Supplements are Not Helpful for Athletes or Regular People

I am an avid cyclist. I would be happy to take any "natural" substance that helped my performance, but did not harm my body. Today, a well know professional pulled out of the Tour of Utah due to a positive finding of synthetic testosterone in a blood sample from July. (Cycling now tests riders randomly, even when they are not racing. They can just show up at your door any day and ask for a test. This is why I believe cycling is getting cleaner.)

Tommy Danielson believes that the positive sample was from a contaminated supplement he was taking . (Let's assume that this former doper, who rode with Lance Armstrong, has reformed as is not lying. I tend to believe him.) Why was he taking a supplement? He likely was taking something that someone recommended as a legal way to improve his performance.

However, there is little evidence that any sports supplements actually improve performance. I haven't reviewed the literature recently. But the last time I checked, the only two supplements that had some minor evidence were: Vitamin C for prevention of colds in endurance athletes and creatine for some body builders and vegetarians who did not get it from their diet.

The supplement industry is basically unregulated. It is a multi-billion dollar industry, but a law in the United States (DSHEA) prevents the Food and Drug Administration from regulating it. Basically, the supplement companies can make any claims they want, as long as they do not say it prevents a disease. Additionally, they are not subject to inspections or quality controls, so contaminants can get into them. (I'm not clear how synthetic testosterone gets into them, but maybe it was made in the same facility as testosterone.)

So why risk taking a supplement that is not going to help you? It might get you disqualified from a race, affect your career, and could even harm you. If you have to take one, and there is solid randomized controlled evidence for it, get it tested or use one certified by USP.

What if you are not an athlete? Maybe you just hear you should take glucosamine, Vitamin D, or Vitamin C to be healthy? As I've said before, multivitamins are not helpful, and may even cause harm. The evidence is clear. STOP taking them.

One of the last hopes of the Vitamin industry was Vitamin D. There was controversy for many years with many recommending its use, despite an National Academy of Medicine report advising against. Now we finally have a good study that supplementing with Vitamin D does not help women with mild "deficiency".

Many people tell me that eating healthy is too expensive. Yet Americans spend billions of dollars a year on supplements that do little to nothing. Let's put that money into buying healthy food. Until the supplement industry can produce high quality randomized controlled trials showing that a product works, I suggest staying away from them.

New Recommendations on Obesity Prevention in Kids

The American Academy of Pediatrics just issued a new report on how to prevent excessive weight gain in kids. Here are the highlights:

1. Education and advice are unlikely to be effective. Environmental change and more advanced behavior modification are more effective.
2. Beverages: eliminate sugary beverages. Limit juice and encourage fruit instead. Water is the ideal beverage for kids to drink. 
3. Limit foods with high caloric density. (I think they got this terminology slightly wrong. Nuts, for instance, are highly caloric, but are also highly healthy. I think they should have said "limit processed food".)
4. Children less than 2 years of age should not have any interaction with electronic entertainment/communication (including tablets, phones, TVs). Those older than 2 should be limited to 2 hours. (My thought: Parents might consider doing the same for themselves!)
5. Kids should be active for 60 or more per day. 
6. Prevention should start before birth by focusing on healthy weight gain and other practices in pregnancy. (My comment: it is hard to work on "healthy habits" once women are pregnant. It is much more effective to get healthy before getting pregnant.)

Of course, these recommendations are worded as being just focused on pediatricians. But, they really apply to any physician or provider taking care of children. Family physicians have a critical role, as we often take care of the Mother before she comes pregnant, and can help initiate prevention earlier than pediatricians and obstetricians. 

Remember 5-2-1-0 for kids (and families):

5 Fruits/Veggies a Day 

2 or less hours of screen time (for those older than 2)

1 hour of physical activity

0 sugary beverages

Reducing Saturated Fat: Worth it?

We recently published an article that was a "Mythbusters" on nutrition.  One of the controversial parts of the article was whether reducing saturated fats was a worthwhile nutritional focus. Of course, all of the major groups, including the IOM, reinforce the importance of reducing saturated fats.

One of the major studies we relied on was a Cochrane review. Cochrane reviews are the "gold standard" of evidence-based medicine. They take all the of the studies on a topic and use a standardized method to compile the evidence. The Cochrane review we relied on was just updated with new data. The results are the same. The plain language summary is:

"The review found that cutting down on saturated fat led to a 17% reduction in the risk of cardiovascular disease (including heart disease and strokes), but no effects on the risk of dying."

Let's break this down. If you replace saturated fats with other fats (but not with carbs), you will not reduce your risk of death. However, you will reduce your risk of a cardiovascular event. But here are what the numbers look like.

In the regular saturated fat group 83 people out of 1000 had Cardiovascular Events over 4.7 years, compared to 70 (95% CI 61 to 80) out of 1000 for the reduced saturated fat group.

Here is the visual for the regular group:

 And here it is for the reduced saturated fat group:

So out of 1000 people on the reduced diet, 13 less will have an event, with no effect on mortality.

Is it worth it?

Either way, it is beneficial to eat less meat and more vegetables. That reduces mortality.

Nutrition Confusionism

The new draft Dietary Guidelines were just released. I won't post the link here, because few people will read the dense document. The major take home points were: eat more whole fruits and vegetables, less sugar, less meat, less saturated fat, less salt, and don't worry about cholesterol too much.

I was just at the Partnership for a Healthier America conference, where lots of nutrition experts mingled with lots of food company executives. There was a lot of confusion and snickering amongst the group. Some decried the Committee for stating that how much cholesterol you eat is not that important. Others asked why saturated fat and salt were still emphasized, even though the best evidence does not support reducing these food ingredients to improve health.

The non-scientists asked the scientists why nutrition is so confusing. They made it sound like the science was constantly changing, but the guidelines committees ignored the science. I listened to this segment of NPR's Science Friday, where the host asks why the nutritionists, "have known that eggs are ok to eat, but the rest of us didn't."

Who is at fault here? I'm not sure. But I recently skimmed through my nutrition courses from when I was an undergraduate at Cornell. I went through my notes where I indicated that we were taught that is very difficult to find an association between salt and hypertension within a population. I also had copious notes stating that the connection between calcium intake and bone health was weak. (Thanks to Charles McCormick for this great class!)

I then went to my intro course table of contents and found our lecture titles: "Diet and serum cholesterol: environment or biology?", implicating that cholesterol in the diet doesn't matter that much. Another was, "Ambiguous connections: salt and hypertension". Thank you Dr. Levitsky for teaching us how to think about the facts without the hype.

The "new" news that we do not have great evidence dietary cholesterol, salt, and other nutrients are critical for health, is really not that new. I was learning it back in 1997.

So now people are telling us nutrition is confusing and that we said salt, cholesterol, and fat are bad and then good. I'm not sure where the confusion comes from. Is it from nutrition researchers who devote their careers to studying the role of one nutrient and its effect on health? Is it from journalists who love to sensationalize the latest food craze based on one study? Or is it from food companies who make so many claims about food and health, that we end up just buying whatever sounds good at the time?

I'm not going to blame one group. We are all part of the problem. But, one thing has been consistent throughout the years. This fact is summed up in this line in the new dietary guidelines report:

"Vegetables and fruit are the only characteristics of the diet that were consistently identified in every conclusion statement across the health outcomes."

So just follow the simple advice to eat more (whole) fruits and vegetables. (Sorry smoothies and vegetable juices don't count.) Avoid the processed junk. That advice is probably a few generations old. 

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Thoughts on the Berkeley Soda Tax

This is a repost from the National Physician's Alliance Blog:

Many political pundits are trying to decipher the lessons from the 2014 midterm elections. I will not try and do that here. But, some of the most interesting results have come from ballot measures. While many people voted for conservative officials, these same voters voted to legalize marijuana, prevent a personhood amendment, and raise the minimum wage.

One of the most interesting measures that passed was the soda tax in Berkeley. San Francisco voters also voted in favor of the tax, but did not reach the 2/3rds majority needed to pass. (The 2/3rds threshold has to do with California law on new taxes.) Others have tried institute a soda tax. The two most notable examples were New York City and Richmond, CA. Both resulted in the American Beverage Association (ABA), an industry trade group, spending millions of dollars to defeat the measures. The ABA spent a few more million in the recent ballot initiative in Berkeley. By law, companies have a fiduciary responsibility to maintain profits for their shareholders. Thus, my conclusion is that they had to spend this money. They feared profits would decline if these measures passed.

The evidence is fairly clear on the likely effects of a soda tax. Various economists have done simulations to show that a tax will likely decrease consumption and purchasing. The health economists have also simulated how many people will be prevented from getting diabetes and heart attacks. Of course, all simulations are based on assumptions. Since we do not have an actual soda tax yet, it is hard to predict exactly what will happen.

But, early indications from data in Mexico, after their soda tax was instituted recently, is that sales are decreasing. If other assumptions hold up (e.g. that people will not go eat candy instead), Mexico’s policy could have an impact on public health. The effects will be more difficult to measure in Berkeley. Berkeley is a small city with many surrounding urban areas without a soda tax. It also has a population that is often changing, due to the University population. However, it still offers us an interesting experiment to see the possible effects of a soda tax. Particularly interesting will be the effect on Berkeley youth.

A signifiant consequence of Berkeley passing a soda tax is a possible ripple effect. Other cities interested in experimenting with public health policy could think about passing a soda tax. California has often been an experimentation ground for innovative policies. The policies preventing smoking in public places started here, leading the way for cities worldwide to institute these bans.

While libertarians may protest against these policies, people still have the freedom to choose whatever they like to purchase. Taxes already exist on other foods in California, such as restaurant food and frozen meals. The soda tax just adds sugary beverages to the mix, albeit at a slightly higher rate.

Finally, many believe that the actual tax is not the real intervention here. The tax on sugary beverages just gets us all talking about the harms of drinking 10 (or many more) teaspoons of sugar at a time. The media is talking about it. Social media is talking about it. If the tax in Berkeley signals to people that drinking sugar is not the “cool” thing to do, than maybe a few more parents will think twice about buying their kids a sugary drink.

Childhood Obesity, Headlines, and Jelly Beans

Remember that game where you guess how many jelly beans are in a jar? Well, if I guess once, I'll probably be wrong. But if I'm allowed to guess 500 times, I might get it right once. But that doesn't mean I'm a good guesser of jelly beans numbers.

The same concept applies to research studies. The more times you test a question, the more likely you are to get a postive result. That doesn't mean that the answer to the question is "yes". It just means you guessed so many times that your were bound to get a correct answer.

The New York Times Missed this point in their article when they wrote the headline:

"Obesity Rate for Young Children Plummets 43% in a Decade"

Sounds like a huge drop. I wish it was. But the researchers tested many age groups to see if there was a decline over 10 years. They checked the age ranges 2-5, 6-11, 12-19, 20-39, 40-59, and >60. When you "guess" if there is a decrease in obesity in all of these age groups, you are likely to find one "yes".

The researchers admit this and even caution interpreting their results this way:

"When multiple statistical tests are undertaken, by chance some tests will be statistically significant (eg, 5% of the time using α of .05). " 

And they conclude:

"Overall, there have been no significant changes in obesity prevalence in youth or adults between 2003-2004 and 2011-2012. "

Yet some how the New York Times missed this, and focused their headline on a minor result. While we might have made small gains against childhood obesity, we haven't really begun to change the trajectory of the epidemic.

 

Can Subway be Healthy?

Today, Subway announced a new agreement with the Partnership for a Healthier America (PHA). PHA is a non-profit group that was started by First Lady Obama to reduce obesity in America.

When I saw Mrs. Obama speak last year at the PHA conference, she was really starting to emphasize that marketing is a big cause of overeating. You can provide all the "health choices" you want, but if you price the unhealthy ones lower, and have ads all over the television for them, they are going to sell more.

The new PHA agreement with Subway takes a step in the right direction. As part of the agreement, Subway will form a policy on advertising to children. (Hopefully PHA will have to approve this policy.) In addition, they will spend $41 million to advertise fruits and veggies to children. This type of advertising is badly needed to compete with the billions of dollars that advertise junk foods to kids.

So the real question is: will this get kids to eat healthier at Subway? In our study of what teenagers buy at Subway and McDonald's, we found they were eating a lot of processed food, few veggies, and a lot of calories.

My view is that the change in marketing is a positive step. But, there is still a problem with much of the food at Subway. We found that teens ate 2,149 mg of sodium in a Subway meal. That's more than 3 times what the National School Lunch Program recommends. Now, in truth, salt amounts are not very important for young kids. But the amount of salt tells us that the food at Subway is highly processed. For instance, the meat and bread have a lot of salt because they are highly processed. And we know that processed food leads to many of the problems of obesity. Notably, in the agreement they were only able to agree to 935mg of sodium in kids meals. That is more than our panel of experts and RAND recommended (700mg).

How else could we know if kids are eating healthier at Subway? I would want to know if they are eating more vegetables. I do not see any specifics in this agreement about Subway reporting how many servings of veggies they are selling to kids. PHA often does require these types of reports, but I do not see it in the press release. The best way to study this is doing what I did: collect receipts from kids and calculate what they are eating. But, it would be much easier if Subway would give vegetable sales out, so that researchers (like me) could analyze it.

What happens if they do get kids to eat more veggies, and somehow less meat and refined grains? What happens when the kids get to the cash register? For those of you who frequent Subway, you know there is a giant display of cookies. The sales clerk almost always asks, "Would you like a cookie and a drink with your sub?" Having cookies at the cash register is a risk factor for disease. So the easiest thing Subway could have done to improve health is to move the cookies to a place kids are less likely to ask for them, and parents are less likely to buy them.

I congratulate Subway and PHA for the agreement, but would like to see some objective and public research/analysis. Without this analysis, the public will not know if this is another Subway marketing scheme or an improvement in what kids are eating.

Salt: How bad is it?

Back in the 1990s, I took two courses that studied the effects of salt on health. Both courses questioned whether reducing salt intake would improve health. In my introductory nutrition course at Cornell, Dr. David Levitsky started to break down the evidence on salt. He showed that reducing salt only reduced blood pressure in some individuals (i.e. those that were salt sensitive). 

I took another course where we really dove into the evidence around salt. Dr. Charles McCormick showed us evidence that there was tremendous variation in salt's relationship with blood pressure. In addition, weight was an important determinant of blood pressure, that overshadowed the effects of salt. Finally the ratio of sodium to potassium was a stronger predictor of high blood pressure, than sodium alone. (Potassium is found in fruits and vegetables.)

A good review of the recent evidence doubting the connection between salt and cardiovascular mortality is here, by friend Dr. Sean Lucan. He states, "Attempting to Reduce Sodium Intake Might Do Harm and Distract From a Greater Enemy."

There have been many skeptics in the salt and high blood pressure connection. Now we finally have an ally: the prestigious Institute of Medicine. They issued a report today saying:

“These new studies support previous findings that reducing sodium from very high intake levels to moderate levels improves health,” said committee chair Brian Strom, George S. Pepper Professor of Public Health and Preventive Medicine at the University of Pennsylvania Perelman School of Medicine. “But they also suggest that lowering sodium intake too much may actually increase a person’s risk of some health problems.”

While salt may not be a primary cause of death, it is a marker of processed food. In our recent study, we found that adolescents ate a tremendous amount of sodium at Subway and McDonald's. It may not be that the salt itself is the harmful part of this diet. It simply may be that foods with high salt are are heavily processed food-like substances. Reducing the amount of salt in these heavily processed "foods", such as processed meat and snack foods, is unlikely to have a very positive effect on health. The real gains will happens if we can get people to eat less of these foods and more potassium containing foods: vegetables.

So enjoy your salt when you add a little to your food. But stay away from foods with a lot of salt on the label. They are likely foods that are shortening your life.

How to tell if a patient is eating well

Today I was invited to give a talk to medical students at UCSF.  The talk was about how to talk to patients about nutrition and behavior change.  I started with this question:

"How do you know if your patient is eating well?"

The first responses I received from the audience were:

"Test cholesterol."

"Test blood sugar."

"Weigh them."

"Waist circumference."

Finally, a brilliant student said, "Talk to them."

I had to reframe the question to: "How would you assess a patient's eating by only talking to them?"  We then had a good talk on objective methods to assess eating behaviors.

I was floored that most of the first answers to the question were, "order more tests."  The medical community has already taught these early medical students that a test is the answer to every question in medicine.  Is it any surprise that we order too many tests with minimal value?

On the positive side, we spent the rest of the hour talking about nutrition and behavior.  I was surprised how well the students knew about current concepts in nutrition.  I hope the next generation of physicians become engaged with their patients about nutrition.  I have faith they will, as long as the current system does not steer them in the wrong way.

Is Local Food the Answer?

In this fascinating post, the authors of Freakonomics talk about a study showing that eating local food may actually increase environmental and monetary costs.  Why?  Economists know that specialization reduces cost.  It actually make take less energy to grow something far away and transport it by boat to California, rather than just grow it here.

So local food may not be the answer to global warming.  But, was that the problem it was supposed to solve?

Growing and purchasing food locally has other advantages.  It makes food-born illness easier to track, as we know where the food is grown.  In an even larger sense, it promotes social cohesion and social interaction.

Many of the problems in our food system arise because we do not know where food comes from.  We do not know who grew it or how they grew it.  For instance, let's take eggs.  For those that eat animal products, would you eat an egg if you knew the hens lived in a crowded, dark shelter with feces covering the ground?  Or would you prefer to eat an egg that came from a farmer that you could ask how the animal lived, what it was fed, and how fresh the egg was?  Buying directly from a farmer does not require a food label; it just relies on talking.

We have created a society that is not in touch with real food.  We don't know what food is.  We think a Big Mac is food.  Buying locally restores our connection to where our food comes from.  We have to weigh those benefits with the possible negative consequences of local food.

We don't need to eat all our food locally.  We just need to be more conscious of where our food comes from.  Eating locally is only part of the answer to the problems with our food system.  It surely solves some problems, but not all.

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.