Health for life

So, how bad is it?

While HHS Secretary Sebelius Affordable Care Act nostrums help the Obama Administrations muddling of policy and election year politics, CMS Chief Actuary Richard Foster has stepped forward (see page 277) with some blunt language about Medicares solvency.  As the Disease Management Care Blog understands it, official projections on just when the money runs out are based on current law. 

Thats the rub:  

"While the Part B projections.... are reasonable in their portrayal of future costs under current law, they are not reasonable as an indication of actual future costs. Current law would require a physician fee reduction of an estimated 30.9 percent on January 1, 2013—an implausible expectation."

"[W]hile the Affordable Care Act makes important changes..., there is a strong likelihood that certain of these changes will not be viable in the long range. Specifically, the [anticipated] annual price updates for most categories of non-physician health services will be adjusted downward each year by the growth in economy-wide productivity. The best available evidence indicates that most health care providers cannot improve their productivity to this degree—or even approach such a level—as a result of the labor-intensive nature of these services."

"Without unprecedented changes in health care delivery systems and payment mechanisms, the prices paid by Medicare for health services are very likely to fall increasingly short of the costs of providing these services. By the end of the long-range projection period, Medicare prices for ... many services would be less than half of their level under the prior law. Medicare prices would be considerably below the current relative level of Medicaid prices, which have already led to access problems.... Well before that point, Congress would have to intervene to prevent the withdrawal of providers from the Medicare market.... "

"Finally, the economic outlook remains more uncertain than usual. Due to the sensitivity of HI trust fund operations to wage increases and unemployment, the current slow recovery from the recent recession adds a significant further element of uncertainty to the trust fund projections."

Written by the fabulous Leigh, Veggie Might is a weekly Thursday column about all things Vegetarian.

In healthy, vegetarian cooking—in any cooking really—there is a shade of difference between bland and subtle. Conventional wisdom holds that if food is good for you it has to taste like a craft project. Well, I like to keep my craft projects and cooking projects separate, unless Amy Sedaris issues a challenge.

That is why I am known to tweak all recipes, especially vegetarian ones, written before 2005. Vegetarian recipes are notoriously bland. I mean, y’all know. We’ve all tried to cook quinoa with spinach, mushrooms, and tofu for unsuspecting carnis, only to have it backfire on occasion.

So this week I was trying to get whittle down the abundance of kasha in my pantry. Kasha, in the U.S. anyway, is buckwheat. In my old Vegetarian Times Complete Cookbook, I found what I thought was the perfect recipe to start with: Kasha with Potatoes and Dill.

It uses the classic Eastern European flavors of onion and dill, which are a bit out of my usual comfort zone, i.e., no garlic, parsley, or cilantro, and it will challenge me to follow a recipe. When working with new flavors, I don’t experiment much.

Well. It turned out to be that textbook hippie food that turns people off of healthy cooking: bland, mushy, with the distinct flavor of Aleene’s Tacky Glue. My Charming Dinner Guest was so polite, adding extra salt and telling me that “No, really, it’s good.” But I knew.

And I was determined to make it good.

Back to the recipe, I was ready to up all the seasonings and adjust the kasha:veg ratio by adding a turnip. I did those things, but I also realized something very important. I screwed it up the first time.

Going through the instructions again, I discovered that I had cooked the kasha way too long the first time. I got paste because I overcooked the grain. The recipe was still light on the onion and dill, but my error took away the subtle, nutty flavor of the kasha, which absolutely makes the dish.

The second go-round was delicious—light and fluffy, with a hint of sweetness from the onion and a counterbalance of tang from the dill. This dish makes a lovely alternative to a potato side, and packs in way more nutrition with the high-fiber kasha giving it a boost.

That is not the first time my hubris in the kitchen has resulted in a grain FAIL. But it’s cool. These little experiments are how I learn. But next time, I won’t jump to blame the recipe before I check my work.

Now my pantry is nearly kasha-free, and my fridge is well full. My menu is set for the week.

~~~
If you like this recipe, you might enjoy

• Quinoa, Mushrooms, and Mustard Greens
• Beets and Greens Curry
• Miso Mashed Potatoes

~~~

Kasha with Root Vegetables and Dill
Adapted from Vegetarian Times Complete Cookbook.
Serves 6


1 medium potato (about 8 oz), chopped (peeled, optional)
1 medium turnip (about 8 oz), peeled and chopped
water to cover

1 cup kasha
2 cups water
1 tsp salt

1 1/2 large onion, chopped
1 tsp olive oil
1/4 to 1/2 cup water
1/4–1/2 cup fresh dill, finely chopped
1 tsp salt

1) In a small saucepan, cover chopped potatoes and turnips with water and bring to a boil. Reduce heat to a rolling simmer and cook for 5 minutes or until just tender. Remove from heat, drain, and rinse with cold water to stop the cooking. Set root vegetables aside.

2) In a skillet, toast kasha over medium high heat for 7–10 minutes or until you smell the roasted grain fragrance. Stir and toss regularly. Set aside kasha.

3) Bring the 2 cups of water and 1 tsp of salt to boil in a small saucepan. Stir in the kasha, cover, reduce heat, and simmer for 15 minutes. Fluff with a fork.

4) While your kasha is cooking, heat oil in a large skillet and add the onion. Cook until onion is soft, about 7–10 minutes. Add water as necessary if the onion starts to stick.

5) Once all your components are ready, combine in the skillet over medium heat. Add to the onion the kasha, root vegetables, dill, and salt to taste. Toss to combine.

6) Serve as a side with a hearty entrée and vegetables. This goes great as a potato alternative with Bean Burgers and a vegetable.

7) Marvel at the subtle flavors and your finely tuned palate.

Approximate Calories, Fat, Fiber, and Price per Serving
158 calories, 1.6g fat, 6g fiber, $.44

Calculations
1 medium potato: 164 calories, .15g fat, 5g fiber, $.15
1 medium turnip: 39 calories, 0g fat, 2g fiber, $0.37
1 cup kasha: 567 calories, 4g fat, 17g fiber, $.83
1 1/2 large onion: 136.5 calories, .5g fat, 75g fiber, $1.00
1 tsp olive oil: 40 calories, 4.7g fat, 0g fiber, $.03
1/2 cup fresh dill: 2 calories, 0g fat, 0g fiber, $.25
2 tsp salt: negligible calories, fat, fiber, and price per serving
Totals: 948.5 calories, 9.35g fat, 24.5g fiber, $2.63
Per serving (totals/6): 158 calories, 1.6g fat, 6g fiber, $.44

Many people with diabetes wonder if their blurred vision signals the beginning of diabetic retinopathy or perhaps another common cause of vision loss, macular degeneration.

While blurred vision occurs with both conditions, there are distinct differences between diabetic retinopathy and macular degeneration.

First, macular degeneration generally results in central vision loss while diabetic retinopathy results in dispersed areas of vision loss.

Heres a normal view:


Heres that same view through the eyes of someone with macular degeneration:


Heres that same view through the eyes of someone with diabetic retinopathy:


You may be able to turn your head to compensate for central vision loss. Compensation for dispersed loss from retinopathy is more challenging.

Another difference between the two is the age at which they develop.

Where age-related macular degeneration usually occurs in an older age group (60 years and older), diabetic retinopathy can and does strike a younger population.

The ADA states:

"After 20 years of diabetes, nearly all patients with type 1 diabetes and >60% of patients with type 2 diabetes have some degree of retinopathy."
- American Diabetes Association: Diabetic Retinopathy

The average age for diagnosis of type 2 diabetes has shifted from the 40s and 50s in recent years towards a younger population, occurring with troubling frequency in adolescents. Type 1 diabetes can occur in children as young as 2 years old.

Twenty years on from childhood or the teen years places someone with diabetes at risk of losing their eyesight at the height of midlife. The ADA says:

"Diabetic retinopathy is estimated to be the most frequent cause of new cases of blindness among adults aged 20–74 years."

________
Photos of vision loss from NIH National Eye Institute via Wikipedia.

Your doctor will see you now!

If only the U.S. health care system had the democracy of the French, the efficiency of the Germans, the primary care of the Brits and the common sense of the Swiss. Then wed be able to see our beret-wearing PCPs ad lib, receive care in 9 minute aliquots, mutter "bullocks!" when were told were too old for dialysis and then die old and quietly at home.

Victor Fuchs, writing in the Jan 2 edition of JAMA, has a slightly different perspective.  He notes that American history is dominated by waves of immigrants who came here to escape oppression. We are far more distrustful of government.  We are also less likely to support redistributive public policies. That may be partly due to a more heterogeneous population that is less sympathetic to the less fortunate when they fall outside the right social or demographic class. Last but not least, our system of government is quite inefficient compared, say, to a parliamentary system.

Thats why:

1. Government spending on health care is comparatively lower: 46% in the U.S. vs. 75% in Organization for Economic Co-operation and Development (OECD) countries.  As a result, a) administrative costs are fragmented, and b) there is less ability to negotiate prices with providers and suppliers

2. There is a different mix of services: in the U.S., less top-down control means more high tech, specialists and amenities with relatively less reliance on physicians and hospitals to render health care services.

What is the way forward?  Dr. Fuchs recommends that future health orm efforts not be modeled on Europe.  Instead, Americans should scale back their expectations and focus on what is necessary, not desireable.

If government is to assume a greater share of health care costs beyond the current 46% level, it should probably worry about funding basic care, not all care.  In addition, Americans are less likely to support total equality; they want to preserve the option of "buying up" when they can afford it.  Last but not least, future orm is going to have to find a middle ground between all the advocacy groups, stakeholders and special interests that dominate the mix of services.

Image from Wikipedia

"If youre telling the truth, hit 1; if not, hit 2.  If youre not sure, please wait on the line....."

If the Disease Management Care Blog accepted the common wisdom about commercial health insurance, itd believe that the businessis is an evil empire controlled by pirates who 1) use weenie print to fool unwitting patients and 2) rely on opaque decision-making to deny coverage for life-saving treatments.

Once again, the DMCB eschews common wisdom:

The reason why insurers have used small fonts in their coverage documents has been because their state regulators likewise use small font in their rule making and require full word-for-word disclosure to the beneficiaries. Think of lawyers run amok and youll understand the main reason for the arcane language.

The good news is that new regulations promise easy-to-understand "labeling." The DMCB thinks thats a step in the right direction, but that doesnt mean that a lack of preciseness wont lead to misinterpretation and wrong assumptions. Time will tell.

As for the opaque decision-making, check out (for example) Aetnas and Humanas open-access coverage documents. Yet, despite a high level of on-line transparency, critics may point out that commercial insurers will still require a hassle-laden preauthorization process.

That may be true, but the DMCB says who can blame them? There is literature here here and here that point out that physicians will readily resort to deception get a proposed treatment covered.

To really make the point, check out this just published Health Affairs article. Using a validated survey on a representative sample of physicians (obtained from the AMAs masterfile, which contains all practicing docs, not just AMA members), about 10% of the respondents indicated that, in the past year, they had lied to a patient. A whopping 50% admitted telling a patient that their prognosis was better than warranted.

Egads. This is not only driving medical costs, its increasing variation and exposing patients to unnecessary and potentially dangerous treatments.

Keep in mind that the fee-for-service Medicare program does not engage in "preauthorization" that can lead to a usal to pay for a treatment.  Rather, Medicare generally pays all claims and then relies on retroactive audits to "claw back"any improper payments.

While that has shielded the Medicare program from being lumped in with all the allegedly evil commercial insurers, the DMCB asks two rhetorical questions about the few bad apples who are hurting the profession:

Which would you rather have for you, your parent or your child: an insurer that scrutinizes a proposed treatment ahead of time and doesnt necessarily take the docs word for it, or an insurer that lets things happen and uses hindsight after the damage is done?

And last but not least, how will the new payment mechanisms, like bundling and shared savings, reduce the likelihood of bad behavior?

So this past weekend, I was able to attend AHS 2012 in Cambridge, MA.  For those of you who dont know, the Ancestral Health Symposium is an annual event that began last year, and it brings together all of the most well-known people in the paleo community for a weekend full of lectures, debates, paleo food, and apparently, large amounts of free chocolate and coffee.  Or maybe it was only me who spent half the conference eating free dark chocolate samples and drinking americanos.  Oh well, coffee is life.

Caveman chocolate.

It was a great weekend, and I got to meet some great people who Ive learned so much from over the past couple of years.  Stephan Guyenet, Chris Kresser, Mark Sisson, just to name a few.  Also got to meet Laura from Ancestralize Me, which was great because shes also on the RD track and I love bitching about My Plate.  I did NOT get to meet Robb Wolf, which I was really disappointed in since hes sort of the ring leader of this whole paleo movement.  Maybe next time.  I was so pleasantly surprised to learn how down to earth and approachable these people were.  Despite their status in the community, they were willing to socialize with everyone and blend in.  I really appreciated their everydayness.

Anyway, over the next few days Ill be discussing my thoughts on some of the main topics from AHS this year, and also talk about the event as a whole and what it means for the future of the paleo community. So without further ado...


Safe Starch Debate
One of the best presentations of the weekend was the safe starch debate involving Paul Jaminet, Chris Kresser, Cate Shanahan, and Ron Rosedale.  Let me first just say how ridiculous it is that were even asking the question "Is there such a thing as a safe starch?"  Im sorry but its stupid.  Especially when it followed Chris Masterjohns great presentation, which explained very clearly how humans, as compared to apes, have evolved the ability to digest greater amounts of starch through salivary amylase.  This is not debatable.  Of course starch is safe.  The question is, how much starch is safe for a given person?  Well, according to Chris Masterjohns data, humans have varying abilities to produce salivary amylase.  So there is a spectrum in terms of the ease at which humans digest starch.  Some can handle it very easily and perhaps in large quantities, while others may have a hard time digesting a lot of starch.

Chris Kresser (middle) dominating the safe starch debate

The obvious answer to safe starch debate is... it depends.  One person may be just fine on a diet high in starch from potatoes and sweet potatoes, while another person may be better off limiting their potato consumption.  There is no one diet for everybody, which is why I think Chris Kresser clearly came out on top in this debate, because he understands this concept.  Ron Rosedale came off as a complete idiot, in my opinion, although he did make some interesting points.  He advocates a low-carb, ketogenic diet for everyone, which I completely disagree with.  Cate Shanahan was on the low-carb side as well, although she was not as militant about it, and I was happy to hear her conclude with the idea that eating real food is what matters most.  Not to forget about Paul Jaminet, I thought he was great in this debate as well, but having read his book, I know he is of the opinion that the optimal human carbohydrate intake is fixed at between 100-150g per day.  Any more, according to him, is toxic.  I just cant agree with that.  So Kresser for the win.

Oh, and theres also that pesky fact that nearly all 7 billion people on earth eat a starch-based diet.  I know that doesnt mean its optimal, Im just saying.  Theyre not killing us.


LDL-P
The concept of LDL-P seemed to be a theme this past weekend.  LDL-P stands for LDL particle number.  In a typical lipid panel from your doctor, they are measuring LDL-C, or LDL concentration.  According to Peter Attia, and Robb Wolf mentioned it in his talk as well, LDL-P is a much better predictor of heart disease than LDL-C. 

From Dr. Attias presentation.  This graph compares LDL-C levels with incidence of heart attack.  Most heart attacks occurred in people with what is considered a "normal" level of LDL-C.  What would conventional medicine do?  Lower the erence range and prescribe more statins.  What should we do?  Get a new fucking risk factor.

Lets make up an example.  Say you have a healthy LDL-C, as measured by your doctor, at 120 mg/dl.  Thats a good thing, as far as hes concerned.  But LDL can vary in size.  If all those particles are small LDL particles, then there must be a lot of them to make up that concentration of 120 mg/dl.  If you have a lot of LDL particles, youre at high risk of heart disease, regardless of what your LDL-C says.  On the other side of the coin, you may have large LDL particles.  In this case, you have fewer total particles that make up that 120 mg/dl.  Here, you would be at low risk.  Of course, you could also look at someone with high LDL-C, say 200 mg/dl, and you could make the case that he or she may or may not be at risk, depending on the size and total number of LDL particles.

I  have been familiar with the LDL particle size idea for a while now.  But according to Dr. Attia, particle size is largely irrelevant in its own rite.  Small, dense LDL particles are very much associated with a higher risk for heart disease, but it is not the small LDL that are causing disease.  It is because small LDL often indicates a large particle number that explains the association with heart disease.  It is not the small, dense LDL itself.  In a situation where someone might have low LDL-C, low LDL-P, and small particles, the risk of disease remains low.  Or if someone has high LDL-C, high LDL-P and large particles, their risk of heart disease is high.

I realize this may be confusing.  But heres the take home message:  It looks like the LDL-C measurement, the one doctors are currently using, is largely useless.  While higher LDL-C may increase the chances that youve got a high LDL-P (only makes sense, right?), the two are not necessarily connected.  We need to start measuring LDL-P if were ever going to get an accurate measurement of heart disease risk.


Thats it for part 1 of my AHS review.  Ive got much more to talk about, so stay tuned for the next part!