Healthy Life Course:

Baby in Bed with Butcher Knife Ad Generates National Reactions

2011-11-17T11:09:00.000-05:00

We've all heard that sleeping with your baby in bed with you is somewhat risky. Soft blankets, a soft mattress, parents rolling on top of their babies...there are plenty of ways a child could suffocate and die by co-sleeping (and many children have). Sudden Infant Death Syndrome (SIDS) is more common in co-sleeping families (babies in same bed as parents).

The city of Milwaukee is taking it one step further by scaring the $#% out of people by releasing these ads. Equating a child sleeping in an adult bed to sleeping with a butcher knife. Wow.

I'll admit it, as a breastfeeding-on-demand Mom, I sometimes lay my son next to me in bed in the middle of the night and we fall asleep together. Call me an insane demon if you want, Milwaukee. (Note--I do move pillows away from his face, he is not covered or twisted in our sheets, and our mattress is pretty firm--love our Tempur-pedic. But I digress).

Here's the press release. And here is CNN's video story about it.

What do you think? Appropriate? Too extreme?

Supreme Court on Health Care Reform: History in the Making

2011-11-14T22:21:00.000-05:00

Today the Supreme Court announced they will make a ruling on whether or not health care reform is constitutional. The arguments will be heard in February or March and a ruling will come in late June, just a few months before election time. This is serious history in the making, people.

This follows the ruling from Florida and 25 other states where the appeals courts struck down the law (the only one of 4 cases).

Roughly speaking, the Supreme Court will decide on two main things: 1) if the individual mandate portion is constitutional and 2) whether the rest of the reform legislation should also be scrapped.

Stay tuned.

More detail can be read on CNN, NPR, Kaiser Health News, or NYTimes.

Eat Organic & Improve I.Q.

2011-04-23T21:15:00.002-04:00

Are you eating organic? If you're not and you are pregnant or planning on having a baby, you might want to consider it. Three new studies have independently come out with results showing that babies exposed to pesticides in the womb have lower IQs than non-exposed babies. Children with the highest levels of exposure scored 7 IQ points lower than children with the lowest levels of exposure. Wow.

All three of these studies were published in the latest issue of the Environmental Health Perspectives Journal.

Read more about it at the NYTimes. Or, read each of the three studies themselves.
1) Prenatal Exposure to Organophosphates, Paraoxonase 1, and Cognitive Development in Childhood.
2) 7-Year Neurodevelopmental Scores and Prenatal Exposure to Chlorpyrifos, a Common Agricultural Pesticide.
3) Prenatal Exposure to Organophosphate Pesticides and IQ in 7-Year Old Children.

If you're not able to go 100% organic, be sure to look at the Environmental Working Group's Shopper's Guide and at least eat the "dirty dozen" organic!

USDA's Releases New Guidelines

2011-02-01T12:40:00.001-05:00

Yesterday, the United States Department of Agriculture (USDA) and the Department of Health and Human Services (HHS) released the new "Dietary Guidelines for Americans: 2010." The guidelines come at an important time--when one of every three Americans is overweight or obese. The main focus of the guidelines is to describe the need to balance calories, in terms of food and exercise, to manage weight appropriately and keep your health in check.

Some of the new food guidelines include:
1) Limit salt for healthy people to 2,300 milligrams. For those with hypertension, diabetes, or kidney disease, or those over the age of 51, or African Americans of any age, salt should be restricted to 1,500 milligrams per day.
2) Alcohol should only be consumed in moderation, meaning: 1 drink a day for women, 2 drinks a day for men.
3) Make half of your plate fruits and vegetables. Avoid over-sized portions of all foods.
4) Drink water instead of sugary drinks.
5) Less than 10% of your daily fats should be saturated and eat more polyunsaturated and monounsaturated (think nuts, olive oil, etc).

These guidelines are not extremely surprising, but important to take note of nonetheless. Americans need to limit their daily intake of salt, sugar, bad fats, and alcohol. Additionally, watch your portions. Some of the messages for consumers can be found here.

The USDA will also be releasing a new food pyramid within the next month or two, so be on the lookout!

Meditation, Memory, & Stress

2011-01-31T13:56:00.000-05:00

According to a study published yesterday in Psychiatry Research: Neuroimaging, meditation might alter your brain for the better.

A group of participants who underwent mindfulness meditation had increased gray matter in the hippocampus, which is where your learning and memory takes place, when compared to a control group. They also had reduced gray matter in the amygdala, or the area where stress and anxiety occur.

The meditation was called Mindfulness-Based Stress Reduction (MBSR) and has origins in Buddhism, where one is supposed to focus on the here and now, being conscious of their breathing, body, and the here and now. Basically, it involves getting to a place where you are not thinking of the past or the future (e.g. to-do list etc), but being completely focused on yourself in the present. The lead author of the paper, Britta Holzel, discusses it in the NYTimes article on the topic.

This meditation has also been shown to reduce blood pressure and improve your attention span. Although more research is needed to understand the mechanisms by which meditation impacts the brain (and larger studies, as this study only had 16 participants and 17 controls), it certainly is promising to improve one's health.

Have you ever tried it? It certainly takes practice. But it might be more practice I decide to do. Will you?

Dime a Drink, What do you Think?

2011-01-27T07:08:00.000-05:00

The state of Maryland is proposing a new tax on all alcoholic beverages.

There are a few reasons for this. One is to reduce the amount of alcohol consumption. Research has shown that as the price of alcohol rises, consumption decreases. Supporters of the tax argue the tax could potentially reduce the number of alcohol-related deaths by 33 each year and reduce those with alcohol-related dependency by 13,000, according to a study done at Johns Hopkins.. This would save the state of Maryland $225 million in health care costs during its first year.

The second reason for the proposed tax is to fund the Medicaid expansion and mental health services for those with developmental disabilities or those needing drug abuse treatment. The bill is expected to raise about $215 million per year for the state of Maryland.

The tax would be a 10 cent tax per alcoholic beverage, which translates to an extra $2.40 per case of beer. The last time taxes were raised on alcohol in Maryland was in 1972. The same bill was introduced in the last session of the Maryland assembly, but failed. A 5-cent tax was proposed the year before that, also failing. There are so far 54/141 state delegates who have signed on to the current bill.

Will it pass? If so, will the funds be administered as they are proposed?

Happy New Year! New Health Law Changes In Effect.

2011-01-02T20:37:00.002-05:00

With the start of 2011, a number of health law provisions are now in place. These include

1) Shrinking the "doughnut hole," meaning that seniors who fall into the doughnut hole (those who have spent between $2,840-$6,448 on medications, including what insurers pay) will now get a 50% discount on brand-name medications. This compares to a $250 rebate they received in 2010.
2) Health insurers can use incentives (such as reduced premiums) for employees who join wellness programs or meet certain health targets. The discounts can be up to 30% of employee-related health insurance costs. More info here.
3) Health insurance companies must now spend 80% (for small-group plans) on improving patient care, as opposed to spending on general profits/salaries, and admin costs. If they fail to do so, they must give rebates to customers (starting in 2012). This percent is 85% for large group plans.
4) Primary care physicians and general surgeons receive 10% more in reimbursements from Medicare.

5) Medicare will pay 100% of preventive care, meaning seniors on Medicare receive free health screenings (e.g. colorectal cancer, mammograms, etc) and other services (e.g. smoking cessation programs).
6) Medicare beneficiaries with annual incomes $85,000+ (for individual) or $170,000+ (for couples) will get smaller subsidies from Medicare Part D (prescription drug coverage)...and the start of higher premiums.
7) Holders of flexible-spending accounts will no longer be able to pay for most over-the-counter supplies with their accounts and will now require a prescription.
8) Community-Based Care Transition Program is underway, which is a Centers for Medicare and Medicaid Services (CMS) Demonstration project designed to put evidence-based care transition services into place for Medicare beneficiaries to reduce the risk of hospital readmissions and improve the quality of care for seniors. Hospitals and community-based organizations apply to the Department of Health and Human Services to implement this program, based on other successful care transition models, which have eased the transition from hospital to home and reduced hospital re-admission rates. More information found here. .
9) Certified Nurse Midwives will now receive the same rate as physicians by Medicare. They were previously only paid 65% of the physician rate.

Mandatory health insurance doesn't come into play until 2014.

For more information, check out: Kaiser Health News

Health Reform is Happening!

2010-09-29T09:18:00.000-04:00

It's been 6 months since the health reform bill was passed. Confused about what is in the health reform bill? Confused about what it means for you? About when things will occur? Then, a great resource to check out is: Health Reform Hits Main Street, a short animated "YouToons" video by the Kaiser Family Foundation.

Last week (Thursday, Sept 23rd) a number of provisions of the bill went into effect. Six of them are as follows: One, insurance companies (for employer plans) are no longer able to deny health insurance coverage to children with pre-existing conditions, such as diabetes or asthma. Two, lifetime limits on coverage are dropped, meaning there is no lifetime limit on what you spend on hospital stays or other medical costs. Three, free preventive care must be given by new health insurance policies purchased. These things include preventive screenings, immunizations, and other preventive tests cannot have a copay. Four, insurance companies are not allowed to drop you from coverage when you get sick and additionally, they can't look for an error on your application form and then deny coverage based on that. Five, there is an expanded appeal process for denied claims, meaning you can do an external appeal to an independent third party (instead of just to your insurer directly). Six, dependent children under the age of 26 can remain on their parent's health insurance policy, as long as their job doesn't offer insurance. The under-26 population are currently one of the most likely to be uninsured groups, and allowing them to be on their parent's plan will generally save money (to pay for other provisions above) by allowing younger and healthier into the insurance pool to reduce the overall risk and thus, premium costs. Go to Getting Covered.org if you have questions about how the dependent coverage rules work in your state.

Pop Quiz: What Disease Costs $600 Billion a Year and Has NO Cure?

2010-09-21T10:57:00.000-04:00

The Answer: Alzheimer's Disease.

According to the World Alzheimer's Report, released today, Alzheimer's Disease costs $600 billion, or 1% of the world's GDP.

Today is World Alzheimer's Day, a day to recognize this tremendous public health problem, create awareness, and to take action. To find events occurring world-wide, click here.

To tell your Congressional representative to vote for the National Alzheimer's Project Act (NAPA), click here. The goal of NAPA is to create a national inter-Agency group within the Department of Health and Human Services to come up with a national plan for fighting Alzheimer's Disease.

War Against McDonalds

2010-09-18T09:12:00.001-04:00

The Physicians Committee for Responsible Medicine, a nonprofit advocacy group with a mission of promoting preventive medicine and conducting clinical research, released a controversial advertisement two days ago. This ad shows a man on a gurney with his death grip (pun intended) on a fast food hamburger. The end shows the McDonald's logo (the largest fast food chain and producer of high-fat, high-sodium, & high-cholesterol meals) with "I Was Loving It."

You can watch the ad by clicking here and can view the NYTimes story by clicking here.

What are your reactions? Mine? Finally someone is educating the television-viewing public about potential dangers and consequences of eating unhealthy.

UnMoral Minds

2010-08-28T18:05:00.002-04:00

Wow, not even peer-reviewed journal articles are safe from false information. Apparently a Harvard researcher, Marc Hauser, may have provided false, made-up data (at least for the control condition of the study) for a 2002 article published in the journal Cognition. Although extremely rare something like this would happen, it's worth taking note of. Sad to say, but this man will likely be looking for a new career. Ironically, he published a book called Moral Minds. It looks like someone teaching others about right and wrong has a few things to learn.

Read the story here. And because I know you're interested (obviously I was), here is the man behind the story and his photo is at right.

Will You Develop Alzheimer's Disease? Do a Spinal Tap and You May Find Out.

2010-08-12T14:57:00.001-04:00

I had to share this extremely interesting study. It is one of the many findings found from the Alzheimer's Disease Neuroimaging Initiative (ADNI), of which I worked a research coordinator for at the University of Kansas Medical Center site. One of the large $60 million study's goals was to look for biomarkers for Alzheimer's Disease. Previously, the only definitive confirmation of an Alzheimer's Disease diagnosis was autopsy, whereupon one could see plaques and tangles in the brain.

Published on Tuesday in the Archives of Neurology, was an article using results from ADNI to predict who with memory loss would go on to develop Alzheimer's Disease. The authors were 100% accurate in using spinal fluid to make this prediction. The article is titled, "Diagnosis-Independent Alzheimer Disease Biomarker Signature in Cognitively Normal Elderly People."

Also interesting was the fact that the authors found this Alzheimer's Disease "signature" biomarker (presence of beta-amyloid plaques and tau tangles) in 36% of people who were cognitively "normal," or healthy people with no signs of memory loss. Would you want to find out if you were going to develop Alzheimer's Disease or not? It might be possible very soon.

A cure though? Not yet possible. The current treatments for Alzheimer's Disease only treat symptoms, not the underlying disease. This means the current medications will ease some of the disease's side effects, but the plaques and tangles will continue to build up in your brain and the disease will progress.

Click here to read a NYTimes news article written about this same study.

Real Men Go To The Doctor

2010-06-16T10:42:00.000-04:00

Recent research shows than men are 24% less likely to visit a doctor than women are. And they are more likely to be hospitalized for health conditions that could have been prevented.

Thus, the Agency for Healthcare Research and Quality (AHRQ--where I am currently employed) released their public service advertising campaign yesterday to promote men's preventive health. The timing coincides with Men's Health Week, which, for 2010, is June 14th through 20th. Laura Landro covered the story in an excellent video for the Wall Street Journal (WSJ), which you can watch here.

Please encourage your friends and family to visit the doctor. Simple preventive tests can detect diseases early, when treatment is easier and your health outcomes will be better. Here is a list of preventive medical tests men should have completed. Immunizations and screening tests for body mass index, cholesterol, blood pressure, depression, sexually transmitted diseases, and colerectal cancer are just a few of the preventive tests that should be done.

There are a number of campaign materials here, including television, radio, and print. I highly suggest checking them out--they are effective, well-crafted, and really interesting! I've included a couple of the print materials and an outdoor banner as the images for this story.

Attention Nonsmokers: Your Mental Health

2010-06-11T17:43:00.000-04:00

According to a recent study published in the Archives of General Psychiatry, second-hand smoke could potentially be causing mental illness. Yep, we know how bad smoke and second-hand smoke are for our physical health, including cancer risks, but it may also affect our mental health. The risk of mental distress is higher among exposed nonsmokers than exposed smokers, 1.5 times higher for psychological distress and 3 times higher for psychological hospitalizations. Mental illness was defined as psychological distress, mainly meaning symptoms of depression and anxiety, and was measured with the General Health Questionnaire. The authors additionally found the risk of psychiatric hospital admissions was higher for people exposed to second-hand smoke. This study provides more reason to encourage your loved ones, coworkers, friends, and the public to quit the lethal habit.

Happy Birthday! Peel an Orange

2010-05-12T19:30:00.000-04:00

A number of nurseries in the UK are trying something new for kids--no more birthday cake, or any sweets for that matter. The elimination of the the age-old tradition of birthday cake is removed from children's diets as part of a program called the "Pre-school Nutrition Project," which is basically a program geared toward encouraging healthy eating. It was set up by the Knowsley Borough Council and Chester University.

I love this. Stick a candle in an apple and I'm happy.

But don't worry, birthday cakes and sweets are still allowed on the kids' birthdays--they just can't be eaten on-site. The sweets will get sent home with parents, who can them decide on their own whether to allow their kids to indulge or not.

Is this taking it too far? Or is this a great idea to combat our overwhelmingly growing obesity problem and teach children healthy eating habits?

Curative+Palliative=New Hospice?

2010-05-11T21:30:00.000-04:00

Prior to health reform, Medicare (federal program for 65+ and disabled) only covered palliative (non-curative) care for individuals on Hospice care. Hospice is both a type of care and a philosophy for terminally ill patients, focused on management and alleviation of pain symptoms and spending the end of one's life with friends and family in a manner of dignity and peace. The focus is on quality of life, rather than lengthening duration of life, or providing cures, and occurs on one's home or a hospice facility.

With health reform becoming law, Medicaid (state-federal program for the poor) must now provide both palliative care and curative care for children with terminal health conditions. Additionally, Medicare is instructed to start approximately 15 demonstration projects around the US (rural/urban mix) to test this palliative and curative combination. Basically, the demonstration projects will be 3-year programs allowing individuals to receive all currently covered Medicare services while simultaneously receiving hospice care. If the demonstration projects show benefits (defined as the impact on patient care and quality of life) without increasing costs, this could become a new policy for Medicare. It is listed as Section 3140 of the Patient Protection and Affordable Care Act (PPACA) (and its reconciled Healthcare and Education Reconciliation Act) and is called the Medicare Hospice Concurrent Care Demonstration Program.

What do you think the outcome will be? Will this combination of therapies work? Will costs increase? Does the addition of curative therapies confuse the point of hospice care (to end life peacefully and with dignity)? Will this make the end of life easier or more difficult for families?

Robots & Quality Health Care

2010-05-05T23:40:00.001-04:00

In yesterday's Wall Street Journal, John Carreyou talks about da Vinci (the robot, not the artist). The da Vinci is a robot used to perform minimally invasive surgeries. The machine costs between $1.4 million and $2.2 million and is manufactured by Intuitive Surgical. It's operated by surgeons with joystick controls with the purpose of providing better visibility and greater flexibility and ease in surgeries.

Tha da Vinci then is argued to be good for patients because leads to: less blood loss, smaller scars, and less infection. Additionally, one study found da Vinci surgeries to cut hospital stays, thus reducing hospital costs by a third. Sounds great, but what are the potential problems?

For one, if unexperienced doctors are performing these procedures, there could be harmful outcomes for patients.

The da Vinci has been marketed as a technological advantage for small hospitals to be competitive with other hospitals. One such hospital, Wentworth-Douglas Hospital, in Dover, New Hampshire, has been using the da Vinci for years. The hospital has performed about 300 surgeries in 4 years. As a comparison, individual robotic surgery experts, like Dr. David Samadi at Mt. Sinai, average 400-600 per year. Now, Wentworth-Douglas hospital is under investigation for quality concerns with the robotic surgeries. There have been some complications in surgeries, but the hospital also notes their da Vinci complication rates are below some recently published rates.

There isn't current data to compare the rates of complications across hospitals, comparing high-volume (high number of procedures in a year) to low-volume. However, there is data on number of procedures and offsetting cots. One recent study in the Journal of Urology said that doctors need to perform over 500 per year to offset costs of traditional surgery.

So how can we ensure that we can allow for technological innovation while ensuring consistently high quality medical care delivered to patients and keeping costs down? If it takes continuous experience (i.e. high volume hospitals, specifically the physicians in the hospitals, performing the procedures frequently) to ensure top-notch quality, how do we ensure access to top quality to less-resourced areas? Can we ensure equality in quality geographically?

The Skinny on Childhood Obesity

2010-04-10T21:56:00.001-04:00

Yesterday, Michelle Obama led the White House Childhood Obesity Summit. The meeting was a follow-up to her (much-needed) Let's Move Campaign she announced in February. We all know childhood obesity is a problem and the first lady is getting some national discussions started on how to combat this public health epidemic within the next generation. Both Health and Human Services (HHS) Secretary Kathleen Sebelius and Surgeon General Regina Benjamin have also s tated their plans to help Americans stop the obesity epidemic.

One of the leading health policy journals, Health Affairs, released their special March 2010 issue (Vol 29, No 3), with the theme: Child Obesity: The Way Forward. In this issue, there are a number of great articles discussing implications of childhood obesity and potential next steps to combat it.

Regarding costs, John Cawley's article on "The Economics of Childhood Obesity," mentioned two interventions shown to be not just effective, but cost-effective in youth. One is the Coordinated Approach to Child Health (CATCH) and the other is Planet Health (cost-effective for females). He argues that we need to use policies and incentives to promote cost-effective interventions and to find other cost-effective measures to stop this problem costing us $14.1 billion in outpatient care and $237.6 billion in inpatient care each year (direct costs).

So, what can we do and what's being done? Thomas Frieden, director of the Centers for Disease Control and Prevention (CDC) was the lead author on an action agenda, "Reducing Childhood Obesity Through Policy Change: Acting Now To Prevent Obesity," in the Health Affairs issue. Recommendations include: food and beverage taxes, zoning policies, banning ads, counterads, increasing exposure to healthy foods, increasing physical activity, and decreasing sedentary behavior. However, the food and beverage taxes would likely need to be pretty high as a study released last week in Health Affairs revealed soda taxes at 4% have no effect on consumption. However, if the tax revenues are used to fund cost-effective interventions for childhood obesity, there is still potential benefit in these increased taxes, also noted by the authors. The authors also called to duty: federal, state, and local governments, parents, the food industry, and businesses to act.

Additionally, issue and policy briefs were released in Washington DC. The Senate Health, Education, Labor and Pensions (HELP) Committee started a series of hearings on child obesity and how to address the epidemic, with the first in the series being the Health Affairs hearing on March 2. A number of stakeholders convened to begin discussions on what can be done, the built environment, and food policy. You can view the Health Affairs Issue Briefing here. Aside: One of the speakers was Debbie Chang, Vice President of Policy & Prevention for Nemours. I consulted with Dr. Cynthia Minkovitz and the Johns Hopkins Women & Child Health Policy Center (WCHPC) on a policy scan last year regarding current policies practiced by youth-serving organizations to promote healthy eating and physical activity. It's exciting to be a part of positive change for our nation.

What are your thoughts on the best way to fight childhood obesity? What is the largest barrier to stopping the epidemic?

Health Affairs, 29, no. 3 (2010): 357-363

The theme issue for Health Affairs was supported by the Robert Wood Johnson Foundation.
Photo of Michelle Obama courtesy of Evan Vucci/Associated Press.

It's National Public Health Week!

2010-04-08T14:55:00.006-04:00

We are halfway through National Public Health Week, which runs from April 5th-11th!! I thought I better get a quick post in to promote public health myself!

So what does Public Health do? Click here to find out!

Click here to view the Statement by Assistant Secretary for Health Howard Koh, MD, MPH.

Health Reform Makes History - What Does it Mean?

2010-03-23T10:31:00.011-04:00

The House voted late Sunday March 21, 2010 (219-212 vote) in favor of sending the Health Reform Bill to President Obama. In addition, the House Democrats made some changes to the Senate's health reform bill (220-211 vote) which now goes back to the Senate. They must pass word-for-word reconciliation. As I post this blog entry, Obama is signing this long-awaited bill for the health of our nation.

32 million uninsured will now have health insurance. Excluded in this number are: illegal immigrants (who are also banned from purchasing in the health insurance exchanges), those eligible for Medicaid who won't enroll until they seek care, and those choosing to pay the fine instead of purchasing health insurance.

Here is a breakdown of (some of) what is included in this historical piece of health legislation.

Effective Immediately up to 6 Months From Now:
1) Insurers can't deny coverage to sick children (due to preexisting health conditions)
2) Free preventive care--screenings and preventive care must be excluded from annual deductibles on any new plans (all other plans affected in 2018)
3) No caps on lifetime benefits and restrictions on annual limits on coverage
4) Young adults allowed to stay on parent's insurance until the age 0f 26
5) Medicare Advantage (Medicare benefits delivered by private firms) gets cuts in spending in 2011
6) Children on Medicaid or state CHIP can't be dropped from now until 2019
7) Excise tax on tanning beds (10%)--"sin" tax
8) Individuals without coverage because of preexisting conditions can purchase it from high-risk pools (to be combined into exchanges in 2014)
9) Rebate of $250 for Medicare seniors in the "donut hole" for prescription drug benefits. First of incremental steps to close the hole (half-closed next year)

Effective in (or just prior to) 2014:

1) Individual Mandate--Everyone must purchase health insurance or pay annual fine of $95 (rises to $695 in 2016) unless they can prove financial hardship.

2) State health insurance exchanges--marketplace of insurance plans--goes into effect
3) Insurers can't deny coverage to adults with preexisting health conditions
4) Insurers required to cover maternity care same as medical procedures
5) Tax credits will start helping pay premiums for working families with incomes up to $88,000 per year
6) Medicaid expanded to cover more low-income people, up to 133% of federal poverty level
7) Medicare payroll tax increase of 1% for individuals making >$200k and couples making >$250k
8) New Medicare tax on unearned income of 3.8% (in 2013)
9) "Donut Hole" closing--Medicare Part D prescription drug coverage gap to be fully closed by 2020

Other items:

In 2018, "Cadillac health plans" are taxed 40% of value of the plan above thresholds (of $10,200 per individual or $27,500 per family)

The bill maintains longstanding federal funding restrictions (known as Hyde Amendment) on abortions. The exception would be in cases of rape or incest, or when the life of the woman would be endangered.

It is estimated by the nonpartisan Congressional Budget Office to cut federal deficits by $143 billion over the next decade. This bill is a landmark piece of legislation to improve the health of our nation's people. In my eyes, this is an incremental step (and focused on health insurance reform), but an amazing step nonetheless.

What are your thoughts about this this historical event, the passing of health reform?

Grass-Fed Beef: Health Effects for You And the Environment

2010-03-12T08:46:00.012-05:00

The provocative documentary, Food, Inc., brings to light some of the environmental and ethical issues with the way we eat. One of the many issues in this Academy Award-nominated documentary, deals with is the farm industry. Cows raised in pastures are raised more humanely and are usually not given hormones or antibiotics. Additionally, the diet for grass-fed cows uses less fossil fuels than corn/soy-fed cows on a feedlot. Grass-fed cows do their own fertilizing and harvesting. Also, although grass-fed cows create more methane, they compensate in a number of ways. Most importantly, pastures reduce greenhouse gas through "carbon sequestration," or carbon capture and storage. They also use less fossil fuels in production and don't emit as much ammonia as feedlots do. The net result, as determined by the Institute for Environmental Research and Education (IERE) is a reduction in greenhouse gases for pastures and significant increases in greenhouse gases for feedlots. See more detail and other environmental benefits of grassfarming at EatWild.

A new report published this week by California researchers in Nutrition Journal shows that meat from grass-fed cows is nutritionally healthier for you too. The article discusses years have research which have shown that grass-fed diets can significantly increase the amount of cancer-fighting antioxidants, Vitamin A and E, and fatty acids in beef. Grass-fed beef is also lower in dietary cholesterol. In sum, grass-fed beef is healthier for your cardiovascular health and lowers your risk of diabetes and other health problems, like obesity as compared to corn/grain-fed cows. However, it's important to note two things. One, the omega-3 fatty acid levels in grass-fed beef are still much lower than in fish, especially salmon. Two, in order to reap the health benefits, you still need to ensure that you choose lean cuts of the beef. The Mayo Clinic has created a guide to the leanest cuts of beef.

For consumers, there are some other issues of interest here. Because the nutrient content is different between the types of beef, the taste is also different, tasting "grassier." Whether that is a good or bad thing is up to you. To read more about the taste difference, check out this article from the NY Times, "There's More to Like About Grass-Fed Beef." Additionally, the cost of grass-fed beef costs more, nearly 3x as much as grain-fed.

Grass-fed beef is sold primarily at local farms and online. If you're interested in purchasing grass-fed meats, EatWild, has a great State-by-State Directory of Farms. You can also take a look at Tallgrass Beef (Kansas), Burgundy Pasture Beef (Texas), and Hedgeapple Farm (Maryland). When shopping in regular grocery stores, be careful of the food labels. Oftentimes, the label will say "grass-fed" when the cows were only fed on grass for the first 6 or 12 months, then transferred to a feedlot. Check out Mother Earth's article, "The Label Says Grass-Fed, but is it?" for more information. As they suggest, the best label to look for is the American Grassfed Association (AGA).

Do you eat beef? If so, what type of beef do you eat? Are you more intrigued by the environmental or the health issues related to beef? Will this information change your behaviors?

Health Reform Passes. Now, The Real Work Begins.

2010-01-13T10:03:00.005-05:00

Well, as I'm sure you're well aware, Health Reform has passed both Houses of Congress. The House of Representatives passed their version on November 7th, 2009 with a vote of 220-215. The Senate passed their version of the health care bill on December 24th, 2009 with a clear 60-39 party-line vote. A clear victory for health-reform advocates (and a nice Christmas gift for those advocates whom celebrate the holiday), the battle is far from over.

Step 1 of the battle was passing the bill. Step 2 now is compromising the two forms and agreeing on the bill's provisions, which is no small task. A number of provisions will be hammered out: 1) national versus state health exchanges (no more public option), 2) definition of, and possible taxing of, "Cadillac" health plans, and 3) how to pay for this health care overhaul. Democrats are focusing on some provisions appealing to all consumers, such as: 1) the cutoff age for children to be on their parents' health plan moved to 26, 2) eliminated co-payments for preventive services, and 3) no more denying coverage to children under the age of 18 with preexisting conditions. However, that doesn't mean Republicans are done fighting. As stated by Minority Leader Mitch McConnell (R-KY), "My colleagues [Republicans] and I will work to stop this bill from becoming law."

I think Adam Zyglis' (from the Buffalo News) Charlie Brown cartoon (above) says it all for our next steps. How far will the compromises go and what will our final version of health care reform look like? Will it be enough?

Health Efficiency

2010-01-13T09:22:00.009-05:00

It's a fact. The United States is not a "leader" in health information technology. But we are trying to say "goodbye" to our old ways of paper records (see photo). We may be able to learn a lot of Denmark, a country that started using electronic health records (EHRs) a year ago. Telemedicine is also greatly utilized in Denmark (an example of Telemedicine can be found here). If the US wants to focus on efficiency in our health care system (we do), then perhaps we should follow our Scandinavian friends' example (Sweden and Norway are also using EHRs).

To quote the 2008 report by the Healthcare Information and Management Systems Society (HIMSS), "healthcare information technology (IT) is a sleeping giant." On top of that, healthcare IT is significantly behind most other sectors (e.g. banking and telecommunications). The report also mentions that Denmark was able to save roughly $120 million per year by using electronic medical records. The Commonwealth Fund will also be publishing a study later this month, which concludes the Danish information system is the most efficient in the world.

US policymakers are studying the Danish system and seeing if it is possible to follow their example as we overhaul our current healthcare system. Although it is used in some US hospitals and clinics, EHRs only exist in the minority of hospitals--about 10%, or about 17% of physicians use EHRs. Compatibility across and within systems needs significant improvement in the US though. However, last week, two large health systems and users of EHRs--Kaiser Permanente and the Department of Veterans' Affairs--announced communication is possible across the two systems (hooray!).

Of course, electronic health records (EHR) aren't without some concerns. Privacy is one of them. Even though the majority of physicians think EHRS will save time and money while improving patient care, many are still worried about possible security breaches. This is one area HIT policymakers will have to focus on while moving forward with the United States' journey to advanced HIT and EHR.

What do you think about the United States and its expanding role into electronic health records using health information technology? I must say that I, for one, am looking forward to the day that I do not have to fill out my prior medical history (AGAIN) at every doctor's appointment I ever make. Have it all in one electronic record would sure be nice.

Health Nuts & Pregnancy Nuts

2009-10-11T11:11:00.012-04:00

Oh nuts. Many people don't fully appreciate all the health benefits we get from them. Nuts are excellent for our heart health by: lowering our LDL (bad) cholesterol, reducing risk of blood clots, and reducing risk of coronary heart disease. They do this by providing a Power 12 List: 1) Omega-3 Fatty Acids, 2) L-arginine, 3) Fiber, 4) Vitamin E, 5) Plant Sterols, 6) Unsaturated Fats, 7) Vitamin K, 8) Vitamin B6, 9) Folate, 10) Vegetable Protein, 11) Calcium, & 12) Magnesium.

In addition to heart health, nuts contribute to health in other ways. They can reduce your risk of diabetes, Parkinson's disease and dementia, macular degeneration, and improve your mood (e.g. walnuts improve serotonin levels in your brain, similar to antidepressant medications).

The best nuts: walnuts, hazlenuts, almonds, cashews, pistachios, pecans, and even peanuts (although not really a nut, but rather a legume). Also, the way in which you eat them matters. Raw or dry-roasted are the best ways and offer equal nutritional value. Oil-roasted nuts have more fat and calories. Try to avoid nuts made with salt--or at minimum, make sure sea salt instead of regular salt is used. If you are a food pyramid follower, nuts belong in the "meat" group.

The nut craze doesn't come without precaution. Please don't go nuts (pun intended) eating these, as just a handful is approximately 200 calories. Everything in moderation. The reason they are so calorically dense is because of nuts' high fat content. These fats are the healthy ones though, polyunsaturated and monounsaturated.

Pregnancy nuts: there is debate about whether consumption of peanuts and other nuts during pregnancy increases the risk that a child will develop a nut allergy or asthma OR conversely, exposure protects a child from developing an allergy or asthma. Be sure to read scientific sources of literature and look at the date of publication. A lot of press came out after the July 15, 2008 article I referenced above and here, but more recent science says the opposite. Be sure to consult with your physician on this.

*photo courtesy of nuthealth.org

Stop Typing, Start Talking

2009-09-30T22:10:00.011-04:00

Take a look around you the next time you're in a mall, on the street, at the zoo or park, or anywhere where you can see a mother with her child. Is she talking to him/her or is she busy on the phone texting/emailing? Technology has its downfalls and teaching communication to our children could be one of them.

Infants learn speech by hearing it, so parents should be sure to talk to their children as much as possible. Identify objects, point out colors, animals, and expose them to a second language. Even if they aren't able to talk back to you yet, those babies are like little sponges, soaking up the information (well, it seeps in anyway). The point here is to try to stop the texts and emails on our Blackberries and iPhones and to remember to talk to your infants. Plus, you're enriching their cognition, and who doesn't want a smart kid?

This is also important, as we know that our ability to acquire new languages is best at very young ages and declines rapidly around puberty. See Steven Pinker's book, The Language Instinct, for more information on that. Also, read about Noam Chomsky, one of the fathers of linguistics. So, teach your children as much vocabulary as you can early and expose them to other languages early. Second-language exposure in junior high is too late for a child to be able to speak with phonetic "nativity."

Finally, to increase communication with your child, try teaching them sign language at a very young age, before they are able to talk. My sister-in-law did this with her children before they could communicate with her verbally and sure enough, the screaming outbursts of frustration were reduced, and the kids communicated more easily with her when wanting "more" or when they were "tired." Not only does communication then increase, but it's suggested they have an increase in cognition, early literacy, and spatial reasoning.

So, start talking to your kids and create some little Einsteins and Beethovens...or Chomskys.

Monkeys, Music, & Health Reform

2009-08-23T09:40:00.007-04:00

Apologies for the absenteeism. Summer has been filled with passing my PhD Comps (hooray), traveling (e.g. Costa Rica & Panama), and working at AHRQ. No excuses really, but I give them nonetheless...

Here are some of my favorite recent stories from the Summer of 2009:

Eat Less and Live Longer. A team at the University of Wisconsin found that caloric restriction in monkeys was associated with reduced diabetes, cancer, and heart and brain disease. How did they do it? Reduce caloric restriction by 30%, and add a vitamin and mineral supplement to ensure adequate nutrition.

Internet Therapy. A recent study published in the Lancet says internet-based psychotherapy for depression works. Specifically, the used cognitive-behavioural therapy (CBT) in real time via the web. Will insurers pay for this type of therapy? Although recent trends say a push in therapy trends for depression is heavy on pharmacotherapy, psychotherapy may be more effective or less costly for those receiving treatment.

Pleasure from Music? Not for Depressed. It appears that the lack of interest and pleasure in depressed individuals is actually visible in neural brain activity. Functional magnetic resonance imaging (fMRI) shows that individuals with depression have less neural activity than non-depressed, even for simple activities like listening to music.

US Life Expectancy at All-Time High. The CDC's Center for Health Statistics revealed new mortality stats in their National Vital Stat Report. The United States life expectancy is now 78, all all-time national high (Japan, Australia, Italy, Canada all still live longer than us). Women are still living longer (life expec is 80.4 yrs) than mean (75.3 years), but the gap is narrowing. Deaths due to the 8/15 leading causes of death have dropped (e.g. flu, heart disease, stroke, diabetes), but raised for Alzheimer's, Parkinson's, and liver disease. Not to play devil's advocate to public health and prevention of disease (i.e. promotion of longer lives), but does prevention actually cost us more money in the long run?

Health Reform. Will it occur this year? Questions? Check the facts and falsities behind the bills and debates here.

5 Months Until Health Reform?

2009-06-01T12:33:00.003-04:00

I took a quick look today at Kaiser Health News (KHN), the new nonprofit news organization devoted to health care policy and politics. They just rolled out today, June 1st, 2009. I added a quick link in my bookmarks also. KHN will be a great, high-quality resource for stories on things like health reform, health care costs, insurance, aging, health IT, and quality and delivery of care issues. I urge you to take a look.

Regarding the title of this post, "5 Months Until Health Reform?," an interview was done with White House health care czar, Nancy-Ann DeParle and she estimates that Obama will have a health reform bill on his desk by Thanksgiving. DaPerle is asked about her thoughts on financing, and the answere appear unclear, although she does state her opinion that health reform will not be funded primarily with taxes and that a scaled back version of health reform (e.g. scaling uninsured number to half) is not an option right now. Full reform is the focus. Also see the KHN article, "Big, Small or Nothing At All? Three Scenarios For Health Reform."

What are your thoughts on health reform? What about Kaiser's new health news, KHN?

You can view the press releases for KHN here: 11-19-2008 and today's roll-out 6-1-2009.

Employers: Rewarding the Healthy

2009-05-25T08:27:00.009-04:00

It is well-understood: being healthy is cheap. Healthier employees are cheaper employees--less costs fo chronic diseases (e.g. diabetes, obesity, cardiovascular health) and less productivity lost.

Employers really do not have any incentives to provide prevention plans for employees, as the majority of employees don't spend their lifetime at one company and leave for new jobs before employers could reap the financial benefits of investing in preventive behaviors of employees. Tax benefits for employers could help. Policymakers are trying to get a larger number of employers to grasp this notion. A recent survey by Hewitt Associates says that 1/3 of employrs are planning to put more of an emphasis on wellness plans. Some large corporations already do, such as General Mills, Dell, and Safeway. More will like

ly follow suit, especially with the proposed policy changes.

Sen Baucus (D-MT) and Sen Harkin (D-IA) are propsing tax incentives for employers that offer wellness programs to employees. This is consistent with Obama's goals for health reform ("invest in prevention and wellness"). A victory for public health--a shift in focus from treating more expensive and downstream diseases, rather than a focus in less-expensive upstream acts of preventing diseases from beginning. But who loses?

A recent Health Affairs article, "Financial Penalties for the Unhealthy? Ethical Guidelines for Holding Employees Responsible for Their Health," looks at the other side of this issue. According to federal Health Insurance Portability and Accountability Act (HIPAA) regulations, employers can give rewards/penalties for up to 20% of the total cost of covering an employee. However, unions and those concerned with personal freedoms are arguing about the blurry ethical line of holding employees responsible and protecting their individual liberties. Considerations about paternalism, personal choice, privacy protection, access to health promotion, and the complexities of developing obesity are brought up on the opposing side.

Where do you stand?

Alzheimer's Project on HBO

2009-05-19T08:49:00.003-04:00

HBO aired a 4-part documentary on May 10th, 2009 on Alzheimer's Disease. The Alzheimer's Project was made in association with the National Institute on Aging at the National Institutes of Health and the Alzheimer's Association. The documentary also features Maria Shriver, First Lady of California, as her father is living with Alzheimer's Disease (she also is exec-producer).

There is no cure for Alzheimer's Disease (AD), although the documentary sheds light on recent research findings and breakthroughs about this devastating disease. Alzheimer's disease is an irreversible and progressive brain disorder that slowly deteriorates memory, judgement, the ability to carry out daily activities, and produces personality changes. The risk for developing AD doubles every 5 years after the age of 65 and nearly 50% of people have the disease by the age of 85. After cancer, it is the most feared disease.

During the time I was obtaining my Master's degree, I was working with the great team at the University of Kansas on both the research and clinical side of Alzheimer's Disease and related dementias. Information about them and research projects can be found here:

The University of Kansas Alzheimer & Memory Program (KU-AMP)

How Many Eggs Do You Have? Scientists Say Females Able to Make Eggs Later in Life.

2009-05-04T15:01:00.007-04:00

I opened up my issue of "Science" magazine from the American Association for the Advancement of Science (AAAS) and saw the article titled, "Study Suggests a Renewable Source of Eggs and Stirs More Controversy." Wow.

Apparently some stem cell biologists, Ji Wu and colleagues, at Shanghai Jiao Tong University in China found that adult ovaries have cells that can give rise to new eggs (oocytes) and then turn into offspring. This really gives a slap in the fact to the idea of females being born with all the eggs they will ever have. A now heated controversary is emerging in reproductive biology. The researchers results come from a series of studies on mice, where they removed their ovaries and sorted through cells to find "germline cells" that eventually turned into eggs and offspring.

Much more research is to be done before we can say anything conclusively, but it looks like we might be able to disprove the idea that females cannot make more eggs. John Tilly, professor of obstetrics and reproductive biology at Harvard Medical School, was not involved with the study, but has also published some controversial ideas about women's ability to produce new eggs. Scientists and researchers everywhere, whom are already in a crazed controversy, have more science in favor of the fact that women are not born with a finite number of eggs.

So, is the biological clock really a psychological clock?

Mental Health Parity: Past, Present, & Future

2009-05-04T14:27:00.015-04:00

Past

For decades, there has been unequal treatment of mental health conditions as compared to physical health conditions, specifically regarding health insurance coverage [1]. Researchers, mental health advocates, and patients have fought for parity for quite a while, gaining little ground.

Some advances were made in September 1996, when President Clinton signed the federal Mental Health Parity Act, into law. It prohibited limits on annual and lifetime mental health coverage [2]. However, more needed to be done as limits on visits for outpatient or days for inpatient still existed [2]. Secondly, the law did not apply to substance abuse [4]. The Act expired on September 30, 2001 [3].

Present: 2007-2009

In the fall of 2007, the Senate passed the Mental Health Parity Act and the House of Representatives approved the Paul Wellstone Mental Health and Addiction Equity Act in March 2008 [1]. The two bills were reconciled and Bush signed full mental health parity into law on October 3^rd, 2008 to close the discrimination gap for those wanting health insurance coverage for mental health and substance use diseases [6]. The law, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (HR 6983), closes some of the loopholes (e.g. eliminating limits on outpatient visits) from the 1996 Mental Health Parity Act.

The new law, effective January 1, 2010, applies to: group health plans with more than 50 employees, Medicaid managed care plans, and some State Children’s Health Insurance Program plans [2, 6]. It is included as an amendment to the Employee Retirement Income Security Act (ERISA). The Act requires that the financial requirements and treatment limitations can’t be more restrictive for mental health/substance abuse services than for medical/surgical services [6]. Insurers will not be able to limit coverage that is “medically necessary.” There are some exemption clauses, which should be addressed in future legislation.

In July 2008, Congress also passed the Medicare Improvements for Patients and Providers Act, to phase in federally mandated mental health parity for Medicare beneficiaries, although all states except for two (Idaho and Wyoming) have existing mental health parity laws [2]. The current Medicare beneficiary cost for psychotherapy and other mental health services will be reduced to 20% by 2014 [2]. The Medicare Improvements Act also expands Part D benefits regarding mental health, including coverage of two new medication classes: benzodiazepines and barbiturates [2, 8].

Future: 2010 and beyond

It is likely that utilization of medially necessary mental health services will increase after January 1, 2010. [9].

It is less likely that costs for mental health services will increase. A study of the Federal Employees Health Benefit (FEHB) Program found that parity in health insurance does not increase costs for behavioral health care [10], and the Congressional Budget Office stated that adding mental health parity will increase health insurance premiums by less than .4% annually [2]. Costs were also reduced with full mental health substance abuse parity for children in the FEHP [12]. However, special attention will need to be paid to keeping costs under control while maintaining and improving upon quality health care services.

Despite the promises of the 2008 parity legislation, we are not without a good number of limitations. First, the insurance parity is limited in scope and does not apply to group health plans with less than 50 employees, Medicare Part A, Medicare managed care, or individual insurance plans [9].

Secondly, only 4 of the 179 quality indicators included in the National Healthcare Quality Report (issued by the Agency for Healthcare Research & Quality) are related to mental illness and the Institute of Medicine (IOM) has suggested new quality measures for mental health care [13, 14]. This will take significant resources, but needs investing in to better assess quality of care for mental health.

Third, even if co-payments are made equal for mental health services and medical services, most mental health services cost less than medical health services (e.g. using social workers and group therapy) and therefore may actually still represent higher coinsurance for value of service provided [9].

Mental health parity has been a topic of concern for decades and we are currently making significant strides toward achieving equality of services for mental and substance abuse disorders. The recently passed Paul Wellstone and Pete Domenici Mental Health and Addiction Equity Act of 2008 provides some promise toward the goal of mental health parity. However, time will tell the true impact of the Act on equality of mental health and substance abuse services. There is a great amount future work and implications for researchers, policymakers, professional organizations, patients, providers, and payers. As our health system enters reform, mental health services will need to be handled with equality to medical services.

References available upon request, but cut out due to space limitations. This is an excerpt of a paper I wrote for Managed Care & Health Insurance at Johns Hopkins. This breakthrough legislation of 2008 is huge for health advocates, patients, and health providers.

Obama "Nudges" Regulatory Czar

2009-05-04T12:06:00.005-04:00

Cass Sunstein, the most cited law professor in the US (some say world) was "nudged" by Obama on April 20, 2009 to be the new "regulatory czar," formally, the Administrator of the Office of Information and Regulatory Affairs (OIRA), Office of Management and Budget.

There are a few hot topics of critique about Sunstein's appointment. One includes his backing of a "senior health discount," an economic method of valuing younger lives more than the elderly. Secondly, he questions the constitutionality of workplace safety laws and the Clean Air Act. Third, some consumer groups are afraid he is going to push his animal-rights ideas in the White House (re: Sunstein's 2004 book, "Animal Rights: Current Debates and New Directions"). His appointment is pending Senate approval.

Sunstein is the author of over 400 publications, his most recent book titled, "Nudge: Improving Decisions About Health, Wealth, and Happiness," coauthored with Richard Thaler. The book expands Econ 101's notion of individuals making rational choices and taps into the true psyche of humans and how we can design environments to help people make better decisions--behavioral economics. The authors use examples of things like 401(k) plans, marriage, and organ donations to explain their view of libertarian paternalism (not bigger government, but better governance). I have yet to read this book, but it is definitely on my to-read list.

More of Sunstein's books include: "After the Rights Revolution" (1990), "Risk and Reason" (2002), and "Laws of Fear: Beyond the Precautionary Principle" (2005). He taught for 27 years at University of Chicago Law School, until last year, when he left to become the Felix Frankfurter Professor of Law at Harvard. He is also the Samuel Rubin Visiting Professor of Law at Columbia. His expertise lies in constitutional law, administrative law, and risk policies.

http://www.whitehouse.gov/the_press_office/President-Obama-Announces-Another-Key-OMB-Post/

http://www.nudges.org/

http://home.uchicago.edu/~csunstei/

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

2009-04-25T17:20:00.010-04:00

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?

References:

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. http://www.ahrq.gov/clinic/uspstfix.htm

4) Breastfeeding Initiatives: Family Resource Guide. American Academy of Pediatrics. http://www.aap.org/breastfeeding/familiesResourceGuide.html

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?

2009-04-25T15:15:00.007-04:00

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: http://nmr.rampard.com/fcc/20090414/frame/index.html.

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). http://www.nice.org.uk

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.

More information: http://www.hhs.gov/recovery/

Foods or Pills? Supplements provide little benefit

2009-04-25T13:09:00.010-04:00

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."

References:

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?

2009-04-25T09:27:00.005-04:00

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

www.pnas.org

CHIP (and not the kind you eat)

2009-04-11T09:56:00.014-04:00

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!

CHIPRA, H.R. 2:

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: http://faculty.jhsph.edu/Default.cfm?faculty_id=1657.

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:

http://www.washingtonpost.com/wpdyn/content/article/2007/03/02/AR2007030200827.html

http://abcnews.go.com/Health/story?id=2925584

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

2009-04-11T09:02:00.007-04:00

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:

http://content.healthaffairs.org/cgi/reprint/28/2/361

"Hello Health's" website:

https://www.hellohealth.com/main/index.html

CNN story on Hello Health:

http://www.cnn.com/2009/HEALTH/01/15/ep.trends.in.ehealth/index.html

I vote for patient safety.

2009-04-10T21:21:00.001-04:00

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; http://content.nejm.org/cgi/content/full/360/15/1550.

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.

Obama & Health Care: Most Likely Outcomes

2008-11-21T14:53:00.001-05:00

Obama has some hefty challenges awaiting him in the White House for sure. The rough economy and war overseas will have to be immediate priorities in January. Health care reform is also in that list of top priorities. Last week, Johns Hopkins School of Public Health (JHSPH) held their 4th event in the Universal Healthcare Series, "Moving Toward Universal Healthcare: Alternative approaches to reform in the US." Harvard's Dr. David Himmelstein was among the speakers, whom pointedly noted that we've had plenty of opportunities for reform, which have failed (think Clinton's 1992 effort and many multiple state attempts). He pointed out that now is our opportunity for reform.

In today's issue of The Lancet, Nellie Bristol discusses Obama's plans for our country and the world's health (Obama's plans for US and global health care). Many project the following are most probable and feasible Obama's immediate administration: reversal of Bush's ban on stem cell research, expansion of State Children's Health Insurance Program (SCHIP), reversal in "Mexico City policy" (aka global gag rule), and the establishment of a comparative effectiveness group (similar to UK's National Institute for Health & Clinical Excellence).

To expand on probable immediate actions, Obama is likely to remove some of the restrictions Bush placed on stem cell research (to only use existing stem-cell lines). Secondly, SCHIP was vetoed by Bush last year after approval from both houses of Congress. Most likely coverage will be expanded by $35 billion to $60 billion (paid by cigarette taxes). Children make up 20% of the US uninsured population (Kaiser Foundation). Expansion of SCHIP appears likely. Next, the Mexico City policy (global gag policy) requires NGOs to agree to neither "perform nor actively promote abortion as a method of family planning in other nations." It was enacted by Reagan in 1984, overturned by Clinton, and put back into place by Bush. Finally, the comparative effectiveness group would look at evidence-based medicine and the Medicare system for physician reimbursements to give guidelines for clinical practice.

What will be the long-term results though? Will we move away from employer-based health insurance? Will we cover all Americans? Will we have better preventive care and can we improve health outcomes with new policy reform? How much will we spend on global health, when the US needs the health improvement also?

It's certainly an interesting time to be near Washington DC and in the field of Health Policy & Management. Be sure to advocate and put full pressure on local representatives to push for health care reform (there is also currently a $1m media campaign targeted at newly elected officials to "keep their promises" for health care reform).

If we don't reform US health care now, (when) will we?