TALKING about a New Year's Resolution

I like social media.  It's a fun way to stay in contact with friends.  Since I've lived in so many places (and gone through so many years of education), I have friends all over.  Since people are so busy, social media makes it easy for me to stay up to date with what my friends are up to.  In the last few years, I've felt like I've been in contact with more people than usual.  This is good, as social connection is a key to human happiness.

Only so much can be conveyed over social media.  Sure I can see who was married and what movies my friends like.  But a lot of human communication is through tone of voice and facial expression.  Status updates do not convey feelings or emotions the way a face-to-face conversation does.  Though I feel more connected to more people now, I feel less deeply connected to my close friends.

My new year's resolution: Call a friend.

Let's be more specific. Training Peaks says not to make resolutions, but to make plans.  I plan to talk 2 friends a month.  The preferred method is via face-to-face conversation.  This is pretty easy for my friends in California.  For those far away, I plan a video chat.  So friends, do not be surprised if I randomly video call you.  I know that a recent NPR report said that many were uncomfortable with video chat, because the person you are calling may be having a bad hair day.  But, the expert reminded us: "Your parents, maybe your siblings or a very close friend, the people that you really want to video-call with are probably people that wouldn't mind if you're having a bad-hair day. They've seen your bad-hair days. They don't care."

I know that 2 friends a month seems like a small task, but think of how many of you I actually spoke to in a real face-to-face conversation in the past year.  Want to get the year started off to a good start?  Be one of the first to help me with my plans.  Contact me and let me know when you are free.  You can find me on Facebook, Gmail, Google+ (hangout preferred!), or your other favorite social media.

Why you don't need fasting blood work

For a long time, the "guidelines" of medicine have insisted that we get fasting cholesterol levels on patients.  Why?  The theory was that we really need to target LDL ("bad") cholesterol, and the only way to find out "exactly" what your LDL was required getting a fasting blood sample.

There are many holes in this guideline.  First, the "lipid hypothesis" has mostly blown over.  Many studies have shown that you can treat lipids really well, but do nothing for the patient.  We can target that LDL to the lowest level, but still not affect whether the patient gets a heart attack or stroke.  A great overview is on this is in this podcast, from the guys at TEC.

Secondly, you don't really need an LDL to make a general risk assessment of how high risk a patient is for a heart attack.  As you can see from this chart, you really only need to know your total cholesterol and HDL ("good" cholesterol) to get an idea of your risk.  The LDL doesn't matter that much.

Now we have a great new study published in the Archives of Internal Medicine, showing that it does not really matter if patients fast or not.  The cholesterol levels do not change appreciably enough that it would affect treatment.  The related commentary falls a little short of advocating for docs to stop doing fasting cholesterol tests, but says that doing so is reasonable for most patients.

Finally, I often had patients come to my office at 2 pm, having fasted all day, just to get their cholesterol test.  This is just inhumane.  I do not feel good when I fast, and I don't think my patients do either.  Doctors need to start accommodating patients instead of following guidelines.

One more thing.  Does your doctor say you need a fasting blood sugar to screen for diabetes?  Nope.  We can screen for that with an A1C test, which doesn't require fasting.

Doctors: Let's start eating like we want our patients to eat

In my new viewpoint in JAMA, I propose that at all the meetings health professionals go to, there should be healthy food.  This may sound like a simple idea, but it has yet to materialize.  Physicians get "mad" at patients for not eating a healthy diet, and then go to a lunch seminar and eat roast beef and cookies.

It is hard to eat healthy in today's America.  Even when I'm at meetings, it's difficult to not take (at least a piece) of a cookie, when they are offered for free.  So let's make it easier by not providing junk food (cookies, soda, chips) at meetings.

Then we can make sure our meals are consistent with the dietary guidelines: they should be mostly made up of vegetables.  Once we do that, we can help our communities eat healthier.  Let's clean up our own eating habits and set an example for our community.

Politics and the Family

In tonight's Republican Convention speeches, we saw two different takes on American culture: the Strict Father and the Nurturing Mother.

For those who follow my blog and politics, you know that I am a fan of George Lakoff's family model of politics.  Briefly, it says that most Americans have two mindsets: a father model, where respect and obedience are of primary importance; and a mother model, where nurturing and love are primary.

We saw both of these models tonight.  Ann Romney spoke mostly about love.  She spoke about struggling families and the love in their relationship bringing them through hard times:

And I want us to think tonight about the love we all share for those Americans, our brothers and sisters, who are going through difficult times, whose days are never easy, nights are always long, and whose work never seems done.

This is exactly the progressive mindset that Lakoff describes.  The interesting point is that Lakoff's research shows that talking in this nurturing model makes people think more progressively and more likely to vote Democratic.  She finished with this:

I said tonight I wanted to talk to you about love. Look into your hearts.

This is our country.

This is our future.

These are our children and grandchildren.

Gov. Christie was next.  He spoke in a different model:

 [My mother] said to always pick being respected, that love without respect was always fleeting — but that respect could grow into real, lasting love.....Tonight, we choose respect over love.

This is Lakoff's father model, which gets people to think like a Republican and vote more conservatively.  Clearly, Christie is more in tune to politics that Ann Romney.  Romney's speech could actually persuade many women to vote Democratic.  But even Christie showed some of the motherly frame of mind:

Instead, the people of New Jersey stepped up and shared in the sacrifice.

This "shared sacrifice" terminology is something that Obama uses regularly to talk about progressive agendas.  Sharing brings up the progressive mindset.  Sharing leads to policies that promote the greater good: health care for all, unemployment assistance, well funded public education, and quality infrastructure.

My parents instilled in me the importance of love more than respect.  I'm not saying that I wasn't taught respect.  Again, all of our minds have both typologies.  But, the strongest underlying theme in my family was that love and nurturing were more important than obedience and respect.  Love and nurturing leads to respect, rather than Christie's claim of vice versa.

The love in my family led me to believe in progressive values.  How has your upbringing made you think about politics?  Have you thought about these mindsets before?

(And thank you to tonight's speakers for possibly convincing a few more people to think like Obama.)

America is Eating Healthy (According to one App)

I'm a big fan of mobile eating apps.  I think they have the potential to change eating habits and change our food environment.  However, I think many of them are purely driven by tech and gaming experts.  This is not a bad thing.  But without involving people who understand medicine and nutrition, the apps are unlikely to actually help people become healthier.

One of the hot new apps is The Eatery, as discussed in this article:
App Shows Promise for Hacking Eating Behavior - Technology Review

Users take a picture of their food.  Other users rate how healthy it is.  10 (green) means super health and 0 (red) means very unhealthy.  Here's a map of the ratings of healthy meals:

Now anyone who understands nutrition will be puzzled by the fact that most of the United States is green, meaning most of the meals people take pictures of are healthy.  Thus, we are all eating healthy and there isn't really a problem with poor eating in this country.

So there are two possibilities:
     1. The people who use the app are mostly healthy eaters.  (Then what purpose does the app have?)
     2. Most of the user ratings are false.  (Most people don't know what a healthy meal looks like.)

I think either possibility is true.  Option 1 will be fixed when there is an expansion of mobile technologies.  Also, if research shows these apps work, then professionals might recommend them to "unhealthy" eaters, expanding the reach of the apps.

To fix option 2, tech companies need to align with nutrition and medical professionals.  This is difficult, as the two types of industries often have different goals.  But it is possible, and together we could change the way we all eat.

Salt: Bad, Good, or We Don't Know?

The following article was the most emailed of last Sunday's New York Times, and is worth a read:

We Only Think We Know the Truth About Salt - NYTimes.com

The questions on the "clear" relationship between high salt intake and mortality are not new.  The article speaks about some of them, but even I remember these questions being raised.  When I was a freshman studying nutrition at Cornell, my introductory nutrition professor, David Levitsky, raised doubts about salt's connection to poor health.

In my favorite class at Cornell, "Mineral Nutrition and Chronic Disease," taught by Charles McCormick, we spent weeks delving into the literature on sodium, blood pressure, and heart disease.  As I left the class, I had serious doubts about the link.  There were clearly some salt-sensitive people with high blood pressure, for which salt reduction reduced their numbers.  But should we reduce the whole population's salt intake?

Still, I thought that even if the benefit of reducing salt was small on an individual level, the population benefits were likely large.  Even a small reduction in everyone's blood pressure could probably prevent deaths.  So in medical school I worked on a petition to the FDA, filed by CSPI, to limit salt in foods.

Now, even if salt itself is not a cause of increased mortality, it may be a marker of something else: poor eating habits.  Maybe the people who eat salt just eat a long of junk food.  Maybe limiting salt would still be a good thing, as people will drink less sugary beverages to quench their thirst.  But it may be prudent to have more research on this public health policy before we cause harm.

We do not want salt to go the way fat went: It was bad, and then it was good.  One thing I know is good: make sure 1/2 of every plate is vegetables and you are walking daily.

We are Winning the Soda War

This week New York Mayor Bloomberg proposed limiting the size of sugary beverages.  This is his latest tactic in reducing consumption of these beverages.  Earlier, he proposed a soda tax.  He also proposed prohibiting SNAP (food stamp) participants from purchasing sodas with government money.  Both of these measures failed because he needed outside approval (i.e. the Stata or Federal government).

His legal team indicates that no outside approvals are needed for this measure.  They have authority under the restaurant laws in New York.  I still think it is likely that the soda and restaurant industries will sue the city.  (McDonald's makes most of their money from soda.)

It would be great if this measure went through.  This intervention is just changing the default size of the drinks, a clear behavioral economic intervention.  People can still buy 2 or 3 or 5 drinks if they want.  It might even be the same price.  The freedom of choice is still there.

The best news from all of this is that we are winning the war on soda.  The industry is becoming defensive.  All of the publicity is giving soda a bad rap.  That's the purpose.  The soda industry spends billions of dollars a year marketing beverages to kids.  All of this negative media around soda gives us a chance to fight against that marketing.

Thank you Mayor for leading us in this war.

Choosing Contraception

The study below provides more evidence on the most effective form of birth control is Long Acting Reversible Contraception (LARC).  LARC includes Intrauterine Devices (a small device that is inserted into the cervix during an office visit) and Implantable Contraception (a small device inserted under the skin).  The advantage of these is that one procedure lasts 3-10 years.  No pills to take, things to insert, shots or anything else for the duration of the implant.  And, if you decide to get pregnant, they can easily be taken out.

Effectiveness of Long-Acting Reversible Contraception — NEJM

This research as others shows that they are more effective than other types of contraception (pills, patches, vaginal rings, etc.).  Here are some visual pictures to help everyone understand.  The numbers are approximate based on the data they show.  Each face below represents one woman over a year.  In the thousand women below, about 2 will have a pregnancy while on a LARC:

For women on a pill, patch or ring, about 48 more (smiley faces with the X's) will have a pregnancy:

LARCs also save money for the patient and the health care system.  There also have minimal side effects.  For instance, some women get increased bleeding with the IUD, but most get less or the same amount of monthly bleeding.

I talk to a lot of women about contraception, but many still choose a pill.  Why?  I'm interested in hearing the perspectives of women.  I think we all have the goal of reducing pregnancies that are not desired.

(Thanks to NNTonline.com for help creating the graphs.)

Gay Marriage: An Economist's Perspective

I'm not an economist, but I like to listen to economists.  They are usually pretty smart.

Today Obama stated that he supports gay marriage.  I support his decision to not take away rights from any individual in this country.  (I'm not going to discuss whether this was the right political decision, as I'm not a political scientist.)

This issue is clearly a wedge issue that divides many Americans.  However, there is an interesting solution from the economists Thaler and Sunstein, who wrote the bestseller book, Nudge:

"Under our approach, the only legal status states would confer on couples would be a civil union, which would be a domestic partnership agreement between any two people.  Marriages would be strictly private matters, performed by religious and other private organizations.  Within broad limits, marriage-granting organizations would be free to choose whatever rules they like for a marriage conducted under their auspices. ....  Instead of channeling every partnership into the same one-size-fits-all arrangement of state marriage, couples could choose the marriage-granting organization that best suits their needs and desires.  Government would not be asked to endorse any particular relationships by conferring on them the term marriage."

There's a solution that should not be as divisive.  Make marriage a private institution, while the government support equality by granting civil unions.  

Can you look at this growth on my back?

Dermatologists often do not like to admit that they look at skin growths all day.  Because the next thing they know, there is someone at a cocktail party asking them to look at a mole on their backside.  (And yes, all Dermatologists regularly attend cocktail parties.)

Should physicians diagnose or treat their friends and family members?  It is a tough issue.  Once you complete medical school (or sometimes even before), you are immediately seen as the know-it-all of everything medicine related.  Physicians want to be helpful to friends and family.  But how far should we go?

Let me start with diagnosis.  This is the most common thing I'm asked by friends and family.  "What do you think is wrong?  Could he have cancer? Why is my pee green?"  The process of diagnosis is probably the most complicated thing most physicians do.  Diagnosis is not as simple as looking in a book at the causes of green pee.  We spend hours in medical school learning how to arrange a proper diagnostic encounter, including how to look at the patient, what tone to use, what words to use, and even which way to cross our legs.  (Crossing your legs away from the patient signals that you are closed to hearing what they have to say.)

When I see a patient in my office, I start by asking open ended questions and letting the patient talk.  Based on what the patient is saying and how they are saying it, I continue down a path until I think I have a diagnosis.  I am also cuing into patients non-verbal responses, which can lead me to new and important questions.  This whole process is disrupted when a family member calls and asks, "Why is my pee green?"  Without the rhythm of the normal diagnostic encounter, the correct diagnosis could be missed.  

There is another reason diagnosis with friends and family members is difficult: some questions are off limits.  If my friend calls me and asks me why she is fatigued, I don't want to ask her if she could be pregnant, how heavy her periods are, or if she has any blood in her stool.  (Weird and awkward, but all causes of anemia.) If my friend asks me about some new joint pain, I don't want to ask him if he's a new sexual encounter, especially if I'm friends with his wife!

Finally, the hardest part of diagnosing friends and family is giving bad news.  What if I think my family member has cancer?  Is it right for me to have to give them that information?  It's unfair to both the physician and the patient.  Giving this type of news is something that only an unbiased physician should do.

Are there diagnostic questions that are ok to ask? Yes.  If I'm riding bikes with you and you fall off your bike, I'm happy to help you decide if you need an ambulance, or if you have a broken bone.  Why?  There's not much of a story to tell.  There are no questions about your sex life involved in broken bones (usually), and it's not likely we will have to address prognosis.  So most urgent situations are fine.

Treatment.  "So my doctor says I have high cholesterol.  Do you think I should take medicine?"  Most of you that know me would probably guess that I would say, "No. Eat more vegetables and ride a bike."  But, that's not fair, because that's my opinion.  Treatment decisions are another complicated interaction between a physician and a patient.  The dyad needs to account for the values of the patient and the long term implications of taking a medication.

But what can I ask you about treatment?  I'm actually much more open to talk about treatment with a family or friend, as long as the decision is made with the treating physician.  I'm happy to give you my opinion if it's in area I know about or can look up.  It actually can be helpful for me to arm you with some questions that you would want to ask your doctor.  But you should always make the final decision with your physician.

Summary: Being a physician that's asked questions by a family or friend is a tough situation. We always want to help, but do not want to hurt.  It's always ok to ask me about my opinion on something, but do not be offended if I suggest you talk to your doctor.  I'm not being rude.  I'm just trying to help.