Health for life

When learning about B12, I was reminded of an article I read a little while ago about B12 deficiency called B12 deficiency: a silent epidemic with serious consequences. The author makes the case that our definition of B12 deficiency may be set too low, and that we can still see symptoms of deficiency at levels that are now considered normal. Currently in the United States, a serum B12 level of less than 100 pg/ml will get you diagnosed with a deficiency, while a range of 200-900 pg/ml is considered normal. But research indicates that those with B12 levels between 200-350 pg/ml, especially older adults, may still show deficiency sypmtoms.

Why is this important? Because B12 is involved in the nervous system and for myelin sheath formation, one of the most common deficiency symptoms is neurological impairment. This could manifest in several ways, including problems with cognition, decreased mobility, or impaired memory. In the elderly, how do we know whether a decline in cognitive function is due to simple aging or due to a subclinical B12 deficiency? We dont. Especially if were A) not testing for serum B12, and B) our deficiency level is set too low.

Interestingly, Japan has increased their cutoff for B12 deficiency to a serum level of 550 pg/ml (confirmed by Wikipedia)... very much higher than our cutoff of 100 pg/ml. Anyone below that level receives treatment. The Japanese also have lower rates of Alzheimers disease and other dementia compared to us here in the States. Its just an association, but there may be a connection there between higher serum B12 in the Japanese and a lack of cognitive decline.

Based on this information, it would seem prudent to keep an eye on B12 status, especially in the elderly. According to the lecture notes, about 15% of the elderly are B12 deficient; the figures in the study cited above place that number at up to 40%. But we dont know how many reside at the low-normal level (a level that would be considered deficient in Japan). B12 supplementation seems to provide far more potential benefit than risk, so I see no reason why we dont give it a shot in those who are subclinically deficient, especially if we can prevent more serious symptoms if levels were to continue to drop.

Talk about a no win situation.  After seeing his "red line" go rudely unheeded, the President is facing the prospect of appearing weak if he does nothing or warmongering if he launches an attack.

Medical decision scientists ask: how did it come to this?

Mr. Obama is correctly admired for his "no-drama informed style of decision-making.  And good physicians, says medical science, should operate the same way.  According to this recent New England Journal article, consciously deliberative and logical approaches to diagnosis and treatment selection are far more reliable than the intuitive shoot-from-the-hip pattern recognition that used to rule the bedside.

Psychologists describe the latter as "Type 1" processing while the former is "Type 2."   Think George W. Bushs gut instincts over Iraqs weapons of mass destruction versus Barack Obamas disciplined rationality when he decided to attack the Bin Laden compound. He undoubtedly used the same methodology when he was pondering Syria.

But, thinks the Disease Management Care Blog, there are limits to brainy decision-making when the choices are overwhelmingly numerous.  In this retail business-oriented TEDTalk, Sheena Iyengar points out that dozens of options lead to procrastination followed by bad choices followed by low satisfaction. 

It can also apply to foreign policy. Given the vast array of pieces and potential moves on the Middle East chess board, little wonder that Mr. Obama would procrastinate for days saying he has "not made a decision," then apparently select an attack option disdained by even the New York Times and then engender even more second guessing by the very Congress that the President has repeatedly criticized as unreliable.

Ditto health care.  The downside to shared decision making is that an overwhelming number of testing and treatment options can lead befuddled patients to a "you decide, doc" mentality that leads the physician to regress to "Type 1" decision-making.

The DMCB isnt too sure how TEDTalks Dr. Iyengars suggested solutions can help the folks in the White House Situation Room, but the DMCB wonders if the national security staff shouldnt have done a better job of presenting the Commander in Chief with 1) a limited number of choices that were 2) more "concrete," as well as 3) arranged into categories with the 4) low complexity options offered first. 

That 4-fold approach could help docs and patients too.  The DMCB looks forward to additional research in the area.

In the meantime, there is one additional medical rule that has withstood the test of time that may also be useful in dealing with Syria. The DMCB offers it up to business and politicians alike: primum non nocere.

In George Romeros campy movie Land of the Dead, the zombies undergo a very worrisome change. While they used to just pathetically stumble around looking for brains to eat, they organize and make menacing plans. The living survivors, holed up inside the fence at the former city of Pittsburgh, have a fight on their hands.

Maybe its the Halloween season, but the recent slew of late night walking dead horror has inspired the Disease Management Care Blog.  Its entered sweeps for a cameo appearance in AMCs cool zombie series.  Its assessed the relative merits of the undead staggering vs. running, being loners vs. in packs and being wrathful vs. both hungry and wrathful.  The DMCB has also discovered one key commonality of this fearsome species: while maximum head trauma undoes the undead, more of them just keep coming and coming. That DMCB thinks that, despite the spouses advice to the contrary, is an important lesson.

The political dimensions of the Affordable Care Act are becoming more zombie-like with each passing week.  According to the Kaiser Health Foundation, public support for health orm has not only remained stubbornly underwhelming, it has just taken a recent downturn.  While its too early to tell if this is bad news or statistical variation, theres no denying President and his allies are being forced to fight one-on-one with undead employer pessimism, oppositional Republicans and the CLASS Acts failures, while more ever more issues slowly stumble closer.  And who can blame the living Dems for their post-apocalyptic anxiety? It was only yesterday that the ACA was a signature achievement and the world was a wonderful place of Congressional majorities, fawning media support and supreme self-confidence.

While supporters of health orm may take comfort in the notion that the zombies have been unorganized and are attacking the margins, the DMCB worries that the Kaiser poll slide may portend a worrisome Romero-esque development: unable to grasp the details if the Affordable Care Act, Americans support for it was always based less on the underlying policy and more on the President himself.  A slip in support, theore, has less to do with the laws merits and more with a shift in what people fundamentally think about Mr. Obama.

With just over a year until the elections, thats a scary thought for this Halloween. It seems the folks inside the White House fence have a fight on their hands.

The US Department of Agriculture has been tracking cheese consumption:



Some cheese facts:

• Average US cheese consumption nearly tripled between 1970 and 2003, from 11 pounds per person to 31 pounds.
  
  
• 60% of our cheese comes from eating out (or ordering in).
  
  
• In 2000 cheese contributed:
  • 26% of the calcium in the US diet (up from 11 percent in 1970)
    
  • 12% of the saturated fat (up from 5 percent in 1970)
    
  • 16% of the sodium (up from 6 percent in 1970)

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Here comes the camel nose!

Kudos to JAMA for tackling what the Disease Management Care Blog has been saying for years: now that the Washington DCs camel nose is under the tent, there is no way health insurance coverage - and the care it pays for - isnt going to become politicized.

Thats the bigger issue in this just-published article by Steven Wolf and Doug Campos-Outcalt. Theyre focusing on the political pressure that is being brought to bear on US Preventive Services Task Force (USPSTF). As readers may recall, the Affordable Care Act requires health insurers to fully cover screening services that are deemed effective by the USPSTF. Drs. Wolf and Campos-Outcalt point out that politics rudely intruded on the USPSTFs determination that the evidence supporting mammography for women under age 50 years was lacking. The resulting firestorm not only prompted Congress to not only waive the USPHSTF recommendation, but led some of its members to question the Task Forces integrity.

As academics writing in peer-reviewed journals are wont to do, the authors suggest that this can be remedied by another layer of bureaucracy. They want a new "firewall" committee to be inserted between the "pure" evidence-based USPHSTF and the "political" fisticuffs of the public square.  Itd be the job of this a new entity to insulate USPHSTF by reconciling the proof and the politics prior to the upload of the final recommendations to the mandarins that are running CMS.

"Another committee?" asks the dismayed DMCB. While that would end the Obamacare fiction that health orm was ever going to be truly "based on science," the real Achilles heel of the JAMA proposal is that it literally doubles the opportunity for political meddling. The smartest political operatives will see this as a target-rich environment and naturally seek to influence all of the committees with any jurisdiction over the medical-industrial complex of laboratory medicine, radiological imaging and medical devices.

The DMCB has bad news for its colleagues who thought that they could have the Washington DC "cake" of enlightened government involvement along with the "icing" of scientific independence. Uncle Sams been given a clinical inch and now hell take a political mile to influence clinical guidelines and define standards of care with a one-size-fits-all mentality sprinkled with a healthy dose of cronyism.  Surprise!

The DMCB has an alternative solution: CMS should tread very caully when it comes to insurance design.  Congress needs to reengineer the preventive health part of the ACA. Instead of building new infrastructure to make up for the emerging failures of the old infrastructure, Washington should be pushing benefit design down, not up, to the local level. It can partner with commercial health insurers to assure that the USPSTF recommendations are considered, but with local committee assessments of market demand, provider opinion and community input to determine whats best for its covered population. It should do this while simultaneously promoting the use of shared decision making to help every patient ponder for themselves when testing is in their best interest.
 
Let a thousand flowers bloom.

Image from Wikipedia

Partly because its a brain tonic for jet lag, the Disease Management Care Blog is trying to come to grips with the "Higgs Boson."

As it understands it, these invisible motes permeate our universe and interact with strangely named subatomic particles in ways that confer mass. The identification of the "boson" apparently explains a lot, like how electrons are so light (little interaction) and why toilet seats are so difficult to raise (much interaction).

Which provides an apt metaphor for Washingtons bosonic permeation of the health care universe.  CMS rates set payment benchmarks, its device approvals determine coverage, IPAB says when a treatment is evidence-based and insurers have little say on the definition of administrative costs. In the meantime, the Federal Register fills space with the microwave radiation of rule-making and now the Supreme Court has set off a Big Bang.

Unfortunately, the DMCB isnt making much progress on the theoretical physics of bosons, photons,leptons, quarks and gluons or, for that matter, on the legal Big Bang physics of mandates, taxes, assessments, collections fines or penalties. If the DMCB is reading Justice Roberts correctly, a low-amount "exaction" that is configured as a "shared responsibility payment" for behavior that is not "unlawful is "within" Congress taxing authority.  Right.

No wonder the Romney campaign is so confused. Without the genius of Peter Higgs or the opaque jurisprudence of John Roberts, theyre as probably perplexed as us normal folks. Better to move on to topics better suited for the rhetoric of the fall campaign, like whether its all really Bushs fault or truly Bushs fault.

You’ve probably seen “a good source of omega 3′s” imprinted on various boxes and bags around the super market and wondered “what are omega 3′s and why should I give a damn?

Omega-3 fatty acids are considered essential fatty acids: Omega 3′s come from a family of unsaturated fatty acids.  Even the healthiest diets need a moderate amount of healthy fats, and omega 3′s are crucial to healthy, sustainable living.  They’re considered “essential” fats – Essential fats are so defined as they are vital for, but cannot be made by, the human body. Only plants can make the vital omega 3 and 6 parent fatty acids, human enzymes can then convert these to other fatty acids such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) which are building blocks of the brain and nervous system. 

Omega 3 Source

 They are needed for the integrity of every cell membrane in the body so particulalry important for the health of vital organs such as the heart and brain.They are necessary for human health but the body can t make them -- you have to get them through food. Omega-3 fatty acids can be found in fish, such as salmon, tuna, and halibut, other seafood including algae and krill and there are plenty of vegan sources of Omega 3′s including spirulina (algae), nuts, flax, and vegetables. Vegan sources of omega-3s include canola oil, broccoli, cantaloupe, kidney beans, spinach, grape leaves, Chinese cabbage, cauliflower, spirulina, and walnuts.

Research shows that omega-3 fatty acids reduce inflammation and may help reduce the risk of chronic diseases such as heart disease, cancer and arthritis.The omega 3 parent fatty acid is called alpha linolenic acid (LNA or ALA) and comes from vegan seeds such as flax, hemp and pumpkin, from nuts such as walnuts, and to a lesser extent from soya and green vegetables. 

Through a series of enzyme-controlled reactions the human body converts this LNA into a number of vital fatty acids including EPA and DHA. Among their many roles EPA is needed for brain function, concentration, and vision, and is also converted into a powerful anti-inflammatory agent. DHA is needed as a building material , particularly for brain structure and so is especially important in pregnancy for the baby’s brain and nervous system development, infants who do not get enough omega-3 fatty acids from their mothers during pregnancy are at risk for developing vision problems and nerve damage.



Additionally, the benefits of omega-3s include reducing the risk of heart disease and stroke while helping to reduce symptoms of hypertension, depression, attention deficit hyperactivity disorder (ADHD), joint pain and other rheumatoid problems, as well as certain skin ailments. Some research has even shown that omega-3s can boost the immune system and help protect us from an array of illnesses including Alzheimer’s disease.

Fish contain unsaturated fatty acids, which, when substituted for saturated fatty acids such as those in meat, may lower your cholesterol. But the main beneficial nutrient appears to be omega-3 fatty acids in fatty fish. Omega-3 fatty acids are a type of unsaturated fatty acid thats thought to reduce inflammation throughout the body. Inflammation in the body can damage your blood vessels and lead to heart disease.

Omega-3 fatty acids may decrease triglycerides, lower blood pressure, reduce blood clotting, boost immunity and improve arthritis symptoms, and in children may improve learning ability. Eating one to two servings a week of fish, particularly fish thats rich in omega-3 fatty acids, appears to reduce the risk of heart disease, particularly sudden cardiac death.

Alzheimers
Polyunsaturated fatty acids found in many fish may prevent damage to brain cells. Eating fish can also reduce the risk of high blood pressure, which is linked with dementia. A French study of 2000 people showed that those who ate seafood at least once a week had a significantly lower risk of dementia over a seven-year period than those who didnt.

Dementia - elderly people who eat fish or seafood at least once a week may have a lower risk of developing dementia, including Alzheimers disease.

Cardiovascular disease - eating fish every week reduces the risk of heart disease and stroke by reducing blood clots and inflammation, improving blood vessel elasticity, lowering blood pressure, lowering blood fats and boosting good cholesterol.

Cancer - the omega 3 fatty acids in fish may reduce the risk of many types of cancers by 30 to 50 per cent, especially of the oral cavity, oesophagus, colon, breast, ovary and prostate.

Asthma - children who eat fish may be less likely to develop asthma.    

Just how do omega-3s perform so many health “miracles” in people? One way, experts say, is by encouraging the production of body chemicals that help control inflammation — in the joints, the bloodstream, and the tissues

But even as important is their ability to reduce the negative impact of yet another essential type of fatty acid known as omega-6s. Found in foods such as eggs, poultry, cereals, vegetable oils, baked goods, and margarine, omega-6s are also considered essential. They support skin health, lower cholesterol, and help make our blood “sticky” so it is able to clot. But when omega-6s aren’t balanced with sufficient amounts of omega-3s, problems can ensue.  In general, Americans eat too much Omega 6 and not enough Omega 3.
You can replace some omega-6s from cooking oils with a third fatty acid known as omega-9 (oleonic acid). This is a monounsaturated fat found primarily in olive oil.

If you think you can get all of your omega 3′s only through fish oil supplements?  Think again.  There are other healthy components of whole foods containing Omega 3′s that make it better for your body and soul – flax, for example, is heavy in fiber which helps lower cholesterol, regulate blood sugars, and improve digestion. 
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If you have diabetes, including more omega-3s in your diabetic meal planner can reduce your risk of certain diabetic complications, as well as:

• Decrease insulin resistance
• Improve mood and lower rates of depression
• Improve symptoms of inflammatory diseases, like asthma and lupus
• Reduce apoproteins, cholesterol and triglyceride levels
• Reduce risk of heart attack
• Reduce risk of macular degeneration
• Reduce risk of some types of cancer
• Reduce risk of stroke.

So just add some Omega 3′s to your diet today!

The love affair between U.S. residents and salt is making us sick: high sodium intake increases blood pressure, and leads to higher rates of heart attack and strokes. Nonetheless, Americans continue to ingest far higher amounts of sodium than those recommended by physicians and national guidelines.

A balanced review of the relevant literature has been published in the March 27, 2013 edition of The New England Journal of Medicine. Theodore A. Kotchen, M.D., professor of medicine (endocrinology), and associate dean for clinical research at the Medical College of Wisconsin, is the lead author of the article.

Dr. Kotchen cites correlations between blood pressure and salt intake in a number of different studies; typically, the causation between lowering salt intake and decreased levels of blood pressure occur in individuals who have been diagnosed with hypertension. Although not as pronounced, there is also a link between salt intake and blood pressure in non-hypertensive individuals. Additionally, recent studies have demonstrated that a reduced salt intake is associated with decreased cardiovascular disease and decreased mortality.

In national studies in Finland and Great Britain, instituting a national salt-reduction program led to decreased sodium intake. In Finland, the resulting decrease in systolic and diastolic blood pressures corresponded to a 75 – 80 percent decrease in death due to stroke and coronary heart disease. Neverthelesss, not all investigators concur with population-based recommendations to lower salt intake, and the reasons for this position are reviewed.

"Salt is essential for life, but it has been difficult to distinguish salt need from salt preference," said Dr. Kotchen. "Given the medical evidence, it seems that recommendations for reducing levels of salt consumption in the general population would be justifiable at this time." However, in terms of safety, the lower limit of salt consumption has not beeen clearly identified. In certain patient groups, less rigorous targets for salt reduction may be appropriate.