What Really Makes You Fat? Should you count calories or carbs? The latest research may surprise you - Well written and balanced article. And in the same issue, a debate between Atkins and Ornish - Low Fat vs. Low Carb The doctors present their dueling diet theories:. Atkins says,

For over 30 years, I've been a lone voice in the wilderness. I am grateful that the National Institutes of Health is now examining controlled-carbohydrate and low-fat nutrition. These studies may end up showing that excessive carbohydrates are the true culprits, not fat. At what point am I allowed to say, "I told you so"?

I have written about that frequently over the past months. Ornish responds,

Here's how you lose weight: burn more calories. Eat fewer calories. That's it.

You can burn more calories by exercising. You can eat fewer calories by consuming less food. You can lose weight on any diet, but it is hard to keep the pounds off because you feel hungry and deprived. An easier way to consume fewer calories is to eat less fat, because there are nine calories in each gram of fat, whereas protein and carbohydrates have only four. So eating less fat allows you to consume fewer calories without eating less food.

I agree with the high-protein advocates that it is wise to eat fewer simple carbohydrates, like sugar, white flour and white rice. They are also low in fiber, so you get a lot of calories that don't fill you up. On top of that, simple carbohydrates get absorbed quickly, causing your blood sugar to zoom up. Your body responds by making more insulin, but too much insulin accelerates conversion of calories into body fat.

The goal, however, is not to go from simple carbohydrates to bacon and brie. Instead you should opt for whole foods with complex carbohydrates such as unrefined whole-wheat bread, brown rice, fruits, vegetables and beans. These are packed with thousands of protective substances. In addition, they are rich in fiber, which slows their absorption, thus preventing a spike in your blood sugar and an excessive insulin response.

They really are not that far apart. This is a good reference.

Spot Reduction? Forget It! Wisdom from a runner.

What should you eat? What should you avoid? Are there 'forbidden foods'? Clearing up nutrition nonsense - Many people mistakenly focus on ‘forbidden’ foods: survey

This new survey suggests that consumers may place an over-emphasis on weight control. Sixty-three percent consider body weight an indicator of healthful eating. Research shows that the increase in obesity in our country reflects an increase in extra-large portion sizes, an excess proportion of high-fat and high-sugar foods in our diets, much too low consumption of fruits and vegetables, and lifestyles that are too often sedentary. But this does not mean that as long as someone’s weight is OK, they must be eating well.

Unfortunately, diet books and advice on the Internet may encourage a variety of food choices quite contrary to what research shows to be healthy eating. If a weight-loss diet results in lost weight — usually because it involves consuming fewer calories — that doesn’t mean it supports overall well-being.

Another misconception is reflected in a statement agreed to by 57 percent of the people surveyed: “I believe there are some foods that I should never eat.” Past surveys showed that increasing numbers of people supported the belief that all foods can fit into a healthful diet, that it’s a matter of the proportion different foods play in our diet rather than being “bad” or good.” But clearly, according to the most current survey, many people still don’t believe that.

Epidemic That Wasn't tells the story of the lack of a Long Island breast cancer epidemic!

For years, it has been widely thought that rates of breast cancer on Long Island are unusually high. But, contrary to popular belief, they are not. The rates on Long Island are not much different from those of the rest of the country — and a number of areas in the Northeast and elsewhere have higher rates.

But the perception of an epidemic has persisted like a suburban legend. Figures that scientists say have no basis in fact, like a breast cancer rate that is 30 percent higher than the national average, have been bandied about at public meetings, and repeated by breast cancer patients, politicians and newspapers, including The New York Times.

So we spent millions of dollars studying this urban myth. Once an activist group believe something, they do no easily accept data.

But Dr. Michael B. Bracken, a professor of epidemiology and public health at Yale University, says the study should never have begun. "It is an example of politicians jumping on the bandwagon and responding to the fears of their local population without really thinking through what is going on in science," he said. Such a study, he added, "is not so much science as a political response."

The study's scientists, in the meantime, find themselves trying to appease two masters, other researchers and breast cancer activists.

Politicians should not make research policy. The squeaky wheel should not make research policy. But I do not live in an ideal world. The NY Times comments today - Breast Cancer Mythology on Long Island

I usually leave malpractice links to medpundit and RangelMD, but this one is so good that I wanted to share it - A plague spread by fee-bitten lawyers. I know the arguments - the patient was injured by the evil medical system. How can we value and limit the financial 'penalty'? Juries do not care, because in their case they believe the insurers, doctors and hospitals have deep pockets. Unfortunately, we need polticians to step up like they did in California. Each suit (even the many unsuccesful suits) damages our health care system - raising costs for patients. Physicians really want to care for patients, that is why we chose medicine. The unintended consquence here is scary.

Maybe we ought to start putting labels on some lawyers, like the kind on the side of cigarette packs: "Warning: Immense jury awards can be dangerous to obstetric care and trauma centers."

...

California's example needs to be emulated, for health's sake. Mississippi's governor, Ronnie Musgrove, is expected to call a special session of that state's legislature to do something about the out-of-sight costs of medical malpractice insurance in his state. Nobody is trying to limit awards for actual damages, but punitive damages are now damaging the public health most of all.

The Bush administration has tried to get Congress' attention as this medical/legal crisis developed. It suggested limiting out-of-control jury awards, but was stymied by the Democrats in the Senate.

When one party has been largely captured by a special interest — in this case, the trial lawyers' lobby — the chances for reform begin to resemble those of a poor patient in urban Philadelphia or rural Mississippi.

Let's hope the Senate gets another chance to cap jury awards beyond actual damages — before more obstetricians take down their shingles, and more hospitals shut down vital services.

In the meantime, the prognosis for reform remains poor. Not every plague, it turns out, is the result of micro-organisms. This one is spread by lawyers.

Well said!

As long time readers know, I worship at the altar of data. I want to know truth not theory. We have preached for years that stretching prevents muscle injuries. Stretching 'fails to stop muscle injury'

These showed that stretching reduces soreness by such a small amount that most athletes would not consider the effect worthwhile. Neither does it significantly help to prevent injuries.

Data from two studies on army recruits in training, whose risk of injury is high, show that muscle stretching prevented on average one injury every 23 years.

...

Researcher Dr Rob Herbert, from the University of Sydney, told BBC News Online the belief that stretching reduced injury first came to prominence in the 1960s.

The theory was that muscles were more likely to spasm, and cause pain, if they were suddenly called into vigorous action.

Dr Herbert said: "It sounded like a good idea, and the timing was perfect - around the time we were learning that physical activity reduced risk of heart disease, so recreational exercise was becoming very popular.

"But like many good ideas, the muscle spasm theory of muscle soreness was wrong and has since been discredited, but the practice of stretching before exercise persists."

Dr Herbert said it was possible that a gentle warm up before strenuous exercise may reduce the risk of injury - but even this was far from certain.

"There is no proven way of preventing muscle soreness associated with unaccustomed exercise apart from repeated performance of that specific type of exercise.

"With unaccustomed exercise, people get sore, but with repeated performance of the exercise they become resistant, for a time, to the muscle damage that causes soreness.

"It appears that the only way to prevent soreness is to get muscle soreness."

For those who like reading the original article - Effects of stretching before and after exercising on muscle soreness and risk of injury: systematic review

After writing about the probable benefits of B complex vitamins for heart disease, I find this article from Great Britain - Warning on vitamin use

Taking extra vitamins is unnecessary for most people and may be harmful if taken in large quantities, a health watchdog has decided.

The Food Standards Agency has confirmed that if people eat a healthy, balanced diet, they should not need to take supplements as well.

Recommended upper safety limits:

• Vitamin B6 - 10 milligrammes/day


• Beta-carotene - 7 mg/day


• Vitamin E - 7.27mg/day


• Copper - 5mg/day


• Zinc - 25 mg/day


• Selenium - 0.2 mg/day


• Silicon - 1,500 mg/day


• Nickel - 0.16mg/day


• Boron - 5.93mg/day

The agency has issued recommended safety limits on nine commonly used vitamins and mineral supplements amid concerns that consumers are potentially putting themselves at risk from overuse.

The list includes Vitamins E and B6, zinc, copper, nickel, silicon, beta-carotene, boron and selenium.

We learn early in medicine that when a bit of something helps, more does not necessarily help more. One aspirin a day helps prevent heart attacks. Many aspirins can cause bleeding. Most drugs have "therapeutic windows". I suspect this is true for vitamins.

The good and bad of going over-the-counter Physicians often have mixed feelings about drugs going OTC. This article gives a nice balance and puts the decision into appropriate perspective. I will briefly discuss 2 drug classes.

Women can now self treat for candida vaginitis. Most women know when they have it, and the treatment usually works well. However, other infections can cause vaginitis. Some vaginitis is not infectious. So some women will waste money and time by self treating incorrectly.

Proton pump inihibitors (Prilosec, Prevacid, Aciphex and the hated Nexium) are a class of drugs which inhibit acid secretion in the stomach. The give relief to ulcers, simple gastritis, and most important GERD (gastroesophageal reflux disease - known to most as the disease associated with heartburn). We already have the histamine 2 blockers OTC (Tagament, Pepcid, Zantac) for these conditions. PPIs work better. So what is my concern? Heartburn or abdominal pain may herald a more serious condition. I believe that my history taking would give me some clues to evaluating some patients further. Gastroenterologists see the worse cases of GERD - which often have complications like stricture or even cancer. If patients self treat for years, they may miss the opportunity for better diagnosis and treatment. On the other hand, OTC equals lower prices for PPIs. The article gives the right balance. I do want OTC Prilosec, but I want patients to still talk to me about the problem periodically.

Poor prescriptions for health prospects

But this private American industry of miracle-makers and lifesavers is now under assault from all directions. Many people apparently want the miracle medicines without paying for them, or paying nearly enough to keep them coming.

Charlatans are rushing forward to posture themselves on a high moral pedestal as the champions of the poor, the sick, and the needy in attacking the pharmaceuticals. But all these self-appointed saviors have never produced one drug or medicine that has ever benefited anyone.

This has been reflected in the still pending congressional debate over a Medicare prescription drug plan. The Senate bill would allow unrestricted importation of American-made drugs from Canada, purchased under Canada's price controls. Moreover, even in the U.S., Medicare reimbursement under the pending plans would fall far short of market prices.

Such provisions would drastically reduce the revenue flow to the pharmaceuticals. That would in effect sharply slash the nation's true budget for research and development of miracle drugs.

Solid profits on the drugs that work are necessary for a time to make the whole process of modern biomedical drug development viable. The research and development is highly expensive, an average of $800 million for each new drug, and the investment in it is very long term, for it takes well more than 10 years for a successful research effort to start making any money.

Pardon me while I hyperventilate. The pharmaceutical industry has good features. New drug classes often help patients greatly. I and most physicians greatly appreciate the advances of the last quarter century - statins, ACE inhibitors, ARBs, quinolones, proton pump inhibitors, etc. What this guy ignores is the greed of some companies. They deserved a good return on Prilosec. They have no excuse for Nexium. Likewise Claritin and Clarinex. They do not need to raise prices each year at a greater percentage than the cost of living. I favor the free market, but this is not the free market.

Nightmare of crack nicotine

Drug Cos. Seek Ban on Price Lists.

A coalition of drug makers sued Health and Human Services Secretary Tommy Thompson for approving Michigan's 6-month-old "preferred drug list" program for Medicaid recipients.

Medications can only get on the list if its manufacturer agrees to offer the drug at a steep discount. If doctors want to prescribe a drug not included on the list, they must get prior approval from the state.

"State programs that restrict access, we feel, violate federal law and can result in harmful consequences to the country's most vulnerable patients," said Jan Faiks, a lawyer for the Pharmaceutical Research and Manufacturers of America or PhRMA.

PhRMA wants U.S. District Court Judge John Bates to stop Michigan's program and similar initiatives in other states. Florida and Louisiana also have the preferred drug list programs, while Connecticut, Missouri, Hawaii, Illinois, Minnesota, Mississippi, New Mexico, North Carolina, Ohio, Vermont and West Virginia are in various stages of implementing such programs, according to PhRMA.

'Spokesmen for the Department of Health and Human Services and the Michigan's Department of Community Health declined to comment on the hearing Wednesday. ' And I refuse to comment.

Depression and diabetes often occur together. Data have shown that depression complicates diabetes, and patients with both have worse outcomes than those with diabetes alone. Fighting depression can help diabetics

More aggressively treating depression in diabetics could dramatically improve their physical health, too, research presented to the American Psychological Association's annual gathering here found.

Twenty million Americans have diabetes. That number is on the rise, and about a third of diabetics have significant depression.

Diabetes doubles a person's odds of suffering from depression, and those who have diabetes are more likely to have major depression.

New studies suggest that treating depression could ease the current epidemic of diabetes, said psychologist Patrick Lustman of Washington University School of Medicine in St. Louis, adding that the strong potential for using depression treatment to also improve diabetics' physical health ''has hardly been tapped.''

...

In seven controlled studies by his team, depression treatment worked for a majority of the diabetics. Most important, as depression eased, the glucose in the patients' blood became better controlled. That's a key factor in preventing the effects of diabetes, Lustman said.

Six of the seven studies used antidepressants. But the seventh, employing what's known as cognitive behavioral therapy, showed the highest success rate, 85 percent, and produced the greatest improvement in glucose control, Lustman said.

The therapy seems to work best because it often spurs physical activity, which helps with both the depression and the diabetes, he said.

Now could we possibly convince insurers to pay for depression care. Mental health disorders receive short shrift regualarly from insurance companies. They do not consider that treating depression might be cost saving!

When you study tobacco addiction, you find astonishing features. Animal studies suggest nicotine is more addicting than heroin. When you talk to patients, and really try to understand the effects of that addiction, you should feel empathy, as withdrawal is like leaving your best friend.

Cigs Ensnare Some Teens Quickly. This story reports on evidence that not only is nicotine withdrawal difficult, for some teenagers addiction comes easy. Everything about this addiction drives me nuts. I have seen patiens smoke through tracheostomies (made after there laryngectomy for a smoking related cancer). Patients often smoke while on home oxygen. Patients argue with me about going outside in the winter to smoke - even after a myocardial infarction or during an exacerbation of their chronic lung disease. AAAARRRRRRGGGGGHHHHH!

Norah Vincent (quickly becoming one of my favorites) writes about psychiatry - Norah on psychiatry - today. For both of these links you need to scroll to the correct day. She finishes with this inspiring paragraph

Psychiatry is something of a racket if you ask me. You’re never better. You’re never cured. There’s no discernable, or at least measurable progress, except with pills, which is, to my mind, all psychiatrists are really good for. And if you tell them you want to stop seeing them because you’re going broke on their fees, they always tell you it’s really just that you’re trying to leave them before they leave you. Abandonment issues, don’t you know. If you tell them they’re wrong, you’re simply in denial. If you tell them they’re idiots, that’s projection. It’s endless tail-chasing fit only for the hopelessly narcissistic who get their kicks out of being in a perpetual state of high-toned “sickness.” Crazy, sexy, cool, or something like that. Talk about emblematic of an age. Jesus.

In a completely different vein, the Bloviator addressed the issue of the uninsured yesterday 8/27/02. He writes dispassionately about our health insurance problems. Read what he says, and the political link.

Seven Weight Loss Resolutions That Really Work. I actually see myself in each of these resolutions. Could you transform yourself into using them?

The Other Deadly Threat

Congress has been shoveling the lion's share of new health research dollars into programs to strengthen the nation's bulwarks against biological and chemical terrorism.

In recent weeks, however, the new director of the Centers for Disease Control and Prevention has been rightly trying to drum up support for more funding to fight other ominous public health threats: the rapid rise of infectious diseases and chronic diseases in recent years.

Dr. Gerberding has it right. Physicians and epidemiologists should set priorities, not politicians. We should analyze the data, listen to experts and then set priorities. Our spending reflects sound bites, campaigning and rhetoric - and this is not a new problem!

Exercise tips have interesting twists. This well written review makes two outstanding points. First, the book's author compares (appropriately) the effects of aging to the effects of weighlessness.

The first twist, as intriguing as it is relatively new, is that aging appears to have much in common with space travel. Evans, an adviser to NASA and former head of a special nutrition and physical fitness team for the National Space Biomedical Institution in Houston, is now running a study to figure out what exercises can best protect astronauts' bones and muscles during a Mars mission, likely to occur in 2013 or 2018.

Indeed, writes Evans, prolonged space flight in near-zero gravity results in remarkable physical changes within the body that are astonishingly similar to our journey into old age. In fact, he says, within weeks of blasting off, the astronauts' muscle cells will atrophy, calcium will be leached from their bones, and normal bone growth will be upset to the point where the risk of fracture soars. Recent research, he says, has determined that one month of space flight yields bone loss equivalent to five years of aging. By Evans's calculations, this means that with their muscles and bones weakened by gravity deprivation, even young, healthy astronauts may become as weak as most 80-year-olds.

Second, he focuses on our technique in weight lifting. He champions the eccesntric rather than the concentric (most readers are now wondering what language I'm typing). Let the article explain,

Evans's exercise prescription (for all of us, not just astronauts and research volunteers) focuses on eccentric (which means away from the body, not weird) muscle movements, as opposed to concentric (or toward-the-body) moves. The idea, which is contrary to the way most muscle builders work out, is that it's the away-from-the-body motion that strengthens muscles most quickly.

Take a biceps curl. When you start with a dumbbell at thigh level and raise it to your shoulder, the raising, or upward-bound, part of the motion is considered concentric; the lowering of the weight back down is eccentric, or as Evans prefers, E-centric. Muscles grow in bulk by undergoing microscopic tears during training; it is during the repair of these tears that muscles increase in size.

And it's E-centric motions that produce the most microscopic tears, hence the most muscle growth. The secret, Evans says, is to raise a weight (or move the business end of an exercise machine) quickly, to a count of two, on the concentric motion and lower it slowly, away from the body, to a count of six, in other words, taking three times as long on the eccentric maneuver.

The book is called AstroFit. I just might buy it.

I was working with residents in clinic yesterday afternoon. One of them presented an anxious 41 year old woman, whose sister had a myocardial infarction at age 41. We were discussing how we would screen her, and what prophylaxis to recommend. A cholesterol panel was an easy choice. We decided to add a C-reactive protein measurement, reasoning that if she had an elevated level, we would add a statin even if her cholesterol measurements were unremarkable. An aspirin a day made sense, then I suggested that we consider a multivitamin which included folate. I based this on some suggestive data about homocysteine as a potential risk factor. So this morning in my browsing I find this article - Vitamin regimen shown helpful to heart patients

A six-month regimen of folic acid, vitamin B12 and vitamin B6 can help prevent recurrence of blocked arteries in patients who have undergone coronary angioplasty.

That's the key finding of a new study, being reported in today's Journal of the American Medical Association, that a top cardiologist says offers further evidence that B vitamins are important in maintaining healthy blood vessels.

...

The vitamin regime decreased by 38 percent the need for repeat angioplasties or coronary bypass operations.

The treatment appears to work by lowering levels of homocysteine, an amino acid long implicated in heart attacks.

To read the primary article in JAMA - Effect of Homocysteine-Lowering Therapy With Folic Acid, Vitamin B12, and Vitamin B6 on Clinical Outcome After Percutaneous Coronary Intervention . I believe that this provides a good excuse to recommend a multivitamin which contains folic acid, B12 and B6 to patients at risk for heart disease. Hopefully, more data will emerge over the next few years.

Land of the free, home of the fat and unhappy

It sneaked up on the nation the way it often creeps up on individuals. Its arrival was a surprise, even though it had been a long time coming. We were used to looking in the mirror and seeing a tough, lean country of do-it- yourselfers. Then, seemingly overnight, our image changed. We looked in the mirror and saw that we had become fat. And we've been upset about it ever since.

Of course, people in other countries have been calling us fat for years. In 1990, France's Le Monde published articles about "les Americains obeses" and referred to our kids as "les enfants du Coca-hamburger." The Coke-hamburger kids.

It's easy to ignore a message from the other side of the Atlantic, but when Southwest Airlines told us this summer it would charge those of us whose derrieres don't fit on one 18.75-inch wide seat for two 18.75-inch seats, we finally woke up.

I assume the royal we means the media. Physicians have known this for years. Generally, we do not know how to manage and treat weight problems. This frustrates us, and our patients.

But we haven't gotten where we are today through eating habits alone. We also don't exercise. In fact, we hardly move at all. Less than 20 percent of American adults exercise the federal government's recommended minimum amount -- just 30 minutes a day, five days a week.

Our kids aren't moving any more than we are. Physical Education has been cut so severely in public schools that many youths get no P.E. at all, or it's offered only as an elective. Playtime after school is spent watching television or exercising one digit -- the thumb -- on the GameBoy or PlayStation.

I type the same message constantly. Weight control requires 2 things, eat less and exercise more. The rare patient makes that committment. Our society gives us too many excuses to eat more and exercise less. Few of us resist the easy path.

The American Obesity Association reports that 89 percent of Americans believe that overweight individuals -- not their environment or genetic makeup -- are to blame for their size. Heavy people feel this condemnation at work, in public and in the doctor's office. A study conducted by Rice University's Department of Psychology found that Texas physicians spent less time with heavier patients than with average-weight patients, and "a significant number indicated that it was a greater waste of time to see patients who were heavier. "

For HMOs and health insurers, it's not a question of a waste of time, but of money. Individuals who fall into the obese category have discovered they cannot get independent health insurance, even if they have no other health problems.

When asked if Blue Cross Blue Shield of Florida denied a 26-year-old woman insurance solely because of her weight, spokesperson Rick Curran said yes, that might have happened. "Obesity," he explained, "is considered a health risk factor that can lead to debilitating and chronic diseases." If a person's weight "significantly exceeds recommended guidelines," he said, "that person might receive a rejection letter that states that their weight would need to become more stable and more closely aligned to what is considered healthy."

It's a cruel policy that won't help anyone but the stockholders of Blue Cross Blue Shield, but Curran is right. Obese people often develop such serious health problems as heart disease and Type 2 diabetes. The research institution Rand reported that "obese individuals spend 77 percent more on medications" than non-obese people. Armed with such statistics, health insurers have decided that doing business with fat people is not cost- effective.

Physicians do spend less time with obese patients. I would guess that we respond to our learned futility by giving up on these patiens. We want to help patients, but we rarely fix problems, we just give patients the tools to help themselves! After you try to help obese patients for several years, you rarely if ever have any successes. This learned behavior affects how we treat the obese.

I suspect that obesity will provide this blogger ammunition for a long time. Oh but that were not so! Would that I could influence patients to change their lifestyle. I know that it can be done, I live the proof. But I do work it every day, choosing my diet, even my cheat meals! I exercise 6 days a week on average, and plan that exercise on a weekly basis. Can we get most Americans to do that? And if you read the British press, they have the same problem!

When the Flu Is Taken Lightly. Influenza is a serious disease with a very high mortality. Influenza vaccination decreases the death rate, especially in the very young and those older than 65.

In an interview, Dr. Poland said he thought that the biggest barrier to more widespread inoculation was a false perception about the dangers of influenza.

"We call every respiratory and gastric illness in winter the flu," he said. "People think flu is a minor illness."

In reality, he said, "Influenza has a very distinct set of clinical symptoms, including the sudden onset of high fever and severe fatigue that literally drives people to bed."

Yesterday's piece linking to Norah Vincent brought out some interesting comments. Here is Jane Brody's reporting on the same issue - A Jubilant Barroom Toast to Smoke-Free Air.

A complete ban on smoking in restaurants and bars has proved not just practical, but also good for business.

As Elena Deutsch, director of tobacco control for the American Cancer Society, pointed out, "Revenue has grown in California bars and restaurants every year since this health measure was enacted in 1998." Now, she added, "almost three-quarters of bar patrons in California like their air smoke free."

Likewise, in a survey by a coalition of antismoking advocates more than 70 percent of New Yorkers said they would go out to bars as much or more often if smoking was banned.

We went to see a play last weekend. After the play we went around the corner to check out a new bar. The stench of cigarette smoke was disgusting and even visible. We passed and went to a coffee house instead.

To paraphrase Norah Vincent, your right to smoke ends in my space. Norah's LA Times piece brought out the letter writers - LETTERS TO THE EDITOR: Smoldering Arguments Over Regulations Against Smoking

For those who do not read the comments, the Bloviator has weighed in on the Scarlet Letter Law. He has written a more complete discussion of this madness. Thanks to blogspot, I can only point you to his blog - you can find the discussion listed today.

States Sued For Pushing Cheaper Drugs Via Medicaid . Just when I think about taking it easy on the pharmaceutical industry - there they go again.

The most popular strategy is requiring prior authorization for high-priced medicines. More than a dozen states are developing preferred drug lists, and several demand extra rebates from companies that do not match the lowest price. Michigan's new program saves $800,000 each week -- or $42 million this year, according to Republican Gov. John Engler.

Oregon expects to save $17 million in the first two years, which would result in nearly $40 million in savings for the federal government, said John Santa, administrator of the state health policy office. Massachusetts and Vermont say they could save $10 million.

If the industry suits are successful, "it will throw the country into chaos," Rivers said. "There are too many big states whose budgets would be devastated by it."

Drug manufacturers argue that prescription medication saves lives and money by preventing emergency room visits and more expensive procedures such as surgery.

"The most economic service [states] can provide is adequate access to prescriptions because it gives the most bang for your buck," Faiks said.

"The Medicaid Act does not let them use prior authorization to hold patients hostage because of money," she said. Although PhRMA objects to the state tactics, the industry is suing the federal government in U.S. District Court in the District of Columbia on the grounds it does not have the authority to permit the state programs. In the lawsuits the industry is challenging the state programs, arguing that the government is more concerned with cost than the health of low-income residents.

PhRMA's legal brief contends that "physicians generally respond to the inconvenience and burden imposed by prior authorization requirements by switching their patients" to a drug on the preferred list. Over time, the suit notes, the shift in prescribing patterns results in large swings in the overall market.

If I understand the pharmaceutical industry, I should use the most expensive drugs to save the most money. Sometimes a very expensive drug makes a difference, but often we can treat the same condition with a less expensive alternative. Working with the indigent and working poor, I have learned to use captopril as my ACE inhibitor of choice for hypertension - because it is generic, very inexpensive, and works at a twice a day dosing for hypertenion. Should I switch to a more expensive antihypertensive?

This is a very serious issue. I will try to stay aware of the developments, but if I miss them, and you see them, please let me know.

Doctors Beginning to Test for Bacteria in Stomach. Next year, at Grand Rounds, I will debate a colleague on this issue - Resolved: Patients with dyspepsia who are H. Pylori positive should receive antibiotics. I will take the pro side, as I am concerned about the risk of GI malignancy. He will argue against, and I am interested in what his arguments will be. What do you think?

Both Medpundit and I rant on this issue consistently. Value of herbal supplements is difficult to verify. A few choice quotes from this solid report of the two-day workshop at the National Institutes of Health:

"I still have too many questions," Curt Furberg of Wake Forest University said last week at a conference sponsored by the NIH. "I couldn't recommend any supplements."

Natural garlic, soy and other herbs ingested as part of the diet apparently are healthful, studies suggest, though in most cases experts still haven't pinpointed the beneficial ingredients or how to fashion them into drugs.

...

The lack of standardization of commercially available supplements also makes them difficult to study. "We need to verify that brands contain what they are supposed to contain," Furberg says.

Consultant Stewart Ehrreich, former head of the Food and Drug Administration's division of heart and kidney drugs, adds that the FDA won't "approve a drug with 17 ingredients without knowing what the active ingredient is."

We quickly criticize the medical establishment if we champion a treatment without testing that treatment. Our standard for supplements should not be any less.

My stated philosophy makes the following article even more disturbing - A Supplemental Pitch: More doctors are selling vitamins and herbs even as scientific debate continues over the health benefits of such products..

Last week, cardiologists at a prominent Arizona clinic began advising patients to try a new, untested dietary supplement that has never before been used to treat heart disease. It's not just any supplement, the clinic says; it's a proprietary formula, designed by doctors.

The idea that top medical specialists are offering guidance in the confusing, controversial world of vitamins, herbs and nutritional products is reassuring to many patients. After all, the guidance is coming from graduates of some of our best medical schools, not holistic gurus or health food store clerks.

But there's a catch. The Arizona Heart Institute has struck a deal with the supplement's maker, Vital Living, that gives the clinic a share in profits from sales of the supplement, as well as 1 million shares of stock options in the company.

Read this article, I find it VERY disturbing. But then I am obsessed by data and ethics.

Stepping up the weight loss. This article, which sets up a series of reports from the ninth International Conference on Obesity in Sao Paulo, Brazil, talk about how one loses weight, and how one maintains that weight loss.

Many experts believe that most people today who want to maintain a healthy weight have to be vigilant constantly in countries such as the USA, where high-calorie foods are ubiquitous and exercise has been programmed out of many people's lives.

"It takes a lot of conscious, cognitive effort," says James Hill, director of the Center for Human Nutrition at the University of Colorado Health Sciences Center in Denver. "People who are not devoting substantial effort to managing body weight are probably gaining weight."

Samuel Klein, president of the North American Association for the Study of Obesity, agrees: "It means making weight management a priority in your life."

Statistics reveal how difficult that is to do. Worldwide, more than 1 billion people are overweight, and of those, 300 million are obese, according to the International Obesity Task Force. A startling 61%, or more than 120 million people, in this country are either overweight or obese, according to government statistics. Obesity is roughly 30 pounds or more over a healthy weight.

While not the only theme of this blog, weight control and exercise articles do consistently attract my attention.

"The bottom line for weight loss is you have to eat fewer calories than your body needs," Rolls says.

Brownell says that if people watch portion sizes, eat fruits and vegetables and less junk, "they'd be 90% of the way toward a healthy diet." And "if anything has become clear over the past 10 years, it's the importance of exercise in weight loss and maintaining."

There you go, eat intelligently and exercise. In our society this represents work. One should ask oneself whether that work is worthwhile. I would argue that question has a simple answer. Make rounds with me and you will probably agree.

Over the past several months, we have increasing evidence that we can decrease the probability that patients will develop Type II diabetes mellitus. Weight loss drugs 'limit diabetes'. Certainly, this will become a major prevention movement. Diabetes mellitus costs the patient and society a large amount. The complications include heart disease, kidney failure, amputations, and blindness. We can prevent much diabetes with either lifestyle modifications or medications. This report studied Xenical as a weight loss aid over a 4 year period.

Weight loss drugs could play a role in protecting obese people from the onset of diabetes, according to a study.

It said that those using the drugs alongside diet changes and exercise were 37% less likely to develop type 2 diabetes than those losing weight through lifestyle changes alone.

We should try to influence lifestyle - exercise and healthier diets - and decrease the obesity burden our country. This study comes from GB, where they also have a significant obesity problem. My crusade against obesity comes from a medical perspective (although I admit to having aesthetic problems also - just check out the picture in this article).

Read this wonderful opinion piece on smoking - Smoky View of Libertarianism: They've abused health--now they abuse philosophy. Then visit her web site and read more on this subject Norah on second hand smoke. She includes one of my favorite lines in the LA Times piece

First, by ignoring one of the central tenets of libertarian philosophy; that is, the oft-cited adage that my right to throw my fist ends at the tip of my neighbor's nose. An oldie but goodie. I can do what I like with my own body, true, so long as--and here's the part sophists omit--what I do doesn't harm anyone else.

Mindscapes, Heartstrings & Soul-searching writes today about 'Health, Weight and Happiness'. Her tale is well told and highlights the downsides of weight obsession. We run a fine balance between appropriate diet and exercise and obsession. Read her tale.

20 Questions for President George W. Bush: A Running Conversation . Many readers know that the current issue of Runner's World features President Bush. Maureen Dowd criticizes the President today about this interview and contrasts it with her perception of what he is not telling us about Iraq - Treadmills of His Mind. While I will not comment on the President and Iraq, I am impressed with his role modelling on exercise. We need more stress on healthy lifestyles. If the President helps a few people get off the couch and workout (and he probably will) then he has done well.

I will quote some of his answers and comment .

What’s your response to people who say they are too busy to have enough time to exercise?
I say they don’t have their priorities straight. These are the same people who say they don’t have enough time for their families. I don’t take that as an acceptable answer. I believe anyone can make time. As a matter of fact, I don’t believe it—I know it. If the President of the United States can make time, they can make time

Exercise is so important that corporate America should help their employees make time. Offer flex time. There should be flex time for families and there should be flex time for exercise. A healthy work force is a more productive work force. We have got to do a better job of encouraging that in America.

As I have said often, one should plan one's exercise week consistently. Stephen Covey's book - 7 Habits of Highly Effective People - encouraged me to consider this philosophy. I like his book and was struck by the 7th Habit . A summary of the Habits - Summary of Stephen R. Covey's
The 7 Habits of Highly Effective People. They summarize the 7th habit thus

Habit 7: Sharpen the Saw
Take time out from production to build production capacity through personal renewal of the physical, mental, social/emotional, and spiritual dimensions. Maintain a balance among these dimensions.

I subscribe to maintaining balance in my life, and espouse that philosophy to my residents, medical students and faculty. All work and no play makes Jack a dull boy. It also leads to burnout. The President's exercise philosophy does not just strengthen the body, it also helps the mind. Exercising gives me a time to sort out ideas. It provides respite from the hassles of the day. After exercising, I have more energy to attack problems.

Finally, what do you view as the greatest health issue facing our nation?
Tobacco, bad food and lack of exercise. A lot of disease can be prevented. And I think you’ll see the health-care systems will evolve toward encouraging prevention. Wise business insurers will work with physical fitness folks to encourage reasonable exercise. Statistic after statistic is beginning to sink into the consciousness of the American people that exercise is one of the keys to a healthy lifestyle.

One of my jobs as President is to set examples. I have an opportunity to send the message to the American people that I’m serious about exercising—and you should be too.

Bravo, clap hands, the President has it right. He does understand that the choices we each make about our lifestyle have profound effects on our longetivity and quality of life. I wish that smoking cessation was just a matter of will.

Physicians understand this message. On the VA inpatient wards, I estimate that over half the patients have serious diseases as a result of lifestyle choices - smoking, lack of exercise, obesity, alcohol abuse and former IV drug experimentation. These "choices" all effect insurance rates and contribute to the high cost of health care.

Can we make a difference? Certainly, we can influence one person at a time. We must discuss lifestyle choices regularly with our patients, our friends and our family. We must understand that our challenge never ends. We must search for the buttons to push that will allow people to make healthier choices. We must start by being role models - like the President.

Myth Vs. Fact: Weight Loss Resolutions. The author addresses several myths. The short story:

• Myth: A resolution to lose weight is an empty gesture; hardly anyone succeeds.
• Myth: Only 5% of all dieters keep the weight off - the rest gain it back.
• Myth: Dieters who habitually lose weight and gain it back should just give up making resolutions to lose weight.
• Myth: Forget crash dieting as a way to keep a weight loss resolution; it will only make you fatter.
• Myth: The problem with following through on a weight loss resolution is that it's so painful.

I am currently in my third year of success. I never reached obesity (BMI <30), nonetheless, I have lost 30 pounds and kept it off. As I read this article I recognized several important issues. I have developed my own dietary modifications. My diet is not strict, but I do eat less high calorie stuff. I do exercise very regularly. I do think about when I am going to "cheat", accept the fun of that cheat, but resume my healthier eating immediately thereafter. Read this article, it may help you.

Prescription drugs to have and to have not. Read this nice opinion piece about celebrity interviews and the pharmaceutical industry.

In my 20s and 30s I remember losing my temper much more often. I would get very aggravated playing golf. Basketball referees could incite my flames in seconds.

Now in my 50s, I rarely get upset. More often I'll laugh at a bad golf shot. I seem (to myself) much more even keeled. It turns out that I'm probably not unusual - Relax! Aging Puts Stress in Perspective

In their study, Almeida and his colleagues examined data from a large government survey of over 1,000 American adults known as the National Study of Midlife in the United States. As part of the study, researchers telephoned participants every evening for 8 consecutive evenings, quizzing them on the amount and type of stressors they had faced that day.

"And we found that, in sheer number of stressors that people reported, there was no difference between younger adults and midlife adults," Almeida said. But while these daily hassles tended to really upset those aged 25 to 39, "boomer" types aged 40 to 59 were more likely to shrug them off.

"For example, being stuck in traffic. The younger people in our sample would report that as more disruptive, more upsetting, than older people," Almeida said. The key was "people's own perceptions, how they view their stressors," he said.

But the nature of what stresses us out as we age appears to change as well. In our 20s and 30s, "it was likely to be over some interpersonal tension or disagreement they have with somebody," such as a lover, coworker or friend, Almeida said.

"Whereas midlife adults, their stressors were more related to being overloaded or having too many demands made on them." This makes sense, he said, because midlife is typically our most productive period, with many of us forced to juggle the demands of career, spouse, children and aging parents.

I find this story very interesting, especially since I spend so much time with students, interns and residents. Many have short fuses, and we try to help them learn how to deal with their stressors productively. Maybe I just have an age advantage.

Sometimes expert panels have wisdom - No evidence soy, garlic pills work Experts: Benefits unproven for popular supplements.

But leading botanical researchers, meeting under the auspices of the National Heart, Lung and Blood Institute, said these products vary greatly in what they contain and some may not even be in a form that can be used by the body.

“The available clinical trial results are not adequate to answer important questions about the potential cardiovascular benefits of garlic,” Christopher Gardner of Stanford University in California told the meeting.

But why should we believe that any supplement will help? Why do we rebel from conventional medicine and data, turning instead to herbal gurus? We should not allow the sale of potentially dangerous supplements - which apparently have no standards for ingredients. Should we allow herbal placebos? Are we satisfied if the supplements just do not harm? I am not satisfied with that standard.

Shaming Young Mothers

This new state law requires women — even 14- and 15-year-old girls, even rape victims — to disclose the name and address of the father of a baby offered for adoption, or else to publish these ads for four weeks. Perhaps not since a tribal council in Pakistan ordered a woman to be gang-raped in June has a government treated women with such contempt.

The new Florida law was meant to reduce the risk of a father's emerging years after an adoption and seeking custody. So the law stipulates that the mother must publish her name and description, along with the names and descriptions of men whom she cannot locate but with whom she had sex around the time of conception.

This law is unbelievable. Will they call these ads the "scarlet letters". Why were they not thinking? Are there any lawyers out there? There must be some constitutional problem here.

Doctor, I feel slightly funny.

There's a theory that the real problem with the NHS is not too few doctors, but too many patients. Some politicians like to pin it on the fact that we've become a nation of accident-prone, alcoholic, smoking lard-buckets. If only we could all learn to eat, drink and be merry responsibly, then half the health budget wouldn't be frittered away on potentially preventable diseases. Sociologists prefer to blame the politicians for creating mass involuntary euthanasia in the UK. It's called living in the North of England. The rich live 10 years longer than the poor and the gap is widening under Labour. Until it narrows, no health service will ever cope.

An additional strain on the NHS is that it is full of patients who have little to gain from being there. The beauty of the NHS – that you can be scraped off the pavement without having to check for your Barclaycard – is also its weakness. Any service that is free at the front door encourages life's little problems to become medicalised. A GP friend was phoned at 3am by the relative of a man marching drunk down the high street with his glass eye balanced on the end of his penis. It's a fine trick, and worthy of an audience, but it doesn't have to be a doctor.

Another GP has a T-shirt with "CAMERA" on it; the Campaign for Real Ailments. Much of his workload consists of defusing the anxiety of an increasingly worried well population who don't have any discernible disease, just an awareness of what might, or might not, be "risk factors". Alas, in the doomed pursuit of a risk-free life, their new health awareness makes them pathologically anxious and they end up on anti-depressants. Great for the drug industry, but not great medicine.

Within the humor one can often find wisdom. Our challenge remains sorting out the worried well from the sick. The most dangerous patient is the somaticizer. Sooner or later their complaints are real. Medicine is easier when you know something is wrong - perhaps that is one appeal of doing a subspecialty - someone out screens out all the complaints. But we must remember (after we stop laughing) that the complainers need us also. They need our relationship and validation. We often help patients without a prescription or a test. Unfortunately, we have no outcome measures to document it - and the bureaurcracy probably does not want to pay for that help.

All fast food is not bad. Sometimes that is your only good option. This article gives you some good choices - Nutrition watchdog praises fast food giants

CNN to Reveal When Guests Promote Drugs for Companies

After learning that some celebrities who talked on its news programs about their health problems were being paid by drug companies, CNN has issued a new policy and will tell viewers about the stars' financial ties to corporations.

CNN will ask celebrities who want to talk about a medical issue whether they are being paid by a company, the network said. If so, the financial tie will be disclosed during the interview, CNN said.

Other news programs — including the "Today" show on NBC, "Good Morning America" on ABC and "The Early Show" on CBS — say that they have also become more careful after they learned that some Hollywood celebrities they had interviewed, including stars like Lauren Bacall and Kathleen Turner, had been paid to help promote drugs or other medical products on their programs.

Pharmaceutical companies have one interest in mind - selling their drug. Jane Galt would probably say that is appropriate in a free market. I would say that society has an interest in minimizing influence which does not necessarily correlate with patients' best interests. I like this development. I believe that I can do a better job recommending medical care than celebrities.

Today's NEJM includes many letters about - "Luxury primary care". Since most readers do not have a subscription, I will quote liberally. If you have access - Luxury Primary Care.

The article by Brennan on luxury primary care (April 11 issue)1 was of particular interest to us as patients of a physician who notified us only two weeks in advance that he would eliminate us from his practice unless we joined MDVIP at a fee of $1,500 per person per year.

Our reaction went from surprise to shock to indignation. For the most part, the services being offered were no different from those we have been receiving — that is, prompt responses to our telephone calls, timely appointments, and adequate examinations and consultation times.

We cannot believe that this kind of medical practice is legal. As Medicare patients, we are entitled to access to our physicians with nothing more than a 20 percent copayment. Without a doubt, if this practice is allowed to continue, we will have a two-tiered medical system in our country. How sad.

All threats to the doctor patient relationship are sad. The patients quoted here refer to medical care as an entitlement. Is your choice of physicians an entitlement? Are Medicare's reimbursement and regulations an entitlement? These are very difficult questions. We do not know why the physicians made this decision. It may just be monetary, or it may be more.

As physicians in the center of the controversy over luxury primary care, we were particularly struck by the absence of the patient's voice in the review by Brennan. The current system of primary care is the creation not of doctors and patients, but of those who pay for care — in general, insurance intermediaries acting on behalf of employers or governments. Since this system is not designed by or for the patients we serve, it is not surprising that there has been widespread dissatisfaction with the results it delivers. When those who pay for services are different from those who receive those services, problems arise. Some patients want something different, and we have responded to that desire.

Our practice is not an answer to the problems of the uninsured, nor is it offered as a solution for all patients or all doctors. Our practice is an answer to the needs of specific persons — patients and doctors — who have felt inadequately served by the system as it exists. We have risked our livelihoods and our reputations in an effort to prove that a better and different way of practicing medicine is possible. We believe that free choice and the marketplace of services and ideas are better alternatives than the status quo. Our success will be measured by our ability to deliver on our promises, as determined by the patients who choose our care.

This is a straightforward, honest response from doctors. Do I necessarily agree with them - no, but I emphathize with their point. They do emphasize a better way of practicing medicine.

Brennan sets out to "examine the . . . ethical issues that arise with [luxury primary care] practices." His chief concern is access, and he concludes with the prescriptive (as opposed to descriptive) statement that "as physicians we have a commitment to the equitable distribution of health care." What is the basis for this statement? Certainly, most people believe that food and shelter are more important than medical care, yet there is no expectation that builders have an obligation to provide for the equitable distribution of housing or that supermarket chains have an o