Sugar Babies

A story that illustrates well the ways diet can influence children’s behavior. The author’s honesty and her willingness to rethink her own actions are what makes this blog post a standout.

The transformation happened in mere minutes. My 3-year-old nephew listed against me as we stood in a chilly, wet schoolyard, waiting for his 8-year-old sister. He popped the hood on his raincoat, rubbed his eyes, and lethargically complained about the cold.

When my niece emerged from her classroom, she handed her brother a sweet treat. One dark chocolate granola bar later, my nephew practically flew on the walk home, a textbook example of a “sugar rush” in action.

Cancer v. the Constitution

A human tragedy, which could become much less common or much more common depending on what the Supreme Court decides.

She hadn’t gone to the doctor because she had no health insurance. The only kind of work she could get in a struggling rural community was without benefits. Her coat and shoes beside the gurney were worn and her purse from another decade. She could never afford to buy it on her own. She didn’t qualify for Medicaid, the local doctor only took insurance, and there was no Planned Parenthood or County Clinic nearby.

So nothing was done about the bleeding until she passed out at work and someone called an ambulance. She required a couple of units of blood at the local hospital before they sent her by ambulance to our emergency department.

I looked at the fungating mass on her cervix. Later the Intern wondered why she hadn’t picked up on the smell. Probably a combination of it being so gradual and denial. It’s amazing what people learn to tolerate when their options are limited.

“I’m very sorry to tell you this looks like a cancer of the cervix,” I said

She looked surprised. “Oh.” She paused in silence as she adjusted to the news. And then quietly she added, “But the doctor back home said you could fix me up. He said you can offer free care because you have the university.”

But we didn’t have free care at the university hospital.

h/t Meteor Blades

Study Confirms Weight Loss Surgery Benefit for Diabetics

This new research confirms what was strongly suggested by earlier studies — that bariatric surgery leads to major weight loss, and either directly or indirectly leads to major improvements in the diabetic status of these formerly obese individuals.

I’ve lectured on this topic in my clinical nutrition class and it generally stimulates fruitful class dicsussion. Essentially, we’re looking at a dangerous condition that is almost entirely preventable through diet and exercise. We then see tens of millions of people failing at prevention and then finding themselves in a terrible situation. Once they’ve reached that point, this surgery clearly leads to much improved outcomes. It’s a classic example of radical measures being offered at a late stage for something that should never have reached that point.

It concerns me that we are now seeing, for what to my knowledge is the first time, a serious suggestion that bariatric surgery be provided to diabetics who are even slightly overweight. Again, where is the prevention?

The following quotes are from the National Public Radio coverage of the story, which I’m citing because unlike the MedPage story cited above, this one mentions recommending this surgery for diabetics with a Body Mass Index as low as 26, which is just barely overweight. (Obesity starts at a BMI of 30, and morbid obesity, which is usually when bariatric surgery is provided, starts at a BMI of 40).

This research raises an important question: Should diabetics start getting this operation more often? Paul Zimmet of the International Diabetes Federation, who co-authored an editorial accompanying the studies, thinks they should.

“Diabetes coupled with obesity is probably the largest epidemic in human history. At the moment, bariatric surgery is seen as a last resort. And it should be offered earlier in management,” Zimmet said in a telephone interview.

But others aren’t so sure. The new studies followed only about 200 patients. And while the operations appear to be pretty safe, there can be complications. And the complications can be serious.

“I think we need longer-term follow-up than what was done in these studies to make sure you’re not trading one problem for another,” said Vivian Fonseca of the American Diabetes Association.

Researchers are now testing whether the surgery works on diabetics who aren’t even obese — people with BMIs as low as 26. And doctors and patients are waiting to see if insurance companies will pay for the operations just to treat diabetes.

Earlier this year, I attended (and spoke) at a U.S. Department of Health and Human Services listening session here in Kansas City that focused on what services should be included in an essential benefits package under health reform. For me, the most unexpected part of the event was that of perhaps 30 presenters, four were bariatric surgeons. I was surprised, in part, because I was aware of the research supporting bariatric surgery and had assumed they were in no danger of being excluded.

Now, in light of this new research that was certainly in the pipeline at the time of the hearing, it occurs to me that their presence (which I assume will be duplicated in many other venues), may have been part of a concerted push for a major expansion of their services into the non-obese market.

Pink Slime Surprisingly Unpopular for School Lunch Menus

Who could have guessed?

Today’s New York Times has an up-to-the-minute pink slime report. Apparently, this is a fast-moving story.

The Miami-Dade school district, one of the nation’s largest, has already said it would opt for pink-slime-free beef, even though it expected it to cost more (exactly how much remained uncertain). State officials in South Carolina said they would procure only the pink-slime-free ground beef once it became available.

But for some school districts — with administrators fielding phone calls from concerned parents and fretting about past food scares — next fall is not soon enough. The Boston school district, among others, has taken the step of purging all ground beef from its menus. Other districts, like the New York City schools, have begun phasing out ground beef containing the additive from their lunchrooms.

Michael Peck, the director of food and nutrition services for the Boston schools, said the district had decided to hold and isolate its entire inventory of ground beef, leaving over 70,000 pounds of beef — worth about $500,000, Mr. Peck estimated — confined to a warehouse until the district knows more about what is in it.

“It’s another example of the alteration of our food supply,” said Mr. Peck, who is concerned about the use of ammonia hydroxide gas to kill bacteria in the product. “Have we created another unknown safety risk?”

The district will put the meat back into circulation if it finds that it is free of the filler, but like many districts, it is frustrated by the difficulty of determining what does and does not contain lean finely textured beef, which does not have to be listed as an ingredient.

“It does speak to the U.S.D.A.’s ability to trace,” Mr. Peck said. He added that the ground beef would be donated or thrown out if the district found that it contained pink slime.

… in the Real World

This Washington Monthly blog post, “The Affordable Care Act in the Real World,” frames the question in ways that should matter most, in terms of how people’s lives are actually affected by the health reform law.

A priest I knew many years ago once said to me, “Turning real human suffering into an abstraction is among the greatest sins.” .

My children now have health coverage through mine, and our family’s health will now sustain itself through my children’s 26th birthdays. A mouth full of cavities was treated, and vision has been a godsend, and my daughters have the ability to go to the doctor at $20 a pop, instead of the $150 a pop uninsured rate, and they don’t have to go willy-nilly to a clinic setting!

A dear friend of mine skirted death with a ruptured colon, had surgery to the tune of over $80,000 because they were uninsured. and worried about preexisting conditions when it came to reversing the colostomy, qualified for insurance so he doesn’t have to carry around a bag for the rest of his life.

Amen.

 

What Will Change if the Supreme Court Overturns Obamacare’s Individual Mandate?

Ezekiel Emmanuel’s op-ed in the New York Times addresses some of the changes that will and will not be affected, if the individual mandate to buy health insurance is overturned as unconstitutional.

The very substantial downside is that 16 million people who would have been insured will not be. This number will rise to 32 million if Medicaid expansion is also deemed unconstitutional. According to Emmanuel, this would also trigger a downward spiral threatening to substantially increase insurance premiums for everyone.

On the other hand, changes such as bundling of payments, which have already begun, lead to better coordinated care and lower costs. These changes will continue apace regardless of what the Supreme Court’s decides.

Tens of thousands of Americans die because of hospital-acquired infections every year, and far more are harmed by medical errors. Last year, authorized by the Affordable Care Act, the Obama administration announced a $500 million program called Partnership for Patients aimed at reducing hospital-acquired infections, errors and other preventable complications. The act also requires Medicare to begin posting online each hospital’s rate of certain medical errors and infections, and to cut payments to hospitals with the highest rates.

Consequently, hospitals across the country are working to reduce preventable hospital errors. Once it’s clear that this is a major priority, significant progress can be made. A few years before the health care reform act was passed, the Hospital of the University of Pennsylvania, where I work, started paying attention to reducing preventable errors, and it managed to reduce infections from intravenous lines to 1 or fewer per month from 30 to 40 per month. All it took was removing intravenous lines whenever they weren’t necessary, changing them regularly and using a more vigorous sterilizing technique when inserting them. Many other institutions are making similar progress now. All of this has nothing to do with the constitutionality of the individual mandate and will continue no matter what the Supreme Court rules.

The same goes for the problem of hospital readmissions. Right now, nearly 20 percent of Medicare patients who are discharged from a hospital are readmitted within 30 days. Some are scheduled readmissions; others occur for completely unrelated health problems, like falls and accidents. But many could be prevented by paying more attention to the coordination of care between physicians and hospitals and by better follow-up after patients are discharged. Beginning this year, the health care reform act will penalize hospitals that have high readmission rates for three conditions: pneumonia, heart failure and heart attacks. This list will later be expanded. As a result, all hospitals are now scrambling to figure out how to create “the perfect patient discharge” so patients don’t become hospital “frequent fliers.”

If the Supreme Court rules that the individual mandate is unconstitutional — in my opinion, an improbable and legally indefensible decision — it will not end health care reform. Hospitals and doctors will continue to work to improve care and control costs. But tens of millions of Americans will continue to be excluded from the health care system, which is hardly an optimal outcome.

 

What About the Uninsured?

Ron Brownstein’s article in the National Journal goes straight to the heart of why health reform is needed.

But the debate over health care reform—which will intensify again next week as the Supreme Court hears oral arguments on challenges to the law’s mandate on individuals to buy insurance—involves more than competing philosophies or political strategies. At its core, it raises an irreducibly tangible question: what, if anything, to do about the nearly 50 million Americans who today lack health insurance?

Those millions of uninsured rarely intrude into the promises from GOP congressional leaders and the party’s presidential field to defend liberty by repealing Obama’s plan. But ignoring them doesn’t make them go away. If the 2012 election rewards Republicans with enough leverage in Washington to erase Obama’s initiative, they will face the choice of finding an alternative means to expand coverage or allowing the number of those without insurance to grow, with far-reaching consequences not only for the uninsured but for those with insurance as well.

Without some policy intervention, there’s little question that access to health insurance will continue to decline. Since 2000, the number of the uninsured has jumped from 36.6 million to 49.9 million, about one-sixth of all Americans.

That number would have been even higher if an additional 20 million people over that period had not obtained coverage through Medicaid and the Children’s Health Insurance Program. This growth partially offset the unrelenting erosion in employer-based care: The share of Americans obtaining coverage from their employer has declined every year since 2000, in good times and bad.

Earlier this month, the Congressional Budget Office forecast that, absent the new health care law, the number of uninsured would rise to 60 million by 2020.

Why Adjust the Dosage on a Useless Drug?

Merrill Goozner is among our nation’s best health policy reporters. His concern about this FDA decision is one that makes a great deal of sense.

Professors Lisa Schwartz and Steven Woloshin of the Center for Medicine and the Media at The Dartmouth Institute for Health Policy and Clinical Practice are raising alarms about a recent Food and Drug Administration decision to approve a new dosage for the  best-selling Alzheimer’s drug Aricept (donepezil). The decision “breached the FDA’s own regulatory standard” and has led to “incomplete and distorted messages” about the drug, they warned in the latest British Medical Journal.

Aricept has become a $2 billion-a-year blockbuster in large part because people caring for elderly patients with dementia are desperate for something, anything to slow their loved ones’ inexorable decline. The original dose for the drug, which was approved in 1996, provided a short-term improvement in memory that faded to insignificance within six months. With its patent due to expire, the companies behind the drug — Eisai and Pfizer — went to the FDA with a clinical trial in 1,400 patients claiming a higher dosage showed better results. The FDA agreed, which gave the companies another three years of marketing exclusivity based on a use patent for that new, higher dose.

Here’s the medical problem with that higher dosage, according to Schwartz and Woloshin. While the clinical trial showed that patients did slightly better in cognition (like recognizing numbers), the drug had no impact whatsoever on their actual functioning in day-to-day life, at least none that their caregivers could notice. Yet the major side effects of the drug — nausea and vomiting — increased significantly. The article claimed that the FDA had said specifically to the trial sponsors that the higher dose had to have an impact that caregivers could notice to win approval. Schwartz and Woloshin charged the FDA with violating its own standards.

Supreme Court Unanimously Rules Against Patenting “Laws of Nature”

This is a most promising development. The biotech companies’ willy-nilly rush to patent everything in sight had to end somewhere. It’s important not to generalize too broadly from this ruling, but it does seem to be a line in the sand that even this corporate-friendly Court felt compelled to draw. Good for them!

The unanimous Supreme Court decision said, “Laws of nature, natural phenomena and abstract ideas are not patentable” under provisions of the US Patent Act.

To be covered by a patent, “an application of a law of nature… must do more than simply state the law of nature while adding the words ‘apply it.’ It must limit its reach to a particular, inventive application of the law,” said the decision written by Justice Stephen Breyer.

“The claims are consequently invalid,” said the court’s decision, which reversed an earlier ruling of the US Court of Appeals for the Federal Circuit.

The patents covered a method developed by Prometheus Laboratory for adjusting dosages of thiopurine treatment for patients with immune system diseases, such as Crohn’s disease, a chronic intestinal inflammation.

The unanimous Supreme Court decision said, “Laws of nature, natural phenomena and abstract ideas are not patentable” under provisions of the US Patent Act.

To be covered by a patent, “an application of a law of nature… must do more than simply state the law of nature while adding the words ‘apply it.’ It must limit its reach to a particular, inventive application of the law,” said the decision written by Justice Stephen Breyer.

“The claims are consequently invalid,” said the court’s decision, which reversed an earlier ruling of the US Court of Appeals for the Federal Circuit.

The patents covered a method developed by Prometheus Laboratory for adjusting dosages of thiopurine treatment for patients with immune system diseases, such as Crohn’s disease, a chronic intestinal inflammation.

Interesting Findings But at What Cost? How Massage Heals Sore Muscles

This study is revealing on more than one level.

First, it clearly documents for the first time that a specific anti-inflammatory process is triggered by massage, involving suppression of pro-inflammatory cytokines and stimulation of the mitochondria, which play a role in cellular repair. For the researchers and the New York Times writer reporting the story, that’s the bottom line.

But after reading it through twice, I find myself appalled at the protocol they used. Taking muscle biopsies on healthy people in order to understand a bodiliy mechanism goes against the grain for me. In essence, what’s being done is to intentionally injure the body in order to understand how it responds to injury. From my perspective, it’s a strange set of bioethics that considers this par for the course. I don’t like this when it’s done to animals and I don’t like it any better when it’s done to consenting humans.

Tiffany Field of the University of Miami Medical School, who is quoted in the article, has for decades been the acknowledged leader in massage research. She’s quite happy with the findings. Much as I would like to be, I find the method through which they were gained to override the benefits they represent.

Their experiment required having people exercise to exhaustion and undergo five incisions in their legs in order to obtain muscle tissue for analysis. Despite the hurdles, the scientists still managed to find 11 brave young male volunteers. The study was published in the Feb. 1 issue of Science Translational Medicine.

On a first visit, they biopsied one leg of each subject at rest. At a second session, they had them vigorously exercise on a stationary bicycle for more than an hour until they could go no further. Then they massaged one thigh of each subject for 10 minutes, leaving the other to recover on its own. Immediately after the massage, they biopsied the thigh muscle in each leg again. After allowing another two-and-a-half hours of rest, they did a third biopsy to track the process of muscle injury and repair.

Vigorous exercise causes tiny tears in muscle fibers, leading to an immune reaction — inflammation — as the body gets to work repairing the injured cells. So the researchers screened the tissue from the massaged and unmassaged legs to compare their repair processes, and find out what difference massage would make.

They found that massage reduced the production of compounds called cytokines, which play a critical role in inflammation. Massage also stimulated mitochondria, the tiny powerhouses inside cells that convert glucose into the energy essential for cell function and repair. “The bottom line is that there appears to be a suppression of pathways in inflammation and an increase in mitochondrial biogenesis,” helping the muscle adapt to the demands of increased exercise, said the senior author, Dr. Mark A. Tarnopolsky.