Monday, January 30, 2012

An Update on Morgellons Disease

Last year, I wrote a blog post about Morgellons Disease, now called Unexplained Dermopathy by the CDC. I wrote the post in response to a study that had just been published by the Mayo Clinic saying that they had found no evidence of infection or infestation in 107 self-diagnosed Morgellons sufferers, and were thus concluding that Morgellons was not an infectious disease, despite claims to the contrary. This week, the CDC has released a report on the subject, likewise concluding that no infective agent could be identified in person suffering from Morgellons-like symptoms.

Despite the findings of the study, it's unlikely that we've heard the last about Morgellons, as many providers working with Morgellons and patients suffering from Morgellons may view the report with some suspicion. Many Morgellons sufferers feel that the medical establishment is dismissive of their symptoms, and are thus unlikely to interpret the study results as anything but more dismissal.

I myself, however, was heartened by some of the interviews the reporters gave. Study co-author Felicia Goldstein has said, 'The absence of evidence is not evidence of absence,' and Mark Eberhard, director of the division of parasitic diseases and malaria at the CDC, has said, 'It's a negative, but it really limits and narrows down the field of possibilities. By removing a couple of the big players - infections and the environment - that still leaves some wide open territory about what could be the causes.' Clearly, people are suffering - the question is, 'From what?' As a naturopathic physician, I believe it is important to acknowledge the legitimate suffering of our patients, listen openly, and help to relieve that suffering.

Thursday, January 26, 2012

What is Strontium?

Strontium is probably the most-heavily studied mineral treatment for osteoporosis that you’ve never heard of, unless you’re a naturopathic doctor or a geriatrician. In the discussion of osteoporosis prevention and treatment, we hear a lot about calcium, magnesium, vitamin D, and vitamin K, but rarely do we hear about strontium – most of us probably couldn’t even find it on a periodic table if we had to. Even so, strontium has a pretty extensive amount of research behind it, and has been shown to not only improve bone density (as measured on a DXA scan), but it has also been shown to help reduce the risk of fracture, which, when you’re dealing with osteoporosis, is the most important thing to see.

So to start with, what is strontium? Strontium is a trace mineral that occurs naturally in the diet, albeit in small amounts, typically about 1-3 mg/day. Typical sources of strontium are whole grains, leafy greens, and root vegetables, i.e. all the usual suspects. As a supplement, however, strontium is typically dosed at a much higher level, in a range of 450mg to 2g per day. Any time a nutrient is dosed at a level much higher than it would occur in the diet naturally, science studies it extensively, to verify that it’s both safe and effective, and strontium is no exception.

Some older articles seemed to suggest some safety issues about strontium, suggesting that strontium might contribute to bone growth disorders. In one case, young rats fed a high strontium diet developed bone mineralization defects, and in another, children living in a part of Turkey with high levels of strontium in the soil (and thus food) demonstrated higher-than-normal incidence of rickets. In both situations, however, the bone disorders seem to have been related to the respective diets’ relatively low levels of calcium. Since then, multiple studies have confirmed that patients taking high doses of strontium, who are eating otherwise balanced diets or taking supplemental calcium, do not develop bone disorders. Indeed, patients taking high levels of strontium for the prevention or treatment of osteoporosis have normal bone structure.

So what about it’s efficacy? In the early 2000’s, two major studies were undertaken to assess whether strontium renalate (a prescription form of strontium used in several European research studies) was an effective treatment for osteoporosis, including its ability to increase bone mineral density (as measured on a DXA scan) as well as its ability to reduce incidence of fractures. The Spinal Osteoporosis Therapeutic Intervention (SOTI) trial and the Treatment of Peripheral Osteoporosis (TROPOS) trials both found that strontium renalate increased bone mineral density and reduced fracture risk in postmenopausal women with osteoporosis, with some of the greatest treatment effect noted in women over 80 years of age (1, 2, 3), who are at the greatest risk of fracture. Data from these studies and other sources prompted the Cochrane Review to award strontium renalate with silver level evidence in the prevention of vertebral and nonvertebral fractures, as well increasing bone mineral density. These two studies demonstrated positive results over relatively short periods of time (three and five years, respectively), and so questions remained about their long-term efficacy. This last year, however, an extension study of women involved in the SOTI and TROPOS studies indicated that strontium renalate continued to support increases in bone mineral density and a strong reduction in risk of fracture over a ten-year period with minimal side effects, thus establishing it’s safety and efficacy over long periods of time.

Sounds great right? Well, here’s the catch. Strontium renalate is not currently approved for use in the United States. The biochemist in me would believe that strontium should be active in forms other than this one – i.e. that strontium chelate, strontium citrate, and other would have similar activity. However, this being science, we need evidence, and unfortunately, there’s not a lot out there on other forms of strontium. I found one study stating that dietary strontium increased bone mineral density in an animal model, suggesting that other forms of strontium may have beneficial effects. On the other hand, I found another study which showed that strontium renalate was far more effective than strontium chloride at delivering strontium to the bone; while this doesn’t tell us for sure about strontium citrate, chelate, etc, it certainly suggests that strontium’s efficacy depends highly on the form it is delivered in.

So the take-home message is this: strontium renalate is effective in the treatment of osteoporosis, but other forms may not be. The paucity of evidence regarding other forms of strontium makes it very hard to make any statements about their effects, beyond speculation or educated guesses – I had my druthers, I’d be calling for research into strontium citrate, strontium chelate, and other forms. If you’re a health care consumer and have been diagnosed with osteoporosis or osteopenia, make sure you’re getting regular DXA scans – other forms of strontium may be effective, but the ultimate test is going to be your own bone density. Continue to follow the tried and true prevention methods, such as calcium and vitamin D supplementation, and engaging in weight-bearing exercise.

Monday, January 23, 2012

Getting Sleepy With Dr Oz

In my practice in Oakland, it seemed as though none of my patients was sleeping enough. Most were getting under six hours a night, many as few as four. I would often joke that I could base my practice entirely around two things - explaining to people what the labs their other doctors have ordered actually mean, and helping people to get some sleep.

Here in Washington DC, where I shadow a cardiologist, we discuss sleep apnea with nearly everyone, as it's rampant in cardiac patients, where it contributes to high blood pressure, obesity, and other chronic problems.

Most of what I would tell my patients involved eating dinner earlier in the evening, turning the computer/TV off at least 45 minutes before bed, keeping the bedroom clear of distractions, and other 'sleep hygiene' practices. This week, Dr Oz, that naturopathic doctor in a medical doctor's clothing, has written an article outlining recommendations for getting better sleep. It's comprehensive, clear, and I daresay I couldn't have done a better job myself. If you're having trouble getting enough sleep, or if anyone you know is, I highly recommend this article. Read on, dear readers, and sleep peacefully.

Thursday, January 19, 2012

A Tale of Two Diets, Part 4: The Conclusions


You’d be hard-pressed to find anyone who didn’t know that McDonald’s and other fast food is bad for you, but we rarely recognize the scope of the problem. In writing this piece, I tried to imagine reasonable portion sizes – if you look back, Tom doesn’t do anything outlandish like eat a second Big Mac, or a whole large pizza, and yet he clocks in at over 4000 calories for the day. If anything, this should tell us how unhealthy the food at fast food chains is.

As I pointed out, the nutritional content of the food is heavily weighted to saturated fat, sugar, sodium and excessive protein. And yet, despite the profusion of these types of nutrients, Tom’s diet is almost totally bereft of fiber, not to mention most vitamins and minerals.

I’ve also tried to show that a diet like this presents health problems in both the short term and the long term. The long term effects of diet, like diabetes, hypertension, heart attack, cancers, etc, sometimes seem distant and unreal, and so it’s not always on the forefront of our minds when we make meal choices. The short term effects, however, are also present – we just don’t always link the causes with their effects. (I once had a patient who had digestive complaints and insomnia, but couldn’t seem to figure it out – when we asked about his diet, he said he ate consumed mainly Hot Pockets and Mountain Dew.) As you can see in this story, Tom’s high intake of refined sugar and caffeine causes his energy to spike and plummet throughout the day, ultimately leaving him exhausted but unable to sleep.  I hope this has helped to bring home the problems with a poor diet.


So let’s talk about Paul’s diet. Paul is eating a very well balanced diet – it’s low in saturated fat, low in sugar, high in fiber, high in protein, and it favors health-promoting unsaturated fats. He clocks in at just under 2000 calories for the day, and as estimating his caloric intake was a little more challenging than Tom’s, I think he’s pretty much right on the money with the amount of food he’s eating throughout the day, and the balance he’s chosen.

His intake of micronutrients is excellent, and Paul’s getting a full spectrum of vitamins and minerals. I didn’t focus heavily on these throughout the discussion, but Paul’s plant-based diet puts him in very good standing to meet his daily needs. Additionally, his consumption of non-nutrient health promoting compounds is high – things like probiotics, plant-based antioxidants, sulfurophane, etc. While these are not technically nutrients, they have excellent health-promoting actions. In all, Paul is eating a well-rounded diet that is helping him to live a happy life in the present and is also working to prevent future disease. Paul should be very pleased with himself.

Wednesday, January 18, 2012

A Tale of Two Diets, Part 3: Dinner and Evening

We now return to our story, already in progress. You may recall that Tom has been eating largely fast food all day, whereas Paul has been eating a pretty varied diet, supplying him with a whole host of nutrients and health-boosting compounds.

4:30pm – The end of the workday is approaching, and both men are starting to get a bit hungry.

Paul has packed hummus and carrots and snacks on them as he winds down at work.
-       The combination of unsaturated fats and fiber in hummus makes it a great snack choice. On the one hand, it’s very healthy, as it contains significant amounts of both of these components, and on the other, it’s satisfying, with the combination of fat and fiber creating a sense of satiety that lasts.
-       And of course, let’s not forget the carrots! Carrots are best known for their beta-carotene content, but also supply some fiber and a reasonable amount of minerals.

Tom decides to power through the late afternoon. He’s fairly stressed out, due in part to the caffeine he’s consumed throughout the day, but also due to his blood sugar, which is dropping yet again, and quickly.

The tally after a late afternoon snack:
Paul – Calories: 1295, Saturated fat: 11.4g, Sugar: 45.1g, Sodium: 637mg, Fiber: 28.7g, Protein: 47g
Tom – Calories: 2410, Saturated fat: 29.5g, Sugar: 122g, Sodium: 2610mg, Fiber: 12g, Protein: 68g

7:00pm – It’s dinner time, and our heroes sit down for their respective meals.

Tom is tired after work, and so has ordered a large pepperoni pizza from Pizza Hut. He sits down in front of the TV, opens a Budweiser and prepares to chill out. He’s not eating the whole pizza, of course, but he’s feeling hungry and in need of something filling, so he eats half of it, finishing the first three slices quickly, and going back for the fourth a little later on in the evening. Over the course of the next few hours, he has another beer before calling it an evening.
-       Of course, the same issues with sugar, saturated fat, and sodium still apply, but let’s move beyond that and talk about variety in Tom’s diet. Each of Tom’s meals today has consisted of a variation on the theme of bread and meat, with cheese being added to both lunch and dinner. While there is certainly a place in the world for each one of these things, when they comprise the backbone of every meal, we start to run into issues. As we’ll see when the tally is counted, Tom’s diet continues to be weighted heavily towards lots of calories, saturated fat, and sugar, at the expense of fiber, vitamins and minerals.
-        Additionally, though protein is an important part of the diet, especially early in the day, Tom’s diet is extremely high in protein, almost to a fault. A diet this high in protein starts to tax the kidneys quite heavily, as they are the part of the body that eliminates nitrogen, an element that primarily enters the diet through protein. This evening’s pizza in particular doubled his day’s protein intake, putting his total protein intake at a whopping 130g (the FDA recommends 50g per day).

Paul has headed home, likewise tired, but feeling alright. He’s not feeling up to making much in the way of dinner tonight, as he made curry last night, so on his way home, he picks up a salmon fillet (which he will grill on his trusty George Foreman), a bunch of broccoli (which he’ll steam), some soy-ginger dressing for the broccoli, and a bottle of red wine (of which he’ll have a glass). Paul’s dinner is remarkably easy, yet nutritious.
-       Fish, and in particular salmon, is a great source of omega-3 fatty acids, a group of very healthy unsaturated fats that help protect the heart, and are anti-inflammatory. The heat from grilling damages these fats somewhat, but their benefit is still present, and they’re a far sight better than saturated fat. Sushi is probably the healthiest way to eat fish, but Paul doesn’t feel like sushi tonight.
-       The broccoli provides the ever-popular fiber, but also provides a variety of compounds that help the liver detoxify efficiently. Sulforaphane, a component of broccoli, not only encourages the liver to produce detoxifying enzymes, but it also has been shown to have a direct cancer-preventing/tumor-suppressing activity. All other members of the Brassica species, including cabbage, kale, cauliflower and Brussels sprouts have this same activity.
-       Paul decides to buy the salad dressing to make the broccoli a bit more interesting, and because Paul reads the nutrition labels on the back of the food he buys, he finds one that is comparatively low in saturated fat and sodium, though they’re it’s still a significant source of sodium for Paul today.
-       Finally, the wine. Unlike the Budweiser that Tom is drinking, which is low in nutrients, but high in calories, the red wine that Paul opts for is rich in antioxidants, just like the green tea he had with breakfast. Consumed in moderation, red wine provides some notable health benefits, and can be part of a healthy diet, not to mention the fact that Paul’s appreciation of good wine enriches his life, as it’s stimulated an interest in traveling to Sonoma Valley as well as Italy, to learn more about the wineries of the world.
-       Paul’s eating quite a lot of protein today, but as he eats a varied diet, there is not a lot of concern about this. Additionally, as Paul bikes to and from work, this extra protein is being put to good use, being broken down for fuel, and being used to build muscle.

The final count:
Paul – Calories: 1909, Saturated fat: 15.4, Sugar: 56, Sodium: 1306, Fiber: 32.7, Protein: 97g
Tom – Calories: 4022, Saturated fat: 53.5g, Sugar: 142g, Sodium: 6272mg, Fiber: 20g, Protein: 130g

10:30pm – Paul heads to bed, having spent the last hour reading last weekend’s newspaper and drinking chamomile tea. Paul drifts off within a few minutes and sleep soundly throughout the night.

Tom, however, tries to sleep, but tosses and turns, his mind racing. He’s exhausted, but he just can’t get to sleep. If we look back on his day, this shouldn’t surprise us – he’s had two 16 oz lattes and a similarly sized Coke! While we’ve been talking a lot about the long-term effects of Tom’s diet, regarding the likelihood that he’ll develop diabetes, heart disease and other diseases, it’s causing him problems in the short term, preventing him from sleeping. Tom won’t get to sleep until after midnight tonight, so when he’s up tomorrow morning, he’ll be groggy, just as he was today.

Tune in again tomorrow to hear me wrap this all up. Until then…

Tuesday, January 17, 2012

A Tale of Two Diets, Part 2: Lunch

Welcome to part two of a weeklong series about two men and their radically divergent diets. If you missed last time, you can find it here.

1:00pm – Lunchtime rolls around and both men have an hour to eat.

Paul has brought his own lunch, and begins to tuck in. Today, he’s eating leftovers from last night – a bowl of curried lentils and rice. He’s also brought along an apple and a small salad of lettuce with olive oil and vinegar dressing, and is washing everything down with water he’s drinking from the metal canteen he keeps at his desk. Paul’s meal isn’t elaborate for sure, but it’s filling.
-       The curry dish and apple both supply fiber, which, as I mentioned before, will help keep Paul feeling full, and will slow the absorption of dietary sugars, thus keeping his blood sugar steady throughout the afternoon.
-       Additionally, the combination of lentils and rice in the curry dish provides a complete protein. Here’s what that means – protein is made up of 20 ‘essential’ amino acids, substances the body needs to function, but can’t make itself, and which can only come from the diet. The foods we eat vary in the amount of these amino acids they provide; most animal products contain all 20 essential amino acids, but many plants provide only a portion of these amino acids. The combination of beans or lentils and rice provides all 20 essential amino acids, making it a staple of any vegetarian diet.
-       Though the lettuce provides little nutritional value itself, the dressing – olive oil and vinegar – is important. Olive oil is an excellent source of unsaturated fat (specifically omega-9 fatty acids). Though there’s been an obsession with low-fat foods for some time, there’s now an increasing trend towards healthier fats, i.e. away from saturated fats towards unsaturated fats. These unsaturated fats have many health benefits, but are probably best known for helping to prevent heart disease.
-       Finally, let’s talk about the spices in Paul’s curry. You might not know it, but Paul’s curry is a veritable powerhouse of anti-inflammatory agents. First and foremost in that category is turmeric, which was long known just for lending the yellow color to curry, but has since been shown to be a strong inhibitor of the inflammation-causing COX-2 enzyme, and has been researched for just about everything from cancer to rheumatoid arthritis. Other curry spices include ginger, also a COX-2 inhibitor, and cinnamon, which has been shown to help the body maintain a steady blood sugar level. Many of the other spices promote healthy digestion, in addition to tasting good.
Additionally, because he’s brought his own lunch, Paul can eat more slowly, and has plenty of time to digest his meal before returning to work.

Tom, on the other hand, is going to his usual – McDonald’s. We’d all like Tom not to go to McDonald’s, but as I said yesterday, Tom likes his routine. The McDonald’s is busy during lunch hour, so Tom has to wait in line to get his order taken and has to wait again to get it filled. Between the walk and the wait, it’s 10:30 before Tom starts eating.
-       He was hungry before walking in, having let his blood sugar drop yet again, and between the wait and the pressure to get back to work in time, he’s pretty stressed out when he eats. As a result, Tom’s sympathetic nervous system is dominant at the moment. The sympathetic nervous system (SNS) is the division of our nervous system that puts us in a fight or flight mode – when it is dominant, it increases blood sugar, increases heart rate, and impairs digestion, all of which are necessary to, for example, run away from a bear or play a game of soccer. However, as I said, it impairs GI activity, making digestion and absorption of nutrients more difficult. The parasympathetic nervous system, the SNS’s counterpart, is best known for promoting a ‘rest and digest’ mode. If you’re wondering what a parasympathetic state looks like, imagine Paul right now.
-       Without going into great detail about Tom’s lunch, it’s essentially more of the same – more saturated fat, more sugar, and more sodium. For lunch, Tom’s having a Big Mac, medium fries, and medium Coke. He leaves still feeling a little hungry, and so he grabs a small bag of chips on the way back to the office, which he’ll eat over the course of the afternoon.

At lunchtime, the score is:
Paul – Calories: 1042, Saturated fat: 9.9g, Sugar: 42.1g, Sodium: 300mg, Fiber: 20.7, Protein: 40g
Tom – Calories: 2410, Saturated fat: 29.5g, Sugar: 122g, Sodium: 2610mg, Fiber: 12g, Protein: 68g

So we could almost stop now. Tom is already well above and beyond a recommended daily caloric intake and sodium intake, has hit a full 150% of the recommended saturated fat intake, and has consumed about three times as much sugar as Paul. Meanwhile, Paul has gotten antioxidants, probiotics, anti-inflammatory herbs, fiber and all sorts of other good things in his diet. I’m going to carry on and talk about the evening because Paul has a few more things to teach us as we head towards the end of the day, and we still have yet to explain why Tom woke so groggy this morning… Tune in next time!

Monday, January 16, 2012

A Tale of Two Diets, Part 1: Breakfast

This week, I’m presenting a serialized version of a talk I’m giving this weekend, a talk that will compare two diets and their health-promoting and health-defeating properties. The talk will follow two men, Paul and Tom, throughout their day, cataloguing what they eat and how their days go. While I generally am not a big advocate of calorie counting, I’m going to do some basic number crunching this week in order to make a point; mainly, however, I’m going to focus on the nutritional content of the food each of these men is eating throughout the day.

I hope you enjoy this little creative endeavor.

7:00 am – Tom wakes up feeling groggy – to understand why he’s groggy, you’ll have to wait until later in the story. Fortunately, today, he didn’t hit the snooze alarm too many times. Tom has a fairly regular regimen, and he does the same thing more or less every day. He’s a pretty consistent guy and he isn’t a big fan of change. He wanders, bleary-eyed, to the shower and hopes the water will wake him up a bit.
Paul wakes up at around the same time feeling refreshed after 8 hours of sleep. He’s also got a pretty consistent routine, and while he doesn’t spring out of bed, he feels up to taking a 20-minute jog before breakfast.

8:00 am – Both men are showered and ready to eat.
Paul has a small bowl of yogurt (1/2 cup), almonds (1/2 cup) and berries (1/2 cup), and washes it down with a cup of green tea. In this meal, Paul is getting a whole host of health-supporting compounds, starting with probiotics.
-       Probiotics will help keep Paul’s digestive system working properly, helping him to digest and absorb his food all day, and helping him fight off anything that might have come in on his food.
-       The fiber in the nuts and berries will help keep Paul feeling full longer, so he’s less hungry throughout the day, and, in the long run, will help keep Paul’s cholesterol down.
-       Antioxidants, found in the berries and the green tea, will help Paul’s liver to breakdown toxins he might encounter in his environment, will help his immune system fight off viruses and bacteria, and will help keep his body in good cardiovascular health.
-       Finally, the substantial serving of protein he’s getting will help him maintain a steady blood sugar through the morning, so he’ll have enough energy to get through work without dozing off.

Tom, on the other hand, doesn’t have any food on hand to eat at home, so he’s going to have to make the first of several trips to McDonald’s that he’ll make today. Because he’s got a bit of extra time, he’s going for the hotcakes and sausage this morning, washing it down with a glass of orange juice and a medium nonfat latte.
-       Though they may taste good initially, the saturated fats in the hotcakes and sausage will predispose Tom to high cholesterol, obesity and high blood pressure in the long run.
-       The sugar in the hotcakes and especially the syrup make Tom more likely to develop diabetes later in life, and will cause Tom more immediate problems later on today.
-       The sodium in the meal, of course, contributes to Tom developing high blood pressure.
-       And finally, Tom’s gotten nearly no antioxidants! This is going to make it especially hard for Tom’s body to deal with the stresses he’s going to suffer as a result of this breakfast.
A plus for Tom’s meal is that he is getting a good amount of protein in his meal, but it’s outweighed by the massive amounts of fat, sugar and sodium.

The tally so far:
Paul – Calories: 410, Saturated fat: 5.8g, Sugar: 20g, Sodium: 174mg, Fiber: 7.2g, Protein: 26g
Tom – Calories: 1000, Saturated fat: 10g, Sugar: 60g, Sodium: 1160mg, Fiber: 3g, Protein: 27g

9:00am – Both men arrive at work. Paul is relaxed and motivated, having biked to work. Tom arrives feeling pretty amped up and ready to go, having finished his morning coffee.

11:30am – Tom is a little worse for wear. The pancakes and coffee that he had for breakfast caused his blood sugar to rise very rapidly, which made him feel great in the short run, but a few hours later, his blood sugar is plummeting. He’s starting to feel restless and is having difficultly paying attention to his work. He’s got a big report due this afternoon, and so when someone at the office says they’re going on a coffee run, he’s first in line with his order – another latte.
Paul is also starting to feel a bit peckish, but his blood sugar has remained relatively steady this morning, so he doesn’t need to eat quite as much, and happily eats a handful of almonds.

The continuing tally:
Paul – Calories: 575, Saturated fat: 6.9g, Sugar: 21.1g, Sodium: 174mg, Fiber: 10.7g, Protein: 33g
Tom – Calories: 1180, Saturated fat: 16g, Sugar: 73g, Sodium: 1290mg, Fiber: 3g, Protein: 37g

So that’s the morning! As you can see, Tom hit 1000 calories at breakfast alone. While most Americans eat more than 2000 calories in a day, 2000-2500 is a good benchmark to assess an average ‘healthy’ American diet. Additionally troubling is that, at 16g of saturated fat, Tom is already at 80% of the recommended daily intake. Though there is no defined daily intake of sugar itself, you can see here that Tom has consumed nearly four times as much sugar as Paul, and about a quarter as much fiber.

Thursday, January 12, 2012

Why is There No Transparency in the Cost of Medicine?

Let me start this week’s blog entry with a series of questions:

How much does a pack of gum cost?
How much does a large pizza cost?
How much does a six pack of Budweiser cost? How about a high-end microbrew?

Easy, right? These items have fairly consistent prices, and we have a general sense of how much to expect to pay for them. Because we know how much they cost, we know when we’re getting a good price.

How about something more complicated? Try these questions on for size:

How much does an oil change cost?
How much should you pay for monthly Internet service?
What’s the price of a flight from New York to Los Angeles?
How much does a lawyer charge as an hourly rate?

Though these are largely service-based costs, most of us know the answers to these questions as well, or if we don’t, we can easily use the Internet and find out. We can probably even shop around a bit and get a good deal on a service we’ve never even used before.

Finally, try to answer these questions:

How much does an annual physical cost?
How much do routine screening labs cost?
How much does a mammogram cost?
How much does a knee replacement cost?
How much does a stress echo cost?

If you’re like most Americans, I’d guess that you have no idea. Why is this? The age of the Internet has produced very sophisticated consumers – we have access to information that allows us to compare prices, services, and any number of individual aspects of a given product. Yet few of us have any idea of how much medical services cost and can’t compare services between providers. Even comparing health insurance plans is difficult – How much does one cost vs another? What’s covered in one or another? What are my likely out-of-pocket expenses for one or another?

Unlike in the rest of the economy, there is little transparency in the healthcare market.

This lack of transparency is in part a result of a third-party payer system – health insurance. Of course, the role played by insurance is important, and there’s even a study out there that shows that health insurance does, in fact, serve it’s most important function – preventing severe economic consequences to illness. However, having an intermediary in the payment for services creates a unique system that exists nowhere else in our modern economy. Consider how odd we would think it if every time we visited the pizzeria, they billed our pizza insurance company, a company that estimated our monthly pizza consumption and gave us a monthly rate based on that projection. As I said, insurance’s role in preventing severe economic hardship has been shown, but it also creates a blind spot for consumers.

I believe that in the age of information, consumers have become remarkably smart, able, and adept. We have the ability to shop around as never before, to research as never before, and to share information as never before, resulting in an increased ability to seek out quality products and find them at reasonable prices. Unfortunately, these new consumer patterns haven’t reshaped healthcare in the same way that they’ve reshaped things like the retail market, and I believe that economic crisis around healthcare is in large part due to the lack of transparency around healthcare costs. Healthcare costs are, of course, multifactorial in origin, but if consumers cannot seek out a good deal, as they can in other parts of the economy, they can’t do their part to bring down healthcare costs.

Fortunately, there are a couple companies out there that are trying to make a difference and help consumers gain access to knowledge.

The first company, who I blogged about last year, when it was still in development, is Castlight Health. Castlight was brought to my attention by an article in the Wall Street Journal that raved about them. Castlight’s mission is literally to ‘cast light’, to make healthcare costs clear, and help companies make smarter choices when providing for their employees. While the company doesn’t reduce the prices of the healthcare plans themselves, their emphasis on transparency brings important market forces into healthcare, which should hopefully, in the long run, bring prices down across the board and force transparency. I applaud the efforts of Castlight.

Another company, working in the area of dental care rather than medical care, is Brighter. Brighter is a membership-based company that gives its members access to pre-negotiated prices for dental services. These types of companies have existed for some time, but the difference I see with Brighter is transparency of pricing. If you’re a consumer without dental insurance seeking to get dental care, it’s really hard to compare prices, or even get a clear quote. Brighter provides clear pricing and reviews of the dentists who participate in their plan, allowing consumers to choose based on their needs.

The economics of the American healthcare system are in need of a great deal of work, as its current situation is simply unsustainable. Undoubtedly, some of that solution is going to mean governmental regulation to ensure equitable practices by insurers, not only including their treatment of consumers, but of providers as well. However, some of that solution is absolutely going to be driven by market forces. Currently, the healthcare industry isn’t subject to a lot of the same pressures that other industries are, and it’s in large part because consumers don’t understand how the money works in healthcare. To be sure, neither of the two companies I mentioned above are perfect, but both are committed to increasing transparency and arming consumers with the information they need to make smart decisions.

The third factor that’s going to solve the healthcare crisis is experimentation. There are a number of models currently in operation that are all competing to be the next big thing in how healthcare operates in the US. On the one hand, there’s an increasing number of concierge medical practices in the US, which are now starting to make inroads into the middle class. There are companies like Qliance, which are leading the move towards 'medical homes', medium-sized clinic that provides routine and urgent care, relegating insurance to emergencies, and not letting it into the routine practice of medicine. There are companies like OneMedical, which offers a hybrid form system, combining the best of concierge medicine and insurance-based practice. And finally, there’s the ever-present possibility of a Canadian or British-style socialized healthcare system, or at least a public insurance option. One of these systems, or perhaps some other form of healthcare, is likely to emerge as a major force in the next few years, challenging our current healthcare system to adapt and improve. We’ll see what happens. Stay tuned.

Tuesday, January 10, 2012

Can You Believe In Yourself?

So for those of you who have been reading for a while, you may have noticed that I'm now adding blog entries on Mondays as well. Ideally, these Monday posts will be short and sweet - just a little bit to get you thinking. The emphasis will be on charts, pictures, videos and fun stuff, rather than the longer, more involved Thursday posts, which will remain meaty.

This Monday's post features my favorite YouTube clip from 2011. You've probably seen it before, possibly many many times before. I'm putting this up here today because this young man has a great message for us adults about self-confidence. We may have mastered how to ride a bike, but we still struggle with eating well, exercising, taking care of ourselves and other grown-up tasks. These grown-up challenges, though they may be more complicated than the one this little boy overcame, require the same kind of determination and self-confidence that he possesses.

Once, you were this young boy - find that person within and use them to help you on your way to health and happiness.

Thursday, January 5, 2012

Making Every Visit Count

Last month, a report appeared in the British Journal of Cancer reporting that nearly half of all cancers in the UK were due to lifestyle choices, and were therefore preventable. As if in response, the NHS Future Forum released a report last week recommending that NHS providers talk to their patients about diet, exercise, smoking, and alcohol consumption at all visits, even if the patient was coming in for an ‘unrelated illness’, in an effort to tackle a dramatic rise in obesity and cancer in the UK. I’d like to take today’s column to laud this initiative and discuss some of the objections that have been raised.
First, though, let’s set the stage. For those not familiar with healthcare in the UK, the UK enjoys a publicly-funded healthcare system, the National Health Service, which was set up after World War II to create a coherent, nation-wide healthcare system. Though some private insurances exist in the UK, the majority of Britons receive their care through the NHS. Because of the scope and size of the NHS, there is an ability to set a national healthcare agenda in a way that is more difficult to achieve here in the States. Our medical system, because it is privately-funded and not fully integrated, allows for doctors to have much more individual freedom in the way they practice, for better or for worse. The way the NHS works means that this recommendation would hold considerable sway in the way docs practice in the UK, should it become an official policy.

Now on to the part where I sing the praises of these recommendations. I blogged earlier this week about the aforementioned study showing that a significant portion of cancers are due to preventable lifestyle factors, factors these recommendations are meant to modify. Additionally, I blogged over the summer about a study which showed that, in combination with each other, smoking, excessive alcohol, poor diet and lack of exercise take about a decade off a person’s lifespan. The imperative of promoting healthy lifestyle to reduce death and disease is clear.

The main objection that has come up against this proposal is that patients would view these questions as intrusive, and may decline to seek medical care for fear that they would be badgered about their habits. While I think there’s a reasonable point to be made here, it’s a poor comment on the clinical skills of clinicians if they are viewed as ‘lecturing’ their patients or ‘intruding’ on their lives. I’d like to think that all doctors, no matter their own personal styles, can learn to communicate in ways that encourage open conversation and partnership with their patients, rather than the moralizing and lecturing we might have expected from our Victorian forebears. The NHS Future Forum’s head, Professor Steve Field, said in an interview to the Guardian that the policy would not create a ‘nanny state’, and I agree, and likewise agree that the practice of healthcare workers asking their patients about health habits need not be overbearing when conducted in a spirit of cooperative problem solving.

The main issue I would raise with the report is that I believe it has an unfortunate misconception at its core. I know this is a large accusation to levy at a report that I’ve just touted very loudly, but I think it’s a true one. Here’s the misconception: that some diseases are unrelated to diet, exercise and other health habits. It’s true that some diseases are more directly caused by environmental and lifestyle factors, but the body’s ability to combat nearly any given illness is largely determined by its nutritional status, how efficiently its organ systems operate, it’s overall antioxidant status and other factors that are strongly influenced by issues such as smoking, diet, exercise, etc. So really, doctors shouldn’t be checking up on these topics even if they are unrelated to the presenting illness, but because they are almost certainly related to the current illness. Not only does checking in on the health habits give the provider an opportunity to help prevent future chronic disease, but it helps the provider deal with the patient’s current illness, whether it be elevated liver enzymes, chronic back pain or the common cold.

The interrelatedness of health habits and disease also goes some of the way to solving the objections raised. Yes, it’s nosy to ask about topics that are unrelated to the current illness, but when you’re asking about factors that are related to the current illness, you’re doing your job as a health care practitioner.

To wrap things up, I think this is great news. By inquiring about health habits at all patient encounters, the NHS would start to shift from a disease-management system to a health-promotion system. A reactive system that deals with problems once they have come up is playing a losing game, because it’s always chasing what has already happened. A proactive system, one that looks down the road, predicts potential pitfalls, and takes action to prevent future problems is positioned to win. As I’ve said, the current proposal is imperfect, but laudable, and it could mark a significant step forward in the fight against diseases both acute and chronic. 

Monday, January 2, 2012

Good News and Bad News on Cancer

If it's true that a picture is worth a thousand words, we shouldn't be surprised that landmark news about cancer comes with pictures, charts, a video, and a long, in-depth article. It's rare that a mass-media source publishes a health-related article as comprehensive and clear as this one, so I recommend that you sink your teeth in, no matter what your level of scientific understanding.

Even though I spend most of my days talking about the importance of diet, exercise and lifestyle, I was surprised by the findings of this study. It wasn't that healthy living is good for you - I wrote about that in a blog a few months ago - it was the fact that a full 40% of cancers are attributable to causes within our control. This is a massive percentage, and one that should make us all stand up and take notice. Though a healthy lifestyle doesn't guarantee that we won't get cancer, it reduces our risk dramatically.

The good news from this report is that we have an incredible amount of control over cancer. The bad news is that we've clearly been remiss in our duties for decades. Excess alcohol, smoking, lack of fresh fruit and vegetables, lack of exercise, and an unhealthy weight all contribute to our likelihood of developing cancer, and are within our power to change. Last week I challenged my readers to make a New Year's commitment to their health by losing weight - what else are you going to do this year to make healthy changes?