December 24, 2013
News Review From Harvard Medical School -- My Top 10 Health News Stories of 2013
- The Affordable Care Act Rollout
- Myth of Metabolically Healthy Obesity
- New Cholesterol and Blood Pressure Guidelines Get Mixed Reaction
- Value of Calcium and Vitamin D Supplements Questioned
- Flu Vaccines – More Choices Than Ever Before
- DSM-V – Changes to Mental Disorders Manual
- The Microbiome – The Bacteria in our Gut Matters
- Hepatitis C Treatment Improves
- Head Injuries Raise More Concerns
- Risks of Cancer Screening Not Well Known
By Howard LeWine, M.D.
Harvard Medical School
It’s hard to imagine how it could have been worse. The President misspoke when he stated that if you had health insurance you could keep it. He didn't specify to the public that your health insurance had to cover specific services to qualify. Mr. Obama's administration is scrambling to find a fix.
In addition, the U.S. Government’s Health Insurance Marketplace launch was a disaster. Having faced the glitches and experienced widespread frustration, people have kept trying to sign up for health insurance coverage. And the exchanges are clearly working better now. But time may have run out to get coverage that starts on January 1.
If you are already covered by Medicare or by health insurance your employer is continuing to offer, the new law likely won't affect you. People most affected by the ACA are those with inexpensive health plans that don’t cover the necessary services required by insurance plans under the new law. You may be required by law to purchase a better-quality health insurance policy. It could cost more in the short term, but may wind up costing you far less if you get sick.
Obamacare does offer advantages, such as:
- You can't be denied coverage because of a pre-existing condition.
- Your coverage can't be canceled because you got sick.
- You’ll get access to free preventive services based on your age and risk.
- You no longer have to worry about lifetime and yearly dollar limits on your health care coverage.
But with no cap on individual health care expenses, the insurance companies could start losing lots of money if too many people exceed the predicted health care expenses. Health premiums in the future would have to rise, perhaps significantly.
I haven't met anyone yet that is totally happy with the ACA. Even if this is not a step in the right direction, we needed change. And that just wasn't happening as health care costs continue to rise at unsustainable rates without improvement in overall quality of care.
Indeed, some obese people have no higher risk of diabetes, stroke or heart attack compared to most people. Obesity is defined as a body mass index (BMI) of 30 or higher. BMI is a number that's based on the relationship between weight and height.
The reason that this subgroup of obese people doesn't have the same diabetes and heart disease risk is almost certainly genetic. Scientists have yet to discover which genes control it.
Here are some facts about the metabolically healthy obese:
- Despite their weight, they tend to have smaller waist sizes than most obese people. A large waist means you carry more belly fat. Doctors call it visceral fat. More belly fat translates to a greater diabetes and heart disease risk.
- Their body cells have normal insulin sensitivity. This means the cells use insulin in a normal way to turn the glucose (sugar) in food into energy. Most obese people develop insulin resistance, when cells don't use insulin well. Insulin resistance is the first step toward type 2 diabetes.
- They tend to have lower total cholesterol levels and normal blood pressure.
- They don't show evidence of lasting, low-level inflammation, which is common in metabolically UN-healthy obese people. Long-term inflammation is linked with an increase in heart disease and stroke risk. A study published earlier this week confirmed the lower levels of inflammation in people who are obese but metabolically healthy.
But obesity ravages the body in other ways. It greatly increases the risk of osteoarthritis, especially of the hips and knees. With inactivity because of painful joints, quality of life suffers and other health problems, such as blood clots in the legs and diminished lung capacity, can shorten life span.
During the last few weeks of 2013, two long awaited guideline updates were released. Both of them were met with some negative comments. But that's true of almost every new guideline. The cholesterol and blood pressure guidelines created more noise since these two conditions affect so many people.
The American Heart Association and American College of Cardiology released new guidelines that upended previous recommendations for who should take a cholesterol-lowering statin drug. The previous guidelines recommended taking a statin if the level of their harmful LDL cholesterol was above a certain number. The guidelines also recommended that many people get their LDL level down to 70 milligrams per deciliter (mg/dL), even if that meant taking a statin plus other medications, a strategy never proven to prevent heart attack or stroke.
The new cholesterol treatment guidelines no longer focus on "the numbers," but instead focus on the risk of heart disease or stroke risk. The panel that created the new guideline referred people to a heart risk calculator. But heart experts challenged the accuracy of the calculator. And many doctors worried that millions of additional healthy people would be considered candidates for a statin drug, when only a small percent of them would actually benefit.
Regarding the new guidelines for treatment of high blood pressure, the main difference was using a higher systolic blood pressure goal for people age 60 and over who don't have diabetes or kidney disease. Systolic pressure is the top number. According to the new guidelines, the evidence suggests that a goal systolic pressure of less than 150 is good enough. The prior goal of a systolic pressure under 140 was the same for adults of all ages.
Many experts say that the 150 goal is too high for people over 60. It may lead to an increase in the number of heart problems and strokes.
What did not get enough emphasis in the new or old guidelines was the importance of tailoring treatment based on your personal situation. For example, a very old and frail person is more likely to feel better and have less fall risk with fewer medicines and a blood pressure higher than 150 or even 160.
We see more and more evidence to suggest that vitamin and mineral supplements should be used only for specific purposes.
To maintain healthy bones, adequate calcium and vitamin D are essential. But taking high doses and more than you need may not provide any additional benefit. In fact, taking too much of either one can be harmful.
How much calcium you need to maintain healthy bones is debated. The Institute of Medicine now recommends 1,000 to 1,200 milligrams a day. This may be too high. Other countries set the daily recommended calcium intake at less than 1,000 milligrams.
Get your calcium from your diet. At this time, calcium pills should only be used when your doctor recommends them. Recent studies suggest that high-dose calcium pills might increase the risks of heart disease and certain types of cancer. Unlike calcium in your diet, calcium in pills also can cause kidney stones.
Good dietary sources of calcium include:
- Dairy products, such as milk, yogurt and low-fat cheese
- Fish with soft bones that you eat, such as sardines or salmon
- Legumes, such as beans, peas and lentils
- Green leafy vegetables, such as broccoli, kale and cabbage
Vitamin D is just as important as calcium to keep bones strong. Getting enough vitamin D through diet alone is often not sufficient. Milk, orange juice and certain other foods and drinks are fortified with vitamin D. But there are few good natural food sources.
People who aren't out in the sun very often may need a vitamin D supplement. We need sunlight to change the inactive form of vitamin D in our skin to the active form. Low sun exposure may cause a lack of vitamin D in our bodies.
Most people in the upper half of the Northern Hemisphere don't get enough sunlight during winter and most of spring and fall as well. We also have been told to avoid sunlight because it ages our skin and causes some types of skin cancers.
The Institute of Medicine recommends 600 to 800 IUs of vitamin D daily. Look for the ones containing 1,000 IU. That gives you a cushion and is very safe.
It's not too late to get the flu vaccine. There is plenty of vaccine available and more choices than ever before. Now there’s even a vaccine available for people with egg allergy.
Everyone age 6 months and older should get a flu vaccine. This is especially true if you or someone you know is more likely to have severe health problems caused by flu. These groups include:
- Children younger than 5
- Pregnant women and women who are trying to get pregnant
- Adults 65 and older
- People under age 20 who take aspirin regularly
- People with heart disease, especially if they have had a heart attack or a hospital stay for angina in the last year.
- People with asthma, emphysema, chronic bronchitis or other lung disease
- People with any condition that can weaken the immune system, including diabetes
- People with a body mass index of 40 or higher
You also should get vaccinated if you are in regular contact with anyone at high risk of severe illness caused by flu. This is especially true if you have or care for a child too young to be vaccinated.
Psychiatrists rely on the Diagnostic and Statistical Manual of Mental Disorders to diagnose a wide range of mental disorders. It lists criteria for every psychiatric illness. Psychiatrists have used the fourth edition of this book for almost 20 years. This year, a new edition, the "DSM-V," was published.
Many psychiatrists and other physicians have harshly criticized this updated version. The DSM-IV required fairly extreme symptoms before a person could be diagnosed with a psychiatric condition. By contrast, the DSM-V requires milder symptoms.
In this new version, grief is considered a form of major depression. Typical or normal events, such as temper tantrums in children and "senior moments" in older people, now have medical names, turning them into diagnoses. Some children who would not have qualified under DSM-IV will now qualify under DSM-V as having attention-deficit hyperactivity disorder (ADHD) or autism.
According to Dr. Allen Frances, the head of the task force that created the DSM-IV two decades ago, this new version will deceive Americans into thinking normal emotions are a sign of disease. "Normal needs to be saved from powerful forces trying to convince us that we are all sick," he said.
Critics have complained that the DSM-V will:
- Stigmatize people who should be considered normal
- Lead to psychiatric medicines being prescribed to people who do not need them
- Make it challenging to do research
With this amount of controversy, we can only hope that the committee working on the sixth version won't waste any time getting started.
The average human gut harbors between 500 and 1,000 bacterial species, the majority of which reside in the large intestine. And each of us has a different mix and our own mix changes in response to diet, where we live and to what else we might ingest.
Most of these gut inhabitants are helpful — indeed, essential — serving functions like producing vitamin K or stimulating the immune system. When this “intestinal microbiome” is disrupted by infection, illness, or treatment with antibiotics, a person’s ability to digest food can be impaired and overall health affected.
In fact, scientists are exploring if and how our microbiome can cause disease. And not just diseases of the intestines, like ulcerative colitis or Crohn’s disease. But perhaps heart disease and cancer.
Changing the microbiome has already become an accepted treatment for people with recurrent or persistent severe diarrhea caused by Clostridium difficile bacteria. C. diff diarrhea is almost always the result of taking antibiotics. C. diff competes for survival with other bacteria in the gut. Antibiotics can kill many of the "good" bacteria, but often not C. diff. This allows C. diff to run wild.
When multiple courses of medicine can't cure C. diff, doctors may recommend a fecal transplant. It may sound disgusting. But it actually is very easy to perform. And the cure rate so far has been incredibly good.
In general, spouses, parents, siblings and the adult children of older patients are the preferred donors. But any healthy person can donate stool. The donor provides a fresh stool sample. Doctors mix and blend it with a salt solution to make a slurry. The slurry is passed through gauze or a coffee filter to remove large undigested food particles.
Doctors have a couple options for delivering the donor stool mixture to the recipient's intestine. The feces can be delivered with a nasogastric tube, which is inserted through the nose and into the lower stomach. The donated feces can also be delivered from the other end by colonoscopy or enema. The whole procedure takes from 5 to 25 minutes, depending on the delivery method.
New drugs for hepatitis C have led to a much better prognosis if started early enough. That’s why it’s recommended that all baby boomers get tested for the virus. Baby boomers include the generation born between 1945 and 1965.
Also a blood test for hepatitis C is recommended for people who:
- Injected or "snorted" drugs in the past
- Currently inject or "snort" drugs
- Had a blood transfusion before 1992
- Had surgery prior to the mid-1980s (when surgeons adopted more rigorous sterile precautions)
- Receive dialysis treatments for kidney failure
- Were born to a mother with hepatitis
- Have served time in jail
- Have gotten a tattoo in a shop that is not regulated by its state and lacks a high safety rating
You can carry the hepatitis C virus for many years without any symptoms. Untreated, it can lead to cirrhosis and liver cancer.
Not only are the newer drugs more effective, they also tend to have fewer side effects than the older ones. They include:
- Boceprevir (Victrelis)
- Telaprevir (Incivek)
- Sofosbuvir (Sovaldi)
Athletes, coaches and parents are now well aware of the potential consequences of repeated concussions. In the past, the athlete usually made the decision about returning to the field or the ice. Now medical clearance is needed before you are allowed to restart activities that could cause head injury.
A concussion is easy to diagnose if one of the following occur after a head injury:
- Loss of consciousness
- Impaired judgment
- Poor coordination
- Balance problems
But the symptoms can be subtle and might not occur immediately following the injury.
Long-term problems that can follow repeated concussions include depression, dementia and changes in personality. Chronic traumatic encephalopathy is a newly defined condition related to head trauma. Autopsies have shown this condition in some former athletes who had repeated concussions. The most dramatic findings have been among men who boxed or played football.
But what are the effects of head injuries that don't cause a concussion? A recent study published in the journal Neurology looked at this question. Based on cognitive testing and brain scans, a season of varsity college football or hockey increased the risk of memory and thinking problems. They all wore helmets, had no prior history of concussion and did not suffer a concussion during the season.
The potential to save lives with cancer screening has been widely promoted. And it's generally accepted as beneficial without risks. But there are risks that public health messages usually don't mention.
A recently published survey suggests that most doctors aren't telling people about the possible harms of cancer screenings. Only 9.5% of the surveyed adults said their doctors had told them that about the risks of over diagnosis and overtreatment. But 80% of them said they did want to be informed of the possible harms before having the screening test.
Cancer screening can lead to potentially invasive and expensive follow-up tests, biopsies and sometimes surgery for abnormal results that turn out not to be cancer. People also may get treatment for cancers that were unlikely to cause harm in their lifetimes.
Of the common cancer screening tests, experts disagree most about routine prostate cancer screening. In fact, now the general advice is for doctors NOT to order a blood test for PSA (prostate-specific antigen) without first discussing the pros and cons. And the highly respected United States Preventive Services Task Force advises against screening men at average risk of prostate cancer.
A mammogram every year or every other year has broader acceptance for women age 50 and older. But some studies suggest that life-saving benefits of mammography are overstated. And doctors rarely discuss the risks before they order a mammogram. The risks include finding spots that aren't cancer. Or the test could find spots that are cancerous but would never have caused harm if left untreated.
In contrast to prostate and breast cancer screening, more solid evidence supports screening for colorectal and cervical cancers.
The reason for this difference is that PSA tests and mammograms don't prevent cancer. They only detect early cancers. Colonoscopy and cervical cell sampling (Pap tests) detect more than just early cancers. They also detect polyps and pre-cancers. With removal or other treatment, cancer can actually be prevented.