days that games were televised, more men were seen in the 4 hours following the event than were seen during the same 4-hour period on nongame days.

An internet report on the study published on Daily News Central quoted Dr. Jerrard as saying, “Men should not risk their health by putting off going to the emergency room because they want to see the final results of a football game. It could be the last game they ever see."

A more recent article, titled “Super Bowl Could Be Heart Health Hazard,” describes the results of another research study. The investigators looked at cardiac events in Germany (greater Munich area) during the World Cup competition in Germany in the summer of 2006. They analyzed results from 4,279 patients. The results showed that cardiac emergencies were more than double the norm on the seven days when the German team played – it was triple for men. The effect was the strongest for people with known heart disease. Ok, this study looked at soccer fans soccer…I believe we can extrapolate the results to American football fans as well...are they any less rabid?

Considering the learnings of these two studies together, leads me to make two recommendations:

• If you have known heart disease, be sure you take your cardiac meds (including aspirin if prescribed) and have your nitroglycerin handy.
• If you get chest pain (or any other serious symptoms) during the game, get yourself to the ER.

Chances are the game is going to be on all of the TV sets in the hospital anyway so you probably won’t miss much. Besides, you can always record it or watch the recaps on ESPN. I am willing to bet that if your problem turns out to be serious, you probably won’t really care who won or lost the game anyway.

by Pat Salber, MD

There are two interesting articles in the Sunday NY Times (Jan. 27, 2008).  One is about the failure of President Bush's Volunteerism Initiative, the other is about the rise of social entrepreneurs.  Volunteerism is usually about helping people.  Social entrepreneurism is about helping people help themselves.  I won't dwell on why the President's Volunterism Initiative is "sputtering," because the story about social entrepreneurs is so much more interesting and inspiring. 

Nicholas Kristof introduced us to social entrepreneurship in a NY Times op-ed when he wrote about Kiva, an online site where you can make microloans to entrepreneurs across the world.  In his most recent Times editorial, "The Age of Ambition," Kristof describes a number of other organizations you might want to include in your list of online favorites:

• Unite for Sight (www.uniteforsight.org) was started by Jennifer Staple, who founded the organization in her dorm room while in college.  Unite for Sight collects old reading glasses in the US and ships them to poor countries.  Last year the organization provided eye care to 200,000 people.
• Injaz (www.injaz.org.jo) trains Arab students in the fundamentals of starting a business.  It was started by Soroya Salti, a Jordanian woman.  It has spread to 12 Arab countries and has the goal of teaching one million students a year.  Per Mr. Kristof:  "My hunch is that Ms. Salti will contribute more to stability and peace in the Middle East than any numberof tanks in Iraq, UN resolutions or summit meetings."
• Orphans Against AIDS (www.orphansagainstaids.org) was founded by Andrew Klaber while he was "playing hooky" from Harvard Business School."  While traveling in Thailand, Mr. Klaber was shocked to learn that teenage girls, orphaned when their parents died of AIDS, were forced into prostitution.  Orphans Against AIDS pays school-related expenses for children  in poor countries orphaned by AIDS.
• Cinepop is one of the most interesting of the organizations described in the Kristof article.  It was founded by a 27 year old Mexican, Ariel Zylbersztejn after learning that 90% of Mexicans can't affort to go to the movies.  The company projects movies on inflatable screens and shows them for free in public parks!  The movies are paid for by advertising.  But Mr. Zylbersztejn didn't limit his focus to just movies.  He "works with micro-credit agencies and social welfare groups to engage the families that come to his moves" in order to help them start businesses or otherwise try to rise out of poverty.  Cinepop plans to take the model to other countries, such as Brazil, India, and China.

Bill Drayton, CEO of Ashoka, an organization (tagline "Everyone is a Changemaker) that supports social entrepreneurs says, "such people neither hand out fish not teach people to fish; their aim is to revolutionize the fishing industry."

It is terrific to read about a this new generation of social entrepreneurs.  Unlike some volunteer programs that falter after the volunteer goes home,this new approach raises the distinct possibility of sustainable improvements in the lives of people struggling with poverty. 

I think Nicholas Kristof sums it up nicely, particularly during this election period when almost every candidate is running on a platform of change, when he says, "Only one person can become president of the United States, but there's no limit to the number of social entrepreneurs who can make this planet a better place."

by Pat Salber

How many times have you heard health professionals, politicians, and others say: “Here in the US, we are fortunate to have the best health care in the world.” I still occasionally hear someone say this, but certainly not as often as in the past. The proponents of this myth generally follow the “best care” statement by noting that Canadians come to the US to get procedures they have to queue for in their own country. These same people scoff at “socialized medicine” in the UK believing that we are must be getting better care than those poor Brits subjected to “government medicine.”

Well, gang, it just isn’t so. The November issue of Health Affairs reports on the results of a 2007 survey of adults in seven countries, including the US, that asked about their health care experiences. The survey and resulting paper, “Toward Higher-Performance Health Systems: Adults’ Health Care Experiences in Seven Countries, 2007,” are the work of researchers at the Commonwealth Fund.

Here is a summary of some of their findings:

• 42% of people in the Netherlands feel that their health care system works well and that only minor changes are needed. In contrast, only 16% of Americans feel that way about our “system” and 34% feel it needs to be completely rebuilt.

• 35% of Americans are “very confident” that they get high-quality, safe care. This is similar to Australians perception of their system and better than the 28% of Canadians and Germans who feel that way. In the Netherlands, 59% are very confident and only 5% are not confident (compared to 21% in the US) about the quality and safety of their care.

• More people in the US and Germany had short waits for elective surgery compared to the other countries, but more people in the US reported not visiting a doctor when sick, skipping tests, treatment, or follow up, and not filling prescriptions or skipping doses of medications because of cost than people in any of the other countries.

• Only Canada (22%) was below the US (30%) in the percent of patients who reported being able to be seen on the same day they called.

• 36% of adults in the US had visited an emergency department in the past 2 years. About 40% of those said the visit was for a condition that could have been treated by a primary care physician is one had been readily available. The figures were similar for Canada, but far lower in Germany and the Netherlands.

Hmmm. According to this report, it appears that you can get stuff you don’t need very badly (e.g., elective surgery) pretty quickly in the US, but more than a few of us are shut out altogether when it comes to getting needed care for acute and/or chronic illness.

When it comes to health care costs, it is remarkable that US per capita spending is about double of the next most expensive care (Canada). These figures are worth looking at in black and white:

	Aus	Can	Ger	Net	NZ	UK	US
Per capita	$3,128	$3,326	$3,287	$3,094	$2,343	$2,724	$6,697
% of GDP	9.5%	9.8%	10.7%	9.2%	9.0%	8.3%	16.0%

Not only are we the most expensive health care in the world, we don’t even cover everyone. 16% of Americans are uninsured at any given point of time (25% are uninsured at some time). Compare that 0% to <2% in the other 6 countries.

So we pay more, some of us get much less and others get nothing compared to the other countries in this study. Best health care in the world? Unless you are rich enough to buy whatever you want, whenever you want it, you might be better off in the Netherlands!

by Pat Salber

Well, only one more day of vacation and it is back to work.   In preparation for the long flight back from Bangkok to San Francisco, I decided to indulge in (more than) a little body work.   I am at one of the most beautiful hotels in the world, the Oriental, situated on the banks of the Chao Phraya, also known as the River of Kings. 

As with all of hotels we have stayed at on this three week journey through SE Asia, this hotel has a spa...and not only a spa, but an Ayurvedic Penthouse!  You have to take a little ferry boat across the river to reach the spa and the fitness center.  Bypassing the latter, I headed for the peacefulness of the heavenly Oriental Spa.

So what is the difference between the types of massage we get in the States and Ayurvedic?  Let me count the ways.  First of all, there are the aromatic oils...each one more delightful than the last...sweet and spicy at the same time. 

Next, unlike the typical massage in the US where you are carefully covered up and massaged one body part at a time, Ayurvedic is performed on the whole body with long strokes from your shoulders to your legs.  This means you have to be uncovered.  

I started the treatment by placing my feet in a lovely copper bowl, filled with rose petals, for a "welcome" foot cleansing.  Then I sat on a wooden stool for an oily back and scalp rub.  Finally, I lay on a traditional massage table, face down, looking into yet another beautiful bowl of rose petals.

After the massage was finished -- sixty minutes of Nirvana -- I was placed in a teak steam bath reminiscent of the steam booths in exercise studios in the 50s and 60s.  Dripping with sweat, my Thai "therapist" next led me to the shower and applied an herbal rub to remove the massage oil.  She scooped warm water from a teak barrel to pour over my body to remove the herbal rub.  This was followed by a long shower  (no water conservation here!) with scented shampoo and conditioner.  OMG, my stress level is minus 100!  I am a noodle!

Over the next few posts, I will share with you my take on diet, exercise, thinnness and fat in SE Asia.   But for now, I am going to sign off and continue to enjoy my natural Ayurvedic high.   Hmmmmmmmm....mmmmmm.

by Pat Salber

I was pretty shocked when I first heard about diabulemia. This is a practice some teens and young women with Type 1 diabetes, are using in order to lose weight. They purposely underdose their insulin allowing their blood glucoses to skyrocket. The excess blood glucose is eliminated in the urine. “Traditional” bulimics purge excess calories by forcing themselves to vomit. Diabulimics purge excess calories by underdosing on insulin and peeing out unmetabolized glucose.

Girls and young women with diabulimia will tell you they feel really crummy as their glucose levels increase and they increasingly rely on metabolizing fatty acids for energy instead of glucose. The end result of underdosing insulin is a state known as diabetic ketoacidosis, that is characterized by high blood glucose and increased acidity of the blood -- a potentially fatal condition.

Here is how one young woman describes (on the internet) what it feels like to be chronically hyperglycemic and ketotic:

“…I skipped all my insulin but two units at night, sometimes only one. I would consume up to 40,000 calories a day, purge maybe half, and pee the rest out. My muscles deteriorated. My hair fell out, and many nights I couldn't breathe.

In February (2003) I had a heart attack after taking up to 80 laxatives a day for three months, so I knew I had to quit that. Even Standford [sic] didn't know what to do. They sent me home and told my Mom to expect to find me dead in my bed one day soon.

My days became consumed with EKGs, getting labs taken, and doctor visits. I was so dehydrated that if I did venture to take my insulin I would gain so much as fifteen pounds of water overnight, so I quit trying.

I became too weak to go anywhere. I would cry for no reason, low cries, because I could barely breathe from all the acid in my lungs. My heart constantly raced, I developed G.E.R.D. [reflux], my labs were always off, and I was very weak. I would sleep 20 hours a day, the other 4 hours I spent between the kitchen and the bathroom, eating , drinking, peeing and sometimes puking. My speech became slower, and it was an effort to even think.

The scariest day was when I lay awake in bed, too weak to move, and I heard my Mom whisper to my brother, "go make sure your sister is breathing".

I didn't know it at the time, but they were planning my funeral.”

Overtime, continual underdosing of insulin also contributes to the development of complications of diabetes, such as retinopathy (diabetic eye disease), nephropathy (diabetic kidney disease), and neuropathy (diabetic nerve damage). It is no laughing matter. Diabulimia is as serious as other, more “traditional” eating disorders such as anorexia and bulimia.

Here is an internet quote from “Jennie,”a women who has “practiced” diabulimia for more than 10 years:

“ I have been suffering for diabulimia for 10 years now.I became diabetic when I was 17 and quickly found out on how to keep my weight down by not taking my shots. 2 years ago I went into diabetic coma for 3 days. The doctors made my family come in and say goodbye because I was not suppose to make it. I thought that would wake me up but it hasn’t. I am 6 feet 1 inch and weighted 130 pounds for the past 10 years. I see the pain in my family eyes but for some reason I just cant get my diabetes under control. I have so much damage to my body that I feel more like a 90 year old instead of a 27 year old. I have completely ruined my chances of ever having children and I have to take a pill everytime I eat in order to digest my food. I have tried many times to get my diabetes under control but everytime I start taking my insulin regularly I gain about 20 pounds of water weight. This gets so frustrating that I just give up. If any one knows a solution to the water weight gain, PLEASE let me know. I take water pills that my doctor gave me but it does not help.”

Like anorexia and bulimia, diabulimia is a body image disorder. Girls and women with this disorder need specialized help to overcome this serious, and potentially fatal, condition. Not all doctors, diabetes educators, or behavioral therapists are adequately equipped to help individuals with diabulimia. If you are suffering from this disorder or if you have a loved one or friend with this disorder, you need to seek help from experts.

The National Eating Disorders Association (NEDA) has an information and referral hotline (800-931-2237). You can also find therapists by using the referral form on their website. Parents, family, and friends can a learn how to support their loved one with an eating disorder through the Parents, Family, and Friends Network.

I did not find any specific reference to diabulimia on the National Eating Disorder Association website, so I suggest interviewing the therapists to find out if they have expertise in this disorder prior to making an appointment. In addition, it is crucial to involve your treating endocrinologist so that he/she can help provide support for management of diabetes and any complications.

Readers, if you have other ideas please post them in the comments section.   Your suggestion could save a life.

by Pat Salber

AGEs stands for “advanced glycation end products.” AGEs are promoters of high oxidative stress and, as such, they are known to play an important role in the development of cardiovascular disease in diabetics.

AGEs are produced by our bodies internally under certain conditions, such as hyperglycemia. They are also present in fairly high amounts in the typical Western diet. Research published in the Journal of the American Diet Association (Goldberg et al 2004) and in Critical Review of Food Science and Nutrition (O’Brien and Morrissey 1989), show that AGEs are present in high levels in dietary mixtures of proteins, lipids, and sugars processed under elevated temperatures, such as broiling, roasting, or grilling.

According to an recent article in Diabetes Care (October 2007), a single ingestion of a drink high in AGEs results in an immediate impairment of a normal blood vessel function – known as “flow-mediated dilation” or FMD. FMD is the expected dilation of arteries that occurs as a response to decreased blood flow (aka ischemia).

Impairment of FMD is widely accepted as an early indication of endothelial dysfunction, a precursor to atherosclerosis. It is postulated that repeated disturbances of endothelial function over time may lead to cardiovascular disease both in diabetics and non-diabetics.

The authors of the study, Jaime Uribarri and colleagues, had previously demonstrated that a diet rich in AGEs impaired FMD, however, because that diet also contained other substances that can cause the vasodilatory defect, they wanted to repeat the study using a “food” that was “free of carbohydrates or lipids or other known vasoactive substances.”

The researchers created the high AGEs food by combining caffeine-free Coca-Cola light with glucose and concentrating it by a rotary evaporation process. The article states that the resultant beverage is AGE-rich, but free of glucose or lipids (it’s not clear to me what happened to the glucose they added to the diet Coke—but heck, I am not a chemist so I just have to take the researchers word for this.)

Anyway, 44 diabetic subjects and 10 non-diabetic subjects got to drink this concoction to see what it did to their FMD. It turns out both diabetics and non-diabetics had a reduction of FMD after drinking the AGE-rich drink. There was no change in FMD when the subjects were asked to drink water.

The authors speculate that ingestion of diets rich in high-AGE foods could, over time, cause multiple insults to the body’s blood vessels and, eventually result in permanent endothelial dysfunction and overt vascular disease.

An accompanying editorial by Dandona et al, in the same journal point out that a reduction in FMD has been associated with an increase in cardiovascular risk. And that multiple studies over the past 10 decade have shown associations between diet and alterations in FMD. One study cited in the editorial (Plotnik et al, JAMA, 1997) documented a predictable reduction in FMD related to eating high-fat, high-carbohydrate fast food. This was prevented by pretreatment with antioxidants.

We are just beginning to scratch the surface of the relationship between ingestion of certain macronutrients and the relationship to insults to the vascular system. Although we know certain foodstuffs, such as saturated and trans-fats, are bad for us, this new line of research on AGEs opens up a whole new avenue to explore – the relationship between how we combine foods, process and cook foods and their impact on our vascular (and thus our entire body’s) health and well-being.

I look forward to exploring more research on this fascinating and important topic.

by Pat Salber

Today is the first ever UN-observed World Diabetes Day led by the International Diabetes Federation. It was established as a result of a resolution passed last December by the General Assembly of the UN. The idea behind the Day is to increase visibility of diabetes world-wide.  Hopefully this will lead to better funding, more research, public education, and other resources being applied to the condition.

The focus of this year’s World Diabetes Day campaign is diabetes in children and adolescents. Diabetes is one of the most common chronic disease of childhood. Children and teens can develop Type 1 diabetes – an autoimmune disorder in which the insulin producing cells in the pancreas are destroyed – or they can develop Type 2 diabetes – a condition caused by the development of resistance to the hormone, insulin.

Type 2 diabetes used to be rare in kids, but with the advent of the childhood obesity epidemic, Type 2 diabetes is now seen in even very young children. Both Type 1 and Type 2 diabetes are associated with serious complications, such as kidney, nerve and eye damage, as well as atherosclerotic vascular diseases, such as coronary artery disease.

Type 1 diabetes is rapidly fatal if not treated with insulin. Type 2 diabetes has a longer course, but if untreated or inadequately treated, lifespan is usually shortened significantly. In developing countries, access to early diagnosis and appropriate treatment of diabetes may be limited resulting in many children dying from a treatable disease. In countries with good access to health care, failure of family members, teachers, and others who care for children to recognize symptoms of diabetes can lead to delays in diagnosis that can occasionally be fatal.

The World Diabetes Day 2007 and 2008 campaigns are focused on changing the status quo with the stated goal that “no child should die of diabetes.”

Here are some statistics that highlight the magnitude of the problem:

• Type 1 diabetes is increasing by 3% per year in children and adolescents and by 5% in pre-school children - that translates into almost 200 children per day developing the disease.
• Of the approximately 440,000 cases of Type 1 diabetes in children worldwide, more than a quarter live in South East Asia and more than a fifth in Europe.
• Type 2 diabetes, previously rare in children, now constitutes between 8 to 45% of new childhood cases depending on geographic location.
• Over the past 20 years, type 2 diabetes has doubled in Japanese children. It is now more common than Type 1 diabetes.
• In native and aboriginal children in North America and Australia, type 2 diabetes range from 1.3% to 5.3%

Diabetes can be very difficult for adults to manage. It involves checking blood glucose levels, taking multiple medications, and in the case of Type 1 diabetes, multiple daily doses of insulin by injection. Imagine how hard it is for children who are also trying to do well at school, make and keep friends, and deal with the emotional issues related to growing up – particularly during adolescence. Families with diabetic children often find themselves overwhelmed by all there is to know and do. Add to that the socioeconomic challenges that people with limited resources face on a daily basis, for example, those living in poverty and the ability to manage diabetes must seem insurmountable. These families and other caregivers need help – to access needed health care and health education and support.

World Diabetes Day highlights these formidible challenges, but we must all respond by supporting this campaign with our time…and yes, with our money. To learn more, go to the World Diabetes Day website, http://www.worlddiabetesday.org.

by Brian Klepper, PhD

There are people who call for market solutions as the answer to every societal problem, but who then work to restrict the information that markets (and societies) must have to function effectively. Often, the truth is that these supposed market advocates need secrecy and opacity to protect their current advantages. If markets were to work as they claim they want, their actual behaviors (or pricing, or performance) would become known, and their positions compromised.

Which brings us to the new, interesting development in the case of Consumers’ Checkbook v CMS. You may remember that Consumers’ Checkbook (CC) is a consumer advocacy organization that sued CMS for the Medicare physician data in 4 states and DC. Seemingly arguing against their previous position, the Bush Administration – which actually has a good record for promoting health care pricing/performance transparency – took the opposite stance in this case, arguing instead that physicians have a right to privacy. (It is tempting to suggest that the AMA’s fingerprints must be all over this, but I don’t know that for sure.)

In any case, much to the surprise of me and, I’m sure, a lot of other people, on August 22nd, the court held with CC and ordered CMS to release the data by September 21st or appeal the decision. CC promptly promised to provide public access to the data, and sued again, this time for the Medicare physician data from the rest of the country.   

On October 19ths, CMS appealed the ruling. This means the Administration will fight to keep physician data out of the public’s hands.

As I’ve said before, in the short term the symbolic importance of this battle cannot be overestimated. Currently, there are few, if any, freely available, robust sources of claims data. Health plans and clearinghouses have the largest data sources, but these are typically proprietary.

If a startup company wants to identify the best performing physicians in any market – the ones who, in a given specialty, consistently obtain the best outcomes at the lowest costs – there is no easy way to independently do that.

Or let’s say you have a family member with a complicated condition or who needs a particular procedure. There is no direct way for you to objectively determine which community physician has the best track record with that condition or procedure. (You CAN get information on which car has the best repair record, which house repair contractor gets the best reviews, and which pizza restaurant delivers the fastest.)

The good news is that the Administration’s position is weak, at best, and won’t last long, even if they win this round. Hospital data is already publicly available and states are now actively publicly reporting key measurements of hospital quality and safety. Why should physicians have a special status that keeps their track records secret from the patients who depend on them? How can this Administration, which argues incessantly for market-based solutions, suppose that the health care marketplace can resolve the crisis when, as the great economist Adam Smith would have pointed out, there is no information to drive the decision-making that healthy markets require.

It is ironic that we’re even still having this discussion. In the first years of the 20th century, the famous surgeon Ernest Codman MD began to campaign for “the end-result system of hospital standardization.” He said,

Hospitals [and surgeons], if they wish to be sure of improvement...must analyze their results, to find their strong and weak points, [and] must compare their results with those of [their peers]...[They should] make this information publicly known so that the future patients might make informed decisions.

In the end, it won’t matter what this Administration does. There is now widespread acknowledgment that much of the health care crisis can be traced to an inability to see what is going on behind the curtain. A tidal wave of sentiment is building in the marketplace, with calls for making the information available, so that decision-makers of all types can make responsible, informed decisions.

It is difficult to imagine that this stonewalling can last much longer. If transparency doesn’t occur through policy change, it will surely happen in the marketplace through vendors with the heft and resources to see it through. If the recent Health 2.0 conference in San Francisco made any point emphatically, it was that a slew of companies are focused on infusing health care with unprecedented levels of transparency and decision-support.

The transition away from an opaque market to one that makes relative pricing and performance known and that rewards the good providers is the real health care reform we’re all looking for. Yes, we need to find a way to re-enfranchise everyone into the system. But that will be much easier if there is reason to believe that we can get excessive care and cost under control.

And to that end, Consumers’ Checkbook v CMS is a sideshow, not a pivotal decision. On this issue, the Bush Administration and whoever is urging them on are anachronisms that will soon be swept away with the buggy whip and White-Out. The real change agent here is technology and the long-overdue realization by purchasers of all kinds that, when markets are opaque, value becomes secondary and many vendors will act most assertively in their own interests first.

by Pat Salber

It is always unbearably sad to learn about a child's death.  But for families with children living with complex chronic conditions, such as progressive neuromuscular diseases or cancer, it is something they must be prepared to deal with.   The miracles of modern medicine simply cannot cure every serious childhood illness. 

Given that, what do we know about where these children die?  A recent study, led by Chris Feudtner, MD, PhD, MPH and colleagues, published in JAMA (June 27, 2007) documented that increasingly these children are dying at home instead of in the hospital - and I believe that is a good thing, allowing both the child and loved ones the comfort and privacy we all want to have at the end of life.  Advances in technology (home ventilators, tube feeding) and greater availability of services to support families at home (pediatric home care and hospice services) have made it easier for children and families to choose to die at home.

Comparing where these very sick children died in 2003 to what happened in 1989, the researchers found that the percent of infants dying at home increased significantly from 4.9% to 7.3%; 1-9 year olds from 17.9% to 30.7%, and 10-19 years olds from 18.4% to 32.2%.

White children were twice as likely to die at home as black or hispanic children - even after adjusting for a variety of factors, such as medical condition or geographic location.  The researchers speculate that differences in access to health care services or technology, cultural attitudes toward palliative and end-of-life carte, and different levels of financial and social support may contribute to this finding.

Dying at home should be an option for all who choose it.  If and when health care reform and universal health insurance become a reality in this country, it is important that palliative care and end-of-life services be a part of the coverage - and not just for children.

 

by Pat Salber

You want to buy organic...you believe it is better to eat fruits and veggies sans pesticides, but, wow! look at the prices on those tomatoes.  So, you slip the non-organic version into your cart and move on to the next grocery decision.  I've been there and done that. 

But there is an alternative to going 100% organic.  It is outlined in nice little blog post, "Five Easy Ways to Go Organic," on the NY Times website.  This article offers a way to go organic -  mostly -  with out going broke.  The idea is to add a small number of organic products to your shopping cart by focusing on ones that can have the biggest impact your family's diet.  This strategy is based on recommendations by pediatrician Dr. Alan Greene, author of "Raising Baby Green."  He suggests buying organic versions of the following foods:

• Milk
• Potatoes
• Peanut butter
• Ketchup (ketchup?)
• Apples

You can read the rationale in the NY Times article, but basically it boils down to these being commonly eaten foods (did you know 75% of tomatoes are eaten in the form of processed foods, such as ketchup and tomato juice? -  I can't remember the last time I ate ketchup.  I think it was when I learned it was one of Pres. Nixon's favorite foods).  These common foods also tend to be heavily contaminated with pesticides.  In the case of ketchup, you should go organic because there are more antioxidants in organic ketchup compared with plain ketchup.

I suggest you assess your usual diet in order to develop an organic strategy that makes sense for you and your family.  Make a list of the most common foods you eat .  Then check them out on the the Food News data set compiled by the Environmental Working Group (it is a pretty scary list) to determine how likely they are to be contaminated with chemicals.   That way, you can choose which foods that make most sense for you to make the organic investment.

Happy eating.

 

 

"Most heart attacks in women are preventable," is the headline of an article posted on NBC.com.  The article describes a study, published in the Archives of Internal Medicine, that was done by the researchers at the Karoinska Institute in Sweden.  Dr. Agneta Akesson and colleagues looked at the diet and lifestyle patterns of almost 25,000 postmenopausal women.  At the time of enrollment none of the women had heart disease, diabetes or cancer.

The researchers asked the women to fill out "food frequency" questionnaires to identify how often they ate 96 different foods.  The researchers analyzed the data and found four major dietary patterns:

• Healthy - vegetables, fruits, and legumes
• Western/Swedish - red meat, processed meat, poultry, rice, pasta, eggs, fried potatoes, and fish
• Alcohol - wine, beer and some snacks
• Sweets - sweet baked goods, candy, chocolate, jam, and ice cream

Other information collected included family history of heart disease, education level, physical activity, and body measurements.

The women were followed for an average of 6 years.  During that time, 308 women had heart attacks.  The investigators found that two of the dietary patterns (healthy and alcohol) were associated with a decreased risk of heart attack.  Women who drank less than a quarter ounce of alcohol daily (that is just a splash in the bottom of your glass) and ate lots of veggies, fruit, whole grains, legumes, and fish had a 57% lower risk of having a first heart attack.  That is a whopping big difference.

If women added three other healthy lifestyle habits into the mix (not smoking, being physically active, and avoiding too much weight gain), they had a 92% lower risk of heart attack.  In other words, most heart attacks in women are preventable by making healthy lifestyle choices.

Now, it is one thing to say, eat healthy, drink in moderation, exercise and maintain a healthy weight.  It is quite another thing to actually do all of those things over the course of an entire lifetime.  On the other hand, if you look at the amount of money the US (and, indeed, the entire world) spends to treat cardiovascular disease, I believe you would find there is enough there to buy each and every person a personal cook and a personal trainer (I believe this is the secret to Oprah's weight loss and maintenance).

I say this tongue in cheek, but it does make the point that we aren't spending our "health" care dollars on the right things.  We spend generously to fix disease, but we are very stingy when it comes to funding health.   It is time to get this right.  There aren't enough dollars in any treasury to treat all of the heart disease we are going to see as a result of the global epidemic of obesity and physical inactivity.  This must be  a top priority of policy makers and health reformers.  Studies, like the Karolinska study, should be used to promote changes in public policy - such as healthy school foods, ensuring that all neighborhoods have access to fresh fruits and vegetables and that they have safe places where kids and adults can move their bodies (without worrying about getting shot in the process).

Every politician, health reformer, and policy wonk ought to know about this study and others that prove that healthy lifestyles mean fewer heart (expensive) attacks - not just in women, but in men as well.  The bottom line is most heart attacks are preventable!

by Pat Salber, MD

There is a short article by Nicholas Bakalar from NY Times News Service in local papers today.  The jist of the article is that the amount of caffeine in three cups of coffee or tea each day may help older women maintain mental sharpness - unfortunately, there doesn't appear to be an effect in older men.

"Le Study" is from French researchers and is published in the journal Neurology in August 2007.  Karen Ritchie, a researcg durectir with the French National Institute for Health and Medical Research is the lead author.  The study included more than 7,000 men and women, average age 74 years old, who were followed for over four years.  They were asked about their coffee and tea intake and their mental acuity was measured by standard tests of visual skills and verbal recall.  The researchers also collected information from the study participants about their education, income, depression, alcohol, and tobacco use, among other factors.

After controlling for other variables, the researchers found that women at age 65 who drank three or more cups of coffee or tea a day were about 30% less likely to have a significant decline in verbal skills than those folks who consumed a cup or less.

By age 85, caffeine drinking women were 70% less likely to suffer deficits in mental acuity compared with women who drank less than a cup of coffee or tea. 

Lead author Ritchie said in the NY Times article "please don't rush out and start drinking coffee.  To suddenly start drinking large quantities of coffee is still really premature as a preventive measure."

In the course of my medical career, coffee has gone from good to bad and now back to good again.  It's hard to say what to make of this latest study.  I would say it is probably a safe course, if you enjoy drinking coffee, to continue to consume it in moderate quantities.  I would wait for confirmatory studies before rushing to Starbucks or Peets to load up on coffee beans as a prophylactic measure against Alzheimers or other age-related declines in mental sharpness.

by Pat Salber

Earlier this year, I wrote about the Food Industry Playing Games with our Children.  Now, thank heavens, HMO giant, Kaiser Permanente (KP), is countering with a food game of its own - a good food game. 

The Incredible Adventures of the Amazing Food Detective was developed by KP to teach youngsters (9-10 years old) about healthy eating and exercise.  Unlike other video games that have inducements to keep kids on the site, exercising only a few fingers at a time, Incredible Adventures only allows 20 minutes of play and then locks the young'uns out, encouraging them to stop playing computer games and go outside for fresh air and exercise instead.  Once locked out, they can't get back into the site for an hour. 

While playing the game, kids learn how to read food labels, how to measure the amount of sugar in drinks and other health skills.   Now that may sound pretty dull, but the site has woven this information into adventures that engage junior food detectives (from the site):

"There has been a mysterious outbreak of unhealthy habits hitting too many boys and girls. If we don't solve these cases, and fast, kids might not make the right food and exercise choices as they grow, and that could be trouble!

All junior food detectives will get secret training on how to eat right and exercise. You can investigate fun games like Whack A Snack, Soccer, and Zap the TV. Plus you can print out classified clues on ways to be healthy, then share them with your parents, teachers, and pals."

Now, as you know, I am not 9 or 10, so I am probably not the best person to evaluate whether the site can engage kids of this age -- and teach them healthy habits to boot.  If you have kids, know kids, or can get kids on the site, write us, let us know.  Can the Incredible Adventures website trump www.Tonythetiger.com" or www.bubbletape.com?  Let me know...

by Pat Salber

 

Perhaps the folks over at Hardee's fast food haven't heard the country is in the midst of an obesity epidemic.  They have just unveiled a new breakfast offering, the Country Breakfast burrito.  It consists of a two egg omelet filled with bacon, sausage, diced ham, cheddar cheese, hash browns and sausage gravy.  Surrounding this protein load is a flour tortilla.  The burrito weighs in at 920 calories.  That's right, 920 calories, about half of what you should ingest in a day.  This little baby also has 60 grams of fat.  All those calories and all that fat will only set you back $2.69.

According to a story by the Associated Press, Brad Haley, Hardees' marketing chief, says that the burrito offers the sort of big breakfast item normally found in sit-down restaurants with an added advantage.  "It makes this big country breakfast portable," he said.

Other Hardee offerings include the Monster Thickburger, a 1,420-calorie sandwich that contains two 1/3-pound slabs of beef, four strips of bacon, three slices of cheese and mayonnaise!  Want a healthy alternative?  Try the Hardees' chicken salad --it is only 1,100 calories and 83 grams of fat.  Supposedly, the chain does offer some low-calorie options, including roast beef and chicken sandwiches.

AP reports that the Center for Science in the Public Interest, a Washington-based advocate for nutrition and health, has called the Hardee's line of Thickburgers "food porn." I love it, food porn!

Jayne Hurley, senior nutritionist at the Center, said the burrito is "another lousy invention by a fast-food company."  The "country breakfast bomb," as she called it, represents half a day's calories and a full day's worth of saturated fat and salt, to say nothing of cholesterol.  "That's all before 10 o'clock in the morning," she said.

Hardees' Haley makes no apologies:  "We don't try to hide what these are," he said. "When consumers go to other fast-food places they feel like they've got to buy two of their breakfast sandwiches or burritos to fill up. This is really designed to fill you up."

Way to go, Hardees.  Keep on fillin' us up.

You are probably wondering if TDWI docs are ever going to stop blathering on about Matt Holt and Indu Subaiya's Health 2.0 Conference.  Probably not, but we will try to keep you entertained with what we saw and heard at this first ever conference of companies doing all kinds of creative things to deliver and support healthcare via the internet.

The meeting was filled with luminaries from both health and technology.  These experts generated a number of quotable quotes as they pontificated from the podium.  Here are some of the more repeatable ones:

• "Healthcare is a hairball "[my all time favorite quote] delivered with wit and grace by Wayne Gattinella, CEO of WebMD Health
• "Healthcare needs Health 2.0 " - David Brailer, MD, former first national Health IT Czar
• "I was surprised by the accessibility of information by patients of all ages and demographics" [paraphrased] - Doug Hirsch , founder of Daily Strength, a social networking site providing support groups for "all of health issues and life challenges"
• "People are the new algorithm" [I love it] - Steven Krein.  Steve is founder of OrganizedWisdom, LLC, a leader in the Health 2.0 movement.  They recently unveiled a new web search platform and launched OrganizedWisdom Health, "the first human-powered, doctor-guided search service for health"
• "It's not just about medicine and technology, it's about living your life" - Karen Herzog, founder of Sophia's Garden - for the life of me I cannot figure out what this site is supposed to do - maybe it isn't completely developed yet or it is down today - all I see are an anonymous quote, some women's names and some nice graphics - who knows??
• "P&G knows more about me and my laundry detergent preferences than pharma companies know about what drugs I'm on" - Ben Heywood, founder of Patients Like Me, a social networking site for people with serious illnesses, such as ALS, multiple sclerosis, Parkinsons, and HIV/AIDS.  Ben started the site after his brother, Stephen, was diagnosed with ALS.
• "Do. Not try" - Yoda via Doug Goldstein, e-Health Futurist and author of "e-Healthcare: Harness the Power of Internet e-Commerce and e-Care"
• "There's a Gandhi moment here; you have to be the change you wish to see in the world" - Gandhi via Joe Gifford, MD, Senior Medical Director of the Regence Group, the biggest Blues plan in the Pacific Northwest
• "On the internet, everyone owns a press" - Bruce Grant, SVP for Business Strategy at Digitas Health, "a next generation marketing agency brand for health care that provides a complete solution for demand generation, demand servicing and relationship building across channels and audiences."  [What???]
• Bruce also gave us this one:  "Power is irreversibly moving to user communities"
• "Trust is not a zero sum game" - Paul Wallace, MD, Senior Advisor for Kaiser Permanente's Care Management Institute
• "The web has fixed a lot of broken industries; it's time to do it for healthcare" - Marty Tenenbaum , Cuairman and Founder of Commercenet.  According to its website, Commercenet is an "entrepreneurial research institute."  Their tag line, We make the world a better place by fulfilling the promise of the Internet." suggests they aim to be the  GE of Health 2.0
• "There is a solid rock, the kind of calcified thing you find at the bottom of the drain. But with collective action, different methods of payment and personalized information based on our genomes, maybe we can begin to erode the edges of the rock" [paraphrased] - This wonderful quote is brought to you by Esther Dyson .  According to Wikipedia, Esther is "a commentator on emerging digital technology and a founding member of the digerati."
  
  

 

 

by Pat Salber

 

It's that time of the year to think about getting vaccinated against influenza.  I got my flu shot at work last week.  I barely felt it thanks to new needle technology and a skilled nurse.  Flu shot clinics are everywhere and, often, the price is quite reasonable.

So why doesn't everyone who should get one do it?  Fear of needles?  Laziness?  Misunderstanding of the potential seriousness of the disease?  I have also heard people say, "I got my shot but I got the flu anyway, so why bother?"

Here are some facts that may help motivate you.  Flu and complications of flu cause about 36,000 deaths and 236,000 hospitalizations per year. Also, if you have ever had the flu you know it is no fun.  Muscle aches, fatigue, malaise, dry cough, headache, and fever are common symptoms.  But you can also have a runny nose and sore throat making it hard to distinguish from a cold. 

Individuals at high risk for bad outcomes from influenza include:

• Adults over the age of 50
• Children ages 6 months to 59 months
• Adults or kids with chronic lung disease, heart disease, blood diseases, diabetes and certain other chronic conditions
• Individuals with conditions that comprise breathing (e.g., spinal cord injury), handling of secretions, or that predispose to aspiration 
• People on long-term aspirin therapy because that can place them at risk for Reye's syndrome, a serious and often fatal complication of influenza

Healthy people who are close contacts of high risk persons should also be immunized.  This includes household members (including children); health care workers and other caregivers, including day care workers. 

Vaccination currently is offered to anyone who wants it providing there is an adequate supply of vaccination and no contraindications to receiving the vaccine (see below).

There are two types of vaccination available.  One is the familiar flu shot which contains three different strains of killed influenza virus.  It must be give every year because flu strains change year to year.  There is also a shot alternative available - the live attenuated influenze vaccine which is administered by nasal spray.  It also contains three strains of virus, but the virus is a live virus that has been attenuated (weakened).

The flu shot can be administered to almost any one (over 6 months of  age).  People who should not get the flu shot include people with a history of serious allergic reactions to eggs or other components of the vaccine.  Vaccination should be posponed if the individual has a moderate or severe febrile illness, although it is ok to get it is you have an illness with a mild fever.  A history of Guillain-Barre syndrome that occured within 6 weeks after a previous flu shot generally (but not always) is a reason not to get the shot.

The intranasal vaccine is currently approved for use in healthy, nonpregnant people ages 5 to 49.  Because this is a live virus vaccine it should not be used when the person being vaccinated is or is in contact with severely immunosuppressed people.

So make your choice (based on the recommendations above) - shot or spray - and call your doctor or get on-line to find out where you can get your flu vaccination.  It is best if you get it now, but, if possible,  no later than the end of November.

 

By Pat Salber, MD

There is a haunting photo by Joao Silva on the front page of the NY Times (10/10/07). A young boy is looking inside a bullet-ridden white Oldsmobile. The front window is shattered and the driver’s side door is dripping bright red blood.

We are not told whether the boy knew or is related to the victims – two women -- one a 59 year old mother of three grown daughters; the other woman was her 30 year old passenger.  We can be fairly certain from expression on this youngster’s face, that this is a life-changing event for him. He will not be the same after this witnessing this horrific scene as he was before.

My speculation about this boy's future is supported by an article in the current issue of BMC Public Health. The authors, Asma Al-Jawadi and Shatha Abdul-Rhma, assessed 3079 children from families who attended primary health care institutions in Mosul, Iraq and found mental disorders in more than one third of the children. Let me repeat that, more than one third of children were found to have mental disorders.

Here are the details of the study. Mothers who came to the primary health centers in Mosul for vaccination of one of her children were included in a systematic sampling randomization. All children of these mothers (ages 1-15 years old) were considered in the interview and examinations. 3079 children were assessed. 1152 were diagnosied with a childhood mental disorder for a point prevalence of 37.4%. The ratio of males to females was 1.22:1.

The top ten diagnoses among the examined children were as follows:

• post-traumatic stress disorder (PTSD) ( 10.5%)
• enuresis (bed-wetting) (6%)
• separation anxiety disorder (4.3%)
• specific phobia (3.3%)
• stuttering &school refusal each had a point prevalence of 3.2%
• l