Saturday, April 25, 2009

Breastfeeding: Benefits to Mothers, Children, Wallets, & Environment

Breastfeeding provides benefits to: mothers and children, as well as family and nationwide cost savings and environmental benefits.  However, only 29% of women are breastfeeding at 6 months after delivery (Healthy People 2010 goal is 50%).  
The benefits for children are: increased immunity and reduced risks of: sudden infant death syndrome (SIDS), obesity, acute otitis media, gastroenteritis, lower respiratory tract infections, asthma, atopic dermatitis, and childhood leukemia. In mothers, there is a decreased risk of type 2 diabetes, cardiovascular disease,  high cholesterol, and breast and ovarian cancer.  There is also a benefit of increased bonding with the mother and baby, which is linked to better brain development and relationship formation in children.  A strong dose-response relationship appears between breastfeeding and infant health in the first year of life. 
Economically speaking, there are no formal studies on cost savings, taking into account time, money on formula, and the cost of medical care.  It has been estimated that bottle-fed infants had US$200 higher medical costs in the first year of life [4].  It is healthier, all-natural, and inexpensive to mothers and families.  At a national level, if we reached the Healthy People 2010 goals of getting 50% of women to  be feeding at 6 months, WIC would save US$6.5million per month!  
There are also benefits to the environment by saving water and eliminating the energy used to create formulas--contributing to waste and air pollution.  Formula tin cans can seep toxic BPA into formula, although there are opinions regarding the levels of potential BPA  on both sides of the argument.   Also, being as formula is dairy or soy-based primarily, the dairy business' pollution needs to be considered, with cows (and their methane), land, resources, and fertilizers providing large emissions.

 Healthy People 2010 goals include getting 75% of women to initiate breastfeeding, 50% to remain feeding for 6 months, and 25% for a full year after delivery.  Breastfeeding is the preferred choice of feeding for all infants, as endorsed by the American Academy of Pediatrics (AAP).   However,  according to a 2002 survey, only 71% of all children had ever been breastfed (16% for a full year).  Late last year the US Preventive Services Task Force came out with their recommendation that primary care providers should encourage and support interventions aimed to increase the prevalence and duration of breastfeeding.  It has also been noted that lay support is extremely effective in getting mothers to initiate and maintain breastfeeding, so programs should be tailored to mothers in this capacity.  The AAP has some great resources for families on their website (below) .  So, the science is there and we're working on the full translation to individual family practice.

Public policy should be more appropriately following the science and should be made to fill in the gaps.  This requires funding support programs and implementing cost-effective breastfeeding intervention programs to encourage more mothers to initiate and maintain breastfeeding activities.  Health insurers also have a role (and I would argue a responsibility) to insure lactation services to produce healthier mothers and children.  Environmental advocacy organizations should bring salience to the environmental costs and benefits for both the public and government.  Researchers have a role in performing some cost-benefit and cost-effectiveness analyses on breastfeeding.

I wanted to make some noise on the breastfeeding horn today.   How many of you were breastfed?  If you are a female, did you, or do you plan to, breastfeed your children?

1) Kuehn BM.  Preventive Services Task Force Endorses Breastfeeding Support in Primary Care.  JAMA 2008;300(22):2598.
2) Chung M, Raman G, Trikalinos T, Lau J, & Ip S.  Interventions in Primary Care to Promote Breastfeeding:  An Evidence Review for the US       Preventive Services Task Force.  Arch Int Med 2008;149(8):565-582.
3) US Preventive Services Task Force (USPSTF).  US Department of Health and Human Services; Agency for Healthcare Research & Quality.
4) Breastfeeding Initiatives:  Family Resource Guide.  American Academy of Pediatrics.
5) Bonuck K, Arno PS, Memmott MM, Freeman K, Gold M, & McKee D.  Breast-feeding promotion interventions:  good public health and economic sense.  J Perinatol 2002;22(1):78-81.

Comparative-Effectiveness: Will we have a US-version of NICE?

The American Recovery and Reinvestment Act (ARRA) of 2009 allocated $1.1 billion for comparative effectiveness research (CER) and associated health services research.  This research will provide new information about the strengths and weaknesses of various health care treatments and strategies, although the research explicity is not to "recommend clinical guidelines for payment, coverage, or treatment."  The compartive effectiveness research will specifically include:  comparison of clinical outcomes, effectiveness, appropriateness of services and procedures to prevent, diagnose, or treat health conditions.  It will also fund data registries, networks, and other ways of creating or compiling health outcomes research data.  

The 15-member Federal Coordinating Council for Comparative Effectiveness Research will coordinate and assist the agencies with the research.  The first public listening session of the Coordinating Council was held 4/14/09 and can be heard here:  
The Institute of Medicine (IOM) was called to create a consensus report by June 30th, 2009 on recommendations for CER.  We'll see this summer how they frame their recommendations for CER in the future. 

The allocation of funds from ARRA for CER is:  $400 million for the Secretary of Health and Human Services (HHS) (Kathleen Sebelius--confirmed 4/21 by Senate Finance Committee); $400 million for National Institutes of Health (NIH); $300 million for the Agency for Healthcare Research & Quality (AHRQ).  [Aside:  AHRQ is the agency I will be working for this summer, my first summer of my PhD program here in the Baltimore/Washington area.  I will be working in the Center for Financing, Access, and Cost Trends working with the Medical Expenditure Panel Survey (MEPS) on costs to families due to mental disorders.]

CER did receive $1.1b, but for perspective, the other areas of spending on improving US health care are:
1) Improving and preserving health care-- $90.1b
2) Health IT--$20.6b
3) Scientific research & facilities--$10.0b
4) Community health care services--$2.8b
5) Comparative effectiveness--$1.1b
6) Prevention & wellness--$1.0b
7) Accountability and IT security--$.1b

Thinking to the future, an idea is that CER could be housed within one center, which could operate to some degree like the National Institute for Health & Clinical Excellence (NICE) in the British National Health Service (NHS).
AHRQ has been suggested as the most likely home for the US version of NICE.  However, there is a debate going on around the formation of something like NICE in the US, primarily because it infers a sense of rationing and includes refusal of care for treatments that are not cost-effective.  Given the unique individualist, anti-government culture of the United States, the degree to which a NICE-like institution could be established in the US is questionable.    Here's hoping the future of CER is embraced by the public and adequately promoted and understood within the realm of health care reform. 

Foods or Pills? Supplements provide little benefit

Several studies have come out with compelling evidence against any benefits of multivitamin or supplement use in benefitting health.  Recently, Neuhouser et al [1] found little or no influence in reducing common cancers, cardiovascular disease (CVD) or total mortality in postmenopausal women, after following them for 8 years.  Muntwyler et al (2002) found no benefit from vitamin E, vitamin C, or mulitivitamins in reducing CVD or coronary heart disease (CHD) in males [2].  A review of all clinical trials and observational studies on supplements yielded an overall consensus that they don't significantly reduce mortality or morbidity [3].

The jury is still out on the benefits of calcium, despite it being the most studied mineral (62,852 Medline articles from 1994-2004) [4].  Sure, we know that calcium helps build strong bones and protects against things like osteoporosis, but other things build strong bones too (e.g. exercise and a healthy diet).  Americans have been trained to think we're supposed to be getting more than 800 mg of calcium per day (approx 3 servings a day), but is that the right amount?  The National Dairy Council (NDC) has strongly pushed and advocated for increasing calcium intake (i.e. "Got Milk?" campaigns), but we don't know for sure if the science matches up.  Recommendations vary widely across countries, ranging from 500-1500 mg for young adults, with the US recommending 1000 mg (daily upper limits to avoid adverse effects are about 2500 mg).  

The FDA does not regulate vitamins, minerals, and supplements.  This is important to remember--anyone can package and sell these things without regulation or proven benefits.  Aware of this or not, about 50% of Americans use vitamin or dietary supplements--contributing to a $20 Billion annual industry.

Do I take a MTV or supplements?  I currently do take a MTV on days when I'm not eating a particulary wide range of healthy foods.  I also take a Calcium/Vit D supplement (Vitamin D assists with absorption of calcium and should be taken in tandem, if taken). 
However, as long as the following criteria are met, dietary supplements are probably not adding any benefit (in some cases, adding harm):

1) Get appropriate levels of physical activity
2) Reduce sodium intake
3) Increase fruit and vegetable consumption
4) Avoid smoking
5) Limit alcohol intake
6) Maintain a healthy body weight

This provides more evidence in support of living a healthy lifestyle and stopping the search for magic pills.  I'm not trying to dissuade anyone from taking supplements, as they are likely to be helpful for those not getting an adequate range of healthy foods and exercise (e.g. developing countries and "unhealthy" individuals).  However, if you live a healthy lifestyle, you're probably wasting your $ on supplements.  
As said by Hippocrates (460-377 BC), "Let food by thy medicine and let medicine be thy food." 
1. Neuhouser ML, Wassertheil-Smoller S, Thomson C, Aragaki A, Anderson GL, Manson JE, Patterson RE, Rohan TE, Van Horn L, Shikany JM, Thomas A, LaCroix A, & Prentice RL.  Multivitamin use and risk of cancer and cardiovascular disease in the Women's Health Initiative cohorts.  Arch Intern Med (2009); 169(3):294-304.
2. Muntwyler J, Hennekens CH, Manson JE, Buring JE, & Gaziano M.  Vitamin supplement use in a low-risk population of US male physicians and subsequent cardiovascular mortality.  Arch Intern Med (2002); 162:1472-1476.
3. Prentice RL.  Clinical trials and observational studies to assess the chronic disease benefits and risks of multivitamin-multimineral supplements.  Am J Clin Nutr (2007);85(1):308S-313S.
4. Weaver CM & Heaney RP (Eds).  Calcium in Human Health. Springer, 2006.  

Predisposed to Depression?

Depression, primarily major depressive disorder (MDD), is the leading cause of disability in adults.  MDD is primarily familial, prompting research to the nature-nurture origins of the disease.  How is depression tied genetically or shaped by environmental factors in individuals?

The exact mechanisms by which depression affects the brain are fairly unknown.    We know there are brain abnormalities and differences, but some studies have shown it to be hard to discern if the brain differences were causes or effects of depression.

Peterson et al looked at a three generation cohort of individuals, assessing those with and without major depressive disorder in two successive generations.  The results of their research appear in last week's Proceedings of the National Academy of Sciences issue (epub ahead of print).  Peterson et al, found that people at risk for depression (those with a family history in 2 generations) had 28% more cortical thinning in the right hemisphere of their brains than those not at risk for depression.  The thinning occured in gray matter, the core processing brain center (the neurons) as opposed to in white matter, information transport system (the myelinated axons).  28% is a significant amount of difference, and correlates to similar magnitudes of structural changes seen in Alzheimer's disease, frontotemporal dementia (FTD), and schizophrenia (although in different brain regions).  

The right hemisphere of the brain is responsible for most of the tasks of attention and visuospatial memory.  Inattention and slight memory impairment occur symptomatically in individuals with depression, and was found to be higher in the high risk individuals as compared to the low risk individuals in Peterson et al.'s study.  The authors note that inattention could also be produced for social and emotional stimuli, thus producing depressive symptoms or MDD.  

It might be too early to state any translational or policy implications from this study, however more light is now shed upon the physiological differences in those at risk vs. not at risk for depression.  These results might be of interest for those with a family history of major depressive disorder who are curious about assessing their future risk of depression.  Check your cortical thickness.   Or don't...and hope your positive environment will reduce your risk.

Peterson BS, Warner V, Bansal R, Zhu H, Hao X, Liu J, Durkin K, Adams PB, Wickramaratne P, & Weissman MM.  Cortical thinning in persons at increased familial risk for major depresssion.  Proc Natl Acad Sci USA. 2009 Apr 14;106(15):6273-8

Saturday, April 11, 2009

CHIP (and not the kind you eat)

An update from my first blog post in November about new issues for Obama's administration.I noted that expansion of SCHIP would likely be expanded.  Well, hooray, it was!

CHIP, the state-administered Children's Health Insurance Program was signed into law by President Obama on February 4th, 2009 and will take effect April 1, 2009.  The important act, formally, H.R. 2: Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009 renews coverage of health insurance for 7 million children and expands it to 11 million children through 2013.  

Brief History:
CHIP was originally authorized in 1997 for ten years, ending in 2007.  Twice in 2007, it was passed by Congress to be vetoed both times by President Bush.  Stopgap legislation was passed by Congress to extend the program for 18 months, ending in March 2009.  
The act amends title XXI of the Social Security Act.  It was introduced on Jan 13, 2009, passed in the House Jan 14, passed in Senate Jan 29, and signed by Obama on Feb 4.  The program will cost $32.8 billion and is paid for with an increase in tobacco taxes ($.62 rise in cig. tax).  

CHIPRA Provisions:
Some key notes about CHIPRA:  
1) States are allocated funds to pay for the program based on projected trends.  
2) New tools, using Express Lane Eligibility, were created to increase enrollment for the the already-eligible-but-not-enrolled uninsured children.  There is also $100 million allocated for grants to promote outreach and enrollment into CHIP and Medicaid.
3) Eligibility rules were changed to: 
       a) limit states (whom still have the ultimate power on income eligibility) from covering above 300% FPL (would then get Medicaid matching rate instead of SCHIP) 
       b) pregnant women can be covered, 
       c) parents (and childless adults) will not be given new SCHIP coverage and eventually phased out the program/moved to a new grant
       d) the 5-year waiting period for legally-residing children and pregnant women has been removed.  
4) There is also a quality initiative to develop evidence-based quality measures for children in SCHIP and to improve the reporting of quality data by the states.  Hooray! Also, $20m for projects on HIT for kids, $25m for projects to prevent childhood obesity, and MACPAC committee to review payment rates (like Medicare's MEDPAC). 
5) Increased access to dental benefits (re: Deamonte Driver death-see links below)
6) Mental health parity!!  I'll have to write another story soon on this topic as I'm pretty excited about the broader legislation passed (and I wrote a 25 page paper for Managed Care on this topic).  However, CHIPRA says that mental health services now must be covered as equally as physical health services.  (Finally getting toward that 1948 WHO definition of health, encompassing physical, mental, and social well-being---and I digress...again).

Side Note #1:  
Lisa Dubay, one of my Professors at Johns Hopkins, was an instrumental player in the SCHIP reauthorization and was present at Obama's signing of the act into law.  She shared photos with us in class.  Her profile can be found here:

Side Note 2
Formerly known as State Children's Health Insurance Program (SCHIP), CHIP, CHIPRA, and SCHIP are roughly synonymous.  

Side Note 3:
For more information about Deamonte Driver, the boy who died due to a tooth infection that spread to his brain, see the links below:

A new version of "Social Medicine" (as in in "Social Network Medicine")

Feeling sick?  Need to see a doctor?  Get out your laptop.  Not to look up the location or phone number of a doctor's office, but to "e-visit" your doctor.  

One Brooklyn, NY based physician practice is transforming medical practice and seeing patients through online visits with social networks.  "Hello Health" offers visits with your doctor through instant messaging (IM), video chats, or for extra fees, a personal home visit.  Patients enroll on their website (link below), do a one-time in person visit, pay a monthly fee of $35, and then pay for the type of visit they wish thereafter (video, home, IM, etc).  There are already 300 patients, and the company has only existed for less than a year.  A second practice is opening in the West Village, NYC.  

This new model does come with risks--such as the protection of patient's electronic health records (EHR) and quality of care for patients (ensuring standards of care).   Also, if allowed to use video to see your patient, doctors and patients don't have to be in the same city, state, or country.  So, the practice of medicine raises issues in various geographical licensure issues.  These issues will have to be addressed with the new health care delivery model.

However, there are no more wait times.  Simultaneously "tweet" your friends and your doctor, while sitting around at home.  As long as you have the internet (and some spare money--not yet covered by insurance), you have access to a doctor.  And imagine the worker productivity changes--instead of missing a 1/2 day to a full day of work (and vehicle mileage), you can take a 20 minute break from work to have a video visit with your doc.  That sounds appealing.

Social networks--facebook, twitter, myspace, etc--are on the rise.  Should the delivery of medical care join the social network revolution?  

Article in Health Affairs:

"Hello Health's" website:

CNN story on Hello Health:

Friday, April 10, 2009

I vote for patient safety.

Medical-device technology firms should not be putting patients at risk (via the oops--we didn't know--non-disclosure of risks on our devices).  See the link to the story from yesterday's NEJM editorial from Curfman, Morrissey, & Drazen;  

Where is the compromise between the free market/business enterprise and FDA regulation?  It better not be on on the risks of the public's health.  I for one, vote for patient safety.