Older Is Better, even with oral contraceptives

New stories, including this one,

Bayer Withheld Yasmin Data From U.S., Former Agency Chief Tells Court - Bloomberg

highlight the elevated risks with the new oral contraceptives. The one under major scrutiny is drospirenone, also known as Yaz or Yasmin.

First, the most important thing: The increased risk of blood clots is small. Your risk of blood clots is probably still higher if you are pregnant. Yes. Your risk of blood clots is higher being pregnant, than being on Yaz or Yasmin. So, patients: Please do not suddenly stop your OCP suddenly. Talk to your doctor first.

When you do talk to your doctor, consider switching to an older contraceptive. One of my mantras in prescribing is that older drugs are usually better, as we know more about their safety. One of my mentors told me, "Never be the first or last to prescribe a new drug." I tend to use norethindone, but any older oral contraceptive will do.

I never understood the hype of Yaz and Yazmin. The drug companies just did a good job marketing it as an acne drug. The truth is, most OCPs work for acne. It appears that Bayer also did a good job of hiding drospirenone's side effects. How many times will we hear this story?

McDonald's: Doing it Wrong

San Francisco's ordinance on free give away toys at fast food restaurants was intended to nudge restaurants to improve the health of their kids meals. The ordinance requires meals that have free toys to meet certain nutritional requirements. The ordinance is a great idea, as the toys are just marketing gimmicks, designed to create brand loyalty with McDonald's.

As this article states, McDonald's, instead of improving their meals, will charge 10 cents for each toy. This will get them around the ordinance and allow them to change meals on their own terms. Still, the pressure from this law got McDonald's to make some changes to the kids meals, such as reducing the portion of fries. But, they are still not healthy. The extra charge will also likely prevent some from buying the toy, as it's not included with that meal.

So it's time to put more pressure on McDonald's, and we have more legal tools that we can use. I want to know why McDonald's has to sell toys. Aren't they in the business of selling food? Why should food establishments sell toys? Why not create a law that states that restaurants cannot sell toys? I'm not yet sure if this is legal, but I would like to find out.

Do Kids Need 3-4 servings of Milk a Day?

Many of you know that I have long said that the benefits of milk were overstated. The article below does a good job of reviewing the evidence why:

Wisconsin milk board overstates dairy’s benefits to children, some experts say | WisconsinWatch.org

The key statements are this:

“The so-called calcium requirement in the United States is based on very short-term studies (that are) irrelevant to long-term calcium needs,”

-Dr. Walter Willett, who chairs the nutrition department at the Harvard School of Public Health

“We know that those individuals who avoid milk and animal products that contain calcium do just fine in terms of their growth, their development, and their bone health,” - Jennifer Nelson, director of clinical dietetics at the Mayo Clinic

“I wonder how the marketing board explains why the highest rates of osteoporosis are found in countries that drink the most milk, or how cows manage to make huge bones that support their weight while eating mostly grass?”- Marion Nestle, Chair of Nutrition at NYU

“It’s hard not to be sarcastic about this kind of marketing,” Nestle added. “Milk is a fine food if you like it, but it is not an essential nutrient.”

Healthy Checkout At Walmart

This video is a great example of a couple of things:

1. Creating healthy checkout aisle shows that behavioral economics works: kids want fruit when it's in their check out aisle.

2. Walmart is doing some more great things in encouraging healthy eating. This was however, a local store initiative. Big Walmart is not yet doing this. Let's how they do.

3. Federal money can work for good. The reason these changes happened was because West Virginia got a grant from the CDC, likely as part of the Affordable Care Act. Federal Money -> States -> Promoting Healthy Changes and Increased Sales.

WATCH IT HERE:

Life in the health lane - News - The Charleston Gazette - West Virginia News and Sports -

Is the Food Industry a Partner in Battling Obesity?

Check out this debate about whether the food industry can be a partner in fighting obesity.  Our study is featured about half way through.



Food Industry Friend or Foe Debate: Yoni's opening arguments from Yoni Freedhoff on Vimeo.

This is just the first in a series of videos by Yoni.  For more, see his blog.

Every day is Medicine Day. But, today is Food Day.

Every day is Medicine Day.  Every time a family doctor like me sees a patient who struggles with weight gain, diabetes, or high blood pressure, I give them medicine.  But today is different.  Today is Food Day.

To be honest, I have long tried to emphasize the importance of food choices in preventing and treating disease.  I high-five my patients when they lose weight or cut out sugar-loaded beverages from their diet.  When people pick a food to eat, they are making one of the most important health decisions of their day.  The vast majority of problems I see in primary care are related to what people eat.  Our food system and our health system are closely linked.  It's no surprise that the faults or our food system contribute to the problems of our health system.  

Our general taxes fund massive giveaways to large agribusinesses, so that they can grow corn (for sugar) and soy.  This makes the major ingredients for most processed foods and beverages cheap, allowing the big food companies to spend billions of dollars a year getting Americans to eat a lot of junk.  And it works. Obesity and diabetes rates are skyrocketing, leading to increased patient suffering and corresponding health care costs.  Guess who pays for those costs?  The same taxes that fund agricultural subsidies help our seniors buy the medications to treat the conditions the subsidies helped cause.

There is a very simple way to break this cycle.  And we don't have to rely on politicians to do it.  All we have to do is know where our food comes from.  Then we just vote with our fork and start eating food that is not part of the industrial food system.

This is the idea behind the first annual Food Day, today, October 24^th (www.foodday.org).  Food Day was founded on six national priorities: reduce diet-related disease by promoting healthy foods, support sustainable farms & cut subsidies to big agribusiness, expand access to food and alleviate hunger, protect the environment & animals by reforming factory farms, promote health by curbing junk-food marketing to kids, and obtain fair wages for all workers in the food system.

One of the best ways to do this is to visit a farmer’s market.  At farmer’s markets we can directly ask the food producer: Where does this strawberry come from?  Did you spray it with pesticide?  Is there any chance it is infected with bacteria from a nearby animal slaughterhouse?  How much do you pay your farm workers?  So visit your farmer's market this week, ask these questions, buy some fruits and vegetables, and provide your family with a few healthy meals.

For those of you who want to celebrate food day in other ways, you can celebrate Meatless Monday by not eating any meat or poultry today (and every Monday).  You can turn your child's television (and internet) off so they do not see all the junk food ads.  Stand outside McDonald's or Taco Bell and warn people about the dangerous food they are planning to eat.  Celebrate water by joining the "Life is Sweeter" campaign and get sugar-loaded beverages out of the buildings where you work.  Or grow a tomato plant on your porch.  You can involve your family in any of these activities, while teaching your children where food comes from.  

While I'm hoping that the 2012 Farm Bill will fix some of the problems with our food system, I'm not optimistic.  However, I am optimistic that many of our food issues can be solved without relying on politicians. By choosing to eat non-industrial food, we can start our own food movement.  

So when I see patients tonight, instead of picking up my pen and writing a prescription for a new medicine, I'm going to write a food prescription for my patients.  I'll give my patients three choices of what I can write: "Eat seven vegetables a day," "Don't Drink Sugar-loaded beverages," or "Give up meat on Mondays."  I hope other doctors follow my lead, and that my patients do too.

Protecting your Prostate and your Package

According to reports out today, the United States Preventive Services Task Force will give a D rating to prostate cancer screening. This means they recommend men should not get the test.

Physicians who have watched the data on prostate cancer screening for awhile could have seen this coming. When I counsel men on PSA (the antigen that screens for prostate cancer) screening, I tell them that the test more likely to harm them then help them. Most prostate cancers are slow growing and never cause problems. How can this be? Cancer is a growth of abnormal cells in your body. The body is always fighting off abnormal growths. It often suppresses early cancers through the immune system and other mechanisms. Even if a cancer continues to grow, it may take years and years to cause something bad. Most people die of a heart attack before the prostate cancer does anything bad.

Now there are a very small amount of people where prostate cancer kills people. The problem is that medicine does not have a way to detect these people. So as in breast cancer, universal screening of women under 40 will result in a lot of people getting mastectomies to prevent one "bad" cancer in women. In prostate cancer, if we screen everyone, we will make millions of men unable to get an erection or be able to hold on to their urine while trying to prevent one prostate cancer.

Screening is not the best way to stop cancer deaths. The best way to prevent them is to stop them in the first place. According to the World Cancer Research Report, you can prevent prostate cancer by eating a lot of fruits, vegetables, and whole grains; and by avoiding a high calcium diet. And that doesn't involve becoming impotent or incontinent.

A Contagious Blog

Having loved the movie "Outbreak," I had to go see Contagion. I was hoping it was going to bring as much intensity as "Traffic." It didn't reach that level. This is not to say it was a bad movie. It was a fairly realistic portrayal of what could happen with an outbreak of a global pandemic.

I felt the most compelling pieces were about who gets what first. We will surely have to ration in a situation like this. Who should get the vaccine or treatment first? Of course, we don't think about rationing in our current health system, even though we do it all the time. Who gets cancer treatment first? Probably the rich insured patients. But not many people are up in arms over this. Things will be different when massive amounts of people are dying daily.

Another lesson of the movie is that most of these emerging viruses are likely to come from humans being close to dead animals. We can do a lot to assure a non-infectious animal. However, even the USDA does not have enough animal inspectors, and Republicans are currently trying to cut food safety initiatives. Compare this to other countries, where there are even less regulations in food preparation. Animal agriculture will continue to create risks for humans in many ways. Kind of makes me want to continue to the call for more people to eat less meat. If you do eat meat, know exactly where it came from. (I.e. buy it yourself from a local farmer.)

The movie also remind us about preparation. Everyone procrastinates this. If we were actually prepared, there would be no rush to the grocery stores last minute. Ready.gov has some good examples of what you need. If you are a camper, you might have many of the supplies already: a stove, freeze-dried food, and a lantern. If you are not a camper, get started! Everyone should remember to get a few jugs of water and leave them in a closet.

The biggest thing we can do to get prepared for these things, is to get vaccinated for things we know about. Influenza kills people. Last year it killed young people. I see too many patients that are afraid of getting the flu shot. I've heard, "It gives you the flu," over and over again. It does not give you the flu. It can't. Some people get an immune response to the vaccine which makes them feel under the weather for a day. For most people, this is tolerable. Consider the other option: dying. It happens. Get your flu shot!!

Most of all, this movie reminds us how critical our public health departments are to our health. We forget about them. But everyday they are investigating new viruses, food poisonings, and poor sanitary conditions. The current climate talks about defunding all governments institutions. This is clearly not the smart thing to do.

Why I Race Bikes

A few weeks ago I participated in the Leesville Gap Road Race. It was my hardest race of the season: 64 miles, horrible roads, climbing, headwinds, with temperatures near 38 Celsius. (That is 100 Farenheit. One thing I learned this year is that to be a cool cyclist, everything has to be Euro.) I almost didn’t finish due to the heat and dehydration, despite drinking over 3 liters of fluid and consuming 1000 calories while riding. After the race my Mom asked me, “Why are you doing this? What are you trying to prove?” I’ve been thinking a lot about that question.

I started cycling with the UCLA cycling team last fall. I joined them to have a group of people to ride with. I never thought I would race. I don’t remember what changed my mind, but I wanted to race. It’s been an amazing year, where I thought I’d stop racing at least twice. Yet I continued on and finished my last (13th) race of the year yesterday.

I sacrificed a lot this year: Thousands of dollars in bike equipment, sports massages, and energy foods; not skiing at all this year so I could keep up with my training and racing (despite a great snow season); weekends with my friends and girlfriend; and SLEEP (especially on those mornings I wanted to stay in bed).

So why sacrifice all this?

Maybe it was all the friends I was making in the cycling community. Maybe it was that I like gear, and cycling has a lot of it. Maybe it was I just wanted a regular way to stay active and in shape.

But I could have been in good shape just riding my bike a few times a week, and not pushing myself with an aggressive training plan. I could have trained for charity/century rides. I could have just exercised on my bike and not taken the risks of racing, which sometimes includes crashes and broken bones. (I’ve been in a few of them this year, but got out with only a few scrapes.)

So why race?
I like winning.

Whether it is in academics, sports, or a debate over some issue, I like to win. There is no winner in exercising. There is no winner in charity rides. (Not that I think charity rides are a bad idea. I may do one this fall.) I know life isn’t all about winning. But winning is what propels humans. It gives us a sense of our ability and purpose.

I just finished watching the Tour de France, which I believe is one of the hardest sporting events in the world to win. (Maybe only second to the Stanley Cup.) If you look a the faces on the winners as they cross the finish line, you will see the excitement in bike racing. While I haven’t won a race, nor done heroin, I think the two probably give a similar feeling.

I almost won a race. I was in the #6 position at the Stanford Road Race with 200 meters to go. But there was a crash from the front and I didn’t get the chance. But that feeling of almost winning is still with me. It was so close and felt so good.

But, as I started in my first non-collegiate races, I realized that winning would be tough. While I still believed, I wasn’t sure I’d win one in my first season. Still, I wanted to race, despite the pain of pushing my legs to their limit in 2-3 hour races. Why?

What else would I be doing? Spending time on facebook? Cleaning my apartment? Watching TV? Reading? Writing a research grant? So many people just sit on their bums all day. Our bodies are not built for that. Pushing myself hard on a bike reminds me what my body was built for: to push, to endure, to work hard.

As Peter Flax said, “We spend our so-called modern lives coddled-breezing through airports on people movers, accepting meeting requests nestled in Aeron chairs, engaging in cruise control to avoid the demands of the gas pedal. Our amazing muscles and capillaries and neural pathways are built to do something far more profound if we put them to the test.” My day job requires me to test my mind. Bike racing allows me to test my body and forget about my day job for a few hours.

There is something primal about racing. One human against another, with a prize at the end. Humans were meant to battle and to pursue speed. Cycling combines the two.

I feel alive on my bike. And I’m having fun. What I’ve described above may not sound like fun to some of you. But, remember that first time you were able to ride a bike? Remember the freedom to push your body into the wind? Remember racing your friend down the street? Remember the feeling of triumph?

Bike racing is fun. I don’t think I need another reason to continue. Except for the fact that I still want to win.

(This post is dedicated to all my team members and my Koach who pushed me beyond my limits this year. I’ll wait for you all at the top of Latigo.)

It's time to stop marketing junk food to kids

(cross post from the NPA Blog)

I’m often faced with parents who want to know what do do with their kids who are overweight. There are a lot of causes of obesity, but the major causes are soda and junk food. The increase in consumption is due to the food industry’s aggressive marketing of junk food to kids.

In 2009, the fast-food industry spent $4.9 billion on marketing. How are parents supposed to fight with an industry that is telling kids to eat more junk food at school, while watching tv, and while on the internet? It’s time to make parenting easier. It’s time for the food industry to stop marketing to kids.

A bi-partisan bill in Congress asked a group of government organizations to come up with VOLUNTARY standards for the food industry on what products it’s ok to market to kids. They came up with very good guidelines. But, they are under big pressure from big food to be weakened, even though they are VOLUNTARY. The government group (the Interagency Work Group- IWG) needs to hear from you on why these standards are really important. They will provide a blueprint on where we should start in stopping marketing junk food to kids.

Please click here to add your comments. Parents around the country will thank you.

Marijuana and Terrorism

Recently, I've turned on some of those Border Patrol tv shows and tv documentaries. They are usually trying to catch marijuana smugglers and growers. It seems marijuana smoking is booming in California, and the cross border trade is feeding this demand. Now I do not have a big problem with people smoking small amounts of marijuana, especially for medical purposes. But, I do have a problem with where the marijuana is coming from.

If you grow your own marijuana, fine. But as some of these programs show, Mexicans are being forced to smuggle or grow marijuana to feed American's desires. In one recent documentary I saw, there were Mexicans who snuck over the border to grow massive amounts of marijuana in forests in California. It's hidden and hard to find, but they have whole camps in rural California growing the stuff. According to the officials most of the men are forced to live in these camps and protect the crop. If they lose the crop, they are threatened with the killing of their families back home. This is terrorism.

Everyone has heard about the Mexican drug crime going on. Is it possible that this is America's fault? Is our greed for drugs forcing families into the drug trade, with no way out. (I also recently saw the great (fictional) movie, Sin Nobre, about what it's like to live in one of the drug gangs.) Think about it: Do you want your weed smoking to be responsible for the rape or murder of families in Mexico?

I spoke to a source in the marijuana business who told me that even if you buy your pot at a legal shop, it's in no way guaranteed that it was grown legally. I think if we want to legalize marijuana, we have to do it fully, and put all operations under supervision. Anyone that sells marijuana should have to verify that it is from a legal growing source.

In the meantime, know where your weed comes from. Just think about the families in Mexico, and the power the drug rings have right now. And if that does not move you, remember that Afganistan is now a prime drug exporting country.

Slowing Down Cars to Speed up Cycling Growth

Another one of my friends was hit while riding her bike this week. She has significant injuries, but is going to be ok. After the shock wore off I started thinking about my new favorite hobby. Most cities, like Los Angeles, are designed for cars, not people or bikes. This is despite the fact that I think biking can save the world, as I mentioned on a previous blog.

New research out describes how separate bike transit ways can reduce bike deaths. (Read the full news coverage here.) Some striking statistics from this story:

• about 51,000 American cyclists suffered injuries as a result of encounters with motor vehicles in 2009, with such accidents accounting for two percent of all traffic fatalities in the United States (according to 2008 figures).
• In the U.S, bike lanes typically consist of merely a painted stripe on the pavement delineating cyclists' portion of the road. In contrast, the Netherlands -- a country half the size of South Carolina, with just under 17 million residents -- is home to about 18,000 miles of separate cycle tracks.

• While more than a quarter of all Dutch commuters get around by bike and 55 percent of Dutch cyclists are women, in the U.S. less than one-half of 1 percent of Americans ride a bike to work and fewer than one-quarter of those riders are women.
• Cycle injury rates are at least 26 times higher in the U.S. than in the Netherlands, the researchers noted.
• The research team pegged the overall relative risk of injury as 28 percent lower on the separated tracks versus biking on a street in traffic.

While I think we need to reconstruct our cities around biking, public transportation, and walking (again see my previous post), I don't think this will happen tomorrow. In the meantime, everyone PLEASE SLOW DOWN WHILE DRIVING. I mentioned the city of Davis, CA as a great biking city, where speed limits are 25mph to make it safer for bikers. Here are some great tips for driving safe around cyclists: please read them. Just slowing down and being extra careful may make you 5 minutes late for a meeting, but could prevent another one of my friends (or me) from having a serious, life-changing injury.

Guideline Experts Fail Again: and this time it costs us

One of the buzz-phrases of health reform and cutting costs has been, "We are going to pay physicians for quality, rather than quality." This sounds good. I would agree with this method.

The question becomes: What is quality health care? For hospital care, one can get pretty good measures of things that happen acutely. Some examples:

-Paying less to a hospital when a patient gets a hospital-acquired illness (e.g. a fall or infection due to lack of sanitary conditions)

-Pay more when a hospital discharges patient with a complete plan for post-hospital care

But for outpatient care, the measures are much harder. Here are some candidates for diabetes care:

1. Pay doctors for how much their patients like them

2. Pay doctors for how long their patients live or what their quality of life is

3. Pay doctors for what their patient's lab values are

Each of these choices has its problem. Option #1 seems like a pretty good option. But you could be a really bad, friendly doctor. (That's not me.) Option #2 seems the best measure, because this is what patients care about. But you can imagine the problems: patients switch doctors, some patients do things that a doctor cannot control, etc.

So we are left with #3, which is how the current proposals urge to pay doctors. The following article reveals how this process has gone terribly wrong:

Sudden Acceleration of Diabetes Quality Measures, February 16, 2011, Pogach and Aron 305 (7): 709 — JAMA

Basically we are using measures that have little research behind them. We are using lab values that do not matter much to patients. Why do we use them? Because the quality experts messed up. They jumped the gun and made quality standards before the research was finished that would give them the answers. I do not think this problem will end. I think we should not rely on paying doctors based on lab values, or intermediate tests that don't have a big effect.

My solution: a mixed payer model. Pay primary care doctors a set fee to take care of patients for a year. Based on a person's age and some other factors, a doctor would get a set amount for the year. The doctor could do whatever they want for that patient. But, if the costs goes above this amount, it's on the doctor's shoulders.

Next: pay doctors like all other professionals, by the hour. Some patient visits take 5 minutes (a cold). Others take an hour (a cancer diagnosis). Fairly simple.

Finally: Pay a group of doctors based on the community's health. So if one city's overall health is increasing more than another's, increase their pay a little bit.

Any of these options is better than paying doctors for lab tests that patients do not care about, and that may not even indicate how good a doctor is.