Good health

The Human Body's Mineral Content

2010-03-02T12:08:00.000-08:00

In most cases, optimal levels of Minerals exist and the essential Minerals must be present in the body in their correct balance. Excessive consumption or accumulation of Minerals is generally as undesirable (i.e. toxic) as a deficiency.

Macrominerals (Essential)
% Average Human Body
Content(70 kg person)
Oxygen 65.4 43 kg
Carbon 18.2 12 kg
Hydrogen 9.5 6.3 kg
Nitrogen 3 2 kg
Calcium 1.67 1.1 kg
Phosphorus 1.14 750 grams
Potassium 0.342 225 grams
Sulfur 0.228 150 grams
Chloride 0.152 100 grams
Sodium 0.137 90 grams
Magnesium 0.053 35 grams
Silicon 0.046 30 grams

Microminerals
Microminerals
Microminerals % Average Human Body
Content(70 kg person) Essentiality
Iron 0.00638 4,200 mg Essentiality
Fluoride 0.00395 2,600 mg Essential
Zinc 0.00365 2,400 mg Possibly Essential
Rubidium 0.000532 350 mg Essential
Strontium 0.000486 320 mg Probably Essential
Lead 0.000243 160 mg Possibly Essential
Copper 0.000137 90 mg Essential
Aluminium 0.0000988 65 mg Toxic
Cadmium 0.0000608 40 mg Toxic
Barium 0.0000344 22 mg Possibly Essential
Cobalt 0.0000304 20 mg Essential
Vanadium 0.0000304 20 mg Probably Essential
Iodine 0.0000228 15 mg Essential
Tin 0.0000228 15 mg Possibly Essential
Selenium 0.0000228 15 mg Essential
Arsenic 0.0000228 15 mg Possibly Essential
Manganese 0.0000198 13 mg Essential
Mercury 0.0000190 12.5 mg Toxic
Nickel 0.0000167 11 mg Possibly Essential
Molybdenum 0.0000122 8 mg Essential
Chromium 0.0000091 6 mg Essential
Bismuth 0.0000045 3 mg Probably Toxic
Lithium 0.0000038 2.5 mg Probably Essential
Uranium 90 mcg Toxic
Boron Probably Essential
Germanium Probably Essential
Bromine Possibly Essential
Gold Probably Non Essential
Silver Probably Non Essential
Beryllium Probably Toxic
Antimony Slightly Toxic
Thallium Toxic

These Substances Facilitate the General Absorption of Minerals

Amino Acids
Cystathionine facilitates the absorption of essential Minerals.
Glutathione facilitates the absorption of essential Minerals.

Enzymes
Glutathione Synthase metabolizes Minerals in the Skin and the Muscles.

Proteins
Orotic Acid facilitates the transport of Minerals into the blood from the digestive tract.

Water
Water is an essential transport mechanism within the body for Minerals.

Forms of Minerals (Generally)

Mineral Form Mineral Bonded With Comments
Inorganic Salts: Phosphates,
Sulfates,
Chlorides Important for Electrolyte balance.
Organic Acid Salts: Ascorbates,
Acetates ,
Citrates Natural and more effectively absorbed by the Digestive System than Inorganic Salts.
Amino Acid Chelates: Amino Acids The best form of absorption of Minerals. Specific Minerals chelate best with specific Amino Acids.

Toxic Minerals
Toxic Minerals are a group of Microminerals that are not essential to human health and which are generally toxic to the body. These Substances Enhance the Elimination of many Toxic Minerals from the Body

Amino Acids
Cysteine (and Cystine) may chelate (bind) with many Toxic Minerals and may facilitate their elimination. The synthetic Amino Acid - Ethylene-Diamine-Tetra-Acetate (EDTA) - is used in Chelation Therapy to bind to and chelate (remove) many Toxic Heavy Metals from the body via the Kidneys.
Methionine may chelate (binds) with many Toxic Minerals and may facilitate their excretion.

Carbohydrates
Alginates may chelate (bind) with most Toxic Minerals in the Intestinal Tract and may prevent their absorption. references
Galacturonic Acid chelates (binds) with many Toxic Minerals and may facilitate their excretion.

Enzymes
Glutathione Peroxidase facilitates the removal of several Toxic Minerals from the body.

Lipids
Alkylglycerols bind (chelate) with many types of Toxic Minerals (especially Mercury) and may facilitate their excretion from the body - Alkylglycerols are unique in that they are one of the few oil-based chelating agents.

Minerals
Selenium binds (chelates) with many toxic Minerals and may facilitate their excretion from the body.

Organic Acids
Fulvic Acid reputedly facilitates the chelation (removal and excretion) of Toxic Minerals from the body’s Cells.

Peptides
Glutathione (usually after incorporation into the Glutathione Peroxidase enzyme) may detoxify several Toxic Minerals.

Smart Drugs
Dimethyl Glycine (DMG) may be a useful chelation and elimination agent.
Vinpocetine may facilitate the removal of some types of Toxic Minerals from the body.

Vitamins
Vitamin E may enhance the detoxification of most toxic heavy metals.

These Foods may Enhance the Elimination of Many Toxic Minerals from the Body

Algae

Kelp may facilitate the excretion of some Toxic Minerals (due to the Algin content of Kelp binding to Toxic Minerals in the Digestive Tract and may thereby facilitating their excretion).

Animal-Derived Supplements

Shark Liver Oil may facilitate the elimination of various Toxic Minerals (especially the toxic Methylmercury form of Mercury) from the body (due to the Alkylglycerols content of Shark Liver Oil).

Mineral Foods

Shilajit reputedly facilitates the chelation (removal and excretion) of Toxic Minerals from the body’s Cells (this capability of Shilajit is claimed to be due to its Fulvic Acid content).

Vegetables

Garlic may facilitate the excretion of some Toxic Minerals.

Mineral Acids

Mineral Acids are inorganic Acid compounds that use Minerals as their base. Mineral Acids are much stronger acids than Organic Acids.

Types of Mineral Acids

Carbonic Acid

Carbonic Acid is a type of Mineral Acid formed from Water and Carbon Dioxide

Derivatives of Carbonic Acid - Bicarbonate Bicarbonate is the ion remaining after the first disassociation of Carbonic Acid. It functions as a central buffering agent against Acids in the Blood.

Therapeutic Uses of Bicarbonate

Metabolism
Bicarbonate (consumed prior to Exercise) may delay the onset of Fatigue and Muscle Weakness in people who undertake strenous Exercise (e.g. Endurance Exercise) and may accelerate the recovery of Muscles following strenuous Exercise (this occurs from Bicarbonate causing Lactic Acid to be secreted out of Muscle Fibers and neutralized).

Musculoskeletal System
Bicarbonate may help to prevent and treat Osteoporosis.
Bicarbonate may Inhibit these Potentially Toxic Substances
Organic Acids
Bicarbonate may help to prevent the Muscle Weakness and Fatigue caused by the excessive accumulation of Lactic Acid in the Muscles during prolonged Exercise (Bicarbonate causes Lactic Acid to be secreted out of Muscle Fibers and neutralized).

Forms of Bicarbonate
Magnesium Bicarbonate consists of Magnesium bound to Bicarbonate. It is only present in Water and is never present in a solidified form. It is responsible for the “hardness” of Water. Potassium Bicarbonate (KHCO3) consists of Potassium bound to Bicarbonate. Sodium Bicarbonate (also known as Baking Soda, Sodium Acid Carbonate, Sodium Hydrogen Carbonate) consists of 32.5% Sodium bound to 67.5% Bicarbonate.

Dosage Recommendations
The usual dosage of Bicarbonate used by people seeking to prevent Muscle Weakness during prolonged Exercise and to accelerate Muscle recovery after prolonged Exercise is 300 - 400 mg per kg of body weight (this would equate to an average dosage of 25 grams).
Hydrochloric Acid

Hydrochloric Acid is a strong Mineral Acid produced by the Parietal Cells of the Stomach. It comprises 0.2% - 0.5% of Gastric Juice.

Biological Functions and Therapeutic Uses of Hydrochloric Acid

Digestive System
Hydrochloric Acid regulates the acidity of the Stomach to optimize Digestion. This occurs primarily through Hydrochloric Acid stimulating the conversion of Pepsinogen to Pepsin (a Proteolytic (Protein- digesting) Enzyme).

Immune System
Hydrochloric Acid may destroy some Detrimental Microorganisms that gain entrance into the body via the Mouth: references
- Hydrochloric Acid may kill some forms of Detrimental Bacteria in the Stomach and Small Intestine:
- Hydrochloric Acid is likely to be important in suppressing Campylobacter jejuni.
- Hydrochloric Acid may suppress or kill Helicobacter pylori (Hypochlorhydria (lack of Hydrochloric Acid) patients have increased levels of Helicobacter pylori).

Oral Health
Hydrochloric Acid deficiency may cause Periodontal Disease (by decreasing the absorption of Calcium in the Alveolar Bone).

Skin
Supplemental Hydrochloric Acid may be useful for the treatment of Hives (as many cases of Hives are believed to occur as a result of Food Allergies resulting from insufficient endogenous production of Hydrochloric Acid).
Vitiligo patients are often found to have sub-optimal levels of Hydrochloric Acid in their Stomachs and replenishment of Hydrochloric Acid (15 cc with each meal) has resulted in many cures of Vitiligo.
Nitric Acid
Phosphoric Acid
Sulfurous Acid

In Obesity Epidemic, What’s One Cookie?

2010-03-02T12:01:00.001-08:00

March 1, 2010, 5:08 pm

By TARA PARKER-POPE
Stuart Bradford

The basic formula for gaining and losing weight is well known: a pound of fat equals 3,500 calories.

That simple equation has fueled the widely accepted notion that weight loss does not require daunting lifestyle changes but “small changes that add up,” as the first lady, Michelle Obama, put it last month in announcing a national plan to counter childhood obesity.

In this view, cutting out or burning just 100 extra calories a day — by replacing soda with water, say, or walking to school — can lead to significant weight loss over time: a pound every 35 days, or more than 10 pounds a year.

While it’s certainly a hopeful message, it’s also misleading. Numerous scientific studies show that small caloric changes have almost no long-term effect on weight. When we skip a cookie or exercise a little more, the body’s biological and behavioral adaptations kick in, significantly reducing the caloric benefits of our effort.

But can small changes in diet and exercise at least keep children from gaining weight? While some obesity experts think so, mathematical models suggest otherwise.
Saul Loeb/Agence France-Presse — Getty Images The first lady, Michelle Obama, spoke last month at the White House about her “Let’s Move” initiative, which aims to change the way children eat and play.

As a recent commentary in The Journal of the American Medical Association noted, the “small changes” theory fails to take the body’s adaptive mechanisms into account. The rise in children’s obesity over the past few decades can’t be explained by an extra 100-calorie soda each day, or fewer physical education classes. Skipping a cookie or walking to school would barely make a dent in a calorie imbalance that goes “far beyond the ability of most individuals to address on a personal level,” the authors wrote — on the order of walking 5 to 10 miles a day for 10 years.

This doesn’t mean small improvements are futile — far from it. But people need to take a realistic view of what they can accomplish.

“As clinicians, we celebrate small changes because they often lead to big changes,” said Dr. David Ludwig, director of the Optimal Weight for Life program at Children’s Hospital Boston and a co-author of the JAMA commentary. “An obese adolescent who cuts back TV viewing from six to five hours each day may then go on to decrease viewing much more. However, it would be entirely unrealistic to think that these changes alone would produce substantial weight loss.”

Why wouldn’t they? The answer lies in biology. A person’s weight remains stable as long as the number of calories consumed doesn’t exceed the amount of calories the body spends, both on exercise and to maintain basic body functions. As the balance between calories going in and calories going out changes, we gain or lose weight.

But bodies don’t gain or lose weight indefinitely. Eventually, a cascade of biological changes kicks in to help the body maintain a new weight. As the JAMA article explains, a person who eats an extra cookie a day will gain some weight, but over time, an increasing proportion of the cookie’s calories also goes to taking care of the extra body weight. Eventually, the body adjusts and stops gaining weight, even if the person continues to eat the cookie.

Similar factors come into play when we skip the extra cookie. We may lose a little weight at first, but soon the body adjusts to the new weight and requires fewer calories.

Regrettably, however, the body is more resistant to weight loss than weight gain. Hormones and brain chemicals that regulate your unconscious drive to eat and how your body responds to exercise can make it even more difficult to lose the weight. You may skip the cookie but unknowingly compensate by eating a bagel later on or an extra serving of pasta at dinner.

“There is a much bigger picture than parsing out the cookie a day or the Coke a day,” said Dr. Jeffrey M. Friedman, head of Rockefeller University’s molecular genetics lab, which first identified leptin, a hormonal signal made by the body’s fat cells that regulates food intake and energy expenditure. “If you ask anyone on the street, ‘Why is someone obese?,’ they’ll say, ‘They eat too much.’ ”

“That is undoubtedly true,” he continued, “but the deeper question is why do they eat too much? It’s clear now that there are many important drivers to eat and that it is not purely a conscious or higher cognitive decision.”

This is not to say that the push for small daily changes in eating and exercise is misguided. James O. Hill, director of the Center for Human Nutrition at the University of Colorado Denver, says that while weight loss requires significant lifestyle changes, taking away extra calories through small steps can help slow and prevent weight gain.

In a study of 200 families, half were asked to replace 100 calories of sugar with a noncaloric sweetener and walk an extra 2,000 steps a day. The other families were asked to use pedometers to record their exercise but were not asked to make diet changes.

During the six-month study, both groups of children showed small but statistically significant drops in body mass index; the group that also cut 100 calories had more children who maintained or reduced body mass and fewer children who gained excess weight.

The study, published in 2007 in Pediatrics, didn’t look at long-term benefits. But Dr. Hill says it suggests that small changes can keep overweight kids from gaining even more excess weight.

“Once you’re trying for weight loss, you’re out of the small-change realm,” he said. “But the small-steps approach can stop weight gain.”

While small steps are unlikely to solve the nation’s obesity crisis, doctors say losing a little weight, eating more heart-healthy foods and increasing exercise can make a meaningful difference in overall health and risks for heart disease and diabetes.

“I’m not saying throw up your hands and forget about it,” Dr. Friedman said. “Instead of focusing on weight or appearance, focus on people’s health. There are things people can do to improve their health significantly that don’t require normalizing your weight.”

Dr. Ludwig still encourages individuals to make small changes, like watching less television or eating a few extra vegetables, because those shifts can be a prelude to even bigger lifestyle changes that may ultimately lead to weight loss. But he and others say that reversing obesity will require larger shifts — like regulating food advertising to children and eliminating government subsidies that make junk food cheap and profitable.

“We need to know what we’re up against in terms of the basic biological challenges, and then design a campaign that will truly address the problem in its full magnitude,” Dr. Ludwig said. “If we just expect that inner-city child to exercise self-control and walk a little bit more, then I think we’re in for a big disappointment.”

Rising Threat of Infections Unfazed by Antibiotics

2010-03-02T11:57:00.000-08:00

February 27, 2010

By ANDREW POLLACK

A minor-league pitcher in his younger days, Richard Armbruster kept playing baseball recreationally into his 70s, until his right hip started bothering him. Last February he went to a St. Louis hospital for what was to be a routine hip replacement.

By late March, Mr. Armbruster, then 78, was dead. After a series of postsurgical complications, the final blow was a bloodstream infection that sent him into shock and resisted treatment with antibiotics.

“Never in my wildest dreams did I think my dad would walk in for a hip replacement and be dead two months later,” said Amy Fix, one of his daughters.

Not until the day Mr. Armbruster died did a laboratory culture identify the organism that had infected him: Acinetobacter baumannii.

The germ is one of a category of bacteria that by some estimates are already killing tens of thousands of hospital patients each year. While the organisms do not receive as much attention as the one known as MRSA — for methicillin-resistant Staphylococcus aureus — some infectious-disease specialists say they could emerge as a bigger threat.

That is because there are several drugs, including some approved in the last few years, that can treat MRSA. But for a combination of business reasons and scientific challenges, the pharmaceuticals industry is pursuing very few drugs for Acinetobacter and other organisms of its type, known as Gram-negative bacteria. Meanwhile, the germs are evolving and becoming ever more immune to existing antibiotics.

“In many respects it’s far worse than MRSA,” said Dr. Louis B. Rice, an infectious-disease specialist at the Louis Stokes Cleveland V.A. Medical Center and at Case Western Reserve University. “There are strains out there, and they are becoming more and more common, that are resistant to virtually every antibiotic we have.”

The bacteria, classified as Gram-negative because of their reaction to the so-called Gram stain test, can cause severe pneumonia and infections of the urinary tract, bloodstream and other parts of the body. Their cell structure makes them more difficult to attack with antibiotics than Gram-positive organisms like MRSA.

Acinetobacter, which killed Mr. Armbruster, came to wide attention a few years ago in infections of soldiers wounded in Iraq.

Meanwhile, New York City hospitals, perhaps because of the large numbers of patients they treat, have become the global breeding ground for another drug-resistant Gram-negative germ, Klebsiella pneumoniae.

According to researchers at SUNY Downstate Medical Center, more than 20 percent of the Klebsiella infections in Brooklyn hospitals are now resistant to virtually all modern antibiotics. And those supergerms are now spreading worldwide.

Health authorities do not have good figures on how many infections and deaths in the United States are caused by Gram-negative bacteria. The Centers for Disease Control and Prevention estimates that roughly 1.7 million hospital-associated infections, from all types of bacteria combined, cause or contribute to 99,000 deaths each year.

But in Europe, where hospital surveys have been conducted, Gram-negative infections are estimated to account for two-thirds of the 25,000 deaths each year caused by some of the most troublesome hospital-acquired infections, according to a report released in September by health authorities there.

To be sure, MRSA remains the single most common source of hospital infections. And it is especially feared because it can also infect people outside the hospital. There have been serious, even deadly, infections of otherwise healthy athletes and school children.

By comparison, the drug-resistant Gram-negative germs for the most part threaten only hospitalized patients whose immune systems are weak. The germs can survive for a long time on surfaces in the hospital and enter the body through wounds, catheters and ventilators.

What is most worrisome about the Gram-negatives is not their frequency but their drug resistance.

“For Gram-positives we need better drugs; for Gram-negatives we need any drugs,” said Dr. Brad Spellberg, an infectious-disease specialist at Harbor-U.C.L.A. Medical Center in Torrance, Calif., and the author of “Rising Plague,” a book about drug-resistant pathogens. Dr. Spellberg is a consultant to some antibiotics companies and has co-founded two companies working on other anti-infective approaches. Dr. Rice of Cleveland has also been a consultant to some pharmaceutical companies.

Doctors treating resistant strains of Gram-negative bacteria are often forced to rely on two similar antibiotics developed in the 1940s — colistin and polymyxin B. These drugs were largely abandoned decades ago because they can cause kidney and nerve damage, but because they have not been used much, bacteria have not had much chance to evolve resistance to them yet.

“You don’t really have much choice,” said Dr. Azza Elemam, an infectious-disease specialist in Louisville, Ky. “If a person has a life-threatening infection, you have to take a risk of causing damage to the kidney.”

Such a tradeoff confronted Kimberly Dozier, a CBS News correspondent who developed an Acinetobacter infection after being injured by a car bomb in 2006 while on assignment in Iraq. After two weeks on colistin, Ms. Dozier’s kidneys began to fail, she recounted in her book, “Breathing the Fire.”

Rejecting one doctor’s advice to go on dialysis and seek a kidney transplant, Ms. Dozier stopped taking the antibiotic to save her kidneys. She eventually recovered from the infection.

Even that dire tradeoff might not be available to some patients. Last year doctors at St. Vincent’s Hospital in Manhattan published a paper describing two cases of “pan-resistant” Klebsiella, untreatable by even the kidney-damaging older antibiotics. One of the patients died and the other eventually recovered on her own, after the antibiotics were stopped.

“It is a rarity for a physician in the developed world to have a patient die of an overwhelming infection for which there are no therapeutic options,” the authors wrote in the journal Clinical Infectious Diseases.

In some cases, antibiotic resistance is spreading to Gram-negative bacteria that can infect people outside the hospital.

Sabiha Khan, 66, went to the emergency room of a Chicago hospital on New Year’s Day suffering from a urinary tract and kidney infection caused by E. coli resistant to the usual oral antibiotics. Instead of being sent home to take pills, Ms. Khan had to stay in the hospital 11 days to receive powerful intravenous antibiotics.

This month, the infection returned, sending her back to the hospital for an additional two weeks.

Some patient advocacy groups say hospitals need to take better steps to prevent such infections, like making sure that health care workers frequently wash their hands and that surfaces and instruments are disinfected. And antibiotics should not be overused, they say, because that contributes to the evolution of resistance.

To encourage prevention, an Atlanta couple, Armando and Victoria Nahum, started the Safe Care Campaign after their 27-year-old son, Joshua, died from a hospital-acquired infection in October 2006.

Joshua, a skydiving instructor in Colorado, had fractured his skull and thigh bone on a hard landing. During his treatment, he twice acquired MRSA and then was infected by Enterobacter aerogenes, a Gram-negative bacterium.

“The MRSA they got rid of with antibiotics,” Mr. Nahum said. “But this one they just couldn’t do anything about.”

New York Times

It's not what you eat, but when you eat

2010-02-18T07:37:00.000-08:00

Submitted by Armen Hareyan on Dec 22nd, 2009

If you have struggled with your weight for a long time, you probably blame your diet failures on a lack of willpower. Let me tell you, willpower has nothing to do with it. I’d wager that the problem isn’t what you eat, it’s when you eat it. Our circadian rhythms regulate our eating patterns. In simple terms, our eating patterns are screwed up. Think of jet lag, only with food.

Most overweight people become out of sync because they either skip breakfast or they eat too little in the morning. They go against their body’s actual needs (fuel in the morning) and make up for it by over-fueling later.

When your body awakens from its eight-hour slumber, it is primed to seek food. Your metabolism is revved up, and levels of certain hormones (cortisol and adrenaline) are at their highest. Your brain needs energy (glucose) immediately.

If you don’t break your eight-hour fast or you eat too little, your brain needs to find another source of fuel. So it activates an emergency system that pulls energy from muscle and destroys muscle tissue in the process. Then when you eat later, the body and brain are still in high-alert mode, so the body saves energy from the food as fat.

Compounding the problem, serotonin levels are highest in the morning. This means that you’re least likely to crave sweets and starches when you first wake up, and you may not feel much like eating. But as the day wears on, serotonin levels dip and the cravings kick in. If you eat these foods, brain serotonin rises, and you begin to associate good feelings with them. This connection between carbs and calm creates an addictive cycle.

People who skip breakfast or engage in other out-of-sync eating behaviors (see box above) set themselves up for metabolic disaster. Their metabolism sputters. They’re plagued by midafternoon fatigue and/or moodiness, so they rev up or unwind with candy bars and sugary coffee drinks. Their bodies burn less of what they eat as fuel and store more of it as body fat. Their bodies lose muscle and gain fat - lots of it.

The Big Breakfast Diet: Eat Big Before 9 A.M. and Lose Big for Life
Written by Daniela Jakubowicz MD
Publisher: Workman Publishing Company (December 15, 2009)
ISBN-10: 0761154930

FISH OIL CAN FIGHT DENTAL DISEASE

2010-02-09T14:19:00.000-08:00

Published Date: 09 February 2010
The discovery of a new natural weapon against dental disease has been welcomed by the UK's leading oral health information charity.
Following a five-year study involving elderly participants in Japan, fish oil has been found to help combat mouth infection and boost oral health in the process.

Dental examinations revealed that a lack of the essential omega-3 fatty acids found
in fish oil in people's diets had strong links with the progression of periodontal (gum) disease.

The new findings, recently published in the Nutrition journal, also revealed that omega-3 fatty acids were strongly effective against a range of oral bacteria.

This news comes in light of similar findings from a US National Institute for Health-sponsored study. Lead author Dr C.B. Huang, from the Oral Health Research Centre at the University of Kentucky's College of Dentistry, commented on the dental health benefits of fish oil.
"The anti-bacterial part of the omega-3 fatty acids could be very important. Certainly, it could be a potential new use of omega-3 fatty acids in the future."

Following these recent journal* findings, Dr. Huang confirmed that ongoing research into anti-bacterial activity would include investigating products such as chewing gum.

In light of the news of these beneficial oral health effects, the British Dental Health Foundation Chief Executive, Dr. Nigel Carter BDS LDS (RCS), commented: "These findings illustrate how the consequences of our diet can be linked to gum disease, the most common dental hygiene issue.There are hundreds of bacteria in our mouths at any one time that contribute to gum disease, which not only threatens tooth loss but, significantly, overall health.

"A healthy mouth can lead to a healthy body so a good oral healthcare routine, including brushing teeth twice a day with a fluoride toothpaste and making regular visits to the dentist are just as important as a healthy, balanced diet."

With evidence of a poor diet linked to a third of all cancer cases, Dr. Carter also stressed: "Eating fish can help lower the risk of cancer, as can an increase in eggs, fruit and vegetables."

The Foundation encourages members of the public with any concerns about the effects of their diet on their teeth to contact the National Dental Helpline on 0845 063 1188.

Self–examination is another simple way of looking after yourself. The Foundation, who run a Mouth Cancer Action Month campaign each November, encourage all members of the public to check their mouths regularly for ulcers which do not heal within three weeks, red and white patches in the mouth and unusual lumps and swellings in the mouth and neck.

*Source: Molecular Oral Microbiology, Volume 25 Issue 1, pages 75-80 "A novel bioactivity of omega-3 polyunsaturated fatty acids and their ester derivatives" Authors: C.B. Huang, J.L Ebersole
ENDS

Study: Soda drinkers at increased risk of pancreatic cancer

2010-02-08T08:25:00.000-08:00

A study published today in the journal Cancer Epidemiology, Biomarkers & Prevention finds that people who drink two caloric soft drinks a week have nearly double the risk of developing pancreatic cancer when compared to those who drink less.

The research tracked 60,524 men and women in the Singapore Chinese Health Study for 14 years and found that the soft-drinkers increased their risk of contracting the deadly cancer by 87 percent. The relationship held up even when smoking and a handful of other habits were taken into account. The study did not look at consumption of diet soda; soft drinks were defined as "sugar-sweetened carbonated beverages."

The study, funded by the National Cancer Institute, notes that lifestyles in Singapore have much in common with those in the U.S. and that the findings should apply to Caucasians as well as to the Asians who were tracked.

Lead author Mark Pereira, an associate professor in the School of Public Health at the University of Minnesota, suggests that the high level of sugar in sodas may boost insulin levels in the body, which in turn might spur the development of pancreatic cancer cells.

But no such connection was found between drinking fruit juices, whose sugar content often matches that of soft drinks.

The findings, while provocative and frightening, could use some perspective. First, the total number of pancreatic cancer cases found over the 14 years of the study was just 140. Of those, 18 occurred among people who'd reported consuming two or more sodas per week, and 12 among those who drank less than two; 110 occurred in people who'd reported drinking no soda.

The study acknowledges that those small numbers might make the association a little more tenuous, "limiting the power" of the data and "giving potential to a chance association." It also cites four earlier studies that examined the soda-pancreatic cancer link that came to varying conclusions, including finding no link at all to finding an association for women but not for men.

Speaking on behalf of the American Beverage Association, consultant Richard H. Adamson said, "The study is, in my opinion, a weak study." Adamson, former vice president for science and technical affairs for the beverage association and, before that, a researcher at the National Cancer Institute, says that the study was "very small with regard to number of cases" of pancreatic cancer for major conclusions to be drawn from its data.

Further, Adamson says, the researchers didn't correct for other known pancreatic-cancer risk factors such as chronic pancreatitis, high-fat diet, workplace exposure to chemicals or gender (males are much more likely to get this cancer than females). The fact that the association didn't hold for juice raises questions, he said, as the sucrose in Singapore soft drinks "breaks down into the same thing that's in juice."

In the end, Adamson said, "The study doesn't scare me. I continue to drink soft drinks."

I'm not a soda drinker, and this study doesn't inspire me to start sipping. But while many public-health advocates believe we'd all be better off without soda in our lives, I'm not sure that if I did enjoy soda I'd stop drinking on the basis of this study alone. Because pancreatic cancer is relatively rare, even doubling your risk leaves your individual risk pretty low.

On the other hand, given the grim prospects for surviving pancreatic cancer (fewer than 5 percent of those diagnosed are alive after five years), and that fact that there's no screening test and very few treatment options, anything we can do to reduce our risk might be worth considering.

How about you? Are you a soda drinker? Does this study make you inclined to cut back?

For more health news, please follow me on Twitter! http://twitter.com/jhuget.

washingtonpost.com

By Jennifer LaRue Huget | February 8, 2010; 12:05 AM ET

Categories: Cancer , Nutrition and Fitness

Mastering The Mystery Of Sleep

2010-02-03T10:35:00.000-08:00

Dr. Joseph Mercola

Posted: February 3, 2010 09:05 AM

Sleep is one of the great mysteries of life. Like gravity or the quantum field, sleep is so fundamental that scientists still don't know exactly what it is. We are learning more about sleep every day, but we still don't understand exactly why we sleep at all. (1)

This report will not solve the mystery of sleep, but will seek to show you how you can get into harmony with the natural cycles of your own brain and body. There is no better example of optimal wellness than to be in harmony with your deepest function: sleep.

The first step is to value sleep as one of your most precious resources for health and happiness. If you do that, you could figure out all the other things that would help you to sleep really well. So the bulk of this report will be all about that first step...but you will also get some of my favorite tips.

Sleep Is an Active Process

We used to think the brain simply shut down for a rest once a day. But the brain doesn't shut down at all during sleep...not like it does under general anesthesia or in a coma. (2) Sleep is an active process, which might better be described as a deeper form of consciousness than as a lack of it.

In fact, there are respected spiritual traditions that describe deep sleep as a vast field of consciousness without content. (3) And advanced meditators have done their thing wired to an EEG machine. Guess what? They go right into slow high amplitude brain waves all over the cortex. (4) They are sitting there on a cushion with the EEG of dreaming or even of deep sleep...and then proceed to describe their experience. (5)

Sleep Away Stress

Did you know that good sleepers and poor sleepers experience about the same number of daily minor stressful events? But good sleepers are less disturbed by these events. (6) Poor sleepers experience both their minor and major life events as being more negative than do good sleepers.

Scientists call this mindset "negative affective reactivity." They can actually predict whether or not a person will rate an upcoming event as being emotionally negative just by looking at the person's brain waves ahead of time. (7) High frequency brain waves on EEG, particularly in the right prefrontal cortex, are a sign of negative emotional arousal. The problem with high neurological arousal is that it can turn into a bad habit. An overly aroused right prefrontal cortex calls for the release of cortisol and other stress steroids that initially help the body in stress.

But continuous high levels of these powerful hormones ultimately cause some of our most serious health concerns...including heart attack and stroke.

Does Stress Cause Poor Sleep, or Does Poor Sleep Cause Stress? Answer: YES

We've known for quite some time, that activation of the hypothalamic-pituitary-adrenal axis increases arousal and causes sleeplessness.

Stress causes poor sleep. And research shows that insomniacs do have elevated cortisol in the middle of the night, when cortisol should be at its lowest. (8) Conversely, poor sleep causes stress. But more recently, researchers have discovered that good quality sleep the night before a stressful event can protect you from negative health consequences. Even though you will still encounter stressful events in your life, good quality sleep gives you better brain chemistry to deal with those events.

Would that be of value to you?

Would Enhancing Your Immune System be of Value?

What is true for brain chemistry is also true for the immune system. Ordinarily, a stressful event will trigger the release of natural killer cells, but in one study, women whose sleep was interrupted for just one night prior to a stressful event had significantly weaker immune responses. (9) The poor sleepers failed to recover from the stress as well as those who slept well.

And researchers have found that less time spent dreaming (REM sleep) was associated with higher evening cortisol levels for healthy men of all ages. (10)

Sleeping Well Can Protect You from Stress Induced Depression ... and a Variety of other Mood Disorders

Serotonin is an important brain neurotransmitter. Altered serotonin activity has been associated with a host of problems such as aggressive and angry behaviors, clinical depression, obsessive-compulsive disorder, migraine, irritable bowel syndrome, tinnitus, fibromyalgia, bipolar disorder, and anxiety disorders. (11)

In a study reported in Journal of Sleep Research, stress plus restricted sleep caused serotonin receptors in the brain to become less sensitive, while stress following sleep had no such negative effect. (12) It is not known how sleep provided this beneficial influence on brain chemistry.

Sleep Improves Performance and Memory

Whenever you are trying to learn something new, such as important information or a new skill--and especially if you are going to be tested on it--please get good quality sleep after the training period and before the test.

In a very interesting study, there were two groups of individuals who trained for a new keyboard skill and were tested on it 12 hours later. One group trained at 10 AM and was tested at 10 PM. The other group trained at 10 PM and was tested the next morning at 10 AM ... after sleep.

Guess what? Sleep increased motor speed by 20 percent without loss of accuracy. (13) Remember, group one was not impaired in any way. You might have thought they would do better having trained when they were fresh in the morning. But sleep proved to be the valuable variable.

Would a 20 percent Increase in Performance be Useful to You?

Sleep is absolutely essential for long-term memory formation and more. You may have heard that everything you have ever seen, heard, tasted, smelled, or touched is recorded in your unconscious mind. Actually, that is false. The vast majority of sensory input is deleted and lost forever. Only the information your brain recognizes as important to your life ever makes it into your memory. Even then, the important stuff is held in temporary memory only until you sleep on it. (14)

Valuable new information and valuable new skills are added to your long-term memory -- only during sleep . But sleep takes it one step further ... While you are sleeping, your brain integrates the day's new information along with existing memories and in light of your values, your goals, and your purpose. That is why I have strongly suggested, in my paper on goal setting, that you do a visualization exercise on your goals just before going to bed each night.

How to Get Your Brain to Solve Problems While You Sleep!

Do you remember how the phrase, "think outside the box" got started? It came from the nine dots puzzle, where you had to connect three rows of three dots forming a square. You had to connect all the dots without lifting the pencil off the paper. (15) The solution requires an insight: you have to extend your lines beyond the box formed by the dots. You have to "think outside the box" to solve the puzzle.

In research involving a similar task, progress could be made in two ways. Slow and laborious-- or with sudden insight. Subjects who slept for eight hours after being presented with the puzzle were twice as likely to gain the key insight. (16) Valuable information, isn't it? Now you know why visualization before sleep works so well. While you are sleeping, your brain searches for new ways to view the information you gained during the day. And it does so according to the vision you provide during the visualization.

Are you starting to get the idea?

Sleep is a precious resource, and you are learning how to get into harmony with it...to neutralize stress, improve your mood, boost your performance and memory, and gain valuable insight into whole new possibilities for your life!

What else could you possibly ask for?

How About Sleeping Away Those Extra Pounds? If you're like most people in modern society, you have to keep an eye on your weight. Americans alone spend $35 billion (each year) on weight-loss products. (17) And what do we have to show for it? 119 million Americans are overweight or obese. And 64 percent are losing the body fat battle.(18) Why? America's trend toward obesity just happens to match its trend toward voluntary sleep restriction. And 70 to 75 percent of Americans report having one or more persistent symptoms of dis-harmonious sleep. (19, 20)

Any connection between obesity and sleep loss?

It turns out sleep-loss is a double whammy for anyone looking to shed pounds because of two hormones that regulate hunger and appetite. Cells in the lining of your stomach secrete the hormone ghrelin. Ghrelin travels to your brain and gives you the urge to eat. Leptin does just the opposite. Fat cells produce it when you've had enough to eat. Leptin in you bloodstream gives you the feeling of satiety. It's a good thing if you're trying to lose weight.

Just two days of restricted sleep caused an 18 percent decrease in plasma leptin levels and a 28 percent increase in ghrelin levels in young healthy men. (21) The result was increased hunger and an appetite for carbs. Definitely not good if you're trying to lose weight.

So in addition to regular exercise and eating according to your metabolic type, getting enough good quality sleep is extremely valuable for maintaining your ideal weight .

Good Sleep Helps Prevent Diabetes Mellitus and Metabolic Syndrome

In one clinical experiment, healthy young men were restricted to just four hours of sleep for six nights and then allowed to recover for six nights. During the sleep-debt period thyroid function went down, while cortisol levels and sympathetic activity went up. (22) But the most important finding in the study was that glucose tolerance tanked during the temporary sleep debt. So chronic sleep-loss could be expected to contribute to the onset of diabetes. (23) And indeed, when a group of men were followed from roughly 1988 through 2004, those who got only five and six hours of sleep per night were twice as likely to develop diabetes. (24)

Poor sleep was associated with a 44 percent increase in the odds of having pre-diabetes among 210 volunteers averaging 46 years of age. (25) Metabolic syndrome is not only the precursor to diabetes, but also to high blood pressure, cardiovascular disease, and other life-threatening diseases. Sleep is a valuable means to combat these problems as well.

Sleeping Well Could Save Your Life

Sleeping too little or too much increases your chances of dying from all causes by up to 15 percent. (26) People who have normal sleep patterns get less cancer. (27) For every hour a woman sleeps more than the recommended seven to eight hours per night, the chances of her getting breast cancer go up by six percent. (28)

Tumors grew two to three time faster in laboratory animals with severe circadian rhythm dysfunction. (29) And working the night shift robbed nurses of a normal dose of melatonin, a powerful anti-oxidant known to protect DNA. The research suggests a correlation between decreased melatonin, elevated estrogen, and the observed higher incidence of breast cancer among night shift nurses. (30)

Your chances of having a heart attack go up by 45 percent if you sleep five hours a night or less, and by 38 percent if you sleep more than nine hours a night. (31)

Getting either too much sleep or too little sleep are both out of harmony with a natural circadian rhythm. Likewise, shift workers run a much higher risk of heart attack as compared to people whose waking and sleeping hours are more normal. (32) Having to change shifts frequently and having to sleep during daylight hours are quite damaging -- possibly even deadly. Here is another interesting study: healthy subjects restricted to 4 hours sleep had 8 hours of high blood pressure the next day. Good quality sleep resulted in normal blood pressure the next day in the control group. (33)

Sleep is valuable here again because the hormone melatonin signals the entire body to shift from daytime running-around mode into night-time healing mode. Melatonin, which is secreted only in total darkness, also stimulates the nighttime release of another equally valuable hormone -- growth hormone. (34)

Sleep and Grow Younger?

Another great benefit of sleep is the nightly release of growth hormone. Growth hormone is vital for normal development of children, but it has wonderfully beneficial effects in adults as well:

• Makes your bones stronger

• Increases your muscle mass through the creation of new muscle cells

• Promotes lipolysis, which helps you lose body fat

• Increases protein synthesis and stimulates optimal maintenance
of all internal organ

• Supports your pancreas' ability to make insulin

• Stimulates your immune system.

All together, growth hormone makes you look and feel younger. Which is why you hear so much about supplements containing growth hormone precursors, and why professional body builders and athletes sometimes risk injecting synthetic growth hormone in artificially high amounts. But you already have a natural way to get your very own growth hormone delivered in just the right concentration at just the right time, every night...if you sleep well.

Growth hormone is released from your pituitary gland just as you enter the deep sleep part of your normal sleep cycle. (35)

A normal sleep cycle goes from light sleep into deep sleep and then back out to the lighter dreaming REM sleep. Most people have about four of these cycles during an optimal seven to eight hour night's sleep. But if you stay up to watch Letterman and still have to get up at 6 AM...you just performed your own voluntary sleep deprivation experiment on yourself. And you just cut your normal dose of growth hormone in half. And you wonder why you feel old on some mornings? It could be because you're hung over with yesterday's half-repaired cellular damage.

Sleep is for re-growing all the tissues of your body so you can feel and be ready to go in the morning. But you need to value sleep enough to go to bed. Now You Know Why I Believe Sleep Belongs at the Very Top of Your List -- Every Day

If you want to maximize your health and effectiveness, live long and be fulfilled in your purpose, try as many of these 33 strategies as possible:

• Review all the benefits you get from sleep--and put it at the top of your list. Value sleep highly as the magical resource it is for you. Whether you consider sleep to be a purely physiological function or a more spiritual encounter with your deeper consciousness...value it highly.

• Go to bed around the same time each night, ideally around 10 PM. But take time before that to prepare. Some researchers even feel that every hour of sleep before midnight is equal to two hours of sleep after midnight.

• Create your own pre-sleep ritual that goes beyond your normal teeth brushing and other practical activities. Make this a special time to set the tone for your journey into deep consciousness. Light candles, read inspirational or spiritual literature, and let your mind consider the big picture.

• Take some time to visualize how you would like tomorrow to be for you. See, hear, and feel what it will be like when you reach your goals. Connect with your overall mission and purpose. Remember, this will tell your brain which of the data stored in temporary memory should be flagged for transfer into longterm memory. New insights may be waiting for you in the morning.

• Create a morning ritual designed to capture these insights, perhaps a special journal on your bedside table. Taking time to record any impressions upon awakening sends a powerful message to your deep consciousness. It says you do in fact value the entire sleep process. It also says you expect results.

• Design your bedroom primarily to support good sleep. Keep it clean and uncluttered...no overflow storage in there, please. Get high quality linens and pillows. Sleep is far more important than half the things you spend money on now. Have complete control of the lighting in your bedroom. Be able to make the room totally dark.

• Avoid turning on the light if you have to go to the bathroom. Any bright light will shut off melatonin production.

• Listen to white noise or relaxation CDs. Some people find the sound of white noise or nature sounds, such as the ocean or forest, to be soothing for sleep.

• If possible try to awaken naturally without the use of an alarm. Your brain will know when it has had enough sleep. Ideally you should wake up with the sunrise. If you must get up before dawn, use a dawn simulator alarm clock which either comes with a light or causes one of your lights to gradually increase in intensity to mimic the rising sun. Many people find these very effective and certainly less disturbing than a loud alarm that can disrupt your adrenal glands and cortisol levels.

• If you must sleep during the day, make the extra effort to completely block all
daylight from your bedroom.

• Dim the lights in your house around 8 PM. Light stimulates the release of
cortisol and shuts down the release of melatonin.

• Stop watching TV or using your computer by 8 PM

• Avoid snacking just before bedtime, particularly grains and sugars. These can raise your blood sugar and inhibit sleep. Then later, when your blood sugar drops, you might wake up and not be able to fall back asleep.

• Keep the temperature in your bedroom no higher than 70 degrees F.

• Wear socks to bed. Due to the fact that they have the poorest circulation, the
feet often feel cold before the rest of the body.

• Eat a high-protein snack several hours before bed. This can provide L-tryptophan, a precursor to melatonin and serotonin.

• Talk to your doctor about reducing or avoiding as many drugs as possible. Many medications, both prescription and over-the-counter, may have effects on sleep.

• Avoid caffeine as much as possible.

• Keep electrical devices as far away from the bed as possible so their electromagnetic fields do not interfere with your nervous system.

• Avoid alcohol. Too much alcohol interferes with deep sleep and will prevent you from getting its healing benefits.

• Avoid foods that you are sensitive to.

• Don't drink any fluids within two hours of going to bed so you won't have to get
up to go the bathroom.

• Take a hot bath, shower or sauna before bed if you have trouble falling asleep.

• Journaling may be helpful if you often lay in bed with your mind racing. Writing you thoughts down may allow you to let go of your concerns before bed.

• Lose weight. Being overweight can increase the risk of sleep apnea, which will
prevent a restful night's sleep.

• Remove your clock from view. It will only add to your worry when constantly
staring at it...2 AM...3 AM...4:30 AM...

• Keep your bed for sleeping. If you are used to watching TV or doing work in bed, you may find it harder to relax and to think of the bed as a place to sleep.

• Have your adrenals checked by a good natural medicine clinician. Scientists have found that adrenal stress can interfere with sleep.

• If you are menopausal or peri-menopausal, get checked out by a good natural medicine physician. Hormonal changes at this time may cause problems if not properly addressed.

• Don't change your bedtime. You should go to bed, and wake up, at the same times each day, even on the weekends. This will help your body to get into a sleep rhythm and make it easier to fall asleep and get up in the morning.

• Make sure you are exercising regularly. Try to make it part of your morning ritual. Exercising in the evening--within a few hours of sleep--may actually serve to stimulate your nervous system and make it more difficult to easily fall asleep.

• Get help if you need it. If after trying everything we have discussed, you still cannot get good quality sleep, by all means do discuss your problem with your physician.

After experimenting with these strategies, feel free to cross out those that do not make sense
to you. Use the rest as seeds to develop your own style of sleeping. I hope you will continue learning about sleep and how you can improve this important part
of your life.

Pleasant dreams...

References

1. Goode, Erica "Why Do We Sleep? ," New York Times, November 11, 2003

2. "Brain Basics: Understanding Sleep: National Institute of Neurological Disorders and
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5. Wilber, K. One Taste, The Journals of Ken Wilber, pp 75-77. Shambala Boston &
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6. Morin, C.M., Rodrigue, S., & Ivers, H. Role of stress, arousal, and coping skills in
primary insomnia. Psychosomatic medicine, 65(2), 259-67.

7. Sutton, Steven K and Richard J. Davidson "Prefrontal brain electrical asymmetry predicts
the evaluation of affective stimuli." Neuropsychologia 38 (2000) 1723-1733

8. Vgontzas, A.N., Bixler, E.O., Lin, H., Prolo, P., Mastorakos, G., Vela-Bueno, A.,
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86(8), 3787-3794.

9. Wright, C.E., Erblich, J., Valdimarsdottir, H.B., & Bovbjerg, D.H. (2007). Poor sleep
the night before an experimental stressor predicts reduced NK cell mobilization and
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10. Van Cauter, E., Leproult, R., & Plat, L. (2000). Age-Related Changes in Slow Wave
Sleep and REM Sleep and Relationship With Growth Hormone and Cortisol Levels in
Healthy Men. JAMA, 284(7), 861-868.

11. Serotonin--Serotonin Neurotransmitter overview, chemical imbalance and treatment
--Serotonin Level and Balance. http://www.anxiety-and-depression-solutions.com/
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12. Roman, V., et. al. (2006). Differential effects of chronic partial sleep deprivation and
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Research, 15(4), 386-394.

13. Walker, M.P., Brakefield, T., Morgan, A., Hobson, J.A., & Stickgold, R. (2002). Practice
with sleep makes perfect: sleep-dependent motor skill learning. Neuron, 35(1), 205-11.

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15. Thinking outside the box--Wikipedia, the free encyclopedia. Retrieved April 1, 2007,
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16. Wagner, U., Gais, S., Haider, H., Verleger, R., & Born, J. (2004). Sleep inspires insight.
Nature, 427(6972), 352-5.

17. Diet Industry Is Big Business, Americans Spend Billions On Weight-Loss Products Not
Regulated By The Government--CBS News. Retrieved April 1, 2007, from http://www.
cbsnews.com/stories/2006/12/01/eveningnews/main2222867.shtml.

18. Obesity2005Report.pdf (application/pdf Object). Retrieved April 1, 2007, from http://
healthyamericans.org/reports/obesity2005/Obesity2005Report.pdf.

19. Walsleben JA, Norman RG, Novak RD. (1999). Sleep habits of Long Island Rail Road
commuters. Sleep(22), 728-734. Retrieved March 21, 2007.

20. Sleep Facts and Stats--National Sleep Foundation. Retrieved April 1, 2007, from http://
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Stats.htm.

21. Spiegel, K., Tasali, E., Penev, P., & Cauter, E.V. (2004). Brief Communication: Sleep
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Ghrelin Levels, and Increased Hunger and Appetite. Ann Intern Med, 141(11), 846-850.

22. Spiegel K, Leproult R, Cauter E. Impact of sleep debt on metabolic and endocrine
function. Lancet, 1999(354), 1435-1439. Retrieved March 21, 2007.

23. Spiegel, K., Knutson, K., Leproult, R., Tasali, E., & Cauter, E.V. (2005). Sleep loss:
a novel risk factor for insulin resistance and Type 2 diabetes. J Appl Physiol, 99(5),
2008-2019. Retrieved March 30, 2007, from http://jap.physiology.org/cgi/content/
abstract/99/5/2008.

24. Yaggi, H.K., Araujo, A.B., & McKinlay, J.B. (2006). Sleep Duration as a Risk Factor for
the Development of Type 2 Diabetes. Diabetes Care, 29(3), 657-661. Retrieved March
26, 2007, from http://care.diabetesjournals.org/cgi/content/abstract/29/3/657.

25. Jennings, J.R., Muldoon, M.F., Hall, M., Buysse, D.J., & Manuck, S.B. (2007). Selfreported
sleep quality is associated with the metabolic syndrome. Sleep, 30(2), 219-23.

26. Kripke, D.F., Garfinkel, L., Wingard, D.L., Klauber, M.R., & Marler, M.R. (2002). Mortality
associated with sleep duration and insomnia. Archives of general psychiatry, 59(2), 131-6.

27. Sephton, S., & Spiegel, D. (2003). Circadian disruption in cancer: a neuroendocrineimmune
pathway from stress to disease? Brain, behavior, and immunity, 17(5), 321-8.

28. McElroy, J.A., Newcomb, P.A., Titus-Ernstoff, L., Trentham-Dietz, A., Hampton, J.M.,
& Egan, K.M. (2006). Duration of sleep and breast cancer risk in a large populationbased
case-control study. Journal of sleep research, 15(3), 241-9.

29. Filipski, E., King, V.M., Li, X., Granda, T.G., Mormont, M., Liu, X., et al. (2002). Host
circadian clock as a control point in tumor progression. Journal of the National Cancer
Institute, 94(9), 690-7.

30. Schernhammer, E.S., Rosner, B., Willett, W.C., Laden, F., Colditz, G.A., & Hankinson,
S.E. (2004). Epidemiology of urinary melatonin in women and its relation to other
hormones and night work. Cancer epidemiology, biomarkers & prevention: a publication
of the American Association for Cancer Research, cosponsored by the American Society
of Preventive Oncology, 13(6), 936-43.

31. Ayas, N.T., White, D.P., Manson, J.E., Stampfer, M.J., Speizer, F.E., Malhotra, A., et
al. (2003). A prospective study of sleep duration and coronary heart disease in women.
Archives of internal medicine, 163(2), 205-9.

32. Knutsson, A., Hallquist, J., Reuterwall, C., Theorell, T., & Akerstedt, T. (1999). Shiftwork
and myocardial infarction: a case-control study. Occup Environ Med, 56(1), 46-50.

33. Lusardi, P., Mugellini, A., Preti, P., Zoppi, A., Derosa, G., & Fogari, R. (1996). Effects
of a restricted sleep regimen on ambulatory blood pressure monitoring in normotensive
subjects. American journal of hypertension : journal of the American Society of
Hypertension, 9(5), 503-5.

34. Valcavi, R., Zini, M., Maestroni, G.J., Conti, A., & Portioli, I. (1993). Melatonin
stimulates growth hormone secretion through pathways other than the growth hormonereleasing
hormone. Clinical endocrinology, 39(2), 19-9.

35. Takahashi Y, K.D. (1968). Growth hormone secretion during sleep. J Clin Invest, 47(9),
2079-90.

John Pranger: The smoke screen of animal research

2010-02-02T08:40:00.000-08:00

By John Pranger

“The medical establishment has become the major threat to health.”
— Ivan Illich in Limits to Medicine: Medical Nemesis, the Expropriation of Health, 1976

Animals are used by pharmaceutical and chemical companies to test the toxicity of drugs and other substances, including cosmetics, household cleaners, and pesticides—and tobacco. This practice has been regularly criticized by doctors and scientists who maintain that animal testing is unscientific, erroneous, and a danger to human health. It merely performs an alibi function for corporations and governments, who hope to protect themselves thereby from legal liability.

This alibi function was confirmed by James D. Gallagher, then director of medical research for Lederle Laboratories, who complained in the Journal of the American Medical Association in 1964: “Another basic problem which we share as a result of the regulations and the things that prompted them is an unscientific preoccupation with animal studies. Animal studies are done for legal reasons and not for scientific reasons. The predictive value of such studies for man is meaningless—which means our research may be meaningless.”

See also

Abolitionists in animal rights movement push for vegan society

Peter Fricker: Mountain View centre must be accountable for welfare of captive animals

The biological variations between species make the results of experiments done on one species inapplicable to any other species, including humans. In addition to this, the various diseases which plague human beings either do not occur naturally in non-humans or they take on a very different form. Put simply, animals can never have human disease due to the basic biological fact that they are not human.

Cigarette smoking is a factor in many diseases, causing an estimated 443,000 deaths each year in the U.S. alone. Why are cigarettes still legal when they are proven harmful? Epidemiology has shown, for instance, that persons who smoke are far more likely to die of lung cancer than persons who do not smoke. Numerous large population studies have been undertaken, and there is not a single retrospective or prospective controlled study that has failed to show that cigarette smoking causes human lung cancer.

In stark contrast to the consistently positive findings linking cigarette smoking to lung cancer in humans, the results of decades of animal experiments are highly contradictory. Most animal studies have failed to show that cigarettes cause cancer.

Perversely, denying medical facts, researchers are forcing animals to inhale cigarette smoke to this day, no scientists having yet succeeded in causing the human type of lung cancer in animals. In 1975’s The Unseen Fight Against Cancer, Dr. Thelma Brumfield Dunn writes: “the induction of lung cancer by tobacco smoking has not been achieved. Almost every conceivable experiment has been devised to induce lung cancers in animals that would duplicate the lung cancers found in man. Chickens and dogs were made to smoke and to inhale, but no convincing lung cancers developed. Hundreds of mice spent a lifetime in smoke-filled rooms yet no increase in lung cancer was found.”

Because of animal studies’ failure to show that cigarette smoking causes cancer, wider and speedy acceptance of the cigarette-lung cancer theory has been seriously retarded, although it is firmly based on studies of actual human populations. Tobacco companies have used the legal alibi of animal testing to keep their products on the market and to frustrate all attempts at instituting meaningful regulation and public health measures. In 1993, the New York Times quoted sworn testimony of William Campbell, then president and CEO of cigarette manufacturer Phillip Morris USA:

Q: “Does cigarette smoking cause cancer?”

A: “To my knowledge, it’s not been proven that cigarette smoking causes cancer.”

Q: “What do you base that on?”

A: “I base that on the fact that traditionally, there is, you know, in scientific terms, there are hurdles related to causation, and at this time there is no evidence that -- they have not been able to reproduce cancer in animals from cigarette smoking.”

Animal studies are almost unbelievably contrived and crude. Dogs with erections (don’t ask how) were forced to inhale cigarette smoke. Most of the dogs failed to maintain an erection after the smoke was inhaled. In the Journal of Urology in 1987, researchers said this observation lent support to the clinical observation that smoking interfered with a man’s ability to maintain an erection.

Laughable or worrying? Why do we have to give our money to people who conjure up such mad science behind locked doors? Why does government continue funding animal experiments with our taxes in spite of their proven inability to cure or prevent disease?

Nearly a century of tormenting animals with cigarette smoke and what’s the upshot? 5.4 million Canadians are addicted to cigarettes—the leading cause of preventable death—and 45,000 Canadians die from smoking each year and that number is growing. When will the “scientists” be satisfied that smoking is unhealthy and that we don’t need their “confirmation” to know this?

John Pranger is the director of communications for the Animal Defense & Anti-Vivisection Society of British Columbia.

Vitamin D and Endurance Exercise

2009-11-16T14:20:00.000-08:00

Nutrition
November 16 2009
Comments

Low vitamin D levels are very likely limiting your running performance, and may compromise your health.

Written by: Reyana Ewing, MPH, RD, CLE

As runners we want to do everything possible to perform well and have a great season. We are meticulous about our training schedules, hydration, sleeping habits, etc. Yet many times we fall short when it comes to nutrition.

My Story

In the summer of 2008 I started to feel rather lethargic during workouts and I struggled to maintain my normal training paces. My recovery from my harder efforts and long runs took longer than usual. I immediately and incorrectly assumed I had low serum ferritin levels indicating iron deficiency anemia.

One colleague to whom I lamented about my chronic fatigue asked me if I had checked my vitamin D levels. “Vitamin D levels?” I exclaimed. I live in California, it is summer, and I am outside way more than the recommended 20 to 30 minutes a day. There is no way I could be vitamin D deficient, especially since in addition to being exposed to sun most days, I eat a very balanced diet that includes a daily multivitamin supplement. However, a visit to my doctor confirmed that my serum 25–hydroxy-vitamin D (25(OH)D) value was dangerously low (18 ng/ml). Normal levels are between 40-70 ng/ml. And for those with chronic diseases such as cancer, heart disease, diabetes, and multiple sclerosis, normal blood levels should be between 55-70 ng/ml. I was shocked.

I immediately started daily supplementation with 1000 IU of vitamin D (Vitamin D3). After 8 weeks, my 25(OH)D level had improved somewhat (28 ng/ml). I did feel slightly better, but I wanted to recover completely, so I upped my dosage to 2000 IU daily. A few weeks later my levels were within the normal range (56 ng/ml). I felt noticeably stronger and was able to hit my usual paces during training. And in October 2008, I set a half marathon personal record.

Deficiency

This was my very first experience with vitamin D deficiency and I have since learned that vitamin D deficiency is becoming an epidemic worldwide, not only in geographic regions where sun exposure is limited. And my discussions with fellow dietitians working with college runners and professional athletes in generally sunny states (Texas and Florida) confirmed the alarming prevalence of vitamin D deficiency across ethnicity and gender.

Athletes who live in northern latitudes (north of 35 degrees), or use sunscreen consistently, perform their sport indoors, or keep their skin covered are at the greatest risk. Melanin affects the production of vitamin D. So those with more melanin or darker skin produce less vitamin D. Since vitamin D is a fat-soluble vitamin, athletes with fat malabsorption problems such as cystic fibrosis, Crohn’s disease, and celiac disease are at risk for deficiency. Those who have normal levels typically (around 50 ng/ml) live in sub-equatorial Africa and work outdoors for most of the summer.

Once thought of as being primarily involved in bone development, activated vitamin D (calcitriol), a steroid hormone, is responsible for regulating more than 1000 human genes. Almost every cell in the human body has receptors for vitamin D. Recent research shows that vitamin D deficiency increases the risk of different types of cancer (such as breast cancer and prostate cancer), as well as heart disease, diabetes, depression, autoimmune diseases, hypertension, obesity, gum disease, chronic pain, muscle wasting, inflammation, birth defects, osteoporosis, influenza and colds, etc.

Importance for Endurance Athletes

We are only just beginning to understand the complexity and importance of vitamin D in relation to health. Of importance to athletes is the function of vitamin D as it relates to overall health, bone density, innate immunity, muscle wasting, and exercise-related inflammation and immunity. To train and race optimally, an athlete should not have any nutrient deficiencies.

Bone Health:

Deena Kastor, Olympic Marathoner, broke her foot in Beijing during the 2008 Olympic Marathon. It was discovered that her calcium levels were normal, but her 25(OH)D levels were reported to be around 15 ng/ml. And Kastor lives in sunny California. Because of an early scare with skin cancer, she is known to apply sunscreen for all of her outdoor runs, thus limiting her ability to manufacture vitamin D from sun exposure. Even with the extensive research to show vitamin D and calcium’s role in preventing osteoporosis, elite, college, and high school athletes continue to be deficient in one or both nutrient(s). Stress fractures are quite prevalent in runners and yet so preventable.

Increased VO2 max:

German research studies dating back to the 1950s show that athletes exposed to vitamin D-producing ultraviolet light had improved athletic performance. Other studies showed that athletic performance peaked at the end of the summer. Peak performance was also associated with 25(OH)D levels around 50 ng/ml. In addition, maximal oxygen uptake was found to drop when less ultraviolet rays reached the earth, for example, in the late fall. This is particularly a problem for marathoners training through the summer for fall marathons.

Reduced Inflammation:

After intense exercise, endurance athletes experience inflammation due to elevated levels of pro-inflammatory cytokines. Vitamin D reduces the production of these cytokines while increasing the production of anti-inflammatory cytokines, thereby speeding the recovery process between hard workouts.

Improved Immunity:

In a February 2009 study published in the Archives of Internal Medicine, vitamin D3 levels were tested in 19, 000 Americans. Those with low levels of vitamin D had the highest incidence of colds and influenza. This is important information for endurance athletes who strive to balance heavy training loads and staying healthy.

What can be done?
Check 25(OH)D levels regularly and supplement as needed.
Check for total 25(OH)D and not 1, 25(OH)D, which will tell you nothing about your blood stores. Total 25(OH)D reflects all sources of vitamin D – from food, UV energy (photo-production), and supplementation.
Deficient athletes measuring less than 30 ng/ml should supplement with 20,000 IU to

50, 000 IU of vitamin D3 per week for 8 weeks andrecheck serum 25(OH)D until normal values are attained.
Get regular, safe, twice-daily (5-30 minutes) exposure to sun between the hours of 10 am and 3 pm. Note that sunscreen and glass (being indoors) reduce or block UV energy.
Supplement with 1000 IU to 2000 IU of vitamin D3 to maintain normal levels.
For those living or competing in northern latitudes (north of Atlanta, GA) little to no vitamin D production will occur, so consumption of fortified foods and supplements is a necessity.

Food Sources of vitamin D

There aren’t many naturally occurring foods that contain vitamin D. Most of the foods containing vitamin D have been fortified, for example milk and certain juices.

Table 1. Food Sources of Vitamin D FOOD Serving IU per serving *
Fish liver oils (cod liver oil) 1TBSP 1360
Herring, cooked 3 oz 1383
Wild salmon, cooked 3.5 oz 981
Farm salmon, cooked 3.5 oz 249
Tuna, canned in oil 3.5 oz 200
Milk, non fat, reduced fat, whole (fortified) 8 oz 100
Margarine, fortified 1 TBSP 60
Egg 1 whole 18
Beef, liver 3.5 oz 15
Cheese 1 oz 12
*IU = International Units

Dietary Supplement Fact Sheet. National Institute of Health (2007)

Caution

High intakes of vitamin D can cause nausea, vomiting, poor appetite, weakness, and constipation. Current safe upper limits are set at 2000 IU by the National Institute of Health, but there are newer data supporting upper limits as high as 10,000 IU per day.

***

Reyana Ewing. Photo courtesy: Fuel to Move.

Reyana Ewing, MPH, RD, CLE is a registered dietitian, sports dietitian and runner based in Santa Rosa, Calif. Find our more about her at www.fueltomove.com

Brain Power - At the Bridge Table, Clues to a Lucid Old Age

2009-05-24T09:04:00.000-07:00

May 22, 2009

By BENEDICT CAREY
LAGUNA WOODS, Calif. — The ladies in the card room are playing bridge, and at their age the game is no hobby. It is a way of life, a daily comfort and challenge, the last communal campfire before all goes dark.

“We play for blood,” says Ruth Cummins, 92, before taking a sip of Red Bull at a recent game.

“It’s what keeps us going,” adds Georgia Scott, 99. “It’s where our closest friends are.”

In recent years scientists have become intensely interested in what could be called a super memory club — the fewer than one in 200 of us who, like Ms. Scott and Ms. Cummins, have lived past 90 without a trace of dementia. It is a group that, for the first time, is large enough to provide a glimpse into the lucid brain at the furthest reach of human life, and to help researchers tease apart what, exactly, is essential in preserving mental sharpness to the end.

“These are the most successful agers on earth, and they’re only just beginning to teach us what’s important, in their genes, in their routines, in their lives,” said Dr. Claudia Kawas, a neurologist at the University of California, Irvine. “We think, for example, that it’s very important to use your brain, to keep challenging your mind, but all mental activities may not be equal. We’re seeing some evidence that a social component may be crucial.”

Laguna Woods, a sprawling retirement community of 20,000 south of Los Angeles, is at the center of the world’s largest decades-long study of health and mental acuity in the elderly. Begun by University of Southern California researchers in 1981 and called the 90+ Study, it has included more than 14,000 people aged 65 and older, and more than 1,000 aged 90 or older.

Such studies can take years to bear fruit, and the results of this study are starting to alter the way scientists understand the aging brain. The evidence suggests that people who spend long stretches of their days, three hours and more, engrossed in some mental activities like cards may be at reduced risk of developing dementia. Researchers are trying to tease apart cause from effect: Are they active because they are sharp, or sharp because they are active?

The researchers have also demonstrated that the percentage of people with dementia after 90 does not plateau or taper off, as some experts had suspected. It continues to increase, so that for the one in 600 people who make it to 95, nearly 40 percent of the men and 60 percent of the women qualify for a diagnosis of dementia.

At the same time, findings from this and other continuing studies of the very old have provided hints that some genes may help people remain lucid even with brains that show all the biological ravages of Alzheimer’s disease. In the 90+ Study here, now a joint project run by U.S.C. and the University of California, Irvine, researchers regularly run genetic tests, test residents’ memory, track their activities, take blood samples, and in some cases do postmortem analyses of their brains. Researchers at Irvine maintain a brain bank of more than 100 specimens.

To move into the gated village of Laguna Woods, a tidy array of bungalows and condominiums that blends easily into southern Orange County, people must meet several requirements, one of which is that they do not need full-time care. Their minds are sharp when they arrive, whether they are 65 or 95.

They begin a new life here. Make new friends. Perhaps connect with new romantic partners. Try new activities, at one of the community’s fitness centers; or new hobbies, in the more than 400 residents’ clubs. They are as busy as arriving freshmen at a new campus, with one large difference: they are less interested in the future, or in the past.

“We live for the day,” said Dr. Leon Manheimer, a longtime resident who is in his 90s.

Yet it is precisely that ability to form new memories of the day, the present, that usually goes first in dementia cases, studies in Laguna Woods and elsewhere have found.

The very old who live among their peers know this intimately, and have developed their own expertise, their own laboratory. They diagnose each other, based on careful observation. And they have learned to distinguish among different kinds of memory loss, which are manageable and which ominous.

A Seat at the Table

Here at Laguna Woods, many residents make such delicate calculations in one place: the bridge table.

Contract bridge requires a strong memory. It involves four players, paired off, and each player must read his or her partner’s strategy by closely following what is played. Good players remember every card played and its significance for the team. Forget a card, or fall behind, and it can cost the team — and the social connection — dearly.

“When a partner starts to slip, you can’t trust them,” said Julie Davis, 89, a regular player living in Laguna Woods. “That’s what it comes down to. It’s terrible to say it that way, and worse to watch it happen. But other players get very annoyed. You can’t help yourself.”

At the Friday afternoon bridge game, Ms. Cummins and Ms. Scott sit with two other players, both women in their 90s. Gossip flows freely between hands, about residents whose talk is bigger than their game, about a 100-year-old man who collapsed and died that week in an exercise class.

But the women are all business during play.

“What was that you played, a spade was it?” a partner asks Ms. Cummins.

“Yes, a spade,” says Ms. Cummins, with some irritation. “It was a spade.”

Later, the partner stares uncertainly at the cards on the table. “Is that ——”

“We played that trick already,” Ms. Cummins says. “You’re a trick behind.”

Most regular players at Laguna Woods know of at least one player who, embarrassed by lapses, bowed out of the regular game. “A friend of mine, a very good player, when she thought she couldn’t keep up, she automatically dropped out,” Ms. Cummins said. “That’s usually what happens.”

Yet it is part of the tragedy of dementia that, in many cases, the condition quickly robs people of self-awareness. They will not voluntarily abandon the one thing that, perhaps more than any other, defines their daily existence.

“And then it’s really tough,” Ms. Davis said. “I mean, what do you do? These are your friends.”

Staying in the Game

So far, scientists here have found little evidence that diet or exercise affects the risk of dementia in people over 90. But some researchers argue that mental engagement — doing crossword puzzles, reading books — may delay the arrival of symptoms. And social connections, including interaction with friends, may be very important, some suspect. In isolation, a healthy human mind can go blank and quickly become disoriented, psychologists have found.

“There is quite a bit of evidence now suggesting that the more people you have contact with, in your own home or outside, the better you do” mentally and physically, Dr. Kawas said. “Interacting with people regularly, even strangers, uses easily as much brain power as doing puzzles, and it wouldn’t surprise me if this is what it’s all about.”

And bridge, she added, provides both kinds of stimulation.

The unstated rule at Laguna Woods is to support a friend who is slipping, to act as a kind of memory supplement. “We’re all afraid to lose memory; we’re all at risk of that,” said one regular player in her 90s, who asked not to be named.

Woody Bowersock, 96, a former school principal, helped a teammate on a swim team at Laguna Woods to race even as dementia stole the man’s ability to form almost any new memory.

“You’d have to put him up on the platform just before the race, just walk him over there,” Mr. Bowersock said. “But if the whistle didn’t blow right away, he’d wander off. I tell you, I’d sometimes have to stand there with him until he was in the water. Then he was fine. A very good swimmer. Freestyle.”

Bridge is a different kind of challenge, but some residents here swear that the very good players can play by instinct even when their memory is dissolving.

“I know a man who’s 95, he is starting with dementia and plays bridge, and he forgets hands,” said Marilyn Ruekberg, who lives in Laguna Woods. “I bring him in as a partner anyway, and by the end we do exceedingly well. I don’t know how he does it, but he has lots of experience in the game.”

Scientists suspect that some people with deep experience in a game like bridge may be able to draw on reserves to buffer against memory lapses. But there is not enough evidence one way or the other to know.

Ms. Ruekberg said she cared less about that than about her friend: “I just want to give him something more during the day than his four walls.”

Drawing the Line

In studies of the very old, researchers in California, New York, Boston and elsewhere have found clues to that good fortune. For instance, Dr. Kawas’s group has found that some people who are lucid until the end of a very long life have brains that appear riddled with Alzheimer’s disease. In a study released last month, the researchers report that many of them carry a gene variant called APOE2, which may help them maintain mental sharpness.

Dr. Nir Barzilai of the Albert Einstein College of Medicine has found that lucid Ashkenazi Jewish centenarians are three times more likely to carry a gene called CETP, which appears to increase the size and amount of so-called good cholesterol particles, than peers who succumbed to dementia.

“We don’t know how this could be protective, but it’s very strongly correlated with good cognitive function at this late age,” Dr. Barzilai said. “And at least it gives us a target for future treatments.”

For those in the super-memory club, that future is too far off to be meaningful. What matters most is continued independence. And that means that, at some point, they have to let go of close friends.

“The first thing you always want to do is run and help them,” Ms. Davis said. “But after a while you end up asking yourself: ‘What is my role here? Am I now the caregiver?’ You have to decide how far you’ll go, when you have your own life to live.”

In this world, as in high school, it is all but impossible to take back an invitation to the party. Some players decide to break up their game, at least for a time, only to reform it with another player. Or, they might suggest that a player drop down a level, from a serious game to a more casual one. No player can stand to hear that. Every day in card rooms around the world, some of them will.

“You don’t play with them, period,” Ms. Cummins said. “You’re not cruel. You’re just busy.”

The rhythm of bidding and taking tricks, the easy conversation between hands, the daily game — after almost a century, even for the luckiest in the genetic lottery, it finally ends.

“People stop playing,” said Norma Koskoff, another regular player here, “and very often when they stop playing, they don’t live much longer.”

CUTTING SALT ISN'T THE ONLY WAY TO REDUCE BLOOD PRESSURE

2009-04-03T07:21:00.000-07:00

Study Suggests Boosting Potassium is also Effective

MAYWOOD, Ill. -- Most people know that too much sodium from foods can increase blood pressure.

A new study suggests that people trying to lower their blood pressure should also boost their intake of potassium, which has the opposite effect to sodium.

Researchers found that the ratio of sodium-to-potassium in subjects' urine was a much stronger predictor of cardiovascular disease than sodium or potassium alone.

"There isn't as much focus on potassium, but potassium seems to be effective in lowering blood pressure and the combination of a higher intake of potassium and lower consumption of sodium seems to be more effective than either on its own in reducing the risk of cardiovascular disease," said Dr. Paul Whelton, senior author of the study in the January 2009 issue of the Archives of Internal Medicine. Whelton is an epidemiologist and president and CEO of Loyola University Health System.

Researchers determined average sodium and potassium intake during two phases of a study known as the Trials of Hypertension Prevention. They collected 24-hour urine samples intermittently during an 18-month period in one trial and during a 36-month period in a second trial. The 2,974 study participants initially aged 30-to-54 and with blood pressure readings just under levels considered high, were followed for 10-15 years to see if they would develop cardiovascular disease. Whelton was national chair of the Trials of Hypertension Prevention.

Those with the highest sodium levels in their urine were 20 percent more likely to suffer strokes, heart attacks or other forms of cardiovascular disease compared with their counterparts with the lowest sodium levels. However this link was not strong enough to be considered statistically significant.

By contrast, participants with the highest sodium-to-potassium ratio in urine were 50 percent more likely to experience cardiovascular disease than those with the lowest sodium-to-potassium ratios. This link was statistically significant.

Most previous studies of the relationship between sodium or potassium and cardiovascular disease have had to rely on people's recall or record of what foods they eat to estimate their level of sodium consumption. This is a less precise measure of sodium intake than urine samples. In addition, many have been cross-sectional rather than follow-up studies.

The new study "is a quantum leap in the quality of the data compared to what we have had before," Whelton said.

Whelton was a member of a recent Institute of Medicine panel that set dietary recommendations for salt and potassium. The panel said healthy 19-to-50 year-old adults should consume no more than 2,300 milligrams of sodium per day -- equivalent to one teaspoon of table salt. More than 95 percent of American men and 75 percent of American women in this age range exceed this amount.

To lower blood pressure and blunt the effects of salt, adults should consume 4.7 grams of potassium per day unless they have a clinical condition or medication need that is a contraindication to increased potassium intake. Most American adults aged 31-to-50 consume only about half as much as recommended in the Institute of Medicine report. Changes in diet and physical activity should be under the supervision of a health care professional.

Good potassium sources include fruits, vegetables, dairy foods and fish. Foods that are especially rich in potassium include potatoes and sweet potatoes, fat-free milk and yogurt, tuna, lima beans, bananas, tomato sauce and orange juice. Potassium also is available in supplements.

Whelton is among the nation's top experts on high blood pressure. He has published more than 400 papers on the subject, and has been the principal investigator on more than $100 million of studies funded by the National Institutes of Health.

Co-authors of the Archives study include Nancy Cook (first author), Julie Buring and Dr. Kathryn Rexrode of Brigham and Women's Hospital; Eva Obarzanek and Dr. Jeffrey Cutler of the National Heart, Lung and Blood Institute; Dr. Lawrence Appel of Johns Hopkins University and Shiriki Kumanyika of the University of Pennsylvania.

###

Based in the western suburbs of Chicago, Loyola University Health System is a quaternary care system with a 61-acre main medical center campus, the 36-acre Gottlieb Memorial Hospital campus and 25 primary and specialty care facilities in Cook, Will and DuPage counties. The medical center campus is conveniently located in Maywood, 13 miles west of the Chicago Loop and 8 miles east of Oak Brook, Ill. The heart of the medical center campus, Loyola University Hospital, is a 570-licensed bed facility. It houses a Level 1 Trauma Center, a Burn Center and the Ronald McDonald® Children?s Hospital of Loyola University Medical Center. Also on campus are the Cardinal Bernardin Cancer Center, Loyola Outpatient Center, Center for Heart & Vascular Medicine and Loyola Oral Health Center as well as the LUC Stritch School of Medicine, the LUC Marcella Niehoff School of Nursing and the Loyola Center for Fitness. Loyola's Gottlieb campus in Melrose Park includes the 250-bed community hospital, the Gottlieb Center for Fitness and the Marjorie G. Weinberg Cancer Care Center.

http://loyolamedicine.org/News/News_Releases/news_release_detail.cfm?var_news_release_id=973440913

Urine Test May ID Unhealthy Diets

2009-03-26T19:54:00.000-07:00

Low potassium level indicates poor nutrition, study finds
Posted March 26, 2009

By Kathleen Doheny
HealthDay Reporter

THURSDAY, March 26 (HealthDay News) -- Someday, a doctor's office assessment of the overall quality of your diet may come from a simple $8 urine test, researchers report.
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Levels of urinary potassium correlate closely with nutrition in general, said study author Dr. Alexander Logan, a professor of medicine at the University of Toronto.

"We can identify people who are eating a poor quality diet by a simple urine test and can recommend an intervention," said Logan, who is also senior scientist at the university's Samuel Lunenfeld Research Institute.

Simply questioning people about their diet isn't as foolproof, he added. "One can get a general idea of [intake of] fruits, vegetables and dairy by asking," he said. But self-reports are notoriously inaccurate. So, Logan's team evaluated 24-hour urine samples from 220 people, aged 18 to 50, all diagnosed with kidney stones.

The participants answered food questionnaires about their food intake and had their weight, height and blood pressure measured.

Logan's team then looked to see if urinary potassium and sodium levels could correlate to diet quality.

They found that the higher the potassium level in urine, the higher the intake of recommended healthy foods such as fruits, vegetables, whole grains and low-fat dairy products.

The lower the potassium, the more likely the food reports were to include more red meat, fast food and sugary, high-calorie drinks.

Those with the highest levels of urinary potassium also tended to have a lower body mass index (BMI), lower diastolic blood pressure and a lower heart rate than did those with lower levels. For instance, people with the highest potassium levels averaged a BMI of 26.5 (under 25 is desirable), while those with the lowest potassium levels had an average BMI of 28.7 (a BMI of 30 is the accepted threshold for obesity).

Sodium levels were not associated with any of those variables, the team found.

The study is published in the April 2009 issue of The Journal of Nutrition.

The Logan research is "an excellent study," said Judith Stern, a distinguished professor of nutrition at the University of California at Davis, who was not involved in the study but reviewed it. Consumers might ask their physician for the test to see if their diet is as healthy as they might think, she said.

"This study supports the [medical] literature that the amount of potassium in urine may objectively measure diet quality," added Jeannie Gazzaniga-Moloo, a dietitian in Roseville, Calif., and a spokeswoman for the American Dietetic Association. "However, the study looked at 24-hour urine collections, which are cumbersome, time-consuming and impractical for some patients," she said.

Moloo called for more research to further validate the findings.

Logan said his team can probably simplify the test to make it a one-time measurement. In the meantime, he advises consumers to pay attention to their fruit and vegetable intake and to follow other healthy dietary guidelines, such as eating three servings of dairy products a day, choosing either low- or no-fat varieties if weight control is a concern.

Logan said his team also plans to study the value of the test in people besides those with kidney disease, including those with irritable bowel syndrome, many of whom eat a poor diet.

More information

To learn more about the dietary guidelines, visit the U.S. Department of Health and Human Services.

Harvard Medical School in Ethics Quandary

2009-03-03T08:58:00.000-08:00

Harvard Medical School students like Kirsten Austad, left; Lekshmi Santhosh, Kim Sue and David Tian, members of the American Medical Student Association, object to the influence of drug companies in the school’s educational curriculum.

March 3, 2009

By DUFF WILSON

BOSTON — In a first-year pharmacology class at Harvard Medical School, Matt Zerden grew wary as the professor promoted the benefits of cholesterol drugs and seemed to belittle a student who asked about side effects.

Mr. Zerden later discovered something by searching online that he began sharing with his classmates. The professor was not only a full-time member of the Harvard Medical faculty, but a paid consultant to 10 drug companies, including five makers of cholesterol treatments.

“I felt really violated,” Mr. Zerden, now a fourth-year student, recently recalled. “Here we have 160 open minds trying to learn the basics in a protected space, and the information he was giving wasn’t as pure as I think it should be.”

Mr. Zerden’s minor stir four years ago has lately grown into a full-blown movement by more than 200 Harvard Medical School students and sympathetic faculty, intent on exposing and curtailing the industry influence in their classrooms and laboratories, as well as in Harvard’s 17 affiliated teaching hospitals and institutes.

They say they are concerned that the same money that helped build the school’s world-class status may in fact be hurting its reputation and affecting its teaching.

The students argue, for example, that Harvard should be embarrassed by the F grade it recently received from the American Medical Student Association, a national group that rates how well medical schools monitor and control drug industry money.

Harvard Medical School’s peers received much higher grades, ranging from the A for the University of Pennsylvania, to B’s received by Stanford, Columbia and New York University, to the C for Yale.

Harvard has fallen behind, some faculty and administrators say, because its teaching hospitals are not owned by the university, complicating reform; because the dean is fairly new and his predecessor was such an industry booster that he served on a pharmaceutical company board; and because a crackdown, simply put, could cost it money or faculty.

Further, the potential embarrassments — a Senate investigation of several medical professors, the F grade, a new state law effective July 1 requiring Massachusetts doctors to disclose corporate gifts over $50 — are only now adding to pressure for change.

The dean, Dr. Jeffrey S. Flier, who says he wants Harvard to catch up with the best practices at other leading medical schools, recently announced a 19-member committee to re-examine his school’s conflict-of-interest policies. The group, which includes three students, is to meet in private on Thursday.

Advising the group will be Dr. David Korn, a former dean of the Stanford Medical School who started work at Harvard about four months ago as vice provost for research. Last year he helped the Association of American Medical Colleges draft a model conflict-of-interest policy for medical schools.

The Harvard students have already secured a requirement that all professors and lecturers disclose their industry ties in class — a blanket policy that has been adopted by no other leading medical school. (One Harvard professor’s disclosure in class listed 47 company affiliations.)

“Harvard needs to live up to its name,” said Kirsten Austad, 24, a first-year Harvard Medical student who is one of the movement’s leaders. “We are really being indoctrinated into a field of medicine that is becoming more and more commercialized.”

David Tian, 24, a first-year Harvard Medical student, said: “Before coming here, I had no idea how much influence companies had on medical education. And it’s something that’s purposely meant to be under the table, providing information under the guise of education when that information is also presented for marketing purposes.”

The students say they worry that pharmaceutical industry scandals in recent years — including some criminal convictions, billions of dollars in fines, proof of bias in research and publishing and false marketing claims — have cast a bad light on the medical profession. And they criticize Harvard as being less vigilant than other leading medical schools in monitoring potential financial conflicts by faculty members.

Dr. Flier says that the Harvard Medical faculty may lead the nation in receiving money from industry, as well as government and charities, and he does not want to tighten the spigot. “One entirely appropriate source, if done properly, is industrial funds,” Dr. Flier said in an interview.

And school officials see corporate support for their faculty as all the more crucial, as the university endowment has lost 22 percent of its value since last July and the recession has caused philanthropic contributors to retrench. The school said it was unable to provide annual measures of the money flow to its faculty, beyond the $8.6 million that pharmaceutical companies contributed last year for basic science research and the $3 million for continuing education classes on campus. Most of the money goes to professors at the Harvard-affiliated teaching hospitals, and the dean’s office does not keep track of the total.

But no one disputes that many individual Harvard Medical faculty members receive tens or even hundreds of thousands of dollars a year through industry consulting and speaking fees. Under the school’s disclosure rules, about 1,600 of 8,900 professors and lecturers have reported to the dean that they or a family member had a financial interest in a business related to their teaching, research or clinical care. The reports show 149 with financial ties to Pfizer and 130 with Merck.

The rules, though, do not require them to report specific amounts received for speaking or consulting, other than broad indications like “more than $30,000.” Some faculty who conduct research have limits of $30,000 in stock and $20,000 a year in fees. But there are no limits on companies’ making outright gifts to faculty — free meals, tickets, trips or the like.

Other blandishments include industry-endowed chairs like the three Harvard created with $8 million from sleep research companies; faculty prizes like the $50,000 award named after Bristol-Myers Squibb, and sponsorships like Pfizer’s $1 million annual subsidy for 20 new M.D.’s in a two-year program to learn clinical investigation and pursue Harvard Master of Medical Science degrees, including classes taught by Pfizer scientists.

Dr. Flier, who became dean 17 months ago, previously received a $500,000 research grant from Bristol-Myers Squibb. He also consulted for three Cambridge biotechnology companies, but says that those relationships have ended and that he has accepted no new industry affiliations.

That is in contrast to his predecessor as dean, Dr. Joseph B. Martin. Harvard’s rules allowed Dr. Martin to sit on the board of the medical products company Baxter International for 5 of the 10 years he led the medical school, supplementing his university salary with up to $197,000 a year from Baxter, according to company filings.

Dr. Martin is still on the medical faculty and is founder and co-chairman of the Harvard NeuroDiscovery Center, which researches degenerative diseases, and actively solicits industry money to do so. Dr. Martin declined any comment.

A smaller rival faction among Harvard’s 750 medical students has circulated a petition signed by about 100 people that calls for “continued interaction between medicine and industry at Harvard Medical School.”

A leader of the group, Vijay Yanamadala, 22, said, “To say that because these industry sources are inherently biased, physicians should never listen to them, is wrong.”

Encouraging them is Dr. Thomas P. Stossel, a Harvard Medical professor who has served on advisory boards for Merck, Biogen Idec and Dyax, and has written widely on academic-industry ties. “I think if you look at it with intellectual honesty, you see industry interaction has produced far more good than harm,” Dr. Stossel said. “Harvard absolutely could get more from industry but I think they’re very skittish. There’s a huge opportunity we ought to mine.”

Brian Fuchs, 26, a second-year student from Queens, credited drug companies with great medical discoveries. “It’s not a problem,” he said, pointing out a classroom window to a 12-story building nearby. “In fact, Merck is right there.”

Merck built a corporate research center in 2004 across the street from Harvard’s own big new medical research and class building. And Merck underwrites plenty of work on the Harvard campus, including the immunology lab run by Dr. Laurie H. Glimcher — a professor who also sits on the board of the drug maker Bristol-Myers Squibb, which paid her nearly $270,000 in 2007.

Dr. Glimcher says industry money is not only appropriate but necessary. “Without the support of the private sector, we would not have been able to develop what I call our ‘bone team’ in our lab,” she said at a recent student and faculty forum to discuss industry relationships. Merck is counting on her team to help come up with a successor to Fosamax, the formerly $3 billion-a-year bone drug that went generic last year. But Dr. Marcia Angell, a faculty member and former editor in chief of The New England Journal of Medicine, is among the professors who argue that industry profit motives do not correspond to the scientific aims of academic medicine and that much of the financing needs to be not only disclosed, but banned. Too many medical schools, she says, have struck a “Faustian bargain” with pharmaceutical companies.

“If a school like Harvard can’t behave itself,” Dr. Angell said, “who can?”

Good or Useless, Medical Scans Cost the Same

2009-03-02T11:06:00.002-08:00

By GINA KOLATA

When Gail Kislevitz had an M.R.I. scan of her knee, it came back blurry, “uninterpretable,” her orthopedist told her.

A poor-quality scan of a ligament, left, and one of high quality. Many scans are done by machines that are a decade old.

Her insurer refused to pay for another scan, but the doctor said he was sure she had torn cartilage that stabilizes the knee and suggested an operation to fix it. After the surgery, Ms. Kislevitz, 57, of Ridgewood, N.J., received a surprise: the cartilage had not been torn after all.

She had a long rehabilitation. And her insurer paid for the operation. But her knee is no better.

More than 95 million high-tech scans are done each year, and medical imaging, including CT, M.R.I. and PET scans, has ballooned into a $100-billion-a-year industry in the United States, with Medicare paying for $14 billion of that. But recent studies show that as many as 20 percent to 50 percent of the procedures should never have been done because their results did not help diagnose ailments or treat patients.

“The system is just totally, totally broken,” said Dr. Vijay Rao, the chairwoman of the radiology department at Thomas Jefferson University Hospital, in Philadelphia.

Radiologists say a decent M.R.I. scan should have clearly shown whether the cartilage in Ms. Kislevitz, a meniscus, was torn. But bad scans, medical experts say, are part of a growing problem with medical imaging.

Many factors contribute. Insurers pay the same for a scan done on a 10-year-old machine as one on the latest model, though the differences in the images can be significant.

Insurers do not distinguish between scans that are done poorly or done well or read by less- or more-qualified doctors. Aside from mammography, whose standards were established by a law that went into effect more than a decade ago, the field is largely unregulated. And increasingly, doctors refer patients to scanning centers they own and profit from.

Ten years ago, the age of a scanner might not have mattered so much. Now, said Dr. Gary Glazer, the chairman of radiology at Stanford, technology has advanced so much that the older scanner “is not the same machine.”

“I can tell you from my experience that between those extremes the gap is huge,” Dr. Glazer said.

Yet, he added, many scanning machines used today are a decade old.

Imaging centers can, if they choose, become accredited by the American College of Radiology. That requires, among other things, scanning a phantom, a device that simulates a body part. Technologists must also be certified, and there are standards for supervising physicians. And the scanners must be regularly assessed to ensure they are properly functioning.

But many centers are not accredited, although the percentage is not known because there is no national registry of imaging centers.

Accrediting will be partly addressed by a little noticed aspect of a wide-ranging Medicare law passed last year. After it goes into effect in 2012, Medicare will pay only for scans done at accredited centers. But imaging experts say the law fixes only part of the problem. High-tech scanning is complicated, and there is no consensus on objective measures to ensure quality. Even with the new law, there is still little assurance that scans will be appropriately ordered and interpreted or that a scanner will be up to date.

Radiologists are struck by the wide variation in the quality of scans, and they say there is little patients can do other than to ask why the scan is necessary and, if it is, to ask about accreditation, the credentials of the person reading the scan and the age of the scanner.

“The studies I see coming from the outside vary from marginal quality to very good quality,” said Dr. Chris Beaulieu, a Stanford radiology professor. “Some of it is related to equipment, and some is related to people with very good equipment who don’t know how to use it right. And on the interpretation side, there is also a very wide range of quality or accuracy, in my opinion.”

Interpretation can be crucial, Dr. Beaulieu added. “A good radiologist can sometimes accurately read scans off of a lower-quality scanner,” he said. “I see that all the time. A good radiologist and a lower-quality scan could be better than a bad radiologist and a good scan.”

But logical as it might seem to pay more for a better scan, there are problems. Health insurers have no way of knowing whether scans are good, said Susan Pisano, a spokeswoman for America’s Health Insurance Plans, a trade group. Doctors, not insurers, receive the images and reports, and all insurers can do is notice if there are frequent requests to redo scans from a particular center.

“We see a lot of poor-quality scans,” said Dr. Freddie Fu, the chairman of the orthopedic surgery department at the University of Pittsburgh Medical Center. “I joke with the patients: The insurance pays the same amount of money for the scan. You get a hamburger somewhere else and a prime rib here for the same price.”

Another concern is the growing number of doctors who refer patients for imaging done by scanners they own and profit from. Studies have found that up to 3.2 times as many scans are ordered in such cases

In a recent report, the Government Accountability Office said nearly two-thirds of the money Medicare paid for imaging was for scans in doctors’ offices. And, the report added, doctors were receiving an ever larger part of their income from providing scanning services. Not only were patients more likely to have scans if a doctor did this, but the quality of some of the scans was questioned.

“No comprehensive national standards exist for services delivered in physician offices other than a requirement that imaging services are to be provided under at least general physician supervision,” the G.A.O. wrote.

Private health insurers were concerned, too. “These are alarming patterns that have also been observed in the private sector,” America’s Health Insurance Plans wrote in a response to the G.A.O.

It is clear why self-referral can be tempting, said Dr. Bruce Hillman, a radiology professor at the University of Virginia.

“It’s all profits,” Dr. Hillman said, adding that a group of doctors can make an extra $500,000 to $1 million a year simply by acquiring a scanner.

For now, radiologists said, patients and insurers are often in a bind.

“If you are going to buy a car,” said Dr. Beaulieu, the Stanford professor, “and you have a certain amount of money to spend, you know what you are getting. You know what you will get if you buy a Yugo or if you buy a BMW.”

But with imaging, Dr. Beaulieu said, “you don’t know: you might get a Yugo and you might get a BMW.”

What’s Eating Our Kids? Fears About ‘Bad’ Foods

2009-02-27T08:23:00.001-08:00

February 26, 2009

By ABBY ELLIN

SODIUM — that’s what worries Greye Dunn. He thinks about calories, too, and whether he’s getting enough vitamins. But it’s the sodium that really scares him.

“Sodium makes your heart beat faster, so it can create something really serious,” said Greye, who is 8 years old and lives in Mays Landing, N.J.

Greye’s mother, Beth Dunn, the president of a multimedia company, is proud of her son’s nutritional awareness and encourages it by serving organic food and helping Greye read labels on cereal boxes and cans.

“He wants to be healthy,” she says.

Ms. Dunn is among the legions of parents who are vigilant about their children’s consumption of sugar, processed foods and trans fats. Many try to stick to an organic diet. In general, their concern does not stem from a fear of obesity — although that may figure into the equation — but from a desire to protect their families from conditions like hyperactivity, diabetes and heart disease, which they believe can be avoided, or at least managed, by careful eating.

While scarcely any expert would criticize parents for paying attention to children’s diets, many doctors, dietitians and eating disorder specialists worry that some parents are becoming overzealous, even obsessive, in efforts to engender good eating habits in children. With the best of intentions, these parents may be creating an unhealthy aura around food.

“We’re seeing a lot of anxiety in these kids,” said Cynthia Bulik, the director of the eating disorders program at the University of North Carolina at Chapel Hill. “They go to birthday parties, and if it’s not a granola cake they feel like they can’t eat it. The culture has led both them and their parents to take the public health messages to an extreme.”

Tiffany Rush-Wilson, an eating disorder counselor in Pepper Pike, Ohio, has seen the same thing. “I have lots of children or adolescent clients or young adults who complain about how their parents micromanage their eating based on their own health standards and beliefs,” she said. “The kids’ eating became very restrictive, and that’s how they came to me.”

Certainly, not all parents who enforce rules about healthy food — or any dietary plan — are setting their children up for an eating disorder. Clinical disorders like anorexia nervosa and bulimia, which have been diagnosed in increasing numbers of adolescents and young people in the last two decades, are thought by researchers to have a variety of causes — including genetics, the influence of mass media and social pressure.

To date, there have been no formal studies on whether parents’ obsession with health food can lead to eating disorders. Some experts say an extreme obsession with health food is merely a symptom, not a cause, of an eating disorder.

But even without firm numbers, anecdotal reports from specialists suggest that a preoccupation with avoiding “bad” foods is an issue for many young people who seek help.

Dr. James Greenblatt, the chief medical officer at Walden Behavioral Care, a hospital specializing in child and adult eating disorders in Waltham, Mass., estimates that he has recently seen about a 15 percent rise in the number of his young patients who eat only organic foods to avoid pesticides.

“A lot of the patients we have seen over the last six years limited refined sugar and high fat foods because of concerns about gaining weight,” he said. “But now, these worries are often expressed in terms of health concerns.”

Lisa Dorfman, a registered dietitian and the director of sports nutrition and performance at the University of Miami, says that she often sees children who are terrified of foods that are deemed “bad” by parents. “It’s almost a fear of dying, a fear of illness, like a delusional view of foods in general,” she said. “I see kids whose parents have hypnotized them. I have 5-year-olds that speak like 40-year-olds. They can’t eat an Oreo cookie without being concerned about trans fats.”

Dr. Steven Bratman of Denver has come up with a term to describe people obsessed with health food: orthorexia. Orthorexic patients, he says, are fixated on “righteous eating” (the word stems from the Greek word ortho, meaning straight and correct).

“I would tell them, ‘You’re addicted to health food.’ It was my way of having them not take themselves so seriously,” said Dr. Bratman, who published a book on the subject, “Health Food Junkies,” in 2001.

The condition, he says, may begin in homes where there is a preoccupation with “health foods.”

Many eating disorder experts dispute the concept. They say that orthorexia, which is not considered a clinical diagnosis, is merely a form of anorexia nervosa or obsessive compulsive disorder.

Angelique A. Sallas, a clinical psychologist in Chicago, says the idea of a “health food disorder” is practically meaningless. “I don’t think the symptoms are significantly different enough from bulimia or anorexia that it deserves a special diagnostic category,” Dr. Sallas said. “It’s an obsessive-compulsive problem. The object of the obsession is less relevant than the fact that they are engaging in obsessive behavior.”

Dr. David Hahn, the assistant medical director at the Renfrew Center, an eating disorders clinic in Philadelphia, also thinks that orthorexics are anorexics in disguise. “I see many patients that are overly concerned with the quality of their food, and that’s the way they express their eating disorder,” he said.

But whatever the behavior is called, those who have lived through a disorder fueled by an obsession with healthful eating say that the experience can be agonizing. Kristie Rutzel, a 26-year-old marketing coordinator in Richmond, Va., began eliminating carbohydrates, meats, refined sugars and processed foods from her diet at 18. She became so fixated on eating only “pure” foods, she said, that she slashed her daily calorie intake to 500. Eventually, her weight fell to 68 pounds and she was repeatedly hospitalized for anorexia.

Today Ms. Rutzel, who said she is normal weight, often talks to young girls in schools and churches about the perils of becoming health-food obsessed.

Laura Collins, a writer who lives in Virginia, was once a parent who was always “moralizing about good and bad foods,” she said. “We didn’t serve candy, my kids didn’t have soda.” Ms. Collins’s daughter, Olympia, became rigid in her eating, fearing food that she worried would make her unhealthy. By age 14, Olympia developed anorexia, her mother said. To help her recover, the family had to rethink its entire approach to food.

Some experts are quick to point out that it is not only parents who may contribute to children’s food anxieties. They cite nutritional programs in schools that may go overboard. “I see younger kids who have an eating disorder precipitated by a nutrition lesson in school,” said Dr. Leslie Sanders, medical director of the eating disorders program at Atlantic Health Overlook Hospital in Summit, N.J.

Over the last five years, Dr. Sanders said, she has seen a rise in the number of children who are fixated on the way they eat: “Some educators categorize food into ‘good’ and ‘bad.’ The kids come home and say ‘Don’t eat French fries’ instead of talking about moderation.”

The problem, according to some nutritional experts, is that many teachers don’t understand nutrition well. “We’re driving our kids absolutely crazy,” said Katie Wilson, president of the School Nutrition Association. “All the stuff about preservatives and pesticides. All an 8-year-old kid should know is that he or she should eat a variety of colors, and don’t supersize anything but your water jug.”

Nina Planck, author of “Real Food: What to Eat and Why,” said that it’s a “total cop out” to lay blame on schools and parents for children’s eating disorders. “The eating disorder comes out of a disordered psyche,” she said. “You can’t blame the information for causing the eating disorders.”

But Jessica Setnick, a dietitian in Dallas and author of “The Eating Disorders Clinical Pocket Guide,” tells a story that suggests parents’ attitudes can affect children. She recalled a mother who brought in her preteen, apparently bulimic daughter. As Ms. Setnick discovered, the girl was not trying to lose weight. “Her mother only served brown rice, but she didn’t like it,” Ms. Setnick said. “She did like white rice. And while I’m not going to tell anyone what they can bring into their own home, we discussed that when the family went out, it would be O.K. to get white rice.”

When the girl told her mother what Ms. Setnick said, the mother was furious, according to Ms. Setnick. “She said, ‘Don’t you know white rice is just like sugar?’ ”

“My heart broke for that girl,” Ms. Setnick said. “She was telling her mother what she needed, and the mother wasn’t listening.”

Ms. Collins, the author of “Eating with Your Anorexic,” a book about her daughter’s struggle with anorexia, and director of the nonprofit organization Feast (Families Empowered and Supporting Treatment of Eating Disorders), offers some perspective.

“It’s a tragedy that we’ve developed this moralistic, restrictive and unhappy relationship” with eating, she said. “I think it is making kids nutty, it’s sucking the life out of our relationship with food.”

Babies Know: A Little Dirt Is Good for You

2009-01-28T09:49:00.000-08:00

January 27, 2009
Personal Health
By JANE E. BRODY

Ask mothers why babies are constantly picking things up from the floor or ground and putting them in their mouths, and chances are they’ll say that it’s instinctive — that that’s how babies explore the world. But why the mouth, when sight, hearing, touch and even scent are far better at identifying things?

When my young sons were exploring the streets of Brooklyn, I couldn’t help but wonder how good crushed rock or dried dog droppings could taste when delicious mashed potatoes were routinely rejected.

Since all instinctive behaviors have an evolutionary advantage or they would not have been retained for millions of years, chances are that this one too has helped us survive as a species. And, indeed, accumulating evidence strongly suggests that eating dirt is good for you.

In studies of what is called the hygiene hypothesis, researchers are concluding that organisms like the millions of bacteria, viruses and especially worms that enter the body along with “dirt” spur the development of a healthy immune system. Several continuing studies suggest that worms may help to redirect an immune system that has gone awry and resulted in autoimmune disorders, allergies and asthma.

These studies, along with epidemiological observations, seem to explain why immune system disorders like multiple sclerosis, Type 1 diabetes, inflammatory bowel disease, asthma and allergies have risen significantly in the United States and other developed countries.

Training the Immune System

“What a child is doing when he puts things in his mouth is allowing his immune response to explore his environment,” Mary Ruebush, a microbiology and immunology instructor, wrote in her new book, “Why Dirt Is Good” (Kaplan). “Not only does this allow for ‘practice’ of immune responses, which will be necessary for protection, but it also plays a critical role in teaching the immature immune response what is best ignored.”

One leading researcher, Dr. Joel V. Weinstock, the director of gastroenterology and hepatology at Tufts Medical Center in Boston, said in an interview that the immune system at birth “is like an unprogrammed computer. It needs instruction.”

He said that public health measures like cleaning up contaminated water and food have saved the lives of countless children, but they “also eliminated exposure to many organisms that are probably good for us.”

“Children raised in an ultraclean environment,” he added, “are not being exposed to organisms that help them develop appropriate immune regulatory circuits.”

Studies he has conducted with Dr. David Elliott, a gastroenterologist and immunologist at the University of Iowa, indicate that intestinal worms, which have been all but eliminated in developed countries, are “likely to be the biggest player” in regulating the immune system to respond appropriately, Dr. Elliott said in an interview. He added that bacterial and viral infections seem to influence the immune system in the same way, but not as forcefully.

Most worms are harmless, especially in well-nourished people, Dr. Weinstock said.

“There are very few diseases that people get from worms,” he said. “Humans have adapted to the presence of most of them.”

Worms for Health

In studies in mice, Dr. Weinstock and Dr. Elliott have used worms to both prevent and reverse autoimmune disease. Dr. Elliott said that in Argentina, researchers found that patients with multiple sclerosis who were infected with the human whipworm had milder cases and fewer flare-ups of their disease over a period of four and a half years. At the University of Wisconsin, Madison, Dr. John Fleming, a neurologist, is testing whether the pig whipworm can temper the effects of multiple sclerosis.

In Gambia, the eradication of worms in some villages led to children’s having increased skin reactions to allergens, Dr. Elliott said. And pig whipworms, which reside only briefly in the human intestinal tract, have had “good effects” in treating the inflammatory bowel diseases, Crohn’s disease and ulcerative colitis, he said.

How may worms affect the immune system? Dr. Elliott explained that immune regulation is now known to be more complex than scientists thought when the hygiene hypothesis was first introduced by a British epidemiologist, David P. Strachan, in 1989. Dr. Strachan noted an association between large family size and reduced rates of asthma and allergies. Immunologists now recognize a four-point response system of helper T cells: Th 1, Th 2, Th 17 and regulatory T cells. Th 1 inhibits Th 2 and Th 17; Th 2 inhibits Th 1 and Th 17; and regulatory T cells inhibit all three, Dr. Elliott said.

“A lot of inflammatory diseases — multiple sclerosis, Crohn’s disease, ulcerative colitis and asthma — are due to the activity of Th 17,” he explained. “If you infect mice with worms, Th 17 drops dramatically, and the activity of regulatory T cells is augmented.”

In answer to the question, “Are we too clean?” Dr. Elliott said: “Dirtiness comes with a price. But cleanliness comes with a price, too. We’re not proposing a return to the germ-filled environment of the 1850s. But if we properly understand how organisms in the environment protect us, maybe we can give a vaccine or mimic their effects with some innocuous stimulus.”

Wash in Moderation

Dr. Ruebush, the “Why Dirt Is Good” author, does not suggest a return to filth, either. But she correctly points out that bacteria are everywhere: on us, in us and all around us. Most of these micro-organisms cause no problem, and many, like the ones that normally live in the digestive tract and produce life-sustaining nutrients, are essential to good health.

“The typical human probably harbors some 90 trillion microbes,” she wrote. “The very fact that you have so many microbes of so many different kinds is what keeps you healthy most of the time.”

Dr. Ruebush deplores the current fetish for the hundreds of antibacterial products that convey a false sense of security and may actually foster the development of antibiotic-resistant, disease-causing bacteria. Plain soap and water are all that are needed to become clean, she noted.

“I certainly recommend washing your hands after using the bathroom, before eating, after changing a diaper, before and after handling food,” and whenever they’re visibly soiled, she wrote. When no running water is available and cleaning hands is essential, she suggests an alcohol-based hand sanitizer.

Dr. Weinstock goes even further. “Children should be allowed to go barefoot in the dirt, play in the dirt, and not have to wash their hands when they come in to eat,” he said. He and Dr. Elliott pointed out that children who grow up on farms and are frequently exposed to worms and other organisms from farm animals are much less likely to develop allergies and autoimmune diseases.

Also helpful, he said, is to “let kids have two dogs and a cat,” which will expose them to intestinal worms that can promote a healthy immune system.

How Do Hospitals Get Paid? A Primer

2009-01-23T07:27:00.000-08:00

January 23, 2009, 6:40 am

By Uwe E. Reinhardt

Uwe E. Reinhardt is an economics professor at Princeton. For previous posts in his series on why the United States spends so much on health care, click here.

Few Americans probably have any inkling of how their neighborhood hospital prices the myriad of distinct services rendered patients. I doubt many patients can understand the long hospital bills that feature exotic items such as “cath porta cath perit” or “OP6-central line reposit,” and so on. Even fewer still likely understand why a Tylenol pill or a rubber glove can carry the humongous price tags hospitals put on them.

Americans can be forgiven their ignorance on this issue because, as I put it in a recent paper on the subject, the pricing of hospital services is best described as “Chaos Behind a Veil of Secrecy.”

For starters, a hospital is paid by several quite distinct methods, depending on who is paying.

The federal Medicare program for the elderly typically pays hospitals a flat fee per hospital case, with a different per-case price for each of close to 600 distinct diagnostically related cases (D.R.G.’s) — such as a hip replacement without complications or one with complications, and so on.

These payments originally were set by Medicare in 1983 to reflect the cost then of producing each D.R.G. case. They have been updated annually and periodically recalibrated by the federal government, with the advice of Congress’s Medicare Payment Advisory Commission, a permanent body of private stakeholders with its own research staff. Through lobbying and other informal political channels the hospital industry can, of course, influence these administered prices as well. Over time, the attempt has been to keep these rates close to the average cost of providing the services per case, although many hospitals claim that often the case payments they receive are below their own full costs.

From the federal-state Medicaid program for the poor, blind and disabled, hospitals receive either (1) case-based payments (D.R.G.’s) or (2) a set amount of dollars per day of inpatient stay (per-diem payments) or (3) fees for individual services and supplies (fee-for-service or F.F.S. payments). The levels of these payments are set unilaterally by the state governments. In many states these payments are much lower than the full cost of providing the services.

Private insurers pay hospitals predominantly on the basis of per-diems or fee-for-service schedules. On average these payments exceed the hospital’s cost of providing the underlying services. The profits built into these payments cover the losses hospitals book on serving Medicare and Medicaid patients, who are billed high prices but often do not pay their bills in full. Private insurers also feed the net profits that most for-profit and not-for-profit hospitals book.

The per-diems or myriad fees that private insurers pay hospitals are negotiated annually between each hospital and each insurance carrier. A given hospital may thus negotiate one by one with several dozen or even several hundred insurers.

Readers may wonder how the many fees that hospitals receive under the fee-for-service method are negotiated separately with each hospital. Generally, the fees are not negotiated individually, but as across-the-board discounts off a giant schedule of list prices that each hospital maintains — like list prices at car dealers that no one actually pays. These schedules of list prices are known as the hospital’s “charge master.” (For an illustration, see this list of prices for some 7,500 items charged by Dameron Hospital in California.) For uninsured patients the discount is negotiated by the hospital on a patient-by-patient basis, with appeal to the patient’s ability to pay.

Each hospital has its own charge master and updates it periodically by its own unique process. Consequently, across hospitals in a given state, the list price for a particular item – e.g., a normal chest X-ray — can vary tenfold or more. In most states — California being one exception — hospitals are not required to make these charge masters public.

Over all, then, annually establishing the prices that a given insurer will pay a particular hospital and the prices charged the uninsured is an enormously cumbersome and highly labor-intensive process not used by any other health system in the industrialized world. It adds a significant component to the high administrative cost that is unique to the American health system.

One interesting aspect of this process is the wide variation in how much a basic medical service costs at different hospitals — a variation that does not appear to be tied to quality.

Tables 6.3 to 6.5 below exhibit ranges or averages of the total payments that two private health insurers make to hospitals in their state for standard medical cases. The data in the table should be understood as the total payments — per diems or fee-for-service — per standard case. I had asked for these data in my role as the chairman of the New Jersey Commission for Rationalizing Health Care Resources in 2007. The tables below are taken directly from the commission’s final report.

Source: New Jersey Commission for Rationalizing Health Care Resources

Source: New Jersey Commission for Rationalizing Health Care Resources

Source: New Jersey Commission for Rationalizing Health Care Resources

No one really understands the determinants of the wide variations in prices paid hospitals by a given insurer for basically the same medical episode. Presumably these variances reflect the relative bargaining strength of the two parties in each instance. Large insurance companies with relatively more market power vis-a-vis doctors and hospitals usually pay lower prices for given services than do smaller insurers with less market power. And traditionally, the uninsured, lacking any market power, have been charged the highest prices (i.e., granted the lowest discounts off the charge master), although in recent years more and more hospitals have switched over to a means-tested schedule of discounts off the charge master.

Critics of the federal Medicare program routinely call Medicare a “dumb” price setter. Perhaps it is. But it stretches one’s cerebral processes to conclude that the varied prices emerging from the cumbersome private market process described above are any smarter or more conducive to a rational, efficient health system. This does not mean, of course, that some economists and other defenders of the system would not try.

U.S. Health Care Costs Part VII: Reining in Doctors Who Cost Too Much

2009-01-23T07:26:00.000-08:00

By Uwe E. Reinhardt

Uwe E. Reinhardt is an economist at Princeton. For previous posts in his series on why America pays so much for health care, click here, here, here, here, here and here.

Last week I wrote about the inexplicably high variation in per-capita health spending across the United States. The rich and highly heterogeneous reader responses have been illuminating and, in some cases, disturbing.

The ideal health systems recommended by readers ranged from government-run, single-payer systems to completely free-market systems in which individuals are responsible for their own health care. Both approaches, of course, ration health care — the first based on the capacity of the existing health care system, and the second based on individual patients’ ability to pay. A judgment of which system is better depends strictly on one’s moral values, not on economics.

I was surprised, though, that so few readers suggested that America’s health care spending issues might have something to do with our fee-for-service payment system.

Studies have shown that physicians are not impervious to the financial incentives inherent in fee-for-service payments. For example, on average, physicians who have a direct financial interest in the use of imaging services, like CAT scans or M.R.I. scans, recommend far more such services for their patients than do physicians without such financial interest (see this and this).

In recognition of the conflict of interest inherent in fee-for-service payment, there is now a worldwide movement to replace the system with so-called “evidence-based case reimbursement”. Under this approach, one single payment would cover all of the supplies and services that are needed, under best, evidence-based clinical practices, to respond adequately to well-defined medical conditions.

Not all health care, of course, can be categorized into neat, episodic bundles for this purpose. For chronic conditions, for example, payment may shift from fee-for-service to annual or monthly fees per patient, and care for such patients might be organized by clinically integrated health systems or by managed care companies procuring health care from different systems on an integrated basis. And for some patients with very complicated conditions, fee-for-service would still persist. One would think, however, that a move toward these alternative payment systems would not only reduce the geographic variations in per-capita health spending, but help control the annual growth of health spending over all.

Aside from payment reform, modern electronic health-information techniques can make doctors and hospitals more publicly accountable for their use of resources through greater transparency. Greater transparency in this realm is the sine qua non of a more cost-effective health system.

For example, it is technically feasible to capture electronically every supply and service requisitioned by every doctor in a hospital for every patient, by type of supply or service ordered. It is also feasible to electronically capture detailed information on the health status of every patient admitted to a hospital.

Combined, these two databases can be reorganized to produce cost-effectiveness profiles for every physician affiliated with a hospital, adjusted for the health status of their patients (in technical jargon, “risk adjusted”). Equipped with such risk-adjusted profiles, hospital administrators could periodically gather all affiliated physicians performing a particular procedure — e.g., coronary artery bypass grafts or knee replacements — into one room and ask those physicians who on average trigger high (risk-adjusted) costs for such procedures to justify these higher costs to their colleagues with lower costs.

The New Jersey Governor’s Commission on the Rationalization of Health Care Resources recommended that the state’s government help finance such hospital-based information systems and make them mandatory at all hospitals in the state. Each hospital administrator would then be required to certify that the physicians affiliated with the hospital have reviewed and discussed these cost profiles at least once a year. For hospitals seeking assistance from the state, these physician cost-effectiveness profiles should be accessible to the governor’s office as a condition for such assistance.

Short of revamping our entire health system, payment reform and more widespread use of electronic information systems most probably could drive even our existing system toward greater cost-effectiveness of care and, most likely, more moderate growth in health spending. There is every reason to believe that the Obama administration will pursue these avenues, as would have his rivals.

U.S. Health Care Costs Part VI: At What Price Physician Autonomy?

2009-01-23T07:24:00.000-08:00

December 26, 2008, 10:07 am

By Uwe E. Reinhardt

Uwe E. Reinhardt is an economist at Princeton. For previous posts in his series on why America pays so much for health care, click here, here, here, here and here.

After a lengthy discourse on health policy with a physician, I asked him to describe the ideal health system from a physician’s perspective. “Everyone in society should have access to needed health care,” he responded. “Only the physician and the patient should decide how to respond to a given medical condition. And someone should reimburse providers of health care at reasonable rates.”

Leave aside the fact that providers of health care are “paid” for their services, not “reimbursed,” the latter method always breeding bad managerial habits. Leave aside also that the definition of “needed” health care is highly elastic. Focus instead on the core of the ideal: complete clinical autonomy for physicians and their patients to throw whatever resources they wish at given medical conditions, usually at someone else’s expense, with little or no accountability for their preferred treatments’ quality or success.

Most physicians, and I would suspect most of their patients, probably subscribe to this ideal. Alas, a mounting body of research leads experts to doubt that physician autonomy actually serves society well and that it will be affordable much longer.

One strand of this research is typified by a landmark study conducted by Elizabeth A. McGlynn and her research associates at the Rand Corporation. The researchers found that, on average, American patients receive the recommended treatment for their condition only slightly more than 50 percent of the time. There are numerous other studies of this genre.

Another strand of research can be found in the famous and equally widely quoted Dartmouth Atlas of Health Care published by John E. Wennberg and his research associates at the Dartmouth Medical School. These researchers have for two decades now alerted Congress, the medical profession and private insurers to huge geographic variations in per-capita health spending that do not seem to be related to commensurate differences in disease rates, the quality of health care processes, clinical outcomes or patient satisfaction.

Table 6.1 below, taken from the Final Report of the New Jersey Commission on Rationalizing Health Care Resources, illustrates these inexplicable geographic variations in per-capita spending. As the chair of that commission, I had asked Dr. Wennberg to develop for the commission data on Medicare spending per beneficiary in New Jersey’s various hospital market areas.

Shown in the table are the average payments for inpatient care that Medicare made per beneficiary residing in a selected number of hospital-market areas during these beneficiaries’ last two years of life. The averages have been statistically adjusted to account for differences in the gender and age of patients who come to different hospitals and also for differences in the fees Medicare pays hospitals. (Although in principle Medicare uses one uniform fee schedule nationwide, some regional adjustments are made to fees to account for local differences in labor and other practice costs). It follows that the data in the table reflect differences in the use of real resources (hospital days, procedures per hospital day, etc.) and not price differences.

The numbers in the chart are all being compared to how much Medicare reimburses hospitals nationwide, on average, for taking care of a patient in the last two years of his or her life. In technical terms, this means that if a number in the table is equal to 1, then the actual spending per beneficiary, or the actual use of hospital days, etc., in the corresponding New Jersey market area is exactly equal to the national average.

For example, the number 3.21 for the St. Michaels Medical Center hospital market area in the table means that, during their last two years of life, Medicare beneficiaries in this area were 3.21 more costly to the taxpayer times for inpatient care than were similar patients nationwide. These patients received 2.34 times more hospital inpatient days than the national average, and each hospital day they received cost 1.37 times as much as the comparable national average. By contrast, for patients in the Atlantic Medical Center market area, the statistics are very close to the national average, because the numbers for that area are all close to 1.

The insight one gains from the table is that Medicare spending per beneficiary varied by a factor of three across New Jersey, depending on the practice style preferred by the physicians caring for these patients. As the right-most column in the table suggest, there does not appear to be any systematic relationship between Medicare spending and Medicare’s hospital-specific quality index.

Hospital executives, confronted with these numbers, have explained that they have little control over the utilization of health-care resources within their hospitals, as that is the prerogative of the private, usually self-employed physicians who have privileges at these hospitals and can look upon the latter as their free workshops. Furthermore, these executives would be loath to reproach the physicians responsible for using the most Medicare dollars, lest those physicians shift their patients to rival hospitals. Most health-care experts accept these explanations.

Dr. Wennberg and his associates at Dartmouth Medical have published similar data for California and for the nation as a whole. In their most recent publication, they show that these enormous variations in per-capita health spending are confined not only to the traditional, government-run, fee-for-service part of Medicare, but are apparent also for Medicare beneficiaries served by the private “Medicare Advantage” plans as well as among the commercially insured patients served by these private plans. They are a feature of all medical practice in America, regardless of who pays for the care.

The wonder is that neither Congress, nor the medical profession, nor private health insurers has so far felt obligated to come to grips with these enormous variations in health spending nor even to evince any curiosity about them.

According to the Dartmouth researchers, if physicians with relatively higher cost preferred practice styles could be induced to embrace the preferred practice styles of their equally effective but lower-cost colleagues, overall per-capita Medicare spending probably could be reduced by at least 30 percent without harming patients, and similarly for commercially insured younger Americans. How can a nation that routinely wails over its high cost of health care ignore such important research?

In a future post to this blog, I shall explore what might possibly be done to address this issue. In the meantime, it would be fascinating to learn from their comments what readers would do, were they American health-care czars.

U.S. Health Care Costs, Part V: Can Americans Afford Medicare?

2009-01-23T07:23:00.001-08:00

By Uwe E. Reinhardt

Uwe E. Reinhardt is an economist at Princeton. For previous posts in his series on why America pays so much for health care, click here, here, here and here.

It is now generally believed that the federal Medicare program for America’s elderly is “unsustainable” and must be “restructured.” This somber assessment is part of the more general cri de coeur so wondrously phrased some years ago in the title of the Brookings Institution’s monograph “Can America Afford to Grow Old?”

What if we couldn’t? What would we do – push the elderly into the ocean on an ice floe?

Of course America can afford to grow old! We can more easily afford it than most other industrialized nations.

The percentage of the American population age 65 or over is 12.4 now and is projected to rise to about 21 by 2050. Only 7 percent of China’s population is 65 or over now, but that figure will shoot up rapidly to over 22 percent by 2050. And in a number of other industrialized countries — notably in Japan, Germany, Italy and Sweden — the elderly already represent close to 20 percent of the population, a level the United States will not reach until about 2040. Yet the world has not come to an end in these older countries.

It’s hard to say what fraction of America’s gross domestic product future generations should allocate to people too old (or too young) to work, and how much should remain with those who have produced that G.D.P. This is a matter to be resolved by those future generations.

They must decide how well the elderly in their midst should be housed, fed and cared for when sick. Our influence over that allocation is minimal, because future generations can always override our decisions while we cannot override theirs. The best we can do today is to put in place public policies that can help G.D.P. grow now and in the future, to ease the pain of sharing. We could also influence somewhat the age structure of future populations through current and future policies on immigration, although there are limits to that approach, because immigrants, too, grow old.

Fortunately, as is shown in the graphical display below, future generations will most likely have the benefit of G.D.P. growth on their side, which should make it easier for them to house, feed and care for larger fractions of elderly citizens.

Current G.D.P. per capita in the United States is about $46,500 (tables B-2 and B-34 here), of which Medicare absorbs slightly over 3 percent, leaving about $45,000 of G.D.P. per capita for other things.

Suppose between now and, say, 2050, inflation-adjusted G.D.P. per capita in the United States grows at an annual compound rate of only 1.5 percent per year, which is conservatively below the roughly 2 percent long-run annual growth rate of real G.D.P. per capita over the past several decades. Even at this low growth rate, inflation-adjusted G.D.P. per capita would grow from $46,500 now to about $87,000 by 2050.

According to the Social Security Trustees’ 2008 Report on the Status of the Social Security and Medicare Programs (Chart B), Medicare will absorb about 8.4 percent of G.D.P. by 2050 if it is not restructured.

But even after that 8.4 percent haircut for Medicare in 2050, there would still be close to $80,000 inflation-adjusted G.D.P. per capita left over for other things in that year, which is still 78 percent more than the non-Medicare G.D.P. per capita that we have today.

Source: Uwe E. Reinhardt.

So what do we mean when we lament that Medicare will not be “affordable” in the future? Do we assume that G.D.P. will be stagnant for the next 40 years?

Those who make such statements, of course, may not even think about real claims on real G.D.P. Instead they may have in mind two quite different propositions.

First, they may argue that even if Medicare were eminently affordable from a purely macroeconomic perspective, its current structure of mainly public financing may not be politically sustainable. There is no question that to allocate as much as 8.4 percent of 2050 G.D.P. to Medicare under its current structure would require sizable tax increases. But social values and preferences can change. Future cohorts of voting retirees and their children in the United States may well countenance the higher levels of taxation already long accepted in other industrialized nations, in return for greater personal financial security.

An alternative proposition may be that, even if (1) sustaining Medicare in its current structure were eminently affordable from a macroeconomic perspective, and (2) it were politically feasible, we still shouldn’t sustain Medicare in its present form because the program wastes real and financial resources.

There is something to the second proposition, as will be explained in detail in my next post to this blog.

Why Does U.S. Health Care Cost So Much? (Part IV: A Primer on Medicare)

2009-01-23T07:22:00.001-08:00

December 12, 2008, 6:30 am

By Uwe E. Reinhardt

Uwe E. Reinhardt is an economist at Princeton. For previous posts in his series on why America pays so much for health care, click here, here and here.

Medicare, the federal health-insurance program for America’s elderly, plays a major and highly controversial role in our health-care system. To many Americans it is a blessing. Others view it as a source of all that’s wrong with American health care. I propose to explore these views in this and the next two posts to this blog.

Congress established Medicare in 1965, when close to 40 percent of America’s elderly lived at or below the federal poverty line. They simply could not afford the ever more sophisticated and expensive health care then starting to come on line.

The program now covers 45 million Americans 65 or older, as well as younger people with permanent disabilities, among them patients afflicted with End Stage Renal Disease. About half of Medicare beneficiaries live at or below 200 percent of the federal poverty line (i.e., $20,800 annual income for a single person and $28,000 for a couple). Over a third of the beneficiaries are afflicted with three or more chronic conditions.

In 2009, Medicare is expected to cost the federal government about $480 billion. That represents over a fifth of total national health spending on personal health care, 13 percent of the federal budget and close to 3.5 percent of the country’s gross domestic product. These outlays are financed with a combination of payroll taxes (41 percent), general tax revenues (39 percent), premiums paid by the elderly (12 percent) and sundry other sources, including interest earned on a trust fund established for the program.

Because Medicare’s benefit package traditionally has been less generous than traditional employment-based private insurance for younger Americans –- it has covered prescription drugs only since 2006 — many beneficiaries have sought supplemental, wrap-around coverage from their former employers (about 33 percent) or from a purchase of a private Medigap policy (about 20 percent). The federal-state Medicaid program for the poor provides such gap coverage for some 7 million (or 15.5 percent) Medicare beneficiaries, called “dual eligibles.”

Even with such supplemental coverage, however, out-of-pocket cost-sharing at the time health care is received has always been high relative to employment-based private insurance for younger Americans. In 2005, the median fraction of income Medicare beneficiaries spent out of pocket for their care was 16.1 percent. For the 11 percent of beneficiaries without supplemental coverage, out-of-pocket spending can absorb 30 percent or more of their income.

Medicare was originally established as a single-payer, government-run, fee-for-service plan whose claims by patients and health care providers were administered, for a modest fee, by a select group of private insurance plans called Medicare Intermediaries -– typically Blue Cross plans. This arrangement is now known as “Traditional FFS Medicare.”

Starting in the 1970s, however, Medicare beneficiaries have had the option of enrolling in a variety of health plans offered by private insurers. Starting with the Medicare Modernization Act passed in December 2003, which offered beneficiaries drug coverage for the first time, these private insurance options have been called “Medicare Advantage” plans. About 23 percent of Medicare beneficiaries have chosen this option.

Driven by an ideological preference for private over government-run health insurance, the Republican Congress in 2003 made taxpayers effectively pay these private plans an average of 13 percent more per Medicare beneficiary than these beneficiaries would have cost taxpayers under the government-run program. Consequently, the private plans can offer beneficiaries superior benefits, which has caused enrollment in them to double from 5.3 million to 10.1 million between 2003 and 2008. Because it is hard to justify this extra public subsidy to the private plans on the basis of health policy, however, it has been highly controversial among health policy experts and is likely to be eliminated by the new Congress in the next few years.

Although often decried by its critics as “socialized medicine,” Medicare remains a highly popular health-insurance product among the elderly, who rate the quality of care they receive under it higher than younger, privately insured Americans rate their health care (see, for example, this and also this, Charts 4:1 to 4:3).

This sentiment is not surprising, because, from both the patient’s and the provider’s perspective, claims processing under Medicare is relatively simple in comparison with the complexity of private health insurance, although Medicare is much more administratively complex than are similar government-run, single-payer health insurance systems in other countries (e.g., Taiwan or Canada).

Furthermore, in surveys of Americans 50 and older, respondents expressed greater trust in Medicare as a source of health insurance, possibly still remembering the late 1990s, when many private plans terminated their coverage of Medicare patients.

In the next post, I shall assess the often-made claim that Medicare is not much longer “sustainable.” Thereafter I shall explore whether Medicare in its current form should be sustained, even if it were affordable in that form. In the meantime, readers who wish more detail on the program than could be offered here may wish to consult the excellent primer on Medicare found at the Henry J. Kaiser Family Foundation’s Web site.

Why Does U.S. Health Care Cost So Much? (Part III: An Aging Population Isn’t the Reason)

2009-01-23T07:10:00.000-08:00

By Uwe E. Reinhardt

Uwe E. Reinhardt is an economist at Princeton.

Update | Professor Reinhardt responds to commenters here.

Not a conference on health care goes by without someone’s asserting that the aging of our population is a major driver of the annual growth in health spending. It sounds intuitively appealing if one contemplates the following two graphs, which are regularly trotted out on such occasions.

Graph courtesy of Uwe Reinhardt.

Graph courtesy of Uwe Reinhardt.

The first graph depicts what is commonly described as the “Baby Boom Tsunami.” The second depicts age-specific health spending per capita in 1999, relative to the spending of Americans in the age group 35 to 44, which is set to 1. These age-specific relative spending profiles do not change much over time for a given country, and they do not much differ among industrialized nations. They show that after age 60 or so, health spending per capita rises sharply with age.

Yet, research around the world has shown that the process of the aging of the population by itself adds only a very small part – usually about half a percentage point — to the annual growth in per-capita health spending in industrialized societies, which tends to range between 5 and 8 percent, depending on the country and the period in question. The bulk of annual spending growth can be explained by overall population growth (about 1.1 percent per year), increases in the prices of health care goods and services, and the availability of ever more new, often high-cost medical products and treatments used by all age groups.

Because this proposition is so counterintuitive, readers may wish to consult two recent research papers on the topic, one penned by the present author, and the other penned by other researchers.

These papers are based on American data. Similar studies have appeared also for Canada, Australia and many other countries in the Organization for Economic Cooperation and Development. Indeed, it may surprise readers that knowing the percentage of a nation’s population that is over age 65 cannot help one explain cross-national differences in health spending per capita, as is shown in the graph further on. As the graph shows, the per-capita health spending of nations is virtually independent of the age structure of its population.

Graph courtesy of Uwe Reinhardt.

Why, then, is the aging of the population such a small driver of annual increases in health spending? The answer can be found in the last graphical display of this commentary. That graph contains the same data as the first graph in this commentary, but the vertical axis is scaled as it should be scaled: from 0 percent to 100 percent. Letting it run from 12 percent to 22 percent stretches the vertical axis and creates the image of the famous Baby Boom Tsunami. It is a form of lying with statistics.

Graph courtesy of Uwe Reinhardt.

As this graph illustrates, the aging of our population is a very gradual process and does not come even close to resembling a tsunami. It is at best a demographic ripple.

Furthermore, current population projections have the fraction of elderly in the United States population peak at around 20 percent. Along with Canada and Australia, we shall be for a very long time the youngest nation in the O.E.C.D. Only in 2025 will the American population be as “old” as many European populations are already today.

As the song goes, relative to other nations we shall be “forever young”!

Why Does U.S. Health Care Cost So Much? (Part II: Indefensible Administrative Costs)

2009-01-23T07:09:00.001-08:00

By Uwe E. Reinhardt

Uwe E. Reinhardt is an economist at Princeton.

In my previous blog post, I showed that America suffers from “excess spending” in its health care system. Here I will discuss one factor that drives up that spending: indefensibly high administrative costs.

To review: “Excess health spending” in this context refers to the difference between what a country spends per person on health care, and what the country’s gross domestic product per person should predict that that country would spend. (The prediction is based on trends in other countries in the Organization for Economic Cooperation and Development.) The word “excess” here should not be taken as “excessive” unless one could demonstrate that what the other O.E.C.D. nations spend is appropriate and what we spend is ipso facto wasteful.

The United States spends nearly 40 percent more on health care per capita than its G.D.P. per capita would predict. Given the sheer magnitude of the estimated excess spending, it is fair to ask American health care providers what extra benefits the American people receive in return for this enormous extra spending. After all, translated into total dollar spending per year, this excess spending amounted to $570 billion in 2006 and about $650 billion in 2008. The latter figure is over five times the estimated $125 billion or so in additional health spending that would be needed to attain truly universal health insurance coverage in this country.

One thing Americans do buy with this extra spending is an administrative overhead load that is huge by international standards. The McKinsey Global Institute estimated that excess spending on “health administration and insurance” accounted for as much as 21 percent of the estimated total excess spending ($477 billion in 2003). Brought forward, that 21 percent of excess spending on administration would amount to about $120 billion in 2006 and about $150 billion in 2008. It would have been more than enough to finance universal health insurance this year.

The McKinsey team estimated that about 85 percent of this excess administrative overhead can be attributed to the highly complex private health insurance system in the United States. Product design, underwriting and marketing account for about two-thirds of that total. The remaining 15 percent was attributed to public payers that are not saddled with the high cost of product design, medical underwriting and marketing, and that therefore spend a far smaller fraction of their total spending on administration.

Two studies using more detailed bilateral comparisons of two countries illustrate even more sharply the magnitude of our administrative burden relative to that in other developed countries.

One of these is an earlier McKinsey study explaining the difference in 1990 health spending in West Germany and in the United States. The researchers found that in 1990 Americans received $390 per capita less in actual health care but spent $360 more per capita on administration.

A second, more recent study of administrative costs in the American and Canadian health systems was published in 2003 by Steffie Woolhandler and David Himmelstein in The New England Journal of Medicine in 2003. The study used a measure of administrative costs that includes not only the insurer’s costs, but also the costs borne by employers, health-care providers and governments – but not the value of the time patients spent claiming reimbursement. These authors estimated that in 1999, Americans spent $1,059 per capita on administration compared with only $307 in purchasing power parity dollars (PPP $) spent in Canada.

More and more Americans are being priced out of health care as we know it. The question is how long American health policy makers, and particularly the leaders of our private health insurance, can justify this enormous and costly administrative burden to the American people and to the harried providers of health care.

Why Does U.S. Health Care Cost So Much? (Part I)

2009-01-23T06:59:00.000-08:00

November 14, 2008, 7:30 am
Why Does U.S. Health Care Cost So Much? (Part I)
By Uwe E. Reinhardt

Uwe E. Reinhardt is an economist at Princeton.

The graph below tells a compact story of United States health spending relative to that of other nations.

Shown on the horizontal axis is the gross domestic product per capita in 2006. The vertical axis represents 2006 health spending per capita. The data points in the graph represent two dozen developed countries that are members of the Organization for Economic Cooperation and Development (O.E.C.D.).

The data are expressed in Purchasing Parity Dollars (PPP$). This metric is designed to adjust for cross-national differences in the purchasing power of national currencies relative to the real goods and services. One can think of PPP$s as dollars that buy roughly the same basket of real goods and services in different countries.

Source: Uwe Reinhardt

You’ll notice that there is enormous variation in health spending per capita in different countries within the O.E.C.D. But the graph also indicates that there exists a very strong relationship between the G.D.P. per capita of these countries (roughly a measure of ability to pay) and per-capita health spending. The dark line in the graph is a so-called regression equation (whose precise mathematical form is shown in the upper left corner).

That line tells us something important about the relationship between a country’s wealth and its health care spending.

Just knowing the G.D.P. per capita of nations helps us explain about 86 percent of the variation in how much different countries pay for health care for the average person. Canada, for example, on average spent only PPP$3,678 on health care per person in 2006, which is about 55 percent of the amount the United States paid per person. But Canada’s G.D.P. per capita in 2006 was also smaller than the comparable United States figure, although not that much smaller (it was 84 percent of the American level).

The line helps us estimate that roughly $1,141 of the $3,036 difference between Canadian and American health spending per capita – or 38 percent — can be explained by the underlying difference in G.D.P. per capita alone.

An additional insight from the graph, however, is that even after adjustment for differences in G.D.P. per capita, the United States in 2006 spent $1,895 more on health care than would have been predicted after such an adjustment. If G.D.P. per capita were the only factor driving the difference between United States health spending and that of other nations, the United States would be expected to have spent an average of only $4,819 per capita on health care rather than the $6,714 it actually spent.

Health-services researchers call the difference between these numbers, here $1,895, “excess spending.” That term, however, is not meant to convey “excessive spending,” but merely a difference driven by factors other than G.D.P. per capita. Prominent among these other factors are:

1. higher prices for the same health care goods and services than are paid in other countries for the same goods and services;

2. significantly higher administrative overhead costs than are incurred in other countries with simpler health-insurance systems;

3. more widespread use of high-cost, high-tech equipment and procedures than are used in other countries;

4. higher treatment costs triggered by our uniquely American tort laws, which in the context of medicine can lead to “defensive medicine” — that is, the application of tests and procedures mainly as a defense against possible malpractice litigation, rather than as a clinical imperative.

There are three other explanations that are widely — but erroneously — thought among non-experts to be cost drivers in the American health spending. To wit:

1. that the aging of our population drives health spending

2. that we get better quality from our health system than do other nations, and

3. that we get better health outcomes from our system

I will comment in more detail on factors that do and do not drive health spending in subsequent posts.

News Keeps Getting Worse for Vitamins

2008-11-28T16:45:00.000-08:00

November 20, 2008, 12:45 pm

The best efforts of the scientific community to prove the health benefits of vitamins keep falling short.

Consumers don’t want to give up their vitamins. (Tony Cenicola/The New York Times)

This week, researchers reported the disappointing results from a large clinical trial of almost 15,000 male doctors taking vitamins E and C for a decade. The study showed no meaningful effect on cancer rates.

Another recent study found no benefit of vitamins E and C for heart disease.

In October, a major trial studying whether vitamin E and selenium could lower a man’s risk for prostate cancer ended amidst worries that the treatments may do more harm than good.

And recently, doctors at Memorial Sloan-Kettering Cancer Center in New York warned that vitamin C seems to protect not just healthy cells but cancer cells, too.

Everyone needs vitamins, which are critical for the body. But for most people, the micronutrients we get from foods usually are adequate to prevent vitamin deficiency, which is rare in the United States. That said, some extra vitamins have proven benefits, such as vitamin B12 supplements for the elderly and folic acid for women of child-bearing age. And calcium and vitamin D in women over 65 appear to protect bone health.

But many people gobble down large doses of vitamins believing that they boost the body’s ability to mop up damaging free radicals that lead to cancer and heart disease. In addition to the more recent research, several reports in recent years have challenged the notion that megadoses of vitamins are good for you.

A Johns Hopkins School of Medicine review of 19 vitamin E clinical trials of more than 135,000 people showed high doses of vitamin E (greater than 400 IUs) increased a person’s risk for dying during the study period by 4 percent. Taking vitamin E with other vitamins and minerals resulted in a 6 percent higher risk of dying. Another study of daily vitamin E showed vitamin E takers had a 13 percent higher risk for heart failure.

The Journal of Clinical Oncology published a study of 540 patients with head and neck cancer who were being treated with radiation therapy. Vitamin E reduced side effects, but cancer recurrence rates among the vitamin users were higher, although the increase didn’t reach statistical significance.

A 1994 Finland study of smokers taking 20 milligrams a day of beta carotene showed an 18 percent higher incidence of lung cancer among beta carotene users. In 1996, a study called Caret looked at beta carotene and vitamin A use among smokers and workers exposed to asbestos, but the study was stopped when the vitamin users showed a 28 percent higher risk for lung cancer and a 26 percent higher risk of dying from heart disease.

A 2002 Harvard study of more than 72,000 nurses showed that those who consumed high levels of vitamin A from foods, multivitamins and supplements had a 48 percent higher risk for hip fractures than nurses who had the lowest intake of vitamin A.

The Cochrane Database of Systematic Reviews looked at vitamin C studies for treating colds. Among more than two dozen studies, there was no overall benefit for preventing colds, although the vitamin was linked with a 50 percent reduction in colds among people who engaged in extreme activities, such as marathon runners, skiers and soldiers, who were exposed to significant cold or physical stress. The data also suggested vitamin C use was linked with less severe and slightly shorter colds.

In October 2004, Copenhagen researchers reviewed seven randomized trials of beta carotene, selenium and vitamins A, C and E (alone or in combination) in colon, esophageal, gastric, pancreatic and liver cancer. The antioxidant users had a 6 percent higher death rate than placebo users.

Two studies presented to the American College of Cardiology in 2006 showed that vitamin B doesn’t prevent heart attacks, leading The New England Journal of Medicine to say that the consistency of the results “leads to the unequivocal conclusion” that the vitamins don’t help patients with established vascular disease.

The British Medical Journal looked at multivitamin use among elderly people for a year but found no difference in infection rates or visits to doctors.

Despite a lack of evidence that vitamins actually work, consumers appear largely unwilling to give them up. Many readers of the Well blog say the problem is not the vitamin but poorly designed studies that use the wrong type of vitamin, setting the vitamin up to fail. Industry groups such as the Council for Responsible Nutrition also say the research isn’t well designed to detect benefits in healthy vitamin users.

Lack of Exercise Explains Depression-Heart Link

2008-11-28T16:42:00.001-08:00

November 26, 2008, 2:43 pm

By Tara Parker-Pope

For years cardiologists and mental health experts have known that depression raises risk for heart attack by 50 percent or more.

But what hasn’t been clear is why depressed people have more heart problems. Does depression cause some biological change that increases risk? Does the inflammatory process that leads to heart disease also trigger depression?

The answer may be far simpler. A new study suggests that people who are depressed are simply less likely to exercise, a finding that explains their dramatically higher risk for heart problems.

Researchers, led by doctors from the Veterans Affairs Medical Center in San Francisco, recruited 1,017 participants with heart disease to track their health and lifestyle habits. As they expected, those patients who had symptoms of depression fared worse. About 10 percent of depressed heart patients had additional heart problems, during the study, compared with 6.7 percent of the other patients. After controlling for other illnesses and the severity of heart disease, the finding translates to a 31 percent higher risk of heart problems among the depressed people, according to the study published this week in the Journal of the American Medical Association.

But once the researchers factored in the effect of exercise, the difference in risk among depressed people disappeared. In the same study, patients who didn’t exercise, whether or not they were depressed, had a 44 percent higher risk of heart problems, after controlling for a variety of factors including medication adherence, smoking and other illnesses.

The findings are important because some earlier studies have suggested a link between antidepressant use and lower heart risk. The explanation may be that patients who take antidepressants start to feel better and take care of themselves, adopting healthy behaviors including exercise. In a study of nearly 2,500 heart-attack patients, published in the Journal of the American Medical Association in June 2003, behavioral therapy to treat depression didn’t change survival rates compared with patients who received regular care. But among about 20 percent of patients in the study who ended up on antidepressants, the risk of dying or suffering a second nonfatal heart attack was 42 percent lower. Another study, called Sadheart (which stands for Sertraline Antidepressant Heart Attack Randomized Trial) showed the death rate from heart-related problems was 20 percent lower among patients taking the drug, although the data weren’t statistically significant.

The research suggests that doctors treating patients for depression should also talk to them about their lifestyle habits, and encourage them to exercise. The findings, say the researchers, suggest that the heart problems associated with depression “could potentially be preventable.”

The evidence that health behaviors fully explain the link between depression and heart disease in this study is convincing, says Dr. Mary A. Whooley, professor of medicine, epidemiology and biostatistics at the University of California, San Francisco. However, she notes the study is limited to older men with stable coronary disease, and as a result, more study is needed of women and other patients with heart disease.

It remains an open question whether the study findings will change the way doctors counsel their patients. “The clinical practice question is a challenging one,” says Dr. Whooley. “It’s easy for us to tell patients to exercise, take their medicines, and refrain from smoking, but actually changing health behaviors is very difficult.”

Scientists Find Clues to Aging in a Red Wine Ingredient’s Role in Activating a Protein

2008-11-28T16:40:00.001-08:00

November 27, 2008

By NICHOLAS WADE

A new insight into the reason for aging has been gained by scientists trying to understand how resveratrol, a minor ingredient of red wine, improves the health and lifespan of laboratory mice. They believe that the integrity of chromosomes is compromised as people age, and that resveratrol works by activating a protein known as sirtuin that restores the chromosomes to health.

The finding, published online Wednesday in the journal Cell, is from a group led by David Sinclair of the Harvard Medical School. It is part of a growing effort by biologists to understand the sirtuins and other powerful agents that control the settings on the living cell’s metabolism, like its handling of fats and response to insulin.

Researchers are just beginning to figure out how these agents work and how to manipulate them, hoping that they can develop drugs to enhance resistance to disease and to retard aging.

Sirtris, a company Dr. Sinclair helped found, has developed a number of chemicals that mimic resveratrol and are potentially more suitable as drugs since they activate sirtuin at much lower doses than resveratrol. This month, one of these chemicals was reported in the journal Cell Metabolism to protect mice on fatty diets from getting obese and to enhance their endurance in treadmills, just as resveratrol does.

Though the sirtuin field holds considerable promise, the dust has far from settled. Resveratrol is a powerful agent with many different effects, only some of which are exerted through sirtuin. So drugs that activate sirtuin may not be as splendid a tonic for people as resveratrol certainly seems to be for mice.

The new finding concerns maintenance of the chromosomes, the giant molecules of DNA that make up the genome.

Each cell has six feet of DNA packed into its nucleus, carrying the 20,000 or so genetic instructions needed to operate the human body. Each cell must provide instant access to the handful of these genes needed by its cell type, but also keep the rest firmly switched off to avoid chaos.

Sirtuin’s normal role is to help gag all the genes that a cell needs to keep suppressed. It does so by keeping the chromatin, the stuff that wraps around the DNA, packed so tightly that the cell cannot get access to the underlying genes.

But sirtuin has another critical role, one that is triggered by emergencies like a break in both DNA strands of a chromosome. After a double strand break, sirtuin rushes to the site to help knit the two parts of the chromosome back together. But in this salvage operation, it leaves its post, and the genes it was repressing are liable to come back into action, causing mayhem.

This, Dr. Sinclair and his colleagues suggest, may be a fundamental cause of aging in mice and probably people, too.

The gene-gagging role of sirtuin was discovered in the 1980s by biologists studying yeast, a standard laboratory organism. Dr. Sinclair and Leonard Guarente of the Massachusetts Institute of Technology found in 1997 that sirtuin could also repair a certain kind of genomic damage in yeast, and in doing so extended the yeast cell’s lifespan. But this particular kind of damage does not occur in mammalian cells, raising the puzzle of why extra sirtuin should be good for them.

Dr. Sinclair’s new report, if verified, resolves this problem by showing that sirtuin has retained its genomic repair role in higher organisms but that the repair is focused on a different kind of genomic damage — that of breaks in a chromosome.

These experiments “elegantly demonstrate” that sirtuin works in much the same way in mammals as in yeast, Dr. Jan Vijg of the Albert Einstein College of Medicine wrote in a commentary in Cell. The question now is whether sirtuin is a pro-longevity factor in mammals, he said in an e-mail message.

Ronald Evans, a biologist at the Salk Institute, said the new report was provocative but did not prove the case that the relocation of sirtuin was a cause of aging. Tests with mice genetically engineered to lack the sirtuin gene could show if the mice suffered from premature aging, as Dr. Sinclair’s idea would predict.

Dr. Sinclair said he agreed that the case for sirtuin’s role in aging had not been proved. “We are careful not to say this is the cause of aging, but based on everything we know it’s not a bad hypothesis,” he said.

It would be nice to test aging in mice that lack the sirtuin gene, as Dr. Evans proposed, but they die too young, Dr. Sinclair said.

Dr. Sinclair has been taking large daily doses of resveratrol since he and others discovered five years ago that it activated sirtuin. “I’m still taking it, and I feel great,” he said, “but it’s too early to say if I’m young for my age.”

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Study Suggests Some Cancers May Go Away

2008-11-28T16:38:00.000-08:00

November 25, 2008

By GINA KOLATA

Cancer researchers have known for years that it was possible in rare cases for some cancers to go away on their own. There were occasional instances of melanomas and kidney cancers that just vanished. And neuroblastoma, a very rare childhood tumor, can go away without treatment.

But these were mostly seen as oddities — an unusual pediatric cancer that might not bear on common cancers of adults, a smattering of case reports of spontaneous cures. And since almost every cancer that is detected is treated, it seemed impossible even to ask what would happen if cancers were left alone.

Now, though, researchers say they have found a situation in Norway that has let them ask that question about breast cancer. And their new study, to be published Tuesday in The Archives of Internal Medicine, suggests that even invasive cancers may sometimes go away without treatment and in larger numbers than anyone ever believed.

At the moment, the finding has no practical applications because no one knows whether a detected cancer will disappear or continue to spread or kill.

And some experts remain unconvinced.

“Their simplification of a complicated issue is both overreaching and alarming,” said Robert A. Smith, director of breast cancer screening at the American Cancer Society.

But others, including Robert M. Kaplan, the chairman of the department of health services at the School of Public Health at the University of California, Los Angeles, are persuaded by the analysis. The implications are potentially enormous, Dr. Kaplan said.

If the results are replicated, he said, it could eventually be possible for some women to opt for so-called watchful waiting, monitoring a tumor in their breast to see whether it grows. “People have never thought that way about breast cancer,” he added.

Dr. Kaplan and his colleague, Dr. Franz Porzsolt, an oncologist at the University of Ulm, said in an editorial that accompanied the study, “If the spontaneous remission hypothesis is credible, it should cause a major re-evaluation in the approach to breast cancer research and treatment.”

The study was conducted by Dr. H. Gilbert Welch, a researcher at the VA Outcomes Group in White River Junction, Vt., and Dartmouth Medical School; Dr. Per-Henrik Zahl of the Norwegian Institute of Public Health; and Dr. Jan Maehlen of Ulleval University Hospital in Oslo. It compared two groups of women ages 50 to 64 in two consecutive six-year periods.

One group of 109,784 women was followed from 1992 to 1997. Mammography screening in Norway was initiated in 1996. In 1996 and 1997, all were offered mammograms, and nearly every woman accepted.

The second group of 119,472 women was followed from 1996 to 2001. All were offered regular mammograms, and nearly all accepted.

It might be expected that the two groups would have roughly the same number of breast cancers, either detected at the end or found along the way. Instead, the researchers report, the women who had regular routine screenings had 22 percent more cancers. For every 100,000 women who were screened regularly, 1,909 were diagnosed with invasive breast cancer over six years, compared with 1,564 women who did not have regular screening.

There are other explanations, but researchers say that they are less likely than the conclusion that the tumors disappeared.

The most likely explanation, Dr. Welch said, is that “there are some women who had cancer at one point and who later don’t have that cancer.”

The finding does not mean that mammograms caused breast cancer. Nor does it bear on whether women should continue to have mammograms, since so little is known about the progress of most cancers.

Mammograms save lives, Dr. Smith said. Even though they can have a downside — most notably the risk that a woman might have a biopsy to check on an abnormality that turns out not to be cancer — “the balance of benefits and harms is still considerably in favor of screening for breast cancer,” he said.

But Dr. Suzanne W. Fletcher, an emerita professor of ambulatory care and prevention at Harvard Medical School, said that it was also important for women and doctors to understand the entire picture of cancer screening. The new finding, she said, was “part of the picture.”

“The issue is the unintended consequences that can come with our screening,” Dr. Fletcher said, meaning biopsies for lumps that were not cancers or, it now appears, sometimes treating a cancer that might not have needed treatment. “In general we tend to underplay them.”

Dr. Welch said the cancers in question had broken through the milk ducts, where most breast cancers begin, and invaded the breast. Such cancers are not microscopic, often are palpable, and are bigger and look more ominous than those confined to milk ducts, so-called ductal carcinoma in situ, or DCIS, Dr. Welch said. Doctors surgically remove invasive cancers and, depending on the circumstances, may also treat women with radiation, chemotherapy or both.

The study’s design was not perfect, but researchers say the ideal study is not feasible. It would entail screening women, randomly assigning them to have their screen-detected cancers treated or not, and following them to see how many untreated cancers went away on their own.

But, they said, they were astonished by the results.

“I think everybody is surprised by this finding,” Dr. Kaplan said. He and Dr. Porzsolt spent a weekend reading and re-reading the paper.

“Our initial reaction was, ‘This is pretty weird,’ ” Dr. Kaplan said. “But the more we looked at it, the more we were persuaded.”

Dr. Barnett Kramer, director of the Office of Disease Prevention at the National Institutes of Health, had a similar reaction. “People who are familiar with the broad range of behaviors of a variety of cancers know spontaneous regression is possible,” he said. “But what is shocking is that it can occur so frequently.”

Although the researchers cannot completely rule out other explanations, Dr. Kramer said, “they do a good job of showing they are not highly likely.”

A leading alternative explanation for the results is that the women having regular scans used hormone therapy for menopause and the other women did not. But the researchers calculated that hormone use could account for no more than 3 percent of the effect.

Maybe mammography was more sensitive in the second six-year period, able to pick up more tumors. But, the authors report, mammography’s sensitivity did not appear to have changed.

Or perhaps the screened women had a higher cancer risk to begin with. But, the investigators say, the groups were remarkably similar in their risk factors.

Dr. Smith, however, said the study was flawed and the interpretation incorrect. Among other things, he said, one round of screening in the first group of women would never find all the cancers that regular screening had found in the second group. The reason, he said, is that mammography is not perfect, and cancers that are missed on one round of screening will be detected on another.

But Dr. Welch said that he and his colleagues considered that possibility, too. And, he said, their analysis found subsequent mammograms could not make up the difference.

Dr. Kaplan is already thinking of how to replicate the result. One possibility, he said, is to do the same sort of study in Mexico, where mammography screening is now being introduced.

Donald A. Berry, chairman of the department of biostatistics at M. D. Anderson Cancer Center in Houston, said the study increased his worries about screenings that find cancers earlier and earlier. Unless there is some understanding of the natural history of the cancers that are found — which are dangerous and which are not — the result can easily be more treatment of cancers that would not cause harm if left untreated, he said.

“There may be some benefit to very early detection, but the costs will be huge — and I don’t mean monetary costs,” Dr. Berry said. “It’s possible that we all have cells that are cancerous and that grow a bit before being dumped by the body. ‘Hell bent for leather’ early detection research will lead to finding some of them. What will be the consequence? Prophylactic removal of organs in the masses? It’s really scary.”

But Dr. Laura Esserman, professor of surgery and radiology at the University of California, San Francisco, sees a real opportunity to figure out why some cancers go away.

“I am a breast cancer surgeon; I run a breast cancer program,” she said. “I treat women every day, and I promise you it’s a problem. Every time you tell a person they have cancer, their whole life runs before their eyes.

“What if I could say, ‘It’s not a real cancer, it will go away, don’t worry about it,’ ” she added. “That’s such a different message. Imagine how you would feel.”

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2008-10-06T12:03:00.000-07:00

October 3, 2008, 11:33 am

What’s the Healthiest Diet of All?

By Peter Libby, M.D.

Diners at an outdoor cafe in Corsica, France. (Ed Alcock for The New York Times)

What exactly do doctors mean by a “healthy diet”?

Many of us consider the Mediterranean diet to be the closest thing known to an ideal meal plan, rich in vegetables, fruits, legumes, cereals, fish, olive oil and, yes, a bit of red wine with meals. Compared to traditional American menu — high in red meat and in butter and other dairy products — the Mediterranean diet is lower in saturated fat, more varied and often more satisfying.

Decades worth of research also suggests that this way of eating is healthier. Many studies have documented reduced rates of heart disease and cancer among those adhering to a Mediterranean diet, compared to those eating more red meat and dairy-based regimens. Most of these studies have involved observations rather than actual intervention trials, however, and they have varied in size.

Now the British Medical Journal has published a systematic compilation of a dozen of the most methodologically sound of these observational studies, which included over 1.5 million people followed for up to eighteen years, analyzing cardiovascular consequences and some other important health outcomes. This large meta-analysis found decreased cardiovascular death as well as cancer mortality, as well as a lowered incidence of Parkinson’s disease and Alzheimer’s disease, in those following the Mediterranean diet versus those on other diets.

While such meta-analyses have limitations and cannot be considered as persuasive as large, randomized intervention trials, the new study further supports the idea that the Mediterranean diet can confer important health benefits.

Different diets abound, many even promoted by physicians. But it’s a mistake to think of a diet as a temporary measure; instead, it is a lifetime commitment to healthy choices. Need to lose weight now? Don’t rush. Take comfort in knowing that even a modest incremental reduction can confer significant health benefits, lowering your risk of heart disease or diabetes. Crash diets only set us up “yo-yo” weight loss and regain.

Whatever eating habits you adopt must be sustainable over the long term. Many researchers regard this as the Mediterranean diet’s greatest strength. You can stick to it, and like it, year after year.

How sad, then, to learn that a diet that whose adherents were among the longest-lived in the world is now fading from view. The governments of Greece, Italy, Spain and Morocco have asked that UNESCO designate the Mediterranean diet an “intangible piece of cultural heritage.” But as The Times recently reported, fast food is proliferating across the Mediterranean region, threatening to propagate a U.S.-style obesity epidemic.

In Greece, three-quarters of the adult population is now overweight or obese, and at increasing risk for diabetes, heart disease and arthritis, among other maladies. “Much of the highly praised diet didn’t exist any more,” said a senior economist at the United Nations. ”It has become just a notion.” Rather than turning our backs on this traditional diet, the new data suggest we could all derive substantial health benefits from it.

[For some dishes with a Mediterranean flair, check out The Times' Recipes for Health. -- Eds.]

Living Longer, in Good Health to the End

2008-08-27T08:00:00.000-07:00

By JANE E. BRODY

Published: August 25, 2008

You don’t have to be an actuary or funeral director to have noticed the striking increase in the length of many Americans’ lives. The obituaries in this or any other newspaper show a growing number of people who depart this world in their late 80s or 90s, or even at 100 or older.

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The fastest-growing segment of the population consists of people over 85, and by 2050 some 800,000 Americans will have celebrated their 100th birthday.

Doomsayers consider this a terrifying trend, bound to bankrupt Social Security and Medicare and overwhelm the ability of doctors and medical facilities to care for the burgeoning population of the oldest old.

But there is increasing evidence that the societal burden of increased longevity need not be so drastic. Long-term studies have shown that how people live accounts for more than half the difference in how hale and hearty they will remain until very near the end.

Many very old people have assumed “bragging rights” about their age and what they can still accomplish despite it, as Michael Kinsley wrote in The New Yorker in April.

At a pool in downtown Los Angeles, Mr. Kinsley encountered a stranger who interrupted his laps long enough to say, “I’m 90 years old.” The man, Richard Ibañez, a retired judge, died in November at age 97, but swam every morning until the last week of his life, his grandson, Christopher A. Karachale, wrote in a letter to the magazine.

A friend’s father, Irving Weinig, who lived in an assisted living facility in New York, requested new clothes for his 104th birthday so he could look spiffy when he had lunch with “the girls,” an activity he enjoyed until his death at 108.

And last spring the Island Nursing and Rehab Center in Holtsville, N.Y., boasted about a new resident, Nora Elizabeth Wright, who was turning 106.

All of these examples speak to a concept proposed in The New England Journal of Medicine in 1980 by Dr. James F. Fries of Stanford University: that adult vigor can be extended well into the ninth decade of life, with illness and disability compressed into a period that shortly precedes death.

Who Lives the Longest?

Many studies have examined the factors that predict the length of people’s lives, with nearly universal agreement that about 35 percent is determined by genes over which we have little or no control.

Dr. Nir Barzilai and colleagues at Albert Einstein College of Medicine found, for example, that individuals “with exceptional longevity” and a low incidence of age-related diseases have significantly larger HDL and LDL particles in their blood, a genetic characteristic that reduces their risk of developing cardiovascular diseases.

Scientists are searching for ways to extend healthy life spans by manipulating “bad” genes, but the potential exists now for modifying many of the environmental factors that account for the other 65 percent of longevity. And I suspect that most of us who hope to join the ranks of the oldest old would like to do so in a manner similar to that of Richard Ibañez and Irving Weinig — in rather good shape physically and mentally almost to the very end.

“Longevity is a Pyrrhic victory if those additional years are characterized by inexorable morbidity from chronic illness, frailty-associated disability and increasingly lowered quality of life,” Dr. William J. Hall of the Highland Hospital Center for Healthy Aging in Rochester wrote in The Archives of Internal Medicine in February.

New Habits Are Effective

Dr. Richard S. Rivlin, an internist and director of the nutrition and cancer prevention career development program at Weill Cornell Medical College, said in an interview that it was never too late to adopt habits that predict a healthy old age.

“While measures started early in life are most likely to have the greatest health benefit,” he said, “older people should never feel that turning over a new leaf at their age is anything but highly effective.”

He said there was clear evidence that measures taken in one’s 70s could help prevent “several important categories of disease, such as hypertension, heart disease, osteoporosis and even cancer.”

In The American Journal of Clinical Nutrition last year, Dr. Rivlin noted that changes in body composition, like loss of bone and muscle and accumulation of body fat, typically accompany aging and can affect health in a variety of ways: poor posture that impairs breathing; falls and fractures; loss of mobility; a reduced metabolic rate; and weight gain that can lead to diabetes, heart and blood vessel disease and some forms of cancer.

But these changes in body composition, he added, “are not an invariable accompaniment of aging.” Much can be done to limit and even reverse them, he said, including restricting calories and following a diet of high-quality protein and limited saturated fat and replacing simple sugars with whole grains rich in fiber.

The Importance of Exercise

A second critical measure for the “young-elderly,” as he calls 70-year-olds, is to “make regular exercise a part of their daily lifestyle,” including aerobic activities that raise the heart rate; weight-bearing activities that strengthen muscles and bones; and stretching exercises that reduce stiffness and improve flexibility and balance.

Another age-related concern is cognitive decline, which is more likely in people with metabolic syndrome, a cluster of modifiable risk factors that includes abdominal obesity, high blood pressure, insulin resistance and abnormal cholesterol levels. Dr. Hall cautioned against therapeutic nihilism in treating older people with such risk factors.

“Chronological age is a very imperfect determinant on which to base medical decision-making,” he wrote.

Dr. Hall’s comments were based on a 25-year study by Dr. Laurel B. Yates of Brigham and Women’s Hospital and her Boston colleagues of 2,357 men who were healthy at an average age of 72 when the study began. Of the 970 men who survived to at least age 90, the primary modifiable predictors of longevity were not smoking; preventing diabetes, obesity and high blood pressure; and exercising regularly.

“Compared with nonsurvivors, men with exceptional longevity had a healthier lifestyle, had a lower incidence of chronic diseases and were three to five years older at disease onset,” the Boston team reported in February in The Archives of Internal Medicine. “They had better late-life physical function and mental well-being. More than 68 percent rated their late-life health as excellent or very good, and less than 8 percent reported fair or poor health.”

Other long-term studies have also pinpointed exercise as the single most potent predictor of healthy longevity, in women as well as in men. It is not that very old people like Judge Ibañez can exercise because they are healthy, these findings indicate. Rather, they achieve a healthy old age because they exercise.

Studies Cast Doubt on Use of Calcium in Some Cases

2008-08-27T07:24:00.001-07:00

By ANAHAD O'CONNOR

Published: April 28, 2005

espite what doctors have long recommended, regularly taking calcium and vitamin D does not prevent fractures in older people who have broken a bone or who have osteoporosis, according to two large studies released yesterday.

People with osteoporosis are often encouraged to consume as much calcium and vitamin D as possible to strengthen their bones and to lower the likelihood of injuries.

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But the new studies, involving thousands of elderly people in Britain who had symptoms of the disease, found that those who took calcium and vitamin D tablets were just as likely to break a bone as those who took neither.

The authors of the reports, published in The Lancet and the British medical journal BMJ, said their findings suggested that for people with brittle bones, relying solely on the supplements might not be enough.

"Our trial indicates that routine supplementation with calcium and vitamin D3, either alone or in combination, is not effective in the prevention of further fractures in people who have had a recent low-trauma fracture," the authors of the Lancet study wrote.

Other experts called the findings important but cautioned that they did not apply to most people.

Just people older than 70, a majority of them women with previous bone injuries, were included in the studies.

Because vitamin D and calcium are widely considered early preventive measures, it is no surprise that the studies failed to find them effective in people who already had osteoporosis or signs of it, said Dr. Steven R. Goldstein, a professor of obstetrics and gynecology at the New York University medical center.

"This is something we've known for a long time, that calcium and vitamin D alone are not enough to treat osteoporosis," Dr. Goldstein said. "Once you've developed frank osteoporosis and a bone fracture, you're going to need medication, not simply vitamin D and calcium to prevent fractures."

Osteoporosis causes bones to become thinner and occurs primarily in the elderly.

About 10 million Americans older than 50 develop the disease each year, and 1.5 million break bones because of it. Osteoporosis can be treated with drugs like biphosphonates that prevent the bones from deteriorating, but doctors often recommend taking supplements or eating foods rich in calcium and vitamin D to build up bone mass.

The largest of the two studies, in The Lancet, followed more than 5,o00 Scots who had broken bones in the last decade. Separated in four groups, the subjects received large doses of calcium, vitamin D, a combination of the two or a placebo. After several years, the researchers found that all four groups had roughly the same number of fractures, mostly to the hip.

Dr. Joan McGowan, an expert on osteoporosis at the National Institutes of Health, said it was surprising that there were not fewer fractures among the people who took the calcium and vitamin D, but that neither was seen a replacement for medication." Nobody thinks calcium and vitamin D are as potent as some of the other bone-active drugs that we have available," Dr. McGowan said.

Let the Sunshine in

2008-08-27T07:22:00.000-07:00

By C. CLAIBORNE RAY

Published: April 15, 2008

Correction Appended

Q. Am I still getting vitamin D when I’m outside on a gray, cloudy day?

Victoria Roberts

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A. Just as it is possible to get a sunburn on an overcast day, it is possible to get the ultraviolet-B radiation needed for the skin to synthesize vitamin D even when skies are cloudy and gray. Efficiency varies, however, with the season, the altitude, skin color, the length of skin exposure and the percentage exposed, and air pollution.

Complete cloud cover halves the energy of ultraviolet rays, and shade reduces it by 60 percent, according to the National Institutes of Health.

The wavelengths of ultraviolet light needed to make vitamin D are from about 290 to 320 nanometers, within the ultraviolet-B range, which is also associated with sunburn and skin damage.

At the earth’s northern latitudes for much of the year, and at the midlatitudes in winter, the sun does not stay far enough above the horizon (45 degrees) for the angle of the sun’s rays to guarantee an efficient ultraviolet-B bath. Northerners may have to rely on the vitamin D synthesized in the summer or on foods and supplements.

Readers may submit questions by mail to Question, Science Times, The New York Times, 620 Eighth Avenue, New York, N.Y. 10018, or by e-mail to question@nytimes.com.

This article has been revised to reflect the following correction:

Correction: April 23, 2008
An answer in the Q&A column on April 15, about people getting vitamin D from exposure to the sun on a cloudy day, and a column on May 17, 2005, about getting the vitamin from exposure to sunlight through a window, incorrectly attributed a position to the National Institutes of Health about sun exposure and vitamin D. The columns also referred to an outdated fact sheet posted on the N.I.H. Web site. The recommendation for 10 to 15 minutes of exposure twice a week is the view of an author cited by the institutes; the N.I.H. itself makes no recommendation on sun exposure. An updated fact sheet on the topic can be found at http://dietary-supplements.info.nih.gov/factsheets.

An Oldie Vies for Nutrient of the Decade

2008-08-27T07:20:00.000-07:00

By JANE E. BRODY

Published: February 19, 2008

The so-called sunshine vitamin is poised to become the nutrient of the decade, if a host of recent findings are to be believed. Vitamin D, an essential nutrient found in a limited number of foods, has long been renowned for its role in creating strong bones, which is why it is added to milk.

Stuart Bradford

Now a growing legion of medical researchers have raised strong doubts about the adequacy of currently recommended levels of intake, from birth through the sunset years. The researchers maintain, based on a plethora of studies, that vitamin D levels considered adequate to prevent bone malformations like rickets in children are not optimal to counter a host of serious ailments that are now linked to low vitamin D levels.

To be sure, not all medical experts are convinced of the need for or the desirability of raising the amount of vitamin D people should receive, either through sunlight, foods, supplements or all three. The federal committee that establishes daily recommended levels of nutrients has resisted all efforts to increase vitamin D intake significantly, partly because the members are not convinced of assertions for its health-promoting potential and partly because of time-worn fears of toxicity.

This column will present the facts as currently known, but be forewarned. In the end, you will have to decide for yourself how much of this vital nutrient to consume each and every day and how to obtain it.

Where to Obtain It

Through most of human history, sunlight was the primary source of vitamin D, which is formed in skin exposed to ultraviolet B radiation (the UV light that causes sunburns). Thus, to determine how much vitamin D is needed from food and supplements, take into account factors like skin color, where you live, time of year, time spent out of doors, use of sunscreens and coverups and age.

Sun avoiders and dark-skinned people absorb less UV radiation. People in the northern two-thirds of the country make little or no vitamin D in winter, and older people make less vitamin D in their skin and are less able to convert it into the hormone that the body uses. In addition, babies fed just breast milk consume little vitamin D unless given a supplement.

In addition to fortified drinks like milk, soy milk and some juices, the limited number of vitamin D food sources include oily fish like salmon, mackerel, bluefish, catfish, sardines and tuna, as well as cod liver oil and fish oils. The amount of vitamin D in breakfast cereals is minimal at best. As for supplements, vitamin D is found in prenatal vitamins, multivitamins, calcium-vitamin D combinations and plain vitamin D. Check the label, and select brands that contain vitamin D3, or cholecalciferol. D2, or ergocalciferol, is 25 percent less effective.

Vitamin D content is listed on labels in international units (I.U.). An eight-ounce glass of milk or fortified orange juice is supposed to contain 100 I.U. Most brands of multivitamins provide 400 a day. Half a cup of canned red salmon has about 940, and three ounces of cooked catfish about 570.

Myriad Links to Health

Let’s start with the least controversial role of vitamin D — strong bones. Last year, a 15-member team of nutrition experts noted in The American Journal of Clinical Nutrition that “randomized trials using the currently recommended intakes of 400 I.U. vitamin D a day have shown no appreciable reduction in fracture risk.”

“In contrast,” the experts continued, “trials using 700 to 800 I.U. found less fracture incidence, with and without supplemental calcium. This change may result from both improved bone health and reduction in falls due to greater muscle strength.”

A Swiss study of women in their 80s found greater leg strength and half as many falls among those who took 800 I.U. of vitamin D a day for three months along with 1,200 milligrams of calcium, compared with women who took just calcium. Greater strength and better balance have been found in older people with high blood levels of vitamin D.

In animal studies, vitamin D has strikingly reduced tumor growth, and a large number of observational studies in people have linked low vitamin D levels to an increased risk of cancer, including cancers of the breast, rectum, ovary, prostate, stomach, bladder, esophagus, kidney, lung, pancreas and uterus, as well as Hodgkin’s lymphoma and multiple myeloma.

Researchers at Creighton University in Omaha conducted a double-blind, randomized, placebo-controlled trial (the most reliable form of clinical research) among 1,179 community-living, healthy postmenopausal women. They reported last year in The American Journal of Clinical Nutrition that over the course of four years, those taking calcium and 1,100 I.U. of vitamin D3 each day developed about 80 percent fewer cancers than those who took just calcium or a placebo.

Vitamin D seems to dampen an overactive immune system. The incidence of autoimmune diseases like Type 1 diabetes and multiple sclerosis has been linked to low levels of vitamin D. A study published on Dec. 20, 2006, in The Journal of the American Medical Association examined the risk of developing multiple sclerosis among more than seven million military recruits followed for up to 12 years. Among whites, but not blacks or Hispanics, the risk of developing M.S. increased with ever lower levels of vitamin D in their blood serum before age 20.

A study published in Neurology in 2004 found a 40 percent lower risk of M.S. in women who took at least 400 I.U. of vitamin D a day.

Likewise, a study of a national sample of non-Hispanic whites found a 75 percent lower risk of diabetes among those with the highest blood levels of vitamin D.

Vitamin D is a fat-soluble vitamin that when consumed or made in the skin can be stored in body fat. In summer, as little as five minutes of sun a day on unprotected hands and face can replete the body’s supply. Any excess can be stored for later use. But for most people during the rest of the year, the body needs dietary help.

Furthermore, the general increase in obesity has introduced a worrisome factor, the tendency for body fat to hold on to vitamin D, thus reducing its overall availability.

As for a maximum safe dose, researchers like Bruce W. Hollis, a pediatric nutritionist at the Medical University of South Carolina in Charleston, maintain that the current top level of 2,000 I.U. is based on shaky evidence indeed — a study of six patients in India. Dr. Hollis has been giving pregnant women 4,000 I.U. a day, and nursing women 6,000, with no adverse effects. Other experts, however, are concerned that high vitamin D levels (above 800 I.U.) with calcium can raise the risk of kidney stones in susceptible people.

Nutrition: Vitamin D May Play Larger Role in Health

2008-08-27T07:14:00.000-07:00

By ERIC NAGOURNEY

Published: August 18, 2008

A lack of vitamin D has been found in some studies to play an unrecognized role in death among people suffering from a variety of medical problems, including heart disease and cancer.

Health Guide: Vitamin D »

More Vital Signs Columns »

25-Hydroxyvitamin D Levels and the Risk of Mortality in the General Population (Archives of Internal Medicine)

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Now researchers say they have evidence that even in the general population, having too little of the vitamin appears to be associated with a higher risk of death.

Writing in The Archives of Internal Medicine, researchers say they looked at the vitamin D levels and death rates of more than 13,000 people over a period of more than six years.

Those who fell in the lowest quarter of vitamin D levels had a 26 percent higher risk of death from all causes than those in the top quarter, found the study, which was led by Dr. Michal L. Melamed of the Albert Einstein College of Medicine.

About 41 percent of men and 53 percent of women in the United States have levels of the vitamin that are considered too low.

The researchers pointed to other studies looking at the role in disease of vitamin D, which can be found in milk and also comes from exposure to the sun. Researchers have found, for example, that deaths from cardiovascular disease are higher in the winter, when less sun leads to lower levels of vitamin D.

The question now, the study says, is whether taking supplements to raise levels of the vitamin would lower the risk of death.

PERSONAL HEALTH; A Second Opinion on Sunshine: It Can Be Good Medicine After All

2008-08-27T07:12:00.001-07:00

June 17, 2003

By JANE E. BRODY

Can sunshine, now shunned by so many who fear skin cancer and wrinkles, save many more lives than it harms? Most definitely, says a leading expert in the field, Dr. Michael F. Holick, a professor of medicine, dermatology, physiology and biophysics at the Boston University School of Medicine.

Dr. Holick, who discovered the active form of vitamin D, has pulled together an impressive body of evidence in support of his advice that no one should be, as he puts it, a ''sunphobe'' or, for that matter, a sun worshiper.

He has concluded that relatively brief but unfettered exposure to sunshine or its equivalent several times a week can help to ward off a host of debilitating and sometimes deadly diseases, including osteoporosis, hypertension, diabetes, multiple sclerosis, rheumatoid arthritis, depression and cancers of the colon, prostate and breast.

In other words, Dr. Holick says, sunshine is good medicine.

But like all medicines, the right dosage is critical to reaping the rewards that sunlight has to offer without suffering unwanted consequences.

Dr. Holick elaborates on these research-based ideas in a small but important book, ''The UV Advantage,'' written with Mark Jenkins, a health writer. Though originally scheduled for publication next month, the book fell victim to a publishing world shake-up and will not come out until the fall or winter.

But given the arrival of the sunshine season, people should have the opportunity to benefit from the doctor's insights without further delay.

A Ubiquitous Hormone

Dr. Holick's argument that controlled exposure to sunshine can have powerful health benefits stems from decades of research into the many roles played by vitamin D in the body. The main source of this essential nutrient is neither food nor dietary supplement. It is sunshine.

Vitamin D is made in the skin when it is exposed to the ultraviolet B (UVB) rays in sunshine, as well as those from tanning machines. But the amount of vitamin D formed in a given period of sun exposure depends on the color of that skin -- that is, how rich the skin is in melanin, which blocks UV rays.

The darker a person's skin, the longer he or she has to be in sun to form a significant amount of vitamin D.

A national study showed that 42 percent of African-American women ages 15 to 49 were deficient in vitamin D by the end of winter. A very dark-skinned person may need to spend up to 50 times as much time in the sun to make the same amount of vitamin D as someone of Scandinavian descent. For the average African-American, 5 to 10 times as much time in the sun will be needed.

Another critical factor is where a person lives in relation to the Equator. The farther away, the less intense one's exposure to UVB rays. This is undoubtedly why people in northern latitudes evolved with light skin, to enhance their ability to absorb UVB rays, and those near the Equator evolved with very dark skin, to limit that absorption to a physiologically desirable amount.

For vitamin D to perform its myriad biochemical roles in body cells, it must first be converted into an activated form, vitamin D hormone. For years it was thought that this process took place only in the kidneys, which then sent tiny amounts of the hormone to the circulatory system for delivery to other tissues.

But studies by Dr. Holick and others have shown that the cells in many different organs do not have to rely on the meager supply of vitamin D hormone from the kidneys. Rather, cells in other tissues, including the prostate, breast, colon and immune system, are also able to convert vitamin D into the active hormone.

Many Health Effects

Everyone should know that vitamin D is critical to the formation and maintenance of normal bones. Even if people consume enough calcium, they cannot build and maintain bone mass if they are deficient in vitamin D. One symptom of vitamin D deficiency is pain and weakness in the muscles and bones. Based on that symptom, Dr. Holick has suggested that some disorders diagnosed as fibromyalgia may in fact be vitamin D deficiency.

Dr. Holick noted a recent resurgence of rickets in the United States, the combined result of exclusive breast-feeding (breast milk has almost no vitamin D) and keeping babies out of the sun or slathered with sunscreen.

A sunscreen with an S.P.F. of 8 blocks 95 percent of the skin's ability to make vitamin D, and an S.P.F. of 15 blocks it by 99 percent.

In the prostate, the vitamin D hormone has been shown to act as a powerful inhibitor of abnormal cell growth, and cells in the colon and breast have similar mechanisms for using this hormone.

A Scandinavian study linked low levels of vitamin D in the blood to a risk of developing prostate cancer that is about 50 percent higher than it is for those with normal and high levels. And in eight years of research conducted in an aging study in Baltimore, experts found that those with low levels of circulating vitamin D had a 50 percent greater risk of developing colon cancer than those with normal to high levels.

Dr. William Grant of the National Aeronautics and Space Administration reported that people who worked outdoors or lived in sunny climates had lower death rates from cancers of the breast, colon, prostate, ovary, bladder, uterus, esophagus, rectum and stomach.

Dr. Grant calculated that 85,000 fewer cases of cancer and 30,000 fewer cancer deaths would occur each year if everyone got as much sun as people living in the Southwest.

The same applies to autoimmune diseases like multiple sclerosis, rheumatoid arthritis and Type 1 diabetes, which is usually diagnosed in children and young adults.

Dr. Holick, meanwhile, has found that exposing people with high blood pressure to UVB rays in a tanning salon lowers their blood pressure readings about as much as a drug will. He also found that increasing vitamin D improved the heart's pumping ability and reduced cardiac strain.

Safe in the Sun

How much vitamin D is enough? Although the official recommended amount ranges from 200 international units for infants to 600 for the elderly, Dr. Holick and other experts say 1,000 units a day are needed, an amount few people consume through foods or supplements. Sunshine must fill in the gap.

''Between 90 percent and 95 percent of most people's vitamin D comes from casual exposure to sunlight,'' Dr. Holick said. He does not advocate tanning. Rather, he proposes exposing unprotected skin to sunlight for a matter of minutes, with the recommended time determined by a person's skin type, the time of year, the time of day and the latitude.

He suggests figuring out how long it takes for one's skin to turn pink in the sun (not burned, just pink) and then exposing a quarter of one's body (e.g., hands, arms and face or, if not the face, then the arms and legs) to the sun for one quarter of that time. After that, if a person plans to remain outdoors, the advice is to cover up or apply sunscreen that blocks both UVA and UVB rays.

For example, a person with Skin Type 2 (characteristic of most Caucasians) that burns easily and hardly tans who lives in the northern half of the country might expose a quarter of the body surface to the sun for 5 to 10 minutes a day between 11 a.m. and 3 p.m. during the next five months to build up enough vitamin D to last through the winter.

Vitamin D Deficiency May Lurk in Babies

2008-08-27T06:47:00.000-07:00

By RONI CARYN RABIN

Published: August 25, 2008

Until she was 11 months old, Aleanie Remy-Marquez could have starred in an advertisement for breast milk. She took to nursing easily, was breast-fed exclusively for six or seven months, and ate little else even after that. She was alert and precocious and developed at astonishing speed, her mother said, sitting at four months and walking by eight months.

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But once Aleanie started putting weight on her feet, her mother noticed that her legs were curving in a bow shape below the knees. Doctors diagnosed vitamin D-deficiency rickets, a softening of the bones that develops when children do not get enough vitamin D — a crucial ingredient for absorbing calcium and building bone, and the one critical hormone that breast milk often cannot provide enough of.

“I thought I was doing the best thing for her,” said Stephanie Remy-Marquez, of Hyde Park, Mass., after blood tests showed her daughter had no detectable vitamin D. X-ray images of the baby’s wrists and knees showed the edges of the bones and growth plates as blurry and fraying instead of crisp and sharp.

“Breast milk is supposed to be an entire meal, dessert and drinks included,” Ms. Remy-Marquez said. “I thought it was the ultimate cocktail.”

Aleanie’s case was unusual enough to be written up in the journal Clinical Pediatrics in May, but several similar reports have been published in recent years. Some experts fear that vitamin D deficiency, which can be asymptomatic, may be more common than pediatricians realize and that rickets — perceived to be a 19th-century scourge that was wiped out with the fortification of milk — may be going undetected.

Physicians have known for more than a century that exclusive breast-feeding may be associated with vitamin D deficiency and rickets, and that the condition is easily prevented and treated with inexpensive vitamin drops or cod liver oil. But doctors are reluctant to say anything that might discourage breast-feeding.

Now some researchers are also linking vitamin D deficiency with other chronic diseases like diabetes, autoimmune disorders and even cancer, and there have been calls to include blood tests of vitamin D levels in routine checkups.

“I completely support breast-feeding, and I think breast milk is the perfect food, and the healthiest way to nourish an infant,” said Dr. Catherine M. Gordon, director of the bone health program at Children’s Hospital Boston and an author of several studies on vitamin D deficiency, including Aleanie’s case.

“However,” Dr. Gordon continued, “we’re finding so many mothers are vitamin D deficient themselves that the milk is therefore deficient, so many babies can’t keep their levels up. They may start their lives vitamin D deficient, and then all they’re getting is vitamin D deficient breast milk.”

Some doctors and public health officials say conditions may be ripe for rickets to re-emerge: more infants are being breast-fed for extended periods, children are drinking more juice or soda and less milk, and they are spending less time exposed to sunlight, which enables the skin to synthesize vitamin D.

Children with dark skin, like Aleanie, who is African-American, appear to be at even greater risk for rickets because they do not synthesize vitamin D through the skin as easily as those with light skin.

The solution, Dr. Gordon said, is not to quit breast-feeding but to supplement breast-fed infants with vitamin drops, as recommended by the American Academy of Pediatrics. The academy issued guidelines in 2003 recommending that infants be given 200 international units of vitamin D daily, and it may be increasing the recommended level soon.

But pediatricians do not consistently prescribe vitamin drops. A 2004 survey of North Carolina pediatricians found that fewer than half routinely recommended them, and one in six never recommended them.

Vitamin D deficiency may not be immediately apparent, even as it affects growth, muscle and bone mineralization, said Dr. Craig Langman, professor of kidney disease and pediatrics at Feinberg School of Medicine in Chicago.

“It sort of sneaks up on you,” he said. “So the worst scenario is the gas tank is empty and the car won’t go — you have rickets. But at very low levels of gas the car doesn’t perform very well and you start having intermittent loss of power and that sort of thing; as a result you may not be forming enough bone during childhood.”

A recent review of 14 studies, done by researchers at the National Institute of Child Health and Human Development and published in The Archives of Pediatrics & Adolescent Medicine in June, found that extreme vitamin D deficiency was rare in the United States, but that up to 78 percent of breast-fed babies who were not supplemented in wintertime were deficient.

Meanwhile, the number of papers describing cases of nutritional rickets in babies and young children in the United States has been accumulating over the past decade or so, from places as disparate as Alaska, Minnesota, Nevada and Texas.

The patients are more likely to be African-American and dark-skinned, and more likely to have been exclusively breast-fed for an extended period of time, without vitamin supplementation. Rates are often higher when there is less sunlight.

In a study conducted by Dr. Gordon of vitamin D levels in 365 mostly African-American and Latino infants and toddlers, 40 percent had low levels and 12 percent were deficient. Although there is a debate about what levels are considered deficient, one toddler in the study was found to have rickets, 13 children showed evidence of bone loss and 3 had bone changes consistent with rickets.

The study, published in The Archives of Pediatrics & Adolescent Medicine in June, found that breast-feeding without supplementation was a significant risk factor.

“Human milk is very low in vitamin D, absolutely — there is no question about that,” said Dr. Frank Greer, professor of pediatrics at University of Wisconsin School of Medicine and Public Health and chairman of the committee on nutrition of the American Academy of Pediatrics. “Historically speaking, we probably got it from the sun, but now we’re afraid of the sun and we don’t go out as much.”

Teenagers are also at risk for vitamin D deficiency. Although their large bones protect them against rickets, they are at risk for osteopenia and even osteoporosis, and may have weaker bones that are more likely to fracture, said Dr. Robert Schwartz, professor of pediatrics at Wake Forest University Baptist Medical Center in Winston-Salem, N.C., who said he had observed cases of osteopenia and osteoporosis in teenagers.

“The tragedy of this is that when they’re young, they’re building up bone for the rest of their life,” Dr. Schwartz said. As people age and their bones weaken, he said: “Those who had adequate vitamin D and calcium will slide down from the top of the mountain. These kids will slide down from the middle.”

The Well column will return next week.

More Articles in Health » A version of this article appeared in print on August 26, 2008, on page F5 of the New York edition.

2008-08-19T11:29:00.000-07:00

Better to Be Fat and Fit Than Skinny and Unfit

Stuart Bradford

By TARA PARKER-POPE

Published: August 18, 2008

Often, a visit to the doctor’s office starts with a weigh-in. But is a person’s weight really a reliable indicator of overall health?

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Increasingly, medical research is showing that it isn’t. Despite concerns about an obesity epidemic, there is growing evidence that our obsession about weight as a primary measure of health may be misguided.

Last week a report in The Archives of Internal Medicine compared weight and cardiovascular risk factors among a representative sample of more than 5,400 adults. The data suggest that half of overweight people and one-third of obese people are “metabolically healthy.” That means that despite their excess pounds, many overweight and obese adults have healthy levels of “good” cholesterol, blood pressure, blood glucose and other risks for heart disease.

At the same time, about one out of four slim people — those who fall into the “healthy” weight range — actually have at least two cardiovascular risk factors typically associated with obesity, the study showed.

To be sure, being overweight or obese is linked with numerous health problems, and even in the most recent research, obese people were more likely to have two or more cardiovascular risk factors than slim people. But researchers say it is the proportion of overweight and obese people who are metabolically healthy that is so surprising.

“We use ‘overweight’ almost indiscriminately sometimes,” said MaryFran Sowers, a co-author of the study and professor of epidemiology at the University of Michigan. “But there is lots of individual variation within that, and we need to be cognizant of that as we think about what our health messages should be.”

The data follow a report last fall from researchers at the Centers for Disease Control and Prevention and the National Cancer Institute showing that overweight people appear to have longer life expectancies than so-called normal weight adults.

But many people resist the notion that people who are overweight or obese can be healthy. Several prominent health researchers have criticized the findings from the C.D.C. researchers as misleading, noting that mortality statistics don’t reflect the poor quality of life and suffering obesity can cause. And on the Internet, various blog posters, including readers of the Times’s Well blog, have argued that the data are deceptive, masking the fact that far more overweight and obese people are at higher cardiovascular risk than thin people.

Part of the problem may be our skewed perception of what it means to be overweight. Typically, a person is judged to be of normal weight based on body mass index, or B.M.I., which measures weight relative to height. A normal B.M.I. ranges from 18.5 to 25. Once B.M.I. reaches 25, a person is viewed as overweight. Thirty or higher is considered obese.

“People get confused by the words and the mental image they get,” said Katherine Flegal, senior research scientist at the C.D.C.’s National Center for Health Statistics. “People may think, ‘How could it be that a person who is so huge wouldn’t have health problems?’ But people with B.M.I.’s of 25 are pretty unremarkable.”

Several studies from researchers at the Cooper Institute in Dallas have shown that fitness — determined by how a person performs on a treadmill — is a far better indicator of health than body mass index. In several studies, the researchers have shown that people who are fat but can still keep up on treadmill tests have much lower heart risk than people who are slim and unfit.

In December, a study in The Journal of the American Medical Association looked at death rates among 2,600 adults 60 and older over 12 years. Notably, death rates among the overweight, those with a B.M.I. of 25 to 30, were slightly lower than in normal weight adults. Death rates were highest among those with a B.M.I. of 35 or more.

But the most striking finding was that fitness level, regardless of body mass index, was the strongest predictor of mortality risk. Those with the lowest level of fitness, as measured on treadmill tests, were four times as likely to die during the 12-year study than those with the highest level of fitness. Even those who had just a minimal level of fitness had half the risk of dying compared with those who were least fit.

During the test, the treadmill moved at a brisk walking pace as the grade increased each minute. In the study, it didn’t take much to qualify as fit. For men, it meant staying on the treadmill at least 8 minutes; for women, 5.5 minutes. The people who fell below those levels, whether fat or thin, were at highest risk.

The results were adjusted to control for age, smoking and underlying heart problems and still showed that fitness, not weight, was most important in predicting mortality risk.

Stephen Blair, a co-author of the study and a professor at the Arnold School of Public Health at the University of South Carolina, said the lesson he took from the study was that instead of focusing only on weight loss, doctors should be talking to all patients about the value of physical activity, regardless of body size.

“Why is it such a stretch of the imagination,” he said, “to consider that someone overweight or obese might actually be healthy and fit?”

well@nytimes.com

Need a Knee Replaced? Check Your ZIP Code.

2008-07-23T20:45:00.000-07:00

Treatments

By STEPHANIE SAUL

Published: June 11, 2007

WHY does health care for the average Medicare patient cost nearly twice as much a year in New Jersey, at $8,076, as it does in Hawaii, at $4,529?

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Regional Differences in Cost and Care

Interactive Graphic: Regional Differences in Costs and Care

The differences are one example of perplexing geographic variations in medical expenses and quality. And in a study that has important implications for the nation’s $2 trillion health care tab, researchers have found that more intensive and expensive care does not necessarily mean better outcomes. In fact, the opposite may be true.

The Dartmouth Atlas of Health Care, a research group that studies variations and costs in medical care, sums it up like this: Geography is destiny. It means that your chances of undergoing certain surgical procedures, visiting the doctor often or even dying in a hospital or at home are related to where you live.

For example, Medicare patients living in Rhode Island undergo knee replacements at a rate of 5 in 1,000 people. In Nebraska, the number rises to 10 in 1,000. Female Medicare enrollees who receive a diagnosis of breast cancer have nearly seven times the chance of having a mastectomy in South Dakota, where the rate is 2 in 1,000, as they do in Vermont, where the rate is .3 in 1,000.

In another comparison, the Dartmouth group, a project of the college’s medical school, analyzed the costs and type of care patients receive in their last six months of life. Those in Oregon spend an average of eight days in the hospital while those in New York spend 35 days. In Oregon, the patient is seen by an average of 14 doctors during that period. In New York, 35 doctors see the patient.

In the last two years of life, the average Oregon patient costs $25,500, and the New York patient, $38,300.

Such differences cannot be explained by rates of illness or cost-of-living deviations. In some cases, drastic variations in Medicare treatment and costs occur even within states. There are almost twice as many hip replacements in Palo Alto as there are in San Francisco, for example. Such variations happen among the country’s top academic medical centers.

Some differences involve choices. Does a patient prefer to live with the pain and inconvenience of a bad knee, or undergo a knee replacement? It depends on personal preference and the advice that doctors give about risks versus rewards. Does a woman with breast cancer elect mastectomy or lumpectomy?

But much of the deviation appears to be caused by what experts call “supply sensitive care,” meaning the number of doctor visits and hospitalizations expand to the system’s capacity. Higher-spending areas have more hospital beds per person and more highly specialized physicians.

In communities with surplus hospital beds, research shows, patients do not necessarily get more elective surgery, but they have more hospital stays, more frequent doctor’s visits and are more likely to be referred to specialists.

Dr. Elliott S. Fisher, who studies health care economics and is a member of the Dartmouth research group, said that part of the problem was the way doctors and hospitals were paid.

“In a payment system that rewards everybody for staying busy, every bit of capacity you have, whether it’s the number of specialists or the number of intensive care beds or the M.R.I. scanner, has to stay fully occupied because they bought them already and they have to keep paying for them,” Dr. Fisher said in a telephone interview.

He told a Medicare Payment Advisory Commission panel last year: “If you’re lying down and spending time in the hospital and seeing more specialists, you also get more tests and minor procedures because that’s what we do when you’re in there.”

Paradoxically, the Dartmouth research, which confirms some similar studies, shows that patients in high-cost areas are not necessarily getting better care. Dr. Fisher said that he and his colleagues found higher mortality rates in higher-spending regions.

“When physicians describe the quality of care, they say the quality of care is worse in the higher-spending regions,” Dr. Fisher told the panel.

Among disturbing findings, Dr. Fisher said, are that tremendous gains in heart attack survival rates during the last 20 years have been smallest in high-spending regions.

One reason is that the risks of being hospitalized, including infections and medical errors, can outweigh the benefits. But the adage about “too many cooks” could also play a role.

“What we hypothesize is happening is that as the complexity of the system increases, it becomes less and less clear who is the responsible physician,” Dr. Fisher said.

Extra care without better outcomes translates into waste in the health care system. Some experts say that waste accounts for as much as if not more than 30 percent of the national spending on health care. Such spending now totals 16 percent of the gross domestic product.

Dr. Fisher said that the spending differences from one area to another are mostly related to discretionary decisions in gray areas, like uncertainty about the proper treatment.

The Dartmouth group’s leader, Dr. John E. Wennberg, began studying such variations in the 1970s while directing a federally financed program in Vermont that analyzed services in state hospitals. He found that rates of common procedures — tonsillectomies, hysterectomies and prostatectomies — varied a lot from town to town.

In Morrisville, for example, Dr. Wennberg found that 63 percent of children under 16 had undergone a tonsillectomy, compared with 7 percent 70 miles away in Middlebury. He found that five doctors in Morrisville were responsible for the deviation. While antibiotics were widely used to treat infections elsewhere, the Morrisville doctors were relying on old methods.

The group’s Web site, dartmouthatlas.org, contains detailed analysis of procedures paid for by Medicare nationwide, as well as interactive graphs. People can use the site to find rates of spending and procedures at their local hospitals.

What is the solution to these problems? One answer involves an increase in primary-care doctors. Research indicates that costs go up and quality declines with increased physician specialization. Dr. Fisher notes that New Jersey, the highest-cost state, has a specialty-oriented approach. He thinks coordination could be the answer.

“I really do believe strongly that we need to foster the development of large physician groups or hospital physician organizations that can be accountable for the quality and cost of care,” he said. “Most of the serious deficiencies in the U.S. health care system are in lack of coordination and fragmentation.”

Policy makers are seeking ways to increase financial incentives for becoming a family doctor, internist or pediatrician, possibly by raising the payments doctors receive for evaluating and managing patients or creating a new reimbursement category for coordinating care.

The average family physician nationwide currently makes $126,000 a year, while the average specialist earns $297,000 a year.

“If you can be a dermatologist and have no night calls and make an average of $290,000 a year, then why go into family medicine?” asked Dr. John G. Scott, an assistant professor of family medicine at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School.

Dr. Scott sums up the situation in New Jersey with a personal anecdote. When he moved there from Arkansas and told an acquaintance he was a family doctor, she responded, “We don’t have those in New Jersey.”

Hoping Two Drugs Carry a Side Effect: Longer Life

2008-07-23T20:24:00.000-07:00

Southern Illinois University School of Medicine

COUNTING CALORIES For a longevity study, this mouse is on a restricted diet.

By NICHOLAS WADE

Published: July 22, 2008

BOSTON, Mass. — One day last month, clad in white plastic garments from head to toe, Dr. David Sinclair showed a visitor around his germ-free mouse room here at Harvard Medical School.

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IN THE LAB Dr. David Sinclair is trying to develop drugs to extend health, and life.

The mice, subjects in studies of health and longevity, are kept in wire baskets under intensive nursing care. A mouse gym holds a miniature exercise machine that tests the rodents’ ability to balance on a rotating bar. In a nearby water maze, mice must recall visual cues to swim to safety on a hidden platform, a test of their powers of memory. Those that forget their lessons are rescued as they start to submerge and humanely dried out under a heat lamp, Dr. Sinclair assured his visitor.

Dr. Sinclair is a co-founder of Sirtris, a company that itself has been swimming in uncharted waters as it works to develop drugs that may extend the human life span. But it seemed to have found a safe platform last month when it was bought last month by the pharmaceutical giant GlaxoSmithKline for $720 million.

Sirtris has two drugs in clinical trials. One is being tested against Type 2 diabetes, one of the many diseases of aging that the company’s scientists hope the drugs will avert. With success against just one such disease, the impact on health “could be possibly transformational,” said Dr. Patrick Vallance, head of drug discovery at GlaxoSmithKline.

The new drugs are called sirtuin activators, meaning that they activate an enzyme called sirtuin. The basic theory is that all or most species have an ancient strategy for riding out famines: switch resources from reproduction to tissue maintenance. A healthy diet but with 30 percent fewer calories than usual triggers this reaction in mice and is the one intervention that reliably increases their life span. The mice seem to live longer because they are somehow protected from the usual diseases that kill them.

But most people cannot keep to a diet with a 30 percent cut in calories, so a drug that could activate the famine reflex might be highly desirable. Dr. Leonard Guarente, an M.I.T. biologist who founded the field of sirtuin biology, thinks the famine reflex is mediated through the sirtuin enzymes. Dr. Sinclair, his former student, discovered that sirtuins could be activated by drugs. The most potent activator that emerged from his screens was resveratrol, a natural substance found in red wine, though in amounts probably too low to be significant for health.

The Sirtris drug being tested in diabetic patients is a special formulation of resveratrol that delivers a bloodstream dose five times as high as the chemical alone. This drug, called SRT501, has passed safety tests and, at least in small-scale trials, has reduced the patients’ glucose levels.

The other drug is a small synthetic chemical that is a thousand times as potent as resveratrol in activating sirtuin and can be given at a much smaller dose. Safety tests in people have just started, with no adverse effects so far.

The hope is that activating sirtuins in people would, like a calorically restricted diet in mice, avert degenerative diseases of aging like diabetes, heart disease, cancer and Alzheimer’s. There is no Food and Drug Administration category for longevity drugs, so if the company is to submit a drug for approval, it needs to be for a specific disease.

Nonetheless, longevity is what has motivated the researchers and what makes the drugs potentially so appealing.

Dr. Christoph Westphal, the chief executive of Sirtris, said of the potential of the drugs, “I think that if we are right, this could extend life span by 5 or 10 percent.” He added that his goal was to develop drugs against specific diseases, with the extension of life being “almost a side effect of our medicine.”

Sirtris was founded in 2004 after Dr. Westphal, then working at a Boston venture capital firm, approached Dr. Sinclair. Because of widespread interest in the sirtuin activation idea, Dr. Westphal had little difficulty raising money and recruiting distinguished scientists to Sirtris’s advisory board.

He later decided to sell the company to GlaxoSmithKline, he said, because it was getting harder to raise money and clinical trials could proceed faster with the larger company’s resources. Sirtris was acquired at an 84 percent premium, better than the 50 percent at which most companies are bought, Dr. Westphal said.

The impact of Sirtris’s drugs, if successful, could extend beyond the drug industry. Dr. Guarente believes that many people might start taking them in middle age, though after having started a family because they may suppress fertility.

Mice on the drugs generally remain healthy right until the end of their lives and then just drop dead.“If they work in people that way, one would look to an extension of health span, with an extension of life as a possible side effect,” Dr. Guarente said. “It would necessitate changing ideas about when people retire and when they stop paying into the system.”

GlaxoSmithKline could put SRT501, its resveratrol formulation, on the market right away, selling it as a natural compound and nutritional pharmaceutical that does not require approval by the F.D.A. “We haven’t made any decisions, but that clearly is an option,” Dr. Vallance said.

If GlaxoSmithKline decides instead to seek F.D.A. approval, it will need to prove that resveratrol is safe in the large doses required for efficacy. Resveratrol seems to exert many influences on the body, some of which are not exerted through sirtuin. “None of us should be naïve enough to think resveratrol won’t have multiple effects, including some you don’t want,” Dr. Vallance said.

GlaxoSmithKline’s purchase of Sirtris has pushed the optimism of sirtuin researchers and others to new heights. “We are all holding our breath,” said Dr. Huber Warner, editor of the Journals of Gerontology. But the success of the drugs is far from assured.

Most potential drugs fail to make it past clinical trials, and the same may prove true for Sirtris’s candidates. The sirtuin-activating chemicals the company has designed could turn out to be toxic. Another uncertainty is that the underlying science is still in flux and debate rages among academic researchers over many details of how caloric restriction works.

Some biologists think that sirtuin is not the only mediator of the famine reflex, and that resveratrol may not work through sirtuin at all in exerting its beneficial effects on mice. “There are data both for and against that hypothesis, though that doesn’t dissuade one from pursuing it as a potential benefit,” said Dr. Thomas Rando, who studies aging in stem cells at Stanford University.

In initial tests in mice, resveratrol has doubled muscular endurance, lowered the bad form of cholesterol, protected against various bad effects of a high-fat diet and suppressed colon cancer. New reports are confirming some of these benefits, but others are ambiguous or puzzling.

According to a study published on July 3 in the journal Cell Metabolism by Dr. Sinclair and Dr. Rafael de Cabo of the National Institute on Aging, resveratrol given to aging mice reduced their cataracts, strengthened their bones, improved coordination and enhanced their health in several other ways. Yet despite their better health, the mice lived no longer than usual.

“Minimally this calls into question one pillar of the GSK investment,” said Dr. Ronald Evans, a leading expert on hormonal responses at the Salk Institute. Dr. Evans said that sirtuin research was promising but unproved, and that he did not agree that sirtuin was the probable mediator of the famine reflex, a concern that “calls into question the second pillar of the GSK investment.”

The frontiers of science are often turbulent, and it can take years for clarity to emerge from confusion. Dr. Westphal said the decision to ignore the academic debate about exactly how resveratrol may work was one of two principal reasons for Sirtris’s quick success. The other was to focus the company’s limited resources on developing just two drugs.

The researchers at Sirtris are no strangers to skepticism. Dr. Guarente and Dr. Sinclair were ridiculed when they first started looking for longevity genes more than 15 years ago, because aging was then considered to be an intractable problem. His colleagues, Dr. Guarente said, “thought I was nuts.”

Dr. Sinclair, when he first arrived as a young postdoctoral student in Dr. Guarente’s lab to work on longevity, was downcast to learn of the other students’ severe doubts. “The view even in Lenny’s lab was that this problem was going nowhere, it was a house of cards that would fall down any month now.” He called his parents in Australia to tell them he may have made a big mistake. But the research led eventually to the discovery of the sirtuinlike proteins and their role in extending the life span of yeast, worms and flies.

He and Dr. Guarente developed the sirtuin field with the hope of increasing longevity. But because of Sirtris’s focus on developing drugs that have the F.D.A.’s approval for specific diseases, both are being less explicit about their hopes of reversing aging. “There’s a much greater chance of a drug that can treat disease than of extending life span,” Dr. Sinclair said.

“I’m becoming more boring in my old age,” he added apologetically.

GlaxoSmithKline’s press releases refer to the sirtuins as “enzymes that the company believes control the aging process.” But Dr. Vallance is more guarded, saying aging is too hard to measure. The goal is not the extension of human life span; rather, “The prolongation of health is the aim,” Dr. Vallance said.

You Name It, and Exercise Helps It

2008-04-29T19:48:00.001-07:00

New York Times

April 29, 2008

Personal Health

You Name It, and Exercise Helps It

By JANE E. BRODY

Randi considers the Y.M.C.A. her lifeline, especially the pool. Randi weighs more than 300 pounds and has borderline diabetes, but she controls her blood sugar and keeps her bright outlook on life by swimming every day for about 45 minutes.

Randi overcame any self-consciousness about her weight for the sake of her health, and those who swim with her and share the open locker room are proud of her. If only the millions of others beset with chronic health problems recognized the inestimable value to their physical and emotional well-being of regular physical exercise.

“The single thing that comes close to a magic bullet, in terms of its strong and universal benefits, is exercise,” Frank Hu, epidemiologist at the Harvard School of Public Health, said in the Harvard Magazine.

I have written often about the protective roles of exercise. It can lower the risk of heart attack, stroke, hypertension, diabetes, obesity, depression, dementia, osteoporosis, gallstones, diverticulitis, falls, erectile dysfunction, peripheral vascular disease and 12 kinds of cancer.

But what if you already have one of these conditions? Or an ailment like rheumatoid arthritis, multiple sclerosis, Parkinson’s disease, congestive heart failure or osteoarthritis? How can you exercise if you’re always tired or in pain or have trouble breathing? Can exercise really help?

You bet it can. Marilyn Moffat, a professor of physical therapy at New York University and co-author with Carole B. Lewis of “Age-Defying Fitness” (Peachtree, 2006), conducts workshops for physical therapists around the country and abroad, demonstrating how people with chronic health problems can improve their health and quality of life by learning how to exercise safely.

Up and Moving

“The data show that regular moderate exercise increases your ability to battle the effects of disease,” Dr. Moffat said in an interview. “It has a positive effect on both physical and mental well-being. The goal is to do as much physical activity as your body lets you do, and rest when you need to rest.”

In years past, doctors were afraid to let heart patients exercise. When my father had a heart attack in 1968, he was kept sedentary for six weeks. Now, heart attack patients are in bed barely half a day before they are up and moving, Dr. Moffat said.

The core of cardiac rehab is a progressive exercise program to increase the ability of the heart to pump oxygen- and nutrient-rich blood more effectively throughout the body. The outcome is better endurance, greater ability to enjoy life and decreased mortality.

The same goes for patients with congestive heart failure. “Heart failure patients as old as 91 can increase their oxygen consumption significantly,” Dr. Moffat said.

Aerobic exercise lowers blood pressure in people with hypertension, and it improves peripheral circulation in people who develop cramping leg pains when they walk — a condition called intermittent claudication. The treatment for it, in fact, is to walk a little farther each day.

In people who have had transient ischemic attacks, or ministrokes, “gradually increasing exercise improves blood flow to the brain and may diminish the risk of a full-blown stroke,” Dr. Moffat said. And aerobic and strength exercises have been shown to improve endurance, walking speed and the ability to perform tasks of daily living up to six years after a stroke.

As Randi knows, moderate exercise cuts the risk of developing diabetes. And for those with diabetes, exercise improves glucose tolerance — less medication is needed to control blood sugar — and reduces the risk of life-threatening complications.

Perhaps the most immediate benefits are reaped by people with joint and neuromuscular disorders. Without exercise, those at risk of osteoarthritis become crippled by stiff, deteriorated joints. But exercise that increases strength and aerobic capacity can reduce pain, depression and anxiety and improve function, balance and quality of life.

Likewise for people with rheumatoid arthritis. “The less they do, the worse things get,” Dr. Moffat said. “The more their joints move, the better.”

Prescription drugs found in drinking water across U.S.

2008-03-10T05:47:00.000-07:00

(AP) -- A vast array of pharmaceuticals -- including antibiotics, anti-convulsants, mood stabilizers and sex hormones -- have been found in the drinking water supplies of at least 41 million Americans, an Associated Press investigation shows.

Officials in Philadelphia say testing there discovered 56 pharmaceuticals or byproducts in treated drinking water.

To be sure, the concentrations of these pharmaceuticals are tiny, measured in quantities of parts per billion or trillion, far below the levels of a medical dose. Also, utilities insist their water is safe.

But the presence of so many prescription drugs -- and over-the-counter medicines like acetaminophen and ibuprofen -- in so much of our drinking water is heightening worries among scientists of long-term consequences to human health.

In the course of a five-month inquiry, the AP discovered that drugs have been detected in the drinking water supplies of 24 major metropolitan areas -- from Southern California to Northern New Jersey, from Detroit, Michigan, to Louisville, Kentucky. Map: See the cities where drugs were found in drinking water »

Water providers rarely disclose results of pharmaceutical screenings, unless pressed, the AP found. For example, the head of a group representing major California suppliers said the public "doesn't know how to interpret the information" and might be unduly alarmed.

How do the drugs get into the water?

People take pills. Their bodies absorb some of the medication, but the rest of it passes through and is flushed down the toilet. The wastewater is treated before it is discharged into reservoirs, rivers or lakes. Then, some of the water is cleansed again at drinking water treatment plants and piped to consumers. But most treatments do not remove all drug residue.

And while researchers do not yet understand the exact risks from decades of persistent exposure to random combinations of low levels of pharmaceuticals, recent studies -- which have gone virtually unnoticed by the general public -- have found alarming effects on human cells and wildlife.

A 'growing concern'

"We recognize it is a growing concern and we're taking it very seriously," said Benjamin H. Grumbles, assistant administrator for water at the U.S. Environmental Protection Agency.

Members of the AP National Investigative Team reviewed hundreds of scientific reports, analyzed federal drinking water databases, visited environmental study sites and treatment plants and interviewed more than 230 officials, academics and scientists.

They also surveyed the nation's 50 largest cities and a dozen other major water providers, as well as smaller community water providers in all 50 states.

Here are some of the key test results obtained by the AP:

• Officials in Philadelphia, Pennsylvania, said testing there discovered 56 pharmaceuticals or byproducts in treated drinking water, including medicines for pain, infection, high cholesterol, asthma, epilepsy, mental illness and heart problems. Sixty-three pharmaceuticals or byproducts were found in the city's watersheds.

• Anti-epileptic and anti-anxiety medications were detected in a portion of the treated drinking water for 18.5 million people in Southern California.

• Researchers at the U.S. Geological Survey analyzed a Passaic Valley Water Commission drinking water treatment plant, which serves 850,000 people in Northern New Jersey, and found a metabolized angina medicine and the mood-stabilizing carbamazepine in drinking water.

• A sex hormone was detected in the drinking water of San Francisco, California.

• The drinking water for Washington, D.C., and surrounding areas tested positive for six pharmaceuticals.

The situation is undoubtedly worse than suggested by the positive test results in the major population centers documented by the AP.

Testing not required

The federal government doesn't require any testing and hasn't set safety limits for drugs in water.

Of the 62 major water providers contacted, the drinking water for only 28 was tested. Among the 34 that haven't: Houston, Texas; Chicago, Illinois; Miami, Florida; Baltimore, Maryland; Phoenix, Arizona; Boston, Massachusetts; and New York City's Department of Environmental Protection, which delivers water to 9 million people.

Some providers screen for only one or two pharmaceuticals, leaving open the possibility that others are present.

The AP's investigation also indicates that watersheds, the natural sources of most of the nation's water supply, also are contaminated. Tests were conducted in the watersheds of 35 of the 62 major providers surveyed by the AP, and pharmaceuticals were detected in 28.

Yet officials in six of those 28 metropolitan areas said they did not go on to test their drinking water -- Fairfax, Virginia; Montgomery County in Maryland; Omaha, Nebraska; Oklahoma City, Oklahoma; Santa Clara, California; and New York City.

The New York state health department and the USGS tested the source of the city's water, upstate. They found trace concentrations of heart medicine, infection fighters, estrogen, anti-convulsants, a mood stabilizer and a tranquilizer.

City water officials declined repeated requests for an interview. In a statement, they insisted that "New York City's drinking water continues to meet all federal and state regulations regarding drinking water quality in the watershed and the distribution system" -- regulations that do not address trace pharmaceuticals.

In several cases, officials at municipal or regional water providers told the AP that pharmaceuticals had not been detected, but the AP obtained the results of tests conducted by independent researchers that showed otherwise.

Of the 28 major metropolitan areas where tests were performed on drinking water supplies, only Albuquerque, New Mexico; Austin, Texas; and Virginia Beach, Virginia, said tests were negative. The drinking water in Dallas, Texas, has been tested, but officials are awaiting results. Arlington, Texas, acknowledged that traces of a pharmaceutical were detected in its drinking water but cited post-9/11 security concerns in refusing to identify the drug.

The AP also contacted 52 small water providers -- one in each state, and two each in Missouri and Texas -- that serve communities with populations around 25,000. All but one said their drinking water had not been screened for pharmaceuticals; officials in Emporia, Kansas, refused to answer AP's questions, also citing post-9/11 issues.

Rural, bottled water also unchecked

Rural consumers who draw water from their own wells aren't in the clear either, experts say.

Even users of bottled water and home filtration systems don't necessarily avoid exposure. Bottlers, some of which simply repackage tap water, do not typically treat or test for pharmaceuticals, according to the industry's main trade group. The same goes for the makers of home filtration systems.

Contamination is not confined to the United States. More than 100 different pharmaceuticals have been detected in lakes, rivers, reservoirs and streams throughout the world. Studies have detected pharmaceuticals in waters throughout Asia, Australia, Canada and Europe -- even in Swiss lakes and the North Sea.

In the United States, the problem isn't confined to surface waters. Pharmaceuticals also permeate aquifers deep underground, the source of 40 percent of the nation's water supply. Federal scientists who drew water in 24 states from aquifers near contaminant sources such as landfills and animal feed lots found minuscule levels of hormones, antibiotics and other drugs.

Perhaps it's because Americans have been taking drugs -- and flushing them unmetabolized or unused -- in growing amounts. Over the past five years, the number of U.S. drug prescriptions rose 12 percent to a record 3.7 billion, while nonprescription drug purchases held steady around 3.3 billion, according to IMS Health and The Nielsen Co.

Medications not all absorbed

"People think that if they take a medication, their body absorbs it and it disappears, but of course that's not the case," said EPA scientist Christian Daughton, one of the first to draw attention to the issue of pharmaceuticals in water in the United States.

Some drugs, including widely used cholesterol fighters, tranquilizers and anti-epileptic medications, resist modern drinking water and wastewater treatment processes. Plus, the EPA says there are no sewage treatment systems specifically engineered to remove pharmaceuticals.

Veterinary drugs also play a role. Pets are now treated for a wide range of ailments -- sometimes with the same drugs as humans. The inflation-adjusted value of veterinary drugs rose by 8 percent, to $5.2 billion, over the past five years, according to an analysis of data from the Animal Health Institute.

Ask the pharmaceutical industry whether the contamination of water supplies is a problem, and officials will tell you no.

"Based on what we now know, I would say we find there's little or no risk from pharmaceuticals in the environment to human health," said microbiologist Thomas White, a consultant for the Pharmaceutical Research and Manufacturers of America.

But at a conference last summer, Mary Buzby -- director of environmental technology for drug maker Merck & Co. Inc. -- said: "There's no doubt about it, pharmaceuticals are being detected in the environment and there is genuine concern that these compounds, in the small concentrations that they're at, could be causing impacts to human health or to aquatic organisms."

Recent laboratory research has found that small amounts of medication have affected human embryonic kidney cells, human blood cells and human breast cancer cells. The cancer cells proliferated too quickly; the kidney cells grew too slowly; and the blood cells showed biological activity associated with inflammation.

Also, pharmaceuticals in waterways are damaging wildlife across the nation and around the globe, research shows. Notably, male fish are being feminized, creating egg yolk proteins, a process usually restricted to females. Pharmaceuticals also are affecting sentinel species at the foundation of the pyramid of life -- such as earthworms in the wild and zooplankton in the laboratory, studies show.

Wildlife problems troubling

Some scientists stress that the research is extremely limited, and there are too many unknowns. They say, though, that the documented health problems in wildlife are disconcerting.

Health Library

MayoClinic.com: Health Library

To the degree that the EPA is focused on the issue, it appears to be looking at detection. Grumbles acknowledged that just late last year the agency developed three new methods to "detect and quantify pharmaceuticals" in wastewater.

"We realize that we have a limited amount of data on the concentrations," he said. "We're going to be able to learn a lot more."

So much is unknown. Many independent scientists are skeptical that trace concentrations will ultimately prove to be harmful to humans. There's growing concern in the scientific community, though, that certain drugs -- or combinations of drugs -- may harm humans over decades because water, unlike most specific foods, is consumed in sizable amounts every day.

Our bodies may shrug off a relatively big one-time dose, yet suffer from a smaller amount delivered continuously over a half century, perhaps subtly stirring allergies or nerve damage. Pregnant women, the elderly and the very ill might be more sensitive.

"We know we are being exposed to other people's drugs through our drinking water, and that can't be good," says Dr. David Carpenter, who directs the Institute for Health and the Environment of the State University of New York at Albany. E-mail to a friend

All About Prescription Drugs

CNN 10 March 2008

2008-02-15T05:43:00.001-08:00

New York Times February 14, 2008, 7:07 pm

Overselling Overmedication

Tags: Big Pharma, mental disorders, overmedication

On the bookshelf behind me at work, I have two new books on the way the pharmaceutical industry is turning us into a nation of hypochondriacal pill-popping zombies: “Shyness: How Normal Behavior Became a Sickness” and “Our Daily Meds.” On the floor, windowsill and shelves of my office at home, I have quite a few more: “Generation Rx” … “The Last Normal Child” … “Toxic Psychiatry” … “Let Them Eat Prozac” … The latest volume, front and center now on my desk, is Charles Barber’s “Comfortably Numb: How Psychiatry Is Medicating a Nation.”

In the book, Barber argues that Americans are being vastly overmedicated for often relatively minor mental health concerns. This over-reliance on quick-fix medication is numbing our nation and dulling our awareness of real and pressing social issues and of non-psychopharmacological therapies and treatments.

Barber is hardly alone these days in this line of reasoning. The notion that American children and adults are being over-diagnosed and overmedicated for exaggerated or even fictitious mental disorders has now become one of the defining tropes of our era.

This storyline persists despite the fact that government research has repeatedly shown that most adults and children with mental health issues don’t get the specialized help that they need. It persists despite the fact that there’s really no way to meaningfully evaluate the degree of over-diagnosis and medication unique to our era, because to do so is essentially to look at the current era in a vacuum. We don’t know how many adults suffered from things like depression in the distant past because no one ever asked. The words and concepts through which we understand common mental health disorders today didn’t exist until the last few decades.

The narrative survives largely uncontested despite the fact, shared by psychiatrist Peter Kramer in his Slate review of Barber’s book, that only tiny numbers of people are receiving mental health services without real, clinical levels of mental health dysfunction or a history of mental illness or trauma. And despite the fact that, contrary to received wisdom, the United States is not a world leader when it comes to the use of psychiatric medications. (The U.S. is “’in the middle’ relative to other countries, and is not an outlier,” a study from M.I.T’s. Sloan School of Management, cited by Kramer, showed last year.)

Just because it feels like, just because it sounds like, just because soaring drug company profits and obnoxious direct to consumer advertising seem to indicate that everyone around us is popping pills like mad doesn’t mean that they are doing so. Nor does it mean that we’re in the grip of some new, previously unheard-of, and uniquely epoch-defining social phenomenon.

People have been unofficially drugging themselves for as long as they’ve had the capability to do so. They smoked cigarettes to boost their concentration. They drank cocktails with lunch and dinner — and more — to deal with anxiety and despair. Prior to the modern era of F.D.A.-regulated prescribing practices, they slugged down untold quantities of tonics and bromides.

All of which suggests that what social critics now identify as the signature event of our time (the urge to manage psychic pain through substance use) may, in fact, almost always have been a facet of the human condition. It may just be that we’re better at it than ever before – with cleaner, safer, less addictive and debilitating tools at our disposal.

Is that a terrible thing to say?

And what if, examined in the light of basic facts, and with a perturbing bit of common sense thrown into the mix, the popular storyline of our fatal corruption by Big Pharma turns out to be, if not utterly baseless, then at least greatly exaggerated?

Kramer, the author of the 1993 bestseller “Listening to Prozac” and, more recently, “Freud: Inventor of the Modern Mind” and “Against Depression,” makes a quite compelling case in his Slate review that the received wisdom about psychiatric drug use today is ahistorical, narrow in its cultural understanding and factually, often wrong.

To illustrate his point, he details research he did for the Carter administration to investigate the then deeply-held belief that a generation of women were being over-medicated with “mother’s little helpers” like Valium. “This inquiry occurred in the context of a broader discussion about whether America was becoming an overmedicated society – whether we were peculiarly averse to discomfort and enamored of the quick fix,” he writes. Yet, after convening a team of experts from the National Institute of Mental Health and other government agencies and studying women’s drug use and physicians’ prescribing patterns, Kramer’s group found that “little in the scientific literature suggested a crisis or even a uniquely American response to anxiety.”

Searching the data didn’t produce a convincing narrative about women being drugged into submission. But the belief that they were was itself deeply meaningful.

“The worries expressed about Valium were our worries: women were being given these more diverse responsibilities, weren’t being given their due, their voices weren’t being heard, the culture in general had a sort of oddness about it, we had a general sense of anxiety or unease and these issues were being explained through the idea that we’re just giving medication to women and not talking to them,” Kramer told me in an interview this week. “There was a sense that something was being covered over. Those issues found their symbol in Valium.”

There’s a lot in this little parable that’s relevant today.

Let’s get beyond statistics, percentage changes in diagnosis rates and billions earned off human suffering by Big Pharma. And let’s just try for a moment to get real.

Most of the critics decrying the over-medicalization of the American mind rest their arguments upon the bedrock assumption that people who have nothing wrong with them – happy-go-lucky types who essentially make a wrong turn on their way to Starbucks or soccer and end up in the consulting room – are being medicated for largely fictitious concerns.

But search your minds and memories: Have you, or people close to you, ever taken medication in a lazy or thoughtless way? Eagerly? As a lark? Ask around a bit; find out what kind of desperation led others to the point where they had to accept psychopharmacological help.

(Write and tell me. Tell us all. But please don’t send abstract social observations or share stories about people you don’t actually know. First-hand knowledge and real life only, thanks.)

The psychiatrists I’ve interviewed over the course of the past four years say that they have yet to be swamped by frivolous patients showing up in their offices looking for pills to help them tweak troublesome little aspects of their personalities. “Not only have I not encountered many [such patients], I haven’t encountered any in my office or even in detailed phone calls,” Kramer, most recently, told me.

There are good reasons to harbor considerable distrust about whether some psychiatrists’ prescribing practices really have patients’ best interests in mind. The Times has repeatedly and extensively covered the pernicious gravy train of payments from the pharmaceutical industry to psychiatrists who help promote their latest products; studies have indicated that receiving drug company money does influence doctors’ prescribing habits.

This is a disturbing, even disgusting, state of affairs. But it’s a fixable situation: Doctors and universities could in the future just say no to the drug money that is believed to corrupt them. They could be required to say no by law. Provided, of course, that the government stepped in to fund more and better research.

Harder to fix is the current social malaise that drives the belief that we have become a Prozac (and Concerta and Zyprexa and Effexor) Nation. What is its cause? How has it spun itself into a storyline about mentally vulnerable children and adults that is largely at odds with the facts?

What purpose does that narrative serve? What do we gain – or lose — through its continuation?

The downside is stigma, misunderstanding, and a lot of righteous indignation. I’m still working on figuring out the upside.

2008-02-15T05:43:00.000-08:00

Nwew York Times February 14, 2008, 7:07 pm

Overselling Overmedication

Tags: Big Pharma, mental disorders, overmedication

Is that a terrible thing to say?

Searching the data didn’t produce a convincing narrative about women being drugged into submission. But the belief that they were was itself deeply meaningful.

There’s a lot in this little parable that’s relevant today.

Let’s get beyond statistics, percentage changes in diagnosis rates and billions earned off human suffering by Big Pharma. And let’s just try for a moment to get real.

(Write and tell me. Tell us all. But please don’t send abstract social observations or share stories about people you don’t actually know. First-hand knowledge and real life only, thanks.)

What purpose does that narrative serve? What do we gain – or lose — through its continuation?

The downside is stigma, misunderstanding, and a lot of righteous indignation. I’m still working on figuring out the upside.

What’s behind the spiraling cost of health care?

2007-12-16T12:37:00.001-08:00

By Sue Mathiesen
Technical Services Director
McGraw Wentworth

Here's the bottom line: Health-care cost increases are in the double-digit range and likely to stay that way.

Survey data from Towers Perrin, an international consulting firm, indicates the average change in health benefits cost increased 11.2 percent in 2001 and 13.7 percent in 2002 and is expected to increase 15 percent in 2003.

In Southeast Michigan, the trend for 2003 is on average 19 percent for Blue Cross Blue Shield of Michigan, 17 percent for Blue Care Network and 14 percent for Health Alliance Plan. The increases are even more substantial for some small employers.

Every company has reviewed strategies to help manage these increases. The most popular strategies have been increasing the employees' portion of the premium or making plan design changes.

Most employers understand the incremental changes that can be made year over year to manage cost increases. However, experts predict that there is no end in sight for double-digit inflation. That's why it's important to understand some of the key drivers of the cost increase, many of which employers cannot influence.

What is driving the rise in health-care benefit costs?

Aging population: On average, health-care costs triple between the 20-29 age bracket and the 50-64 age bracket, and triple again between 50-64 and the 75-plus age bracket.
Chronic health conditions: The overall health of our nation is declining. Chronic health conditions are no longer just confined to the elderly. Obesity is increasing, as is the incidence of diabetes. Heart disease is also on the increase. Smoking continues at a high rate across the country. Medical expenses for a chronically ill patient average $3,074 per year. Medical expenses for patients without chronic conditions average $817 per year.

Employers can affect chronic health conditions by sponsoring focused disease management and wellness programs. Studies show that employers who offer lifestyle improvement programs can effectively manage their health-care costs.

New technologies and prescription treatments: With the increase in chronic conditions, there has been an improvement in treatment protocols. With new medications and technology, patients have greater opportunity to manage their conditions. New technologies and drugs, however, have a significant impact on health-care spending. Typically, new technology results in better efficiency and lower cost. This is not the case in the health-care industry.
Medicare/Medicaid/federal employee health program shortfalls create payment gap: Government-sponsored programs set "approved amounts" and payment guidelines that providers must accept. The approved amounts are significantly lower than "retail" cost. Services for Medicare or Medicaid patients are not any less expensive than for private patients. Therefore, providers look to balance their income by charging private patients more to close the income gap. Seventy-three percent of all health-care dollars are funneled through federally sponsored health programs. Therefore, decreases in reimbursements in this area mean that premiums must increase costs substantially and over proportionally in the private sector.
Care for the uninsured costs everybody: Today many organizations are downsizing. Most individuals have an opportunity to elect COBRA, but the premiums are substantial and many can't afford the coverage. Emergency rooms cannot condition receipt of care on insurance coverage status. Consequently, when an uninsured person receives treatment, in all likelihood the provider will not receive compensation. The providers will offset these costs by charging insured patients a more substantial fee for service.
Attitudes toward health-care increases utilization: Americans demand and expect the highest standards when receiving health care. Most people do not understand the "true cost" of the health-care services they receive. Some employers are encouraging employees to be more involved in the cost of their care by sponsoring consumer driven medical programs. These programs increase participants' out of pocket cost and encourage them to spend their health-care dollars wisely.

These are just a few factors responsible for double-digit increases in health-care costs. There is no end in sight to these increases and there is no apparent solution. The feasibility of a national health-care program will always be a topic for discussion. But a national health-care program will not eliminate the major cost drivers. Instead, it will attempt to control cost through rationing care, which is the polar opposite of how care is received now.

There is no immediate resolution to this issue. Employers will continue to review the incremental changes that can be made to manage cost increases across the organization. Likewise, employees need to take responsibility for their health and, if necessary, make lifestyle changes. The issues driving health-care increases are complex and interwoven. It is apparent that the solution is not an easy one and may not be found in the immediate future.

McGraw Wentworth is a broker/consultant in Troy specializing in employee group benefits for mid-sized organizations. For more information on this and other health-care issues, visit www.mcgrawwentworth.com.

Major drivers of health-care cost

Medical advances 23%
General inflation 20%
Rising provider expenses 20%
Increased consumer demand 16%
Government mandates and regulations 8%
Litigation and risk management 8%
Other 5%

Source: PricewaterhouseCoopers, April 2002

MEDICAL MAZE - Legal Loophole Ensnares Breast-Cancer Patients

2007-12-16T12:35:00.000-08:00

Shirley Loewe Chooses
The Wrong Clinic
And Starts Long Ordeal

By JOHN CARREYROU
September 13, 2007

LONGVIEW, Texas -- In June 2003, Shirley Loewe went to Good Shepherd Medical Center here with a softball-size lump in her breast and was diagnosed with a rare form of breast cancer. She didn't know it, but she had just made a big mistake.

Ms. Loewe was uninsured. Under federal law, she could have gotten Medicaid coverage -- and saved herself a lot of hardship -- if she'd gone to a different clinic less than a half-mile away. But by walking through Good Shepherd's doors, Ms. Loewe unwittingly let that opportunity slip and embarked on a four-year journey through the Byzantine U.S. health-care system.

It was an odyssey that would take her to five hospitals, two clinics, two charitable organizations and two nursing homes in two states. She was denied assistance or care at least six times along the way, for reasons that ranged from not being poor enough to not being sick enough.

Ms. Loewe eventually got treatment, but at personal cost and great aggravation. To qualify for charity assistance, she had to reduce her $15,000-a-year income as a hairdresser by cutting back on her working hours and giving up her home. Later, she lucked into first-class care thanks to a serendipitous encounter at a Little League game.

Ms. Loewe is one of thousands of women who get caught in a loophole in the Breast and Cervical Cancer Prevention and Treatment Act each year. Under the little-known law passed by Congress in 2000, uninsured women under age 65 who are diagnosed with breast or cervical cancer can have their treatment covered by Medicaid, the government-funded health program for the poor, even if they don't meet all of its eligibility criteria.

But the law gives states an escape hatch. Rather than provide coverage to all comers, states can choose to cover only those diagnosed at clinics that get funding from a federal cancer-detection program. Texas chose the more restrictive option.

After cancer activist groups lobbied its legislature, Texas recently changed its version of the law to cover women diagnosed by any health provider starting Sept. 1. But 21 states continue to exclude patients diagnosed outside the federal cancer-detection program.

Niko Ferguson sits with her mother, Shirley Loewe.

The Treatment Act loophole is just one of a number of cracks in the patchwork of laws and regulations that govern the U.S. health-care system. Crafted by lawmakers to save money, these coverage gaps can turn the quest for care into a daunting obstacle course for the country's 45 million uninsured when serious illness strikes. Perhaps nowhere is the problem as stark as in Texas, where one in four residents lacks health insurance -- the highest proportion of uninsured in the nation.

A California native, Ms. Loewe was a free spirit. In the 1970s, she lived in a cabin in the Sierra Nevada mountains with her husband and her two children, a boy and a girl. Tragedy befell the family when the boy died from croup, a respiratory illness that afflicts young children. Ms. Loewe later divorced and moved to East Texas, settling in this small, working-class city. She worked long hours at Today's Cuts, a local hair salon, to make ends meet. Like many uninsured Americans, she went without health insurance because her employer didn't offer any and she couldn't afford it on her own.

Fear and Denial

Ms. Loewe first noticed a nickel-sized mass in her left breast in early 2003, according to her medical records. But she was distracted by the death of her father that spring. Her lack of insurance, combined with the fear and denial experienced by many cancer patients, also made her put off a doctor visit. By the time she showed up in late June at the emergency room at Good Shepherd, one of two hospitals in Longview, the mass had grown to nearly four inches in diameter.

Ms. Loewe earned too much to get Medicaid in Texas the regular way, but she would have qualified for it under the Treatment Act had she been diagnosed by the Wellness Center, a nearby clinic that participates in the federal cancer-detection program. Good Shepherd could have referred her there, but instead it sent her to Byron Cook, a staff surgeon. Dr. Cook diagnosed Ms. Loewe with inflammatory breast cancer, a rare and aggressive cancer that is often fatal, and referred her to a local oncology clinic, the Longview Cancer Center.

A Good Shepherd executive says the hospital didn't know about the Treatment Act. A spokesman for the Texas Department of State Health Services says it relies on participating clinics to get the word out. "I don't want to get into a game of finger-pointing because that's not useful to anyone," the Texas spokesman says.

TEXAS' NEW LEGISLATION

"A woman who received a breast or cervical cancer screen service under Title XV of the Public Health Service Act and who otherwise meets the eligibility requirements for medical assistance for treatment of breast or cervical cancer as provided by Subsection (y) is eligible for medical assistance under that subsection, regardless of whether federal Medicaid matching funds are available for that medical assistance. A screening service of a type that is within the scope of screening services under that title is considered to be provided under that title regardless of whether the service was provided by a provider who receives or uses funds under that title."

-- Texas Bill No. 1696, which took effect Sept. 1, 2007

Michelle Trich, the Wellness Center's executive director, says the clinic does community outreach, but doesn't know of any specific effort to get neighboring Good Shepherd to refer patients to the clinic.

With no means to pay for medical bills, Ms. Loewe went to her county's indigent clinic. The only assets she listed were $40 in cash and $60 in a checking account, but her application was rejected. Her most recent paycheck showed she had earned $7,096.02 in the first 5½ months of the year. That translated into an annual income far higher than the $8,980-a-year limit imposed by the county's charity guidelines for a single adult.

So Ms. Loewe cut back her hours to reduce her income. No longer able to afford her rent of $400 a month, she moved out of her apartment and rented a travel trailer from a friend for $200 a month.

Meanwhile, Lewis Duncan, an oncologist at the Longview Cancer Center, started Ms. Loewe on a classic treatment regimen of chemotherapy drugs, provided free by the drug makers' patient-assistance programs. On Aug. 4, 2003, she reapplied for charity assistance at the county clinic. With her lower wages, Ms. Loewe was approved, and the county began to pay for her treatment.

The county also agreed to pay for an antidepressant. Family members say Ms. Loewe felt helpless and afraid. Her daughter, Niko Ferguson, who lives in Denver, says her mother would often cry when they talked on the phone.

Ms. Loewe's sister, Tonna Day, who lives in the neighboring town of Gladewater, says Ms. Loewe desperately wanted to be treated at the M.D. Anderson Cancer Center, the world-renowned cancer hospital in Houston. Mrs. Day says Ms. Loewe thought she would stand a better chance there.

She may have been right. Last year, M.D. Anderson opened the world's first dedicated clinic for inflammatory breast cancer. The hospital's five-year survival rate for the disease is over 40%. The national five-year survival rate is a little above 30%.

Ms. Loewe called M.D. Anderson but was told she needed a referral from her oncologist. She asked Dr. Duncan for the referral, but he refused, Mrs. Day says.

Dr. Duncan says he knew from experience that M.D. Anderson didn't take charity-case referrals unless the patient's diagnosis was unusual and the treatment couldn't be handled locally. Contacting it about Ms. Loewe "would have been a waste of time," he says.

A spokesman for M.D. Anderson says the cancer hospital does accept in-state referrals of charity cases regardless of the type of diagnosis. Had Ms. Loewe been covered by Medicaid, she would have stood an even better chance of admission; M.D. Anderson treats Medicaid patients no differently than those who are covered by private insurance.

Frustrated and confused, Ms. Loewe searched on the Internet and contacted an advocacy group called Native American Cancer Research, which fights cancer among Indian tribes. From her mother Ms. Loewe had inherited membership in the Oklahoma-based Chickasaw tribe.

Linda Burhansstipanov, NACR's president, says she first tried to requalify Ms. Loewe for Medicaid through the Treatment Act by suggesting she get screened at a program clinic for cervical cancer. But the effort was rejected by the Texas health department. The department spokesman says that would be tantamount to Medicaid fraud.

Later, as NACR was trying other avenues of help, Ms. Loewe phoned in tears because the county indigent clinic suspended its assistance, alleging she had ramped up her working hours, Ms. Burhansstipanov says. NACR intervened and got her reinstated. A supervisor at the county clinic says there's no record of Ms. Loewe being dropped from the county welfare rolls during that time.

Mrs. Day recalls visiting her sister around this time and being shocked by Ms. Loewe's living conditions. The 24-foot trailer was leaking gas and Ms. Loewe was complaining about a violent headache, which Mrs. Day figured was caused by the leak. "I told her: 'For Pete's sake, come live with us,' " Mrs. Day remembers. At first, Ms. Loewe wouldn't hear of it. But she wept, relented and moved in with her sister and brother-in-law that night.

After four months of chemotherapy, Ms. Loewe's tumor had shrunk by half but wouldn't get any smaller. Her doctors decided it was time for a mastectomy. Dr. Cook's office repeatedly asked Ms. Loewe how the operation would be paid for, according to Mrs. Day and Ms. Burhansstipanov. He finally scheduled the surgery in early November 2003 after receiving a consent fax from the county saying it would cover the costs.

Ms. Loewe's daughter, Mrs. Ferguson, flew in from Colorado to be with her mother for the operation. Mrs. Ferguson, who works as a nurse, noticed her mother and the surgeon weren't getting along, and became alarmed when Dr. Cook referred to removing the wrong breast the day before the surgery.

Dr. Cook says he doesn't remember the incident. He says Ms. Loewe got first-rate care and that she simply waited too long before getting the lump in her breast checked out. "She didn't exactly seek what you call early attention," he says.

The surgery went smoothly. Ms. Loewe underwent radiation therapy for five months until April 2004, when she went into remission. She returned to work full-time at Today's Cuts and moved back into an apartment next to the one she had once lived in.

The reprieve was short-lived. Three months later, Mrs. Ferguson noticed her mother was having trouble talking when they were on the phone. Mrs. Day took her sister back to Good Shepherd. The news wasn't good: Ms. Loewe's cancer had returned and metastasized to the brain, where it had spawned a tumor. The hospital gave Ms. Loewe only a few months to live.

Convinced Ms. Loewe wasn't receiving top-quality care, Mrs. Ferguson decided to bring her mother to Denver. Ms. Loewe moved in with her daughter's family in a Denver suburb. She slept on a donated mattress on the floor of her grandson's room.

But the move brought new complications. Ms. Loewe applied for Medicaid coverage in Colorado, but she was told the process could take as long as a year because she needed to establish residency in the state, her daughter and Ms. Burhansstipanov say.

A spokeswoman for the Colorado Department of Healthcare Policy and Financing, which administers the state's Medicaid program, says she has no idea why Ms. Loewe was told that. States are required by federal law to act on a patient's application within 45 days and there is no time delay to establish residency.

THE BREAST AND CERVICAL CANCER PREVENTION AND TREATMENT ACT OF 2000

Passed by Congress on Oct. 24, 2000, the law was intended to provide Medicaid coverage to uninsured women with breast or cervical cancer who didn't meet all of Medicaid's eligibility criteria, such as income limits. (Read the law.)

Congress gave states the option to implement the law either generously or more restrictively. Under the generous but more costly option, states can grant Medicaid coverage to all comers regardless of where their cancer is diagnosed. Under the more restrictive option, they can deny coverage to women diagnosed outside a federal cancer-detection program. Twenty-two states chose to do the latter. One of them, Texas, switched to the more generous option Sept. 1.

Created in 1990, the federal cancer-detection program, known as the National Breast and Cervical Cancer Early Detection Program, is funded by the Centers for Disease Control and Prevention and administered by state health departments. Its reach is limited: The $190 million annual budget is enough to serve only 15% of uninsured women eligible for breast-cancer screening; and its services are available only through participating health providers.

There are about 200 such providers across Texas. In Longview, the participating provider is the Wellness Center. The clinic is located less than half a mile from Good Shepherd Medical Center, the hospital where Shirley Loewe was diagnosed with breast cancer in June 2003.

Under Texas' original version of the law, patients like Ms. Loewe had to have at least part of their cancer diagnosis performed, or paid for, by a participating clinic to qualify for Medicaid coverage. Because she was diagnosed at Good Shepherd and not the nearby Wellness Center, Ms. Loewe couldn't qualify. Getting re-screened at the Wellness Center after already being diagnosed somewhere else would have been considered Medicaid fraud.

Through her contacts in the Denver medical community, Mrs. Ferguson found a neurosurgeon, J.D. Day, who was willing to operate on her mother free. But the hospital where Dr. Day performed his surgeries, Swedish Medical Center, refused to make its facilities available unless Ms. Loewe or her family paid $90,000 up front, Mrs. Ferguson says. Mrs. Ferguson and her husband, who is also a nurse, had only a few thousand dollars in the bank.

Dr. Day, who is now an associate professor of neurosurgery at the University of Texas Health Science Center at San Antonio, confirms Mrs. Ferguson's account. A spokeswoman at Swedish Medical Center says the hospital has no record of Ms. Loewe seeking admission. "It's not consistent with the way we handle these cases every day," she says.

Dr. Day's office referred Mrs. Ferguson to the Colorado Neurological Institute, a charity organization for patients with brain illnesses that has a partnership with Swedish Medical Center. While talking on the phone to a social worker at the institute, Mrs. Ferguson remembers expressing frustration over her mother's situation. She says the social worker replied: "People die every day waiting for the system to catch up. Why is your mother any different?" Mrs. Ferguson says she broke down in tears.

Luanne Williams, the institute's executive director, says what the social worker told Mrs. Ferguson is "unfortunately a true statement, but I agree that it was an insensitive thing to say to a person in that situation."

Mrs. Ferguson next tried the Denver Health Medical Center, a county hospital that provides charity care to numerous uninsured patients. She was told that her mother couldn't qualify for indigent care there because her house was located in a different county.

Mrs. Ferguson then contacted the University of Colorado Hospital and argued that her mother's case was an emergency. She says the university hospital told her it was under no obligation to admit Ms. Loewe because her brain tumor resulted from a pre-existing condition -- breast cancer -- and therefore didn't qualify as an "emergency medical condition."

Unwilling to take no for an answer, Mrs. Ferguson recalls putting the following scenario to the hospital: What if her mother stopped taking her antiseizure medication and went into a coma? Wouldn't it have to treat her then? Mrs. Ferguson says the hospital replied that in such a scenario, it would stabilize Ms. Loewe and then discharge her.

A spokeswoman at the University of Colorado Hospital says illnesses like cancer aren't considered emergency conditions under the strict sense of federal statutes against patient-dumping. "We frankly do not have the financial resources to provide care to medically indigent patients whose conditions are not immediately life- or limb-threatening," she added in an emailed statement.

Mrs. Ferguson, who is personally opposed to universal health care because she thinks it would lower the quality of care, was discouraged. "I remember thinking: 'How can they let her die just because she doesn't have health insurance in this state?' " she says.

In early August, Mrs. Ferguson brought Ms. Loewe, who could no longer be left alone, to one of her son's Little League games. The mother of a teammate, Kelly Fulton, noticed Ms. Loewe on the sidelines. Mrs. Fulton was the former administrative director of a neurosurgery group at another Denver hospital, St. Anthony Central. Her husband, Matt Fulton, used to be the hospital's chief executive officer.

The Fultons put Mrs. Ferguson in touch with John Nichols, a neurosurgeon at St. Anthony Central. Dr. Nichols agreed to see Ms. Loewe right away. His prognosis was much more upbeat than the one she had been given in Texas. And unlike Swedish Medical Center, St. Anthony agreed to take Ms. Loewe on free. On Aug. 17, Dr. Nichols operated on her and removed most of the tumor.

On Oct. 13, 2004, nearly three months after she applied, Colorado granted Ms. Loewe Medicaid coverage and covered the costs of the surgery retroactively. The following month, she returned to St. Anthony for treatment under a Gamma Knife, a machine that emits powerful gamma rays, to dissolve what was left of the tumor. The procedure was a success.

Over the following 18 months, Ms. Loewe had several recurrences of cancer in her chest, but she went into remission after more rounds of chemotherapy and radiation. In May 2006, body and brain scans came back clear. Once unable to talk, Ms. Loewe fully recovered her speech and was able to function autonomously.

Tired of the cold Rocky Mountain weather and missing her friends, Ms. Loewe persuaded her daughter to let her move back to Texas. She rented an apartment in Gladewater near her sister's house and went back to work at Today's Cuts. Ms. Loewe's daughter bought her a used Chevy Cavalier. Ms. Loewe reapplied for Medicaid coverage in Texas and this time got it promptly. Life went back to normal.

But last spring, the cancer came back with a vengeance. An MRI showed numerous tumors in Ms. Loewe's brain, and she went into steep neurological decline. This time no surgery would make a difference.

Battle With Bureaucracy

Ms. Loewe's battle with the health-care bureaucracy wasn't quite over, though. She underwent radiation in Tyler, Texas, to ease her pain and after 21 days was transferred to a Gladewater nursing home. Medicaid covered the Gladewater nursing home but wouldn't pay for Tyler. Medicare, the federal program for the elderly that also provides coverage to disabled people, would pay for only the first 20 days in Tyler. Mrs. Loewe's daughter wound up paying for the extra day -- $124. (Medicaid eventually reimbursed her for most of it).

On a late June morning, Ms. Loewe lay in bed, emaciated and writhing in pain. Her left arm and hand were swollen to three times their size from lymphedema, a side effect of her breast surgery. Embarrassed by her appearance, she hid the huge black scar left on the top of her head by her brain surgery under a grey beret.

She reacted little when told that her ordeal could have been avoided had she gone to a different clinic back in 2003. "It's very complicated when you don't have health insurance," she whispered. "I really don't understand it much."

Ms. Loewe died on June 25 at age 55. Her daughter sold her car to pay for her cremation.

Write to John Carreyrou at john.carreyrou@wsj.com

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