Friday, March 30, 2012

I Am Not Alone

For over a decade, Thomas Perls, MD, the founder and director of the New England Centenarian Study, has been studying longevity. A Harvard trained geriatrician, Dr. Perls arguably is one of the foremost expects in the U.S. on the topic. Therefore, given my own growing interest in life expectancy and the factors that influence a long life, it was a special delight for me to have spoken to him for over an hour the other day.

I found Dr. Perls to be both a kindred spirit and a validator of many of my conclusions. For example, he is a staunch critic of the Anti-Aging Medicine movement. All of my research has led me to the conclusion that anti-aging is a hoax. Although some interesting areas of study have emerged such as the role of telomeres and what happens to all human cells (apoptosis (death), senescence (shut done), and cancer) and how this may one day lead to actual treatments to stop or reverse aging, today there is no validated science to conclude that any anti-aging treatments or processes exist.

Dr. Perls is also no fan of general supplementation. He believes, as do I,  that the supplement industry is perpetuating a hoax on the American people that supplements contribute to greater health and longevity. They do not and may, in fact, accomplish the opposite.

We also discussed his life expectancy calculator which exists in three versions. One for children, one for adults, an one for seniors. We discussed the science behind the calculator and how it can be improved to make it more than an interesting insight into one's longevity and more of a motivator to make lifestyle changes likely to lead to improved health and increased longevity.

It was really great for me to speak with an educator, scientist, and physician who has expertise that far surpasses my own in a field of study that for over a year I have devoted myself to gaining some expertise, and to hear that all of the conclusions I have reached in a far shorter period of intense review have been vindicated.

The disciples of supplements are many and they include many of the thought leaders in the U.S. when it comes to health, such as the celebrity doctors (and NY Times best selling authors) like Furman, Oz, Weil, and Hyman. They have assumed the bully pulpits and have developed large audiences for much of their nonsensical advice.

Accordingly, I have felt at times like Sisyphus, the tragic Greek mythological figure, futilely pushing a boulder up a hill never to reach the top.  My conversation with Dr. Perls, which we are scheduled to continue, has re-energized my efforts to educate an unknowing public to the dangers of supplements and anti-aging medicine. My goals remain to inform the masses of the only true evidence based science that is known with some scientific certainty concerning what it takes to improve one's health and live longer--practicing a healthy lifestyle. I say thank G-d for the likes of Dr. Perls who is also waging the good fight against the immeasurable, but growing odds against us to spread the evidence-based facts.

Thursday, March 29, 2012

What will it take to get Americans to adapt healthier behaviors?

Today, Sen. Ron Wyden, D-Ore., with support from Sen. Rob Portman, R-Ohio, is expected to introduce the bipartisan "Medicare Better Health Rewards Program Act of 2012." The bill would establish a program to award points for participation in a variety of wellness and prevention services and provide tax-exempt cash rewards to beneficiaries who achieve certain point levels.

In a 1998 analysis, The Health and Retirement Study (HRS), a 20-year nationwide survey of the health, economic and social status of older Americans, showed that wealth is tied directly to health. A major health shock, such as a heart attack or stroke can severely affect not only an older person's overall health, but also their long-term financial situation. Household income and wealth decline considerably after a health shock and income losses last for at least 10 years; most household wealth loss comes from lost earnings rather than from high out-of-pocket medical expenses.

On Tuesday, February 28, 2012, I wrote a blog titled “Our aversion to loss is greater than our desire for gain.” In that blog, I conveyed what I learned from Kevin Volpp, MD, PhD, a UPENN Professor in Behavioral Economics, which was that loss aversion is more powerful than gain motivation. The two pieces of information above raise a number of interesting questions.

1.    Will cash incentives motivate healthier behavior?
2.    Should cash penalties be used instead
3.    Instead of cash incentive, should the government publicize the financial effects of poor health and the benefits of good health?
4.    What would be the expected net economic effect of the "Medicare Better Health Rewards Program Act of 2012."

Before, answering these questions, for the sake of full disclosure, I am a provider of preventive services. The availability of cash incentive would theoretically make it easier for me to attract Medicare beneficiaries to take advantage of preventive benefits, thereby increasing my practice revenue.

Okay, now to the answers. In his book Drive, Daniel Pink argues that incentives ultimately do not work because without intrinsic motivation, the effects of incentives wane. Having run a service business for over 20 years, I can concur that incentives are a tricky lot.  I found that while incentives focus the mind on certain goals, they inadvertently distract from equally important goals. 

You may ask why not simply create a comprehensive list of goals? My experience is that the more goals involved, the less likely any of them are to be followed. Furthermore, when incentives are introduced, they can have negative consequences. For example, once one realizes that he may not be able to achieve the intended reward, he adapts the opposite tack and abandons any efforts whatsoever.  I’ve seen this happen repeatedly.

The other problem with incentives is called adverse selection.  This means that they may attract those likely to have been motivated to pursue the goals anyway and ignored by all others. The net effect is that you are providing rewards with no overall change in behavior and outcomes. Therefore, I am cynical that cash incentives will ultimately encourage seniors to improve their health by taking advantage of the smorgasbord of available preventive services. That said, utilization of such services as the Medicare Annual Wellness Visit are incredibly low today, in the 5% range, and therefore I think something must be done. 

The second question asks if penalties are more likely to work. Most politicians shy away from anything that may be deemed punitive but the facts remain as Dr. Volpp confirmed, risk aversion is a powerful motivator. That’s why I believe that people who engage in unhealthy behavior should be penalized by paying higher insurance premiums.  I think it is only fair to take accountability for one’s actions and suffer the consequences of one’s poor choices. There is precedence for such an approach. Car drivers with poor driving records pay higher insurance premiums and this approach is understood and accepted by society at large. We may not like it, but accept that there must be consequences to receiving moving violations and causing accidents. I think people will ultimately accept such reality in relationship to health insurance as well. That said, I am highly skeptical that such an approach would ever be adapted so I won’t argue its merits at length.

The third question focuses on public health messaging, which outside of the campaign to stop smoking is virtually non-existent.  Previous efforts like the Smokey the Bear and Don’t Litter campaigns achieved wide dissemination and although I don’t have hard data, I suspect were successful in decreasing wildfires and littering.  I think Medicare would be wise to gear up its marketing efforts to inform, encourage, and educate the senior population, as well as the population at large about both the availability of preventive befits and their value. My experience with patients demonstrates that most patients have a low health IQ, routinely follow misinformation, and generally need better guidance.  As Sy Syms the retailer would proclaim, “An educated consumer is our best buyer,” I believe that a better educated population will become a healthier one.

The final question regarding the net economic benefits is the hardest to answer. I believe that if the Act becomes law then utilization will go up. However, I fear the long term sustainability of such an approach, and as previously discussed the possibility for things to actually get worse.
There is no doubt that something needs to be done. For that reason alone, if the government is not prepared to start a marketing effort to educate the public, and will not adapt disincentives to encourage healthy behavior, then I meekly endorse the incentive plan. I do so with the caveat that close attention be paid to its effects with the ability to pull the plug if negative results begin to filter in. My final recommendation is that since this issue isof such economic significance, we try all three approaches immediately before more draconian measures are needed. Given a choice among the three, I choose in this order, premium penalties, educating the public, and paying rewards. How would you choose?

Monday, March 26, 2012

When It Comes To Reading About A New Medical Study, I Say Caveat Lector.

There are so many potential and intrinsic problems with medical study results that they could fill the pages of a book.  In fact, I plan on writing such a manuscript in the not too distant future to help the lay person make some sense of the never-ending blizzard of medical studies whose results when reported by the media seem to confuse everyone, including doctors.

In the interim, here’s one of the key problems with the reporting of study results worth noodling on-the issue of relative risk versus absolute risk. For example, a recent headline trumpeted that depression plus diabetes doubles one’s risk for dementia. Wow, that sounds like a big deal to double the incidence of the fearsome dementia.  However, while the study showed a 100% increase in risk, the actual rate for dementia only increased from 1% to 2%. In terms of relative risk, the incidence rate doubled.  However, in relationship to absolute risk it merely increased 1%. That’s two very different sides of the same story.

Another example applies to Statins, the blockbuster cholesterol reducing drugs that decrease cardiac events 33%. However, that is the relative risk reduction.  An absolute risk reduction analysis, however, tells a different story.  Would it surprise you to learn that 100 people need to take a statin drug for one person to benefit?  Statin studies show that cardiac events are decreased from 3 out of 100 to 2 out of 100 patients, which means that 100 people must take the drug and potentially suffer its side-effects, for one person to see a reduced risk for a heart attack or stroke.
A third example, as cited in a recent Wall Street Journal article titled When Risk Is a Red-Meat Issue by Carl Bialik speaks to the health risks associated with eating red meat.  Although, I am not a fan of any significant meat consumption, I can appreciate the author identifying how the media’s handling of the study’s results was misleading as headlines focused on a relative death risk increase of 20% versus an absolute death risk rise of 0.2 percentage points. That’s a big difference.

I’ve read some 10,000 studies over the past year or so and it’s amazing to me how many ways others can interpret the same studies.  That why people often are confused by new studies because to grab headlines the media often chooses the most contentious, surprising, or alarming aspect of the study, instead of the most actionable aspect.  Unfortunately, the lay person never reads the actual study behind the headline and may not even get past the headline to read the study details. And that assumes that the article writer actually provides all the details of both the relative and absolute benefits.

As I said earlier, that are many deceptive aspects of reporting studies and until someone actually teaches people how to make sense of the avalanche of studies, the best advice really is the Latin phrase, Caveat Lector translated to “let the reader beware.”

Sunday, March 25, 2012

Supreme Court Should Consider Issue of Far Greater Consequence

Tomorrow, the U.S. Supreme Court is set to hear arguments about the constitutionality of the Affordable Care Act (Act), which some refer to as “Obamacare.” The most contentious of the Act’s requirements is called the Individual Mandate that requires citizens to secure health insurance or pay a fine. The idea behind this mandate is that too many people do not have insurance, which is ultimately bad for society. Yet, there is more to Obamacare than just the Act.
While the Supreme Court’s decision will surely be deemed monumental, it may very well be misguided. Instead of deciding should everyone have insurance it could be ruling on something far more consequential—what role should individuals play in staying healthy and preventing disease? Instead of focusing on insurance, we should be focusing on what creates the need for it. Undoubtedly, both the greatest expense and greatest determinants in health care are prescribed by what we do and how we act. 
A fact that is widely ignored is that another facet of Obamacare actually addresses this issue by supporting many primary preventive measures that can profoundly impact the future of our health care system.  These measures offer the opportunity to debate a fundamentally more intrusive issue of far greater consequences. Can and should our government impose a mandate on its citizens to maintain good health by requiring adherence with preventive measures in order to access cost-effective health coverage? Or should our tax dollars continue to fund free, unlimited healthcare for people, such as smokers, who with gross negligence majorly contribute to their expensive, chronic poor health?
To help answer this question, we must first address the efficacy of primary prevention, which concentrates on the mitigation of health risk factors created by lifestyle. These factors include diet, physical activity, stress, sleep, smoking, and alcohol, to name a few. Many who challenge the cost versus benefits of prevention include diagnostic tests as part of the equation.  They argue that the incidence of false positive tests increase rather than decrease costs.
For the sake of discussion, I choose to ignore such tests because they typically diagnose rather than prevent disease; although, some basic blood tests, such as for cholesterol and sugar, can be helpful in identifying risk factors for heart disease and diabetes. However, primary prevention is mostly based on lifestyle modification through counseling and education.  The Centers for Disease Control state emphatically that the evidence for the power of prevention is now indisputable. Numerous well designed studies now support the assertion that lifestyle modification can and will improve health and decrease healthcare costs.
Some 2,500 years ago, Hippocrates wrote that “prevention is preferable to cure” and over 200 years ago, Benjamin Franklin wrote that “an ounce of prevention is worth a pound of cure.” I humbly put forth a new spin on this concept--"prevention is the best insurance.”  This is not meant to be a mutually exclusive concept. Obviously, insurance has a role to play.
Cars are a great example of this duality.  While the law mandates that every car be insured, it also regulates countless other aspects of safety measures such as seat belts, airbags, turn-signals, traffic rules, etc. To drive, one must have a license and to get a license, one must pass knowledge and skill tests.  Drivers with clean records are rewarded while other drivers pay penalties. We require car insurance because cars can cause much damage to human life and property; car accidents can be catastrophic. So why are we so regulated in reference to cars and not health? Are unhealthy lifestyles any less catastrophic to the person and society, which ultimately bears the cost for care for those over 65?
However, when it comes to health, the major legal debate seems to be about insurance and its related costs. Why is there limited discourse about preventing the types of problems for which most of the costs related to insurance are spent—chronic diseases? Interestingly enough, when the Obama administration drafted related legislation with the help of Congress, it recognized the need for both and added Medicare's first coverage of primary preventive services meant to identify health risk factors and address them before they become full blown diseases.  
Surely, insurance offers peace of mind when you get sick. Used properly, it can stop small problems from developing into more severe, if not life threatening issues. However, insurance does not in and of itself prevent health problems. Some may even argue that it does just the opposite by creating a licensing effect that allows us to live our lives without fear of health consequences because we expect our insurance to pay for the needed medical interventions when we become sick. This over-reliance on treatment instead of prevention is probably the root cause for our spiraling up health care costs that now consume 17% of our gross national product.
Obamacare also facilitates the Centers for Medicare & Medicaid Services (CMS) to institute a number of initiatives related to health care innovation intended to improve care, increase access, and decrease costs. At the same time that the Supreme Court will be hearing arguments next week, CMS is set to announce grants totaling up to $1 billion to funding innovations meant to cost-effectively improve health and health care. Innovations may be game changers. Government should incentivize good health practices, just like car insurance companies reward good driving records, lower premiums for students with good academic records, and for those who complete driver’s education classes, by implementing new incentive-driven lifestyle interventions that could pay huge dividends by decreasing health costs while improving health.
We as a society have already accepted both the need for insurance and the value of preventive measures related to cars. Doesn't it seem logical to do the same in relation to health care? With 78 million baby boomers set to swell Medicare's already substantial ranks, we can hardly afford the delay. Obamacare may not be perfect, but I think it is a step in the right direction.
Although, I lean Republican (compassionate conservative) and will most likely support the next Republican nominee because of other issues I have with the Obama Presidency, I am first a doctor looking out for the best interests of his patients.  Today, Obamacare best meets that priority.

Tuesday, March 20, 2012

What's The Big Deal About Vitamin D? It turns out quite a bit.

Vitamin D deficiency has become a hot topic with headlines about its dangers becoming ubiquitous.  Of course, not everyone agrees on what the problem is and how to best treat it.  
Accordingly, I’ve compiled a list of questions and answers to help people navigate through the plethora of issues raised. If you have additional questions, please send me an email at

1.      Can sun exposure restore vitamin D to adequate levels?
It is well documented that lack of exposure to sunlight is a major risk factor for vitamin D deficiency. Therefore, you would think if you increased your exposure to sun, you would be all set. That may not be the case according to one doctor.
Here is an excerpt from Medscape News article from today:
"The 'epidemic' in vitamin D deficiency is clearly not from too little sun exposure," and dermatologists can be confident in insisting that their patients continue their sun protection efforts, said Richard Gallo, MD, PhD, here at the American Academy of Dermatology (AAD) 70th Annual Meeting.
"Clearly solar exposure is an influence — there is no doubt about that — but you cannot predictably say that a certain amount of exposure will normalize vitamin D deficiency," said Dr. Gallo, chief of dermatology and professor of medicine and pediatrics at the University of California, San Diego.
I’m not sure that all doctors agree with Dr. Gallo and I still believe that some sun exposure, up to 15 minutes per day (avoid mid-day peak sun) is prudent unless you have already had skin cancer. By the way, your belly skin absorbs sun the best.

2.      What level of Vitamin D defines deficiency?
Serum 25(OH)D - The circulating half-life of 25(OH)D is 2 weeks. This is the best test to determine vitamin D status. A 25(OH)D level of less than 32 ng/mL is considered vitamin D insufficient. A 25(OH)D level of less than 15 or 20 ng/mL have been used to define vitamin D deficiency. Intestinal calcium absorption is optimized at levels above 32 ng/mL. An Institute of Medicine report recommends that patients should have serum vitamin D levels above 20 ng/mL, but the American Endocrine Society sets this level at 30 ng/mL

One issue I have not seen addressed is the fact that Vitamin D is a fat soluble vitamin and blood teats only detect circulating Vitamin D and not fat-stored Vitamin D. I'm not sure if this is significant in diagnosing deficiency, but I would love to hear if you know of anyone who studied this issue.

3.      Who should be tested for Vitamin D deficiency
It is generally recommended to screen only those individuals who are at high risk for vitamin D deficiency, including patients with osteoporosis, malabsorption syndromes, black and hispanic individuals, obese individuals (BMI >30 kg/m2), and those with several other medical conditions.
I don’t agree with these recommendations as I have found deficiency among a much broader group of patients. I don’t believe we should test everyone, but I do believe in testing everyone over the age of 65 who routinely avoids sun exposure.

4.      Is testing of parathyroid hormone (PTH) necessary to make the diagnosis of Vitamin D deficiency?
No, but it is helpful. An elevated PTH is supportive of the diagnosis.

5.      What is the recommended daily intake of Vitamin D?
There is some debate on this one. Some say for adults it is 800 IU, others 1,000 IU, and still others, even higher. I unscientifically vote for 1,000 in absence of deficiency and initial 2000 to restore levels. Others supplement at much higher dosages, even to 50,000 IUs. 

6.      Is Vitamin D toxic at higher levels?
At blood levels of 125 ng/ML, Vitamin D may be toxic and that is why I believe in treating deficiency more cautiously so to avoid going from one unhealthy extreme to another. Doses can always be increased as needed. Obviously, the greater the deficiency, the higher the restorative dose should be.
7.      Which form of Vitamin D--D2 or D3--is best to treat deficiency?
Most scientists agree that D3 (cholecalciferol) is much better but studies support D2 (ergocalciferol) as well. Stick with D3 which everyone accepts.

8.      Is milk a good source of Vitamin D?
Milk may be an unreliable source.  Fortified milk may contain less than the stated amount of vitamin D3 on the product (in some cases less than 80% of the amount), so if the only reason you are drinking milk is for Vitamin D, drink Almond Milk instead which is also fortified.

9.      What foods are good sources of Vitamin D?
Most dietary sources of vitamin D do not contain sufficient amounts of vitamin D to satisfy daily requirements. Foods thought to contain high amounts of vitamin D3 are oily fish, such as salmon and mackerel. A single serving (3.5 oz) of wild-caught salmon has 988 ± 524 IU vitamin D3, an amount that remains unchanged after baking but that decreases by 50% if the salmon is fried in vegetable oil. In comparison, farm-raised salmon has only 25% the content of vitamin D3 found in the flesh of wild salmon, whereas blue fish and mackerel have even lower vitamin D3 levels, at 280 ± 68 and 24 IU, respectively. Vegetables and fruits are not a good source for vitamin D.
The following foods contain the indicated amounts of vitamin D, as reported by the US Department of Agriculture's (USDA's) Nutrient Data Laboratory
·         Fortified milk (8 oz) - 100 IU
·         Fortified orange juice (8 oz)  100 IU
·         Fortified cereal (1 serving) - 40-80 IU
·         Pickled herring (100 g) - 680 IU
·         Canned salmon with bones (100 g) - 624 IU
·         Mackerel (100 g) - 360 IU
·         Canned sardines (100 g) - 272 IU
·         Codfish (100 g) - 44 IU
·         Swiss cheese (100 g) - 44 IU
·         Raw shiitake mushrooms (100 g) - 76 IU
·         Most multivitamins (1 tab) - 400 IU

10.  Does Vitamin D deficiency lead to cancer, both types of diabetes, and increased mortality (death)?
Recent studies suggest that it does, but further study is necessary. Best to stay at healthy blood level regardless of future study results.

11.  Are there prescription drugs that lead to Vitamin D deficiency?
Drugs such as Dilantin, phenobarbital, and rifampin can induce hepatic p450 enzymes to accelerate the catabolism of vitamin D.

12.  Does Celiac Sprue increase risk for Vitamin D deficiency?
Yes, due to malabsorption.

13.  Who is at greatest risk of Vitamin D deficiency?
Elderly homebound and institutionalized individuals don’t get much sun exposure. However, a study from Boston determined that nearly two thirds of healthy, young adults in Boston were vitamin D insufficient at the end of winter. People with dark skin and older people are also at increased risk because their skin does not absorb sunlight as well as others.

14.  Are there any physical findings for Vitamin D deficiency?
Other than rickets and osteoporosis in extreme cases, in adults with a severe vitamin D deficiency, a physical examination can reveal periosteal (outer surface of bone) bone pain. This is best detected using firm pressure on the sternal (chest) bone or tibia (larger leg bone).

Monday, March 19, 2012

Letter I Just Sent To Dr. Oz Show - edited

I have been watching your show for the past several weeks. After a number of episodes, I have done extensive research into some of the recommended supplements and have not only found that many do not have supporting evidence but in fact, have evidence to the contrary.

The problem I have with these almost daily pronouncements is that you as a physician are making recommendations that some of my patients are following which are inappropriate for them. This is creating a dangerous situation. Your moral imperative and first rule as a physician should be to do no harm.

Your show's disclaimer is a mere blur which no reasonable person can read and I have even heard you state in reference to your supplement pronouncements to your audience that you have "asked [them] to follow them to the letter." You are potentially liable if something terrible happens.

It is only a matter of time until someone, if it has not already happened, gets seriously injured related to the type of medical advice you are giving. I know many emotions have already been negatively impacted by the false hopes you have allowed to air on the show like allowing hyperbaric oxygen therapy to be proclaimed as a cure for Alzheimer's.

I want the record to reflect that the show, the producers, and you were duly warned of the dangers of recommending unvalidated, potentially dangerous supplements and treatments to an unwary but eager for valid solutions audience.

To prevent this from happening, you should caution the audience whenever there are no valid studies to support the use of a recommended product. A prime example would be Forksolin (aka Coleus forskohlii) for which the only human study supporting its use for weight loss was deemed an advertisement, and a second more reliable study showed no efficacy in weight loss.

A word to the wise should be sufficient.