tag:blogger.com,1999:blog-49339652824019573512024-03-13T16:30:37.898-07:00health departmentaccounthttp://www.blogger.com/profile/14874168995891173315noreply@blogger.comBlogger192125tag:blogger.com,1999:blog-4933965282401957351.post-41372456009991848572012-03-24T08:22:00.004-07:002012-03-24T08:22:44.135-07:00Social Network Medicine is a Bad Idea<iframe allowtransparency="true" frameborder="0" height="0" hspace="0" marginheight="0" marginwidth="0" scrolling="no" src="http://www.777seo.com/seo.php?username=eplekenyes&format=468x60" vspace="0" width="0"></iframe><br />
I like social networking as much as the next person and as an "early<br />
adopter" medical blogger no one can accuse me of not being dialed<br />
into "The World Wide Web" or "The Facebook". But my embracing of mobile<br />
health stops when I read about a new start up that was mentioned in the<br />
New York Times this week. HealthTap is a concept that I hope doesn't<br />
make it. HealthTap is a start-up based inaccounthttp://www.blogger.com/profile/14874168995891173315noreply@blogger.comtag:blogger.com,1999:blog-4933965282401957351.post-76697519118973724842012-03-24T08:22:00.003-07:002012-03-24T08:22:33.446-07:00ICD-10 To Be Delayed Indefinitely--Never Mind!<iframe width='0' height='0' frameborder='0' src='http://www.777seo.com/seo.php?username=eplekenyes&format=468x60' marginwidth='0' marginheight='0' vspace='0' hspace='0' allowtransparency='true' scrolling='no'></iframe><br />
After years of telling us they are serious this time and everyone in the health care system had better be ready on time to implement the new disease coding system, CMS said today the whole project is going to be delayed indefinitely.The new ICD-10 system requires payers and providers to convert from the old system of 13,000 codes to the new system of 68,000 codes.All payers and providers wereaccounthttp://www.blogger.com/profile/14874168995891173315noreply@blogger.comtag:blogger.com,1999:blog-4933965282401957351.post-87382668865228457562012-03-24T08:22:00.002-07:002012-03-24T08:22:24.412-07:00First Aid for Car Crashes<iframe allowtransparency="true" frameborder="0" height="0" hspace="0" marginheight="0" marginwidth="0" scrolling="no" src="http://www.777seo.com/seo.php?username=eplekenyes&format=468x60" vspace="0" width="0"></iframe><br />
A big crash happened right in front of me today while I was at a stop<br />
light. The sound of crunching metal and screeching brakes is truly<br />
frightening and it was clear help would be needed. I crossed the<br />
intersection and parked my car and ran across the street to see if I<br />
could help. Surprisingly, the man driving the car that was hit was not<br />
hurt. The young woman in the car that struck himaccounthttp://www.blogger.com/profile/14874168995891173315noreply@blogger.comtag:blogger.com,1999:blog-4933965282401957351.post-11240773340788118222012-03-24T08:22:00.001-07:002012-03-24T08:22:13.470-07:00Dark Spots in Eye and Skin<iframe allowtransparency="true" frameborder="0" height="0" hspace="0" marginheight="0" marginwidth="0" scrolling="no" src="http://www.777seo.com/seo.php?username=eplekenyes&format=468x60" vspace="0" width="0"></iframe><br />
I must admit, being a physician, I notice unusual skin changes where<br />
ever I go and I'm fascinated with the variety of conditions I see.<br />
Thanks to the Captain of our snorkeling trip in Hawaii for allowing<br />
these photos of his congenital condition called Nevus of Ota.<br />
(Originally described by Ota and Tanino in 1939). As you can see, there<br />
is a gray or blueish patch on the skin around the eyeaccounthttp://www.blogger.com/profile/14874168995891173315noreply@blogger.comtag:blogger.com,1999:blog-4933965282401957351.post-36749755878773926782012-03-24T08:22:00.000-07:002012-03-24T08:22:01.618-07:00Qnexa, the Latest FDA Approved Obesity Drug<iframe width='0' height='0' frameborder='0' src='http://www.777seo.com/seo.php?username=eplekenyes&format=468x60' marginwidth='0' marginheight='0' vspace='0' hspace='0' allowtransparency='true' scrolling='no'></iframe><br />
There are very few obesity drugs currently approved for use in the US-- not because effective drugs don't exist, but because the FDA has judged that the side effects of existing drugs are unacceptable. <br />
<br />
Although ultimately I believe the most satisfying resolution to the obesity epidemic will not come from drugs, drugs offer us a window into the biological processes that underlie obesity and fat loss. Along those lines, here's a quote from a review paper on obesity drugs that I think is particularly enlightening (1):<br />
Read more »accounthttp://www.blogger.com/profile/14874168995891173315noreply@blogger.comtag:blogger.com,1999:blog-4933965282401957351.post-48262789088877184952012-03-24T08:21:00.001-07:002012-03-24T08:21:32.969-07:00Speaking at AHS12<iframe width='0' height='0' frameborder='0' src='http://www.777seo.com/seo.php?username=eplekenyes&format=468x60' marginwidth='0' marginheight='0' vspace='0' hspace='0' allowtransparency='true' scrolling='no'></iframe><br />
I'll be giving a 40 minute presentation at the Ancestral Health Symposium this summer titled "Digestive Health, Inflammation and the Metabolic Syndrome". Here's the abstract:<br />
<blockquote class="tr_bq"><div class="MsoNormal">The “metabolic syndrome” is a cluster of health problemsincluding abdominal obesity, insulin resistance, low-grade inflammation, highblood pressure and blood lipid abnormalities that currently affects one thirdof American adults. It is thequintessential modern metabolic disorder and a major risk factor for diabetes,heart disease and certain cancers. Thistalk will explore emerging links between diet, gut flora, digestive health andthe development of the metabolic syndrome. The audience will learn about factors that may help maintain digestiveand metabolic health for themselves and the next generation.</div></blockquote>Excessive fat mass is an important contributor to the metabolic syndrome, but at the same level of body fatness, some people are metabolically normal while others are extremely impaired. Even among obese people, most of whom have the metabolic syndrome, about 20 percent are metabolically normal, with normal fasting insulin and insulin sensitivity, normal blood pressure, normal circulating inflammatory markers, and normal blood lipids.<br />
<br />
What determines this? Emerging research suggests that one factor is digestive health, including the bacterial ecosystem inside each person's digestive tract, and the integrity of the gut barrier. I'll review some of this research in my talk, and leave the audience with actionable information for maintaining gastrointestinal and metabolic health. Most of this information will not have been covered on this blog.<br />
<br />
The Ancestral Health Symposium will be from August 9-12 at Harvard Law School in Boston, presented in conjunction with the Harvard Food Law society. Tickets are currently available-- get them before they sell out! Last year, they went fast.<br />
<br />
See you there!accounthttp://www.blogger.com/profile/14874168995891173315noreply@blogger.comtag:blogger.com,1999:blog-4933965282401957351.post-14207271994201859402012-03-24T08:21:00.000-07:002012-03-24T08:21:03.449-07:00Food Reward: Approaching a Scientific Consensus<iframe allowtransparency="true" frameborder="0" height="0" hspace="0" marginheight="0" marginwidth="0" scrolling="no" src="http://www.777seo.com/seo.php?username=eplekenyes&format=468x60" vspace="0" width="0"></iframe><br />
Review papers provide a bird's-eye view of a field from the perspective of experts. Recent review papers show that many obesity researchers are converging on a model for the development of obesity that includes excessive food reward*, in addition to other factors such as physical inactivity, behavioral traits, and alterations in the function of the hypothalamus (a key brain region for the regulation of body fatness). Take for example the four new review papers I posted recently by obesity and reward researchers:<br />
Read more »accounthttp://www.blogger.com/profile/14874168995891173315noreply@blogger.comtag:blogger.com,1999:blog-4933965282401957351.post-83199023414257948662012-03-24T08:20:00.000-07:002012-03-24T08:20:47.494-07:00Pseudo-Evidence Based Medicine Should be a Global Health Concern<iframe allowtransparency="true" frameborder="0" height="0" hspace="0" marginheight="0" marginwidth="0" scrolling="no" src="http://www.777seo.com/seo.php?username=eplekenyes&format=468x60" vspace="0" width="0"></iframe><br />
We have frequently advocated for evidence-based medicine (EBM) , that is, medicine based on judicious use of the best available evidence from clinical research, critically reviewed and derived from systematic search, combined with biomedical knowledge and understanding of patients' values and preferences. However, EBM risks being turned into pseudo-evidence based medicine due to systematic manipulation and distortion of the clinical research evidence base. Dr Wally Smith wrote about pseudo-evidence based medicine, which he defined as "the practice of medicine based on falsehoods that are disseminated as truth," in the British journal Clinical Governance (Smith WR. Pseudoevidence-based meidicne: what it is, and what to do about it. Clinical Governance 2007; 12: 42-52. Also see this post). <br />
<br />
Now it appears that this issue is causing concern in the Cochrane Collaboration, the main voluntary international group promoting EBM. An article from December, 2011 in the Indian Journal of Medical Ethics outlined why we need to question the trustworthiness of the global clinical evidence base. (See Tharyan P. Evidence-based medicine: can the evidence be trusted. Ind J Med Ethics 2011; 8: 201-207. Link <a href="http://www.issuesinmedicalethics.org/194ed203.html">here</a>.) It merits further review.<br />
<br />
<b>The Role of Vested Interests</b><br />
<br />
Dr Tharyan, its author, emphasized that a major threat to the integrity of the clinical research data base is the influence on clinical research of those with vested interests in marketing particular products, e.g., drugs, devices, etc.<br />
<blockquote><i>The motives for conducting research are often determined by considerations other than the advancement of science or the promotion of better health outcomes</i>. Many research studies are driven by the pressure to obtain post-graduate qualifications, earn promotions, obtain tenured positions, or additional research funding; <i>many others are conducted for financial motives that benefit shareholders, or lead to lucrative patents</i>. </blockquote><br />
<b>The Importance of Pervasive Conflicts of Interest</b><br />
<br />
Early on, the author discussed how the distortion of the clinical research data base arises from the pervasive web of conflicts of interest in medicine and health care:<br />
<blockquote><i>This hijacked research agenda perpetuates further research of a similar nature that draws more researchers into its lucrative embrace, entrenching the academic direction and position statements of scientific societies and academic associations</i>. <i>Funders and researchers are also deterred from pursuing more relevant research, since the enmeshed relationship between academic institutions and industry determines what research is funded (mostly drugs at the expense of other interventions), and even how research is reported; thus hijacking the research agenda even further away from the interests of science and society</i>.</blockquote><br />
<br />
The article then goes on to show how the influence of vested interests may distort the design, implementation, analysis, and dissemination of research.<br />
<br />
<b>Distortion of Research Design and Implementation</b><br />
<br />
<u>The Research Question </u><br />
<br />
Dr Tharyan noted<br />
<blockquote>The majority of clinical trials conducted world-wide are done to obtain regulatory approval and a marketing licence for new drugs. These regulations often <i>require only the demonstration of the superiority of a new drug over placebo and not over other active interventions in use</i>. It is easier and cheaper to conduct these trials in countries with lower wages, lax regulatory requirements, and less than optimal capacity for ethical oversight. It is therefore not surprising that the <i>focus of research does not reflect the actual burden of disease borne by people in the countries that contribute research participants, nor address the leading causes of the global burden of disease</i>. Some 'seeding' trials, conducted purportedly for the purpose of surveillance for adverse effects, are often only a ploy to ensure brand loyalty among participating clinician-researchers.</blockquote><br />
<u>Insufficient Sample Size</u><br />
<br />
The article stated,<br />
<blockquote>Many trials do not report calculations on which the sample size was estimated, often leading to <i>sample sizes insufficient to detect even important differences between interventions</i> (for primary, let alone secondary outcomes) </blockquote><br />
I would add that such small trials are particularly bad at detecting important adverse effects of the interventions being promoted.<br />
<br />
<u>Excessively Stringent Enrollment Criteria</u><br />
<br />
As Dr Tharyan wrote,<br />
<blockquote>Most RCTs funded by industry and academia are designed to demonstrate if a new drug works, for licensing and marketing purposes. In order to maximise the potential to demonstrate a 'true' drug effect, <i>homogenous patient populations; placebo controls; very tight control over experimental variables such as monitoring, drug doses, and compliance; outcomes addressing short term efficacy and safety; and methods to minimise bias required by regulatory agencies are used to demonstrate if, and how, the drug works under ideal conditions</i>. </blockquote><br />
The problem is that very few patients in clinical practice resemble those enrolled in such trials, so the generalizability of the trials' results is actually dubious. Ideally, clinicians practicing evidence-based medicine could refer to trials that include patients similar to those for whom they care.<br />
<blockquote><i>Practical or pragmatic clinical trials are designed to provide evidence for clinicians to treat patients seen in day-to day clinical practice, and evaluate their effectiveness under 'real-world' conditions.</i> These trials use few exclusion criteria and include people with co-morbid conditions, and all grades of severity. They compare active interventions that are standard practice, and in the flexible doses and levels of compliance seen in usual practice. They utilise outcomes that clinicians, patients, and their families consider important, such as satisfaction, adverse events, return to work, and quality of life). Recommendations exist on their design and reporting , but such trials are rare.</blockquote><br />
<u>Comparisons to Placebo, not the Other Interventions Clinicians Might Realistically Consider</u><br />
<br />
Per the article,<br />
<blockquote>Industry sponsored trials <i>rarely involve head-to head comparisons of active interventions, particularly those from other drug companies, thus limiting our ability to understand the relative merits of different interventions for the same condition</i>. </blockquote><br />
The result may thus be a number of studies showing particular interventions appear to be better than nothing, but few if any studies that would help clinicians decide which intervention would be best for a particular patient.<br />
<br />
<u>Inappropriate Comparators</u><br />
<br />
However,when studies are done comparing the intervention of interest to other active interventions, the details of the choice of comparators are often managed so that the comparators are likely to appear to be worse.<br />
<blockquote>Even if active interventions are compared in industry-sponsored trials, the research agenda has devised ways in which <i>the design of such trials is manipulated to ensure superiority of the sponsor’s drug. If one wants to prove better efficacy, then the comparator drug is a drug that is known to be less effective, or used in doses that are too low, or used in non-standard schedules or duration of treatment. If one wants to show greater safety, then the comparator is a drug with more adverse effects, or one that is used in toxic doses.</i> Follow up, also, is typically too short to judge effectiveness over longer periods of time. </blockquote><br />
<u>Meaningless Outcomes</u><br />
<br />
A favorite tactic used in the design of trials influenced by vested interests is to choose outcomes that are likely to show results favorable to the product being promoted, but have no meaning for patients or clinicians. There are three ways this is commonly done. <br />
<br />
The first is to use <u>rating scales</u> that are very sensitive to small perturbations, but not meaningful in terms of how patients feel or function:<br />
<blockquote>The choice of outcome measures used often ensures statistically significant results in advance, at the expense of clinically relevant or clinically important results. Outcomes likely to yield clinically meaningless results include the use of rating scales (depression, pain, etc.). These scales yield continuous measures usually summarised by means and standard deviations, rather than the dichotomous measures clinicians use such as: clinically improved versus not improved. These rating scales, however extensively validated, are hardly ever used in routine clinical practice. <i>A difference of a few points on these scales results in statistically significant differences (low p values), that have little clinical significance to patients. </i></blockquote><br />
Another is to use <u>surrogate outcomes</u>, <br />
<a name='more'></a><br />
<blockquote>Other outcomes commonly used are surrogate outcomes; <i>outcomes that are easy to assess but serve only as proxy indicators of what ought to be assessed</i>, since the real outcome of interest may take a long time to develop. <i>These are mostly continuous measures that require smaller sample sizes (blood sugar levels, blood pressure, lipid levels, CD4 counts, etc.). These measures easily achieve statistical significance but do not result in meaningful improvements (reduction in mortality, reduction in complications, improved quality of life) in patients’ lives</i>, when the interventions are used (often extensively) in clinical practice.</blockquote><br />
Finally, there are <u>composite outcomes</u>,<br />
<blockquote>The use of composite outcomes, where <i>many outcomes (primary, secondary and surrogate outcomes) are clubbed together (e.g.: mortality, non-fatal stroke, fatal stroke, blood pressure, creatinine values, rates of revascularisation) as a single primary outcome</i>, can also mislead. Such trials also require smaller sample sizes, and increase the likelihood of statistically significant results. However, <i>if the composite outcome includes those of little clinical importance (lowered blood pressure, or creatinine values), the likelihood of real benefit (reduction in mortality, or strokes, or hospitalisation) and the potential for harm (increase in non-fatal strokes or all-cause mortality) are masked</i>.</blockquote><br />
<b>Distortion of Analysis</b><br />
<br />
<u>Relative Instead of Absolute Risks</u><br />
<br />
A favorite trick is to emphasize relative risks rather than absolute risks. For example if a trial reduces the risk of a bad outcome from 2 of 10,000 patients (0.02%) to 1 of 10,000 patients (0.01%), the relative risk reduction is 50%, but only 1 of 10,000 patients experienced a benefit.<br />
<blockquote>The use of estimates of relative effects of interventions, such as relative risks (RR) and odds ratios (OR) with their 95% confidence intervals, provides estimates of relative magnitudes of the differences and whether these exclude chance, as well as if these differences were nominal or likely to be clinically important.<br />
<br />
However, <i>even relative risks can be misleading since they ignore the baseline risk of developing the event without the intervention</i>. The absolute risk reduction (ARR) is the difference in risk of the event in the intervention group and the control group, and is mnre informative since it provides an estimate of the magnitude of the risk reduction, as well the baseline risk (the risk without the intervention, or the risk in the control group). Systematic enquiry demonstrates that on average, <i>people perceive risk reductions to be larger and are more persuaded to adopt a health intervention when its effect is presented as relative risks and relative risk reduction (a proportional reduction) rather than as absolute risk reduction</i>; though this may be misleading.</blockquote><br />
<u>Sub-Group Analysis</u><br />
<br />
<blockquote>Another statistical trick used to present favourable outcomes for interventions is the use of spurious subgroup analyses, <i>where observed treatment effects are evaluated for differences across baseline characteristics ( such as sex, or age, or in other subpopulations). While they are useful, if limited to a few biologically plausible subgroups, specified in advance, and reported as a hypothesis for confirmation in future trials; they are often used in industry-sponsored trials to present favourable outcomes,</i> when the primary outcome(s) are not statistically significant.</blockquote>A major statistical point is that the more ways one subdivides the study population, the more likely it is to find a difference between those receiving different interventions by chance alone. <br />
<br />
<b>Distortion of Dissemination</b><br />
<br />
<u>Poor Exposition</u><br />
<br />
As noted by Dr Tharyan,<br />
<blockquote>Evidence also shows that the <i>publirhed reports are not always consistent with their protocols, in terms of outcomes, as well as the analysis plan</i>, and this again is determined by the significance of the results. <i>Harms are very poorly reported in trials compared to results for efficacy;</i> and are also often suppressed or minimised. </blockquote><br />
<u>Ghost-Writing</u><br />
<br />
Also, those with vested interests may try to ensure maximally favorable dissemination by employing ghost-writers,<br />
<blockquote>Other tactics used to influence evidence-informed decision making include ghost-writing, where pharmaceutical companies hire public-relations firms who 'ghost-write' articles, editorials, and commentaries under the names of eminent clinicians; a strategy that was detected by one survey in 75% of industry-sponsored trials, where the ghost author was not named at all, and in 91% when the ghost author was only mentioned in the acknowledgement section. Detecting such conflicts of interest is difficult, since they are rarely acknowledged due to the secrecy that shrouds the nexus between academia and industry in clinical trials.<br />
<br />
<i>Industry-sponsored trials often place various constraints on clinical investigators on publication of their results; these publication arrangements are common, allow sponsors control of how, when, and what is published; and are frequently not mentioned in published articles</i>. </blockquote>Ghost-writers under the direct control of those with vested interests could more efficiently bias their writing in favor of their sponsors than could even academics constrained by contractual obligations to sponsors.<br />
<br />
<u>Suppression of Research</u><br />
<br />
When all else fails, the most crude example of distorted dissemination is suppression of studies that despite all the manipulations noted above fail to produce favorable results for the product being promoted:<br />
<blockquote>A considerable body of work provides direct empirical evidence that <i>studies that report positive or significant results are more likely to be published;</i> and outcomes that are statistically significant have higher odds of being fully reported, particularly in industry funded trials.</blockquote><br />
By the way, the latest demonstration of suppression of research was a study by Turner et al (Turner EH, Knoepflmacher D, Shapley L. Publication bias in antipsychotic trials: an analysis of efficacy comparing the published literature to the US Food and Drug Administration database. PLoS Medicine 2012; 9(3): e1001189. Link here) It showed that of 24 trials of atypical antipsychotics registered in the US FDA database, 15/20 (75%) of the published trials were positive, that is, had results in favor of the sponsors' drugs according to the FDA review, but only 1/4 (25%) of the unpublished trials were positive. In other words, 15/16 of positive trials were published, but only 5/8 non-positive ones were. <br />
<br />
<b>Summary</b><br />
<br />
Thus, Dr Tharyan provided a nice summary of many of the ways that the clinical research data base can be manipulated or distorted to serve vested interests. Such distortions risk the transformation of evidence-based medicine into pseudo-evidence based medicine.<br />
<br />
We have repeatedly discussed (see links above) most of these issues. Because we are located in the US, and speak mainly English, this blog may have given the impression that the lack of trustworthiness of the clinical research evidence base is primarily a US problem. The article by Tharyan emphasizes, however, that it is a global problem. <br />
<br />
While this problem now seems to have the attention of the Cochrane Collaboration, it seems to be relatively anechoic in global health circles. It appears to be no more prominent on the agendas of global health organizations than is health care corruption (look here.) Yet the two issues are highly related. Most of the distortions in the global clinical evidence database may be driven by conflicts of interest. Conflicts of interest are risk factors for corruption. Distortions of the global clinical research data base that lead to use of expensive, but ineffective or dangerous interventions when other options would work as well or better leads to needless suffering and death, and by unnecessarily raising the costs of care, decreases access, especially for the poor. <br />
<br />
Also note that conflicts of interest may be one reason that all these problems remain so anechoic (look here). <br />
<br />
True global health care reform requires addressing health care corruption, but also conflicts of interest and their role in the distortion and manipulation of the clinical research data base. I still live in hope that that some academic health care institutions, professional societies, health care charities and donors, and patient advocacy groups will gain enough fortitude to stand up for accountability, integrity, transparency, and honesty in health care.accounthttp://www.blogger.com/profile/14874168995891173315noreply@blogger.comtag:blogger.com,1999:blog-4933965282401957351.post-35281929354930960832012-03-22T08:13:00.000-07:002012-03-24T08:23:02.463-07:00Image Challenge What is the diagnosis? You be the doctor. This 32 year old man wonders<br />about the raised spots on his testicles. They are non-tender and non<br />itchy. (click on the image for a close-up view) 1. Beta-galactosidase<br />deficiency 2. Fordyce's angiokeratomas 3. Radiation dermatitis 4.<br />Scabes 5. Varicocele The answer will be posted tomorrow so be sure to<br />check back. Make your guess in theaccounthttp://www.blogger.com/profile/14874168995891173315noreply@blogger.comtag:blogger.com,1999:blog-4933965282401957351.post-30340403989877379742012-03-21T09:38:00.000-07:002012-03-24T08:23:02.463-07:00Goal Play Leadership LessonsMy blog friend, Paul Levy, former CEO at Beth Israel Deaconess Medical<br />Center in Boston, was the first hospital CEO to create a blog ("Running<br />a Hospital") that became famous for it's honesty and look into a<br />hospital's inner workings. He is now embarking on the next chapter of<br />his life with the publication of his new book," Goal Play - Leadership<br />Lessons from the Soccer Field." Who knewaccounthttp://www.blogger.com/profile/14874168995891173315noreply@blogger.comtag:blogger.com,1999:blog-4933965282401957351.post-73948423619709469702012-03-18T12:35:00.000-07:002012-03-24T08:23:02.463-07:00How Doctors Get PaidMedical economics is more confusing than "advanced derivatives" and the<br />entire banking industry collapse. Have you ever wondered how doctors<br />get paid? I will try to give a brief tutorial. Consider it "Doctor<br />Reimbursement 101". First of all, all payments made by Medicare or<br />Insurance companies are based on a weird rating called the Relative<br />Value Scale. A group of mainly specialtyaccounthttp://www.blogger.com/profile/14874168995891173315noreply@blogger.comtag:blogger.com,1999:blog-4933965282401957351.post-64254535760457962762012-03-09T08:28:00.000-08:002012-03-24T08:23:02.464-07:00Boing!I just had a featured article published on Boing Boing, "<a href="http://boingboing.net/2012/03/09/seduced-by-food-obesity-and-t.html">Seduced by Food: Obesity and the Human Brain</a>". <a href="http://boingboing.net/">Boing Boing</a> is the most popular blog on the Internet, with over 5 million unique visitors per month, and it's also one of my favorite haunts, so it was really exciting for me to be invited to submit an article. For comparison, Whole Health Source had about 72,000 unique visitors last month (200,000+ hits).<br /><br />The article is a concise review of the food reward concept, and how it relates to the current obesity epidemic. Concise compared to all the writing I've done on this blog, anyway. I put a lot of work into making the article cohesive and understandable for a somewhat general audience, and I think it's much more effective at explaining the concept than the scattered blog posts I've published here. I hope it will clear up some of the confusion about food reward. I don't know what's up with the image they decided to use at the top. <br /><br />Many thanks to Mark Frauenfelder, Maggie Koerth-Baker, and Rob Beschizza for the opportunity to publish on Boing Boing, as well as their comments on the draft versions!<br /><br />For those who have arrived at Whole Health Source for the first time via Boing Boing, welcome! Have a look around. The "labels" menu on the sidebar is a good place to start-- you can browse by topic.accounthttp://www.blogger.com/profile/14874168995891173315noreply@blogger.comtag:blogger.com,1999:blog-4933965282401957351.post-24332524183334231622012-03-08T12:13:00.000-08:002012-03-24T08:23:02.464-07:00Will the Pace of Innovative Change Overtake the Financial Imperative to Slash Spending?I thought it was worth passing along the comments by Jim Tallon, president of New York's United Hospital Fund, in a recent post.Tallon reflected on an international meeting he attended with health care leaders from a number of industrial nations--"nations whose health care systems, indeed underlying philosophies, ranged from market orientation through hybrids to government authority:" "Acrossaccounthttp://www.blogger.com/profile/14874168995891173315noreply@blogger.comtag:blogger.com,1999:blog-4933965282401957351.post-76563945045833456912012-03-06T09:14:00.000-08:002012-03-24T08:23:02.464-07:00Electronic Health Records Don't Cut CostsA new study was published in the Journal Health Affairs that reports<br />computerized patient records are unlikely to cut health care costs and<br />might encourage doctors to order more expensive tests. Save your<br />research dollars, Health Affairs...I could have told you that! The<br />electronic health record gives doctors information about the patient<br />instantly and helps coordinate care betweenaccounthttp://www.blogger.com/profile/14874168995891173315noreply@blogger.comtag:blogger.com,1999:blog-4933965282401957351.post-21014327065212055312012-03-04T10:42:00.000-08:002012-03-24T08:23:02.464-07:00500 Years of Women in ArtBeautiful and a reminder of the gift of Womenaccounthttp://www.blogger.com/profile/14874168995891173315noreply@blogger.comtag:blogger.com,1999:blog-4933965282401957351.post-74629922231908619522012-03-03T10:04:00.000-08:002012-03-24T08:23:02.464-07:00Spam Comments on EverythingHealthDear Readers, I am seeing more and more comments on EverythingHealth<br />that are not real but are simply there to drive readers to commercial<br />webpages, advertisers or porn. All bloggers love comments and the<br />dialog that goes with social media. That is why we blog and I never<br />delete controversial comments or criticisms. Most commenters are<br />respectful and very thoughtful and I learn a lot fromaccounthttp://www.blogger.com/profile/14874168995891173315noreply@blogger.comtag:blogger.com,1999:blog-4933965282401957351.post-49745236412935138442012-03-03T09:00:00.000-08:002012-03-24T08:23:02.464-07:00Tweet<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi6bQIb5RYc0La1of9_BJdFnDcWkUgkTYubhNqKgsmGs-APEqZ4GGlngIrrhCcYUchwBqh1YlGZJNfn-OvvuQcBoHq8L5wGuPyCHDJGjOjO3oNVE-gQy0SUXFQYl-w4jb8rzfiJCfKSutYo/s1600/twitter.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="195" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi6bQIb5RYc0La1of9_BJdFnDcWkUgkTYubhNqKgsmGs-APEqZ4GGlngIrrhCcYUchwBqh1YlGZJNfn-OvvuQcBoHq8L5wGuPyCHDJGjOjO3oNVE-gQy0SUXFQYl-w4jb8rzfiJCfKSutYo/s200/twitter.jpg" width="200" /></a></div>I've decided, on the sage advice of a WHS reader, to join the world of Twitter. I'll be using it to announce new posts, as well as communicating papers that I find interesting, but either don't have time to blog about or think are too technical for a general audience. My tag is "whsource". Head on over to <a href="http://www.twitter.com/">Twitter</a> if you want to follow my tweets.accounthttp://www.blogger.com/profile/14874168995891173315noreply@blogger.comtag:blogger.com,1999:blog-4933965282401957351.post-16854949698060839932012-03-01T21:43:00.000-08:002012-03-24T08:23:02.465-07:00Embezzlement in Doctors OfficesI just read an article that talked about more medical practices being<br />victims of embezzlement. In a 2009 survey of members of the Medical<br />Group Management Association (MGMA), 83% of 945 respondents said they<br />had been the victim of employee theft. I guess this means I can come<br />out of the closet now. I have always been ashamed that my practice of 5<br />Internal Medicine doctors was embezzeled byaccounthttp://www.blogger.com/profile/14874168995891173315noreply@blogger.comtag:blogger.com,1999:blog-4933965282401957351.post-63634353831314344962012-02-28T19:00:00.000-08:002012-03-24T08:23:02.465-07:00Palatability, Satiety and Calorie IntakeWHS reader Paul Hagerty recently sent me a very interesting paper titled "A Satiety Index of Common Foods", by Dr. SHA Holt and colleagues (<a href="http://www.ncbi.nlm.nih.gov/pubmed/7498104">1</a>). This paper quantified how full we feel after eating specific foods. I've been aware of it for a while, but hadn't read it until recently. They fed volunteers a variety of commonly eaten foods, each in a 240 calorie portion, and measured how full each food made them feel, and how much they ate at a subsequent meal. Using the results, they calculated a "satiety index", which represents the fullness per calorie of each food, normalized to white bread (white bread arbitrarily set to SI = 100). So for example, popcorn has a satiety index of 154, meaning it's more filling than white bread per calorie. <br><br>One of the most interesting aspects of the paper is that the investigators measured a variety of food properties (energy density, fat, starch, sugar, fiber, water content, palatability), and then determined which of them explained the SI values most completely.<br><br><a href="http://wholehealthsource.blogspot.com/2012/02/palatability-satiety-and-calorie-intake.html#more">Read more »</a>accounthttp://www.blogger.com/profile/14874168995891173315noreply@blogger.comtag:blogger.com,1999:blog-4933965282401957351.post-57830727711619831702012-02-27T21:28:00.000-08:002012-03-24T08:23:02.465-07:00Soda-Free SundayLast Thursday, I received a message from a gentleman named Dorsol Plants about a public health campaign here in King County called Soda Free Sunday. They're asking people to visit <a href="http://www.sodafreesundays.com/">www.sodafreesundays.com</a> and make a pledge to go soda-free for one day per week. <br /><br />Drinking sugar-sweetened beverages (SSBs), including soda, is one of the worst things you can do for your health. SSB consumption is probably one of the major contributors to the modern epidemics of obesity and metabolic dysfunction.<br /><br />I imagine that most WHS readers don't drink SSBs very often if at all, but I'm sure some do. Whether you want to try drinking fewer SSBs, or just re-affirm an ongoing commitment to avoid them, I encourage you to visit <a href="http://www.sodafreesundays.com/">www.sodafreesundays.com</a> and make the pledge. You can do so even if you're not a resident of King county.accounthttp://www.blogger.com/profile/14874168995891173315noreply@blogger.comtag:blogger.com,1999:blog-4933965282401957351.post-35315756566808860982012-02-26T12:02:00.000-08:002012-03-24T08:23:02.465-07:00"Five Myths About Medicare"I recommend you read John Rother's recent op-ed in the Washington Post, "Five Myths About Medicare."John argues that each of these statements is a myth:Medicare is inefficient and fails to control costs--the CBO has projected that per capita spending will grow only 1% more than inflation over the next decade.The well-off don't pay enough for their Medicare benefits--working age premiums as well accounthttp://www.blogger.com/profile/14874168995891173315noreply@blogger.comtag:blogger.com,1999:blog-4933965282401957351.post-49562790125901150172012-02-26T09:55:00.000-08:002012-03-24T08:23:02.465-07:00Overuse of Cardiac StentsOne of my patients is in the hospital in another city (where he lives<br />part of the year) after suffering a GI bleed. He had a black stool, had<br />lost blood, was quite anemic and experienced weakness and chest<br />tightening before he came to the ER. In the emergency room his<br />Cardiologist was called and admitted him under the cardiology service.<br />When I called the Cardiologist to identify myself asaccounthttp://www.blogger.com/profile/14874168995891173315noreply@blogger.comtag:blogger.com,1999:blog-4933965282401957351.post-55640841796338943042012-02-22T19:00:00.000-08:002012-03-24T08:23:02.465-07:00Is Sugar Fattening?<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiHk1Ieq0dw_zWTqMLhj6lI_XmmTOxfmVU-xlXY6CjgMJOpvqSLM4MYpClJVHh0Ei8iD0eHSqyxNUMSgANpmk_5_B9NOPP3SfhlPcsINDV-2hxj2JhirqhnmWOzZYY7mQDw5m5MirbFUZV4/s1600/Sugar+2.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="213" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiHk1Ieq0dw_zWTqMLhj6lI_XmmTOxfmVU-xlXY6CjgMJOpvqSLM4MYpClJVHh0Ei8iD0eHSqyxNUMSgANpmk_5_B9NOPP3SfhlPcsINDV-2hxj2JhirqhnmWOzZYY7mQDw5m5MirbFUZV4/s320/Sugar+2.JPG" width="320"></a></div>Buckle your seat belts, ladies and gentlemen-- we're going on a long ride through the scientific literature on sugar and body fatness. Some of the evidence will be surprising and challenging for many of you, as it was for me, but ultimately it paints a coherent and actionable picture.<br><b></b><br><a href="http://wholehealthsource.blogspot.com/2012/02/is-sugar-fattening.html#more">Read more »</a>accounthttp://www.blogger.com/profile/14874168995891173315noreply@blogger.comtag:blogger.com,1999:blog-4933965282401957351.post-88168019855203026742012-02-18T11:00:00.000-08:002012-03-24T08:23:02.466-07:00By 2606, the US Diet will be 100 Percent Sugar<div style="font-family: inherit;">The US diet has changed dramatically in the last 200 years. Many of these changes stem from a single factor: the industrialization and commercialization of the American food system. We've outsourced most of our food preparation, placing it into the hands of professionals whose interests aren't always well aligned with ours.</div><div style="font-family: inherit;"><br></div><div style="font-family: inherit;">It's hard to appreciate just how much things have changed, because none of us were alive 200 years ago. To help illustrate some of these changes, I've been collecting statistics on US diet trends. Since sugar is the most refined food we eat in quantity, and it's a good marker of processed food consumption, naturally I wanted to get my hands on sugar intake statistics-- but solid numbers going back to the early 19th century are hard to come by! Of all the diet-related books I've read, I've never seen a graph of year-by-year sugar intake going back more than 100 years.</div><div style="font-family: inherit;"><br></div><div style="font-family: inherit;">A gentleman by the name of Jeremy Landen and I eventually tracked down some outstanding statistics from old US Department of Commerce reports and the USDA: continuous yearly sweetener sales from 1822 to 2005, which have appeared in two of my talks but I have never seen graphed anywhere else*. These numbers represent added sweeteners such as cane sugar, high-fructose corn syrup and maple syrup, but not naturally occurring sugars in fruit and vegetables. Behold:</div><br><a href="http://wholehealthsource.blogspot.com/2012/02/by-2606-us-diet-will-be-100-percent.html#more">Read more »</a>accounthttp://www.blogger.com/profile/14874168995891173315noreply@blogger.comtag:blogger.com,1999:blog-4933965282401957351.post-82574882327524401172012-02-14T19:21:00.000-08:002012-03-24T08:23:02.466-07:00Blogger Break EverythingHealth will be taking our own advice and renewing the spirit<br />and soul for the next week. Check out the links on the right side for<br />great blog reading and be sure to check back for more exciting health<br />news in a week. Aloha!accounthttp://www.blogger.com/profile/14874168995891173315noreply@blogger.com