Sugary Drinks and Increased Risk of Cardiovascular Disease

 

sugary-drinks

American adults who drink one (or more) sugary drinks a day have a 27% greater increase in abdominal fat tissue compared with Americans who don’t, according to a new data analysis from the Framingham Heart Study in the journal Circulation.

Deposition of fat in this location is associated with the development of cardiovascular disease and type 2 diabetes, both of which produce adverse health consequences.

Although the exact biological mechanism is unknown, added sugars—especially fructose—may trigger insulin resistance and increase fat accumulation, which raises the risks for these serious consequences.

In this investigation, researchers enrolled 1,003 participants (mean age 45) from the Framingham Study’s Third Generation cohort and measured their quantity and quality of abdominal fat tissue at baseline and again 6 years later using C.A.T. scans. Subjects also reported their sugar-sweetened beverage and diet soda intake on a food frequency questionnaire.

Over a 6-year follow-up period—and after adjusting for participants’ age, gender, physical activity, body mass index, and other factors—abdominal fat tissue volume increased by:

  • 658 cm3 for non-drinkers and occasional drinkers (once a month or less than once a week)
  • 707 cm3 for frequent drinkers (once a week or less than once a day)
  • 852 cm3 for those who drank at least 1 beverage daily

The researchers concluded that, although age alone accounts for increasing fat, drinking sugar-sweetened beverages led to a significantly greater increase in abdominal fat tissue. In contrast, they observed no such association with drinking diet soda. Needless to say, observation of general dietary guidelines is also required to minimize accumulation of excess fat.

As a result, the researchers urged all people to be mindful of how many sugar-sweetened beverages they drink. To policy makers, this study adds more evidence to the growing body of research suggesting sugar-sweetened beverages may be harmful to health, providing arguments for public efforts to restrict such consumption.

Sugar-sweetened beverages are the largest contributor of added sugar intake in the United States. In 2001 to 2004, the usual intake of added sugars for Americans was 22.2 teaspoons per day, or an extra 355 calories. The American Heart Association recommends a limit of 100 calories per day of added sugars for most women and 150 calories per day for most men.

This information simply adds more support to the idea that sugar, in itself, is a dangerous dietary component. I will disclose more about this in the next blog.

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NUTRITION: THE GREATEST CHALLENGE FACING OUR PLANET

nutritiion

Despite all the issues raised during this election season, arguably the two most important challenges faced by humanity are nutrition and global warming, neither of which seems to be gaining sufficient attention, especially the former.

In this discussion, I will address the issue of nutrition.

Poor nutrition is the leading cause of poor health in the U.S. and globally, casing more deaths and disability than any other factor, being the number one cause of illness. Nevertheless, it is largely ignored by the political system. Our food procurement is also the leading cause of environmental impact on the planet. Food production accounts for 70% of water use, 90% of tropical deforestation, immense challenges to the oceans and fish stock, and as much greenhouse gas emissions as all of the world’s transportation—cars buses, planes, trains and ships—combined. Food production is the crucial cause for either harm or positive change, requiring secure sustainable systems for us, and especially, our future generations.

To gain some perspective, we spend $3 trillion each year on U.S. health care—five times more than all our military spending, and nearly one in five dollars of the entire U.S. economy. Despite this emphasis on health care, which certainly could be improved and made more cost efficient, the only real way to reduce the hundreds of billions of dollars we spend each year on preventable and curable diseases is through better lifestyle in the population, especially better dietary habits. Just the cost of diabetes alone, which is largely preventable though better lifestyle, amounts to about $322 billion yearly. If we add the costs of other diet-related diseases, such as heart disease, obesity and its consequences, cognitive decline, and several cancers, we reach approximately $1 trillion annually. These stark facts alone should trigger major bipartisan political efforts, something akin to our past moon and present cancer efforts.

As a societal issue, our food system contributes to harsh inequities. Those with lower incomes and less political clout often have the worst diets, leading to a vicious cycle of poor health, lower productivity, increased health costs, and sustained poverty.  These disadvantages usually start with kids, resulting in poor health in general with associated poor concentration and school performances.

Thus food strongly influences disease, the environment, the economy, and social justice. Despite these profound effects, however, as the current elections unfold, we see little attention devoted to the effects of preventable diseases and their spending implications. These considerations should thrust our food system into a leading role among politicians, media and candidates for office, but they do not. Candidates for office should be familiar with nutrition’s central role in the current and future success or our nation, and the voters must demand to know where they stand on these issues. The electorate must be informed enough to ask the right questions and cast their votes appropriately.

In the near future we need another White House Conference on Nutrition. The only previous conference of the nature was in 1969—47 years ago—which established important advances such as improved programs for school lunch, child nutrition, nutrition education, greater access to food assistance for women, and children, consumer protection and information, and others. In these intervening 50 years, our food system has changed considerably. A new emphasis on food and nutrition is essential, including for health, hunger, medical care, jobs, the economy, and sustainability. For instance, genetic modification of food sources offers—despite widespread misunderstanding—the opportunity for increased worldwide production with reduced adverse environmental impact and less need for potentially toxic insecticides, as we explained previously (http://www.mortontavel.com/2013/06/21/). Other advances in nutrition science have us poised to deliver major breakthroughs toward a healthier and more prosperous nation. But first we must have the conversation, and as we enter the final phase of the 2016 elections, it’s time for food to be subject of major conversation. If we ask the right questions and elect our leaders wisely, we can bring together modern science and the public to a position to achieve real change.

 

 

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HOW MUCH WATER DO WE NEED?

    

        water

I am often asked about how much water one should consume each day.

For most people, the answer is straightforward: Drink enough to satisfy your thirst. But that’s a bit overly simplistic, so let’s explain in more detail:

Water is a vital bodily component. An average adult contains about 55% water by weight, and an infant, about 75%. So, to maintain this large amount, an adequate daily supply is necessary, especially in the summer months when needs are higher.

Sources of water for consumption are plentiful: plain water tops the list, but it’s present in most beverages and foods as well. Fruits like watermelon, grapes, etc. are excellent sources of water. But as I have mentioned before, avoid sugar-sweetened beverages and so-called “sports” drinks like Gatorade unless you are involved in prolonged strenuous activities in hot weather: This latter issue is noted at the following: lhttp://www.mortontavel.com/2015/06/17/. Water content in beverages such as coffee and tea counts toward this total as well.

An adequate intake of fluid from all food and beverages for men over age 50 is 3.7 liters (almost 4 quarts) daily, which includes about 13 cups from beverages and food sources combined. For women in this age range, this figure is 2.7 liters (slightly less than 3 quarts) a day, with about 9 cups coming from water and other sources. Most people actually consume that much, despite the popular concept that one should consume 8 glasses of liquids daily. Water contained in foods makes up to about 22% of the average individual’s water intake. According to national survey data, men actually drink a combined equivalent of about 11 cups of beverages per day, and women, about 10 cups.

The kidneys play a key role in regulating the body’s fluid balance, working best when supplied with adequate water and being more stressed in the presence of dehydration.

Since the brain is about 75% water, staying hydrated helps this organ function as well. Although research on the effects of dehydration on the brain is inconsistent, short-term impacts seem to enhance mood and alertness.

In some forms of arthritis such as osteoarthritis (the most common form), you can help fight the associated inflammation by staying hydrated. The Arthritis Foundation recommends “prehydrating”—drinking water before you exercise, not just after you’ve worked up a sweat—to help people with arthritis engage in physical activity with less discomfort.

         WHAT SHOULD WE BE DOING?

It’s important to consume enough fluid from all sources to keep your body hydrated, but claims that drinking even larger quantities can enhance health are unsupported by science. So the idea that there are such things as “water cures” is a myth. One exception is that strong evidence links good hydration with reduced risk of kidney stones. So if you have had such a problem, or are at risk for any reason, then extra water makes sense.

As we age, the body’s needs may require more than is dictated simply by thirst alone because it’s easy to miss warning signs that may warn of dehydration. As a general rule, if you’re over 50, try to drink regularly even when not thirsty—an extra glass with each meal—especially in hot weather.

Extra fluid can help prevent constipation, especially if combined with plenty of fiber, but fluid alone is probably not very helpful.

Overall, for total hydration, plain water is the best choice, but also useful are fruit juices, coffee, tea and milk. As mentioned, sugary soft drinks and the like should be avoided, especially since they are major contributors to the obesity epidemic, as previously presented: (http://www.mortontavel.com/2015/12/15/).

I might add that bottled water is generally no better—and sometimes worse—than that taken from most taps, but that was reviewed in a previous post (http://www.mortontavel.com/2014/06/10/).

In conclusion, although there is no need to constantly guzzle water, there is reason to insure that you’re getting enough, especially it you’re over 50. So this summer and all year long, help yourself by staying healthy and hydrated and avoid the extra calories of sugary drinks. Opt instead for the inexpensive and ubiquitous choice of plain water out of the tap!

 

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SMOKING, DRINKING, AND THE NEW PLAYER: MARIJUANA!

marijuana

We medical practitioners have long been preaching about the dangers of both smoking (tobacco) and drinking in excess (alcohol). But nowhere has the old adage “familiarity breeds contempt” been more appropriate than in connection with these two vices. We seem to ignore the fact that tobacco smoke accounts for at least 450,000 deaths yearly in this country alone. And although the numbers are not as clear in regard to excessive alcohol consumption, we do know that alcohol accounts for numerous deaths yearly, both acutely or chronically. As we leisurely sip our martinis at cocktail parties, we pay little heed to this danger, finding it reassuring that—in contrast to many confirmed alcoholics—we are able to confine our intake to safe quantities at less frequent intervals.

And now we are being confronted by a new challenge: Marijuana! This substance is moving to center stage because of its legalization in such states as Colorado and because of political pressure on the federal government to avoid conflict with the states and stop incarcerating users and sellers of marijuana.

Unfortunately, until now, far too little research has been done on this substance—either for medical uses as well as for recreational purposes. But one thing is quite clear: Marijuana will never account for as many deaths as do both tobacco and alcohol.

For a clear-headed discussion of the subject of marijuana, I refer you to a recent article written by Sheila Kennedy, my cousin, who normally comments accurately on many important topics of public and political concern. http://www.sheilakennedy.net/2016/08/smoking-and-drinking/

In this article, she makes an eloquent case for legalization, or at least decriminalization, of marijuana. It’s well worth reading!

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Meal Replacement Products

diet alts

      Meal Replacement & Weight Management Powders and Beverages

      These days we are encountering an increasing number of nutritional supplements in a bottle. There are many different reasons for using such a product, which can be in a “ready-to-drink” form, or which you make from a powder. For example, you may not have time for a meal but want something more healthful rather than a snack food. Or you may be on a diet and it’s easier for you to use a single product with the right balance of nutrients and calories than having to select the right foods yourself. Or maybe you want to boost your protein intake with the convenience of a meal replacement rather than a strict protein product.

The United States Department of Agriculture (USDA) recommends that most adults who perform light to moderate activity get roughly 2,000 to 3,000 calories per day from a varied diet in which approximately 60% or fewer calories come from carbohydrates, at least 10% come from protein (meat and vegetable proteins), and about 30% come from fats — with less than 10% of calories coming specifically from saturated fat. Healthcare professionals tend to suggest a somewhat higher percentage of calories from protein (15% to 20%) and a lower percentage from carbohydrates, although recommendations vary. Nutrition powders and drinks can help provide some of these nutrients but they are not recommended as a total substitute for food, as they lack some of the vitamins, minerals, fibers, and phytonutrients found in whole foods.

Meal replacement powders typically come in canisters or packets ready to be mixed with water, milk, juice, or other beverage. Meal replacement drinks often come in ready-to-drink cans or bottles. These products are marketed as dieting aids and meal replacements. Unlike, protein powders, they generally provide a more balanced ratio of protein, carbohydrates, and fats, as one might get from a healthful meal.

Unlike nutrition bars, which need to contain a good amount of carbohydrates to give them a reasonable texture, feel and taste, meal replacement powders and shakes do not. Consequently, makers of these powders and shakes can offer more flexibility in the nutritional content of these products. For example, it is quite possible to find powders and shakes with half the fat and carbohydrates of most nutrition bars, while often offering twice the protein.

   Advantages: They have been shown to help people on diets lose more weight, improve blood sugar control for people with type 2 diabetes, and boost protein intake to increase muscle mass. They can also offer a more healthful alternative to snack foods when you are unable to have a regular meal. In particular, meal replacements offer protein in a convenient form, along with carbohydrates (and often fiber) as well as fats. The products, however, are not meant to replace all of your meals and consumption of whole foods, such as fruits and vegetables. Although quite variable, most products provide about 10 to 20 grams of protein per serving but vary in the amounts and types of carbohydrates and fats they include. They may also contain a range of vitamins, and minerals.. Serving sizes also range widely, from about 25 to 60 grams providing from 90 to 400 calories.

One important caution must be given for all such products: Do not substitute any of them for all of your meals or be fooled into thinking that you can skip eating whole foods.

Depending upon the needs of each individual, it’s impossible to suggest the best choices, but we can list some good picks based upon accuracy of labeling and features such as protein, energy, fiber and cost.

           Meal Replacements for Weight Loss:
A review of six randomized, controlled clinical studies comparing the effects of partial meal replacement plans (consisting of a reduced calorie diet providing between 800 and 1600 calories daily in which one to two meals per day were replaced with a liquid, vitamin and mineral fortified meal replacement product) with conventional, reduced-calorie diets found that after three months, those who used a meal replacement product lost an average of about six pounds more than those who followed a reduced-calorie diet without meal replacement (approximately 13 1/2 lbs. versus 71/2 lbs., respectively)    Among the four studies which continued for another 9 months, people who consumed meal replacement products had a total average weight loss of about 15 lbs. by the end of one year, while those who maintained a reduced-calorie diet without meal replacements had a total average weight loss of about six lbs. One word of caution:  It should be noted that the authors of the review were each associated with either Slim Fast or the “Slim Fast Nutrition Institute,” and that most of the studies in the review appeared to use SlimFast products and/or were funded by Slim Fast

Increasing Muscle Mass and Strength:
Protein is necessary to build, maintain, and repair muscle. Meal replacement products which are high in protein can help you boost your protein intake. Be aware, however, that while getting more protein can help you increase muscle mass, it won’t increase strength unless used as part of appropriate exercise program.

Quality Concerns:
Neither the U.S. Food and Drug Administration (FDA), nor any other federal or state agency, routinely tests meal replacement powders and drinks for quality.. One independent source found that among the 11 meal replacement powders and drinks selected and tested, only 7 met quality standards and were approved based on their quality and labeling.

Which product to consider: The product you choose depends very much on your purpose for it. However, when looking for a meal replacement, I would look for one with a reasonable balance of protein, carbs, and fat, some fiber, some vitamins and minerals, and, hopefully, a reasonable cost. With that in mind, the following are top picks among the products in this review which passed tests for quality:

For General Use:  Special K Protein has a good balance of nutrients, including fiber, provides a good amount of energy (180 calories), and is reasonably priced ($1.90 for a 10 fl. oz. bottle). However, the majority of its 28 grams of carbohydrates is from sugar (18 grams), which is a bit high, and some flavors may contain caffeine. Caffeine is absent in flavors such as Red Berry, Chocolate Delight, or French Vanilla.
Special K Protein is comparable to the very popular Ensure Original, which provides about the same amount of protein and fat. Ensure provides more carbs (40 vs. 28) and, consequently, more Calories (220 vs. 180), but, like Special K Protein, most of the carbs in Ensure is sugar (23 grams). Both products provide an array of vitamins and minerals. Ensure Original, however, provides no fiber, while Special K Protein provides 5 grams.

For extra protein:  IsAgenix IsaLean Shake Natural — Berry Harvest. This product provides more protein than most others . It also provides fiber, is low in sugar, and offers 250 calories. It’s more expensive than most products ($3.62 per 61 gram packet) but serving sizes are larger.

For dieting: There is likely no “magic” meal replacement formula for losing weight from a diet. What seems to be most important is that the dieter is able to stick with a reduced calorie diet over a sufficient period of time. A reduced-calorie meal which is convenient and satisfies the senses and hunger is what is needed. Having some fat in the meal helps with this (as well as being nutritionally important), and fiber may also help, as it slows digestion. Two lower-calorie products which seem to fit this bill are Atkins Day Break Strawberry Banana and SlimFast Advanced Nutrition — Creamy Chocolate. They are both come in 11 fl. oz. ready-to-drink containers and are relatively inexpensive: Atkins costs $1.50 and SlimFast costs 16 cents more — but provides twice the protein.

Conclusion: Depending on your needs, one of these products may be worth considering. If for nothing else, they could be used to replace the empty calories contained in most snack, or “junk” foods.

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CUPPING, ANOTHER FORM OF “WOO”

Cupping     

Woo (sometimes called Woo Woo) refers to ideas considered irrational or based on extremely flimsy evidence or that appeal to mysterious occult forces or powers.

According to the standard dictionary, this term is applied to emotions, mysticism, or spiritualism, outside of the bounds of science. It can also represent a person who harbors mystical beliefs. Medical science also recognizes woo as a synonym for pseudoscience or quackery. Basically it boils down to pure nonsense or irrationality.

   Now let’s apply Woo to a real contemporary situation: Did you notice several round red circles on the torso of Michael Phelps, the all time greatest swimmer?  These blemishes resulted from a practice known as “cupping therapy”, which is an ancient form of treatment in which a local suction is created on the skin, which is provided by suction created with heat (fire) or mechanical devices (hand or electrical pumps). Practitioners believe this mobilizes blood flow in order to promote healing. All the critics of alternative medicine, including myself, call cupping “pseudoscience nonsense”, “a celebrity fad”, and “gibberish” Pharmacologist David Colquhoun writes that cupping is “laughable… and utterly implausible”. Despite a total lack of validity, Chinese cupping has gained much publicity due to its usage by famous sport figures including not only Phelps, but also Denver Broncos player DeMarcus Ware, Olympians U.S. gymnast Alexander Naddour, and others. Actually, there is no evidence that cupping works any better than a placebo, i.e. any dummy pill or useless maneuver.

With regard to the placebo effect, however, it can be quite powerful, for past studies have demonstrated that even athletic performance can be enhanced slightly by placebos (dummy treatments), a point that I documented in my book, “Snake Oil is Alive and Well”. This effect supports the idea that the mind can be a powerful influence on not only the sensation of pain, but even physical performance! The placebo effect is ubiquitous and can explain identical “cure” rates stemming from other nonsensical forms of “treatment” such as magnetic therapy, reflexology, acupuncture, faith healing and many others. Placebo effects are most powerful when there is physical contact (laying on of hands) by the practitioner, supported by expectations of success, usually combined with elaborate and convoluted rituals and explanations. Aiding this effect is the natural tendency of all maladies to fluctuate or spontaneously resolve; thus any type of intervention that precedes an improvement stands to receive the unearned credit for “success”.

So, when Phelps goes out a winner, could the cupping have accounted for his success? You be the judge!

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The Narcissistic Personality Disorder: Sound Familiar?

As a physician I have receiving training and dealt with various mental disorders, but have been impressed recently by a report shedding more light on the issue of narcissism, which seems to be entering into the political arena. While we now live in a culture that some would call narcissistic, with millions of people constantly taking selfies, spewing out tweets and posting everything they do on YouTube and Facebook, many of us possess some qualities that can be considered narcissistic. Only a few, however, harbor an extreme form, and thus, some would consider this a form of insanity.

So what are these features? The common characteristics of extreme narcissism were described by Joseph Burgo, a clinical psychologist, in his book “The Narcissist You Know”. In it he describes the extreme narcissist as a breed unto themselves. They may be highly successful in their chosen fields but extremely difficult to live with and work with. Their characteristics are the following:

*Highly competitive in virtually all aspects of his life, believing he possesses special qualities and abilities that others lack; portrays himself as a winner and all others as losers.

*Displays a grandiose sense of self, violating social norms, throwing tantrums, even breaking laws with minimal consequences; generally behaves as if entitled to do whatever he wants regardless of how it affects others.

*Shames or humiliates those who disagree with him, and goes on the attack when hurt or frustrated, often exploding with rage.

*Arrogant, vain and haughty and exaggerates his accomplishments; bullies others to get his own way.

*Lies or distorts the truth for personal gain, blames others or makes excuses for his mistakes, ignores or rewrites facts that challenge his self-image, and won’t listen to arguments based on truth.

Of course, nearly all of us possess one or more narcissistic traits without crossing the line of a diagnosable and pathologic disorder. And it is certainly not narcissistic to have a strong sense of self-confidence based on one’s abilities.

“Narcissism exists in many shades and degrees of severity along a continuum,” Dr. Burgo said, and for well-known people he cites as extreme narcissists, he resists making an ad hoc diagnosis of narcissistic personality disorder, as defined by the American Psychiatric Association.

The association’s diagnostic manual lists a number of characteristics that describe narcissistic personality disorder, among them an impaired ability to recognize or identify with the feelings and needs of others, grandiosity and feelings of entitlement, and excessive attempts to attract attention.

Dr. Giancarlo Dimaggio of the Center for Metacognitive Interpersonal Therapy in Rome, wrote in Psychiatric Times that “persons with narcissistic personality disorder are aggressive and boastful, overrate their performance, and blame others for their setbacks.”

According to the Mayo Clinic, people with a narcissistic personality disorder think so highly of themselves that they put themselves on a pedestal and value themselves more than they value others. They may come across as conceited or pretentious. They tend to monopolize conversations, belittle those they consider inferior, insist on having the best of everything and become angry or impatient if they don’t get special treatment.

Underlying their overt behavior, however, may be “secret feelings of insecurity, shame, vulnerability and humiliation,” Mayo experts wrote. To ward off these feelings when criticized, they “may react with rage or contempt and try to belittle the other person.”

Dr. Burgo notes that many “grandiose narcissists are drawn to politics, professional sports, and the entertainment industry because success in these fields allows them ample opportunity to demonstrate their winner status and to elicit admiration from others, confirming their defensive self-image as a superior being.”

The causes of extreme narcissism are not precisely known. Theories include parenting styles that overemphasize a child’s special abilities and criticize his fears and failures, prompting a need to appear perfect and command constant attention.

Although narcissism has not been traced to one kind of family background, Dr. Burgo wrote that “a surprising number of extreme narcissists have experienced some kind of early trauma or loss,” like parental abandonment. The family lives of several famous narcissists he describes, Lance Armstrong among them, are earmarked by “multiple failed marriages, extreme poverty and an atmosphere of physical and emotional violence.”

As a diagnosable personality disorder, narcissism occurs more often in males than females, often developing in the teenage years or early adulthood and becoming more extreme with age. It occurs in an estimated 0.5 percent of the general population, and 6 percent of people who have encounters with the law who have mental or emotional disorders.

As bosses and romantic partners, narcissists can be insufferable, demanding perfection, highly critical and quick to rip apart the strongest of egos. Employee turnover in companies run by narcissists and divorce rates in people married to them are high.

“The best defense for employees who choose to stay is to protect the bosses’ egos and avoid challenging them,” Dr. Burgo said in an interview. His general advice to those running up against extreme narcissists is to “remain sane and reasonable” rather than engaging them in “battles they’ll always win.”

Despite their braggadocio, extreme narcissists are prone to depression, substance abuse and suicide when unable to fulfill their expectations and proclamations of being the best or the brightest.

The disorder can be treated with drugs and psychological counseling, though therapy is neither quick nor easy. It can take an insurmountable life crisis for those with the disorder to seek treatment. “They have to hit rock bottom, having ruined all their important relationships with their destructive behavior,” Dr. Burgo said. “However, this doesn’t happen very often.”

If this disorder is actually a form of insanity—or at least a severe mental disability—one might logically ask whether such an individual should be allowed to run for high public office such as the presidency. You make that call!

Trump2

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DRUG PRICES: WHY ARE THEY SO HIGH AND CAN WE DO ANYTHING ABOUT IT?

drug prices

    America spends a tremendous amount for prescription drugs—$424 billion last year alone. And that number is rising fast with no sign of slowing down anytime soon. We often encounter horror stories of drug companies that decide to raise prices to astronomical levels, and we wonder why they get away with such reprehensible behavior. The answer is, sadly, because they can!

We have long known that when new drugs are patented, the originating company gains the exclusive right to be a de facto monopoly for the life of the patent, ordinarily 17 years. After that, competition is allowed to enter and, in theory, provide generic versions, which should cause the prices to drop considerably. But now we are witnessing a significant increase in both new and some older drugs as well.

Let’s look at some reasons for such high prices:

Reason 1): Drug companies can charge whatever price they want. There is simply no regulatory source, government or otherwise, that has the power to control drug pricing. When asked why they are charging apparently exorbitant prices, they often respond by claiming they are recouping very high costs for research and testing. This is partially true, but, for large companies such as Pfizer, approximately 16% of their revenue is devoted to research, whereas they spend about 30% on selling, marketing, and advertising expenses. Moreover, taxpayers already shoulder a substantial portion of those research costs. About 38% of all basic science research is paid for with tax money through federal and state governments, according to a recent study published in the AMA journal.

There is also no restraint on companies’ raising prices on already marketed drugs that continue under patent protection.  For instance, in the past year or so, Abilify, given for bipolar disorder and other mental problems, increased over 10% to approximately $1,000 per average monthly prescription.

Reason 2): Insurance companies are charging you more. In theory, these companies should be protecting you against high prices, but instead, they have been passing on the elevated prices through raising your co-pay or deductible amounts, or simply raising your premiums, all of which, in effect, pass on much of the high costs directly to the consumers.

Reason 3): Old drugs are being reformulated as costly “new” drugs. One example is that of insulin, a drug that is over 100 years old. But companies repeatedly change its formulation, allowing them to get new patents each time. For instance, one new form of insulin is called Toujeo, given by an injection that lasts for about 1 week. Each dose of 450 units may cost about $350, and depending upon how much one requires, can amount to tidy sums for the company.

Reason 4: Generic drug shortages can trigger massive price increases. For various reasons, shortages of basic ingredients of generic drugs can arise and lead to price gouging. One example is that of the old drug, colchicine, commonly used for the treatment of gout, a form of arthritis. In past years this drug could be purchased for mere pennies, but now, it retails for approximately $8 per pill, and often as many as 8-10 pills or more can be necessary for a single attack. A daily dose of one pill or more may also be needed on an extended basis.

Reason 5): “Specialty” drugs can be “out of sight”. The rise of super-expensive, so-called specialty drugs is a real threat. For example, the hepatitis C medications, Sovaldi and Harvoni, can cost up to $95,000 for a single 12 week course of treatment.

At present, according to a recent report by the Congressional Research Service, these drugs account for less than 1% of prescriptions in the U.S. but represent about one-third of total drug spending by consumers. Since drug companies push heavily in the direction of such highly profitable products, it is likely that by 2020 very expensive drugs will constitute an even bigger chunk of drug spending.

More than half of the 56 medications approved by the FDA in 2015 were of this specialty variety, and more than 900 biologic drugs are currently under development. While these products offer great hope for the future, this raises the important question of how society is going to afford them.

Compounding this problem, competition in this specialty arena may not eventually bring down prices as one would usually expect, for many such drugs are biologics—medications derived from living microorganisms. That makes them much more difficult to copy than conventional drugs, meaning that cheaper generics are far more difficult to produce in a reasonable period of time.

HOW CAN WE DEAL WITH THIS PROBLEM?

The drug companies should be encouraged to adopt a more humane policy, which would involve controlling prices at a more reasonable level, certainly in line with overall inflation. But at least they should be forced by the public to justify apparently unreasonable prices. For instance, Vermont passed a bill that requires these companies to justify high costs and price increases, and to calculate the financial effect on insurance premiums with many specified drugs. This measure at least raises public awareness and provides misbehaving companies with bad PR, something that should get their (and their stockholders’) attention. In most foreign countries, governmental intervention causes prices for the same drugs to be considerably less than in the U.S. For instance, in the U.K., a centralized advisory board calculates the value of a medication by taking into account a drug’s efficacy, safety, and total benefits to the healthcare system. As a result the price of the same drugs in that country averages about 50% less then here. Although reasons vary from country to country, prices in the U.S. are far greater than all the other western nations.

Our government should do more to curb these prices, and could accomplish this through the following means: First they could set a limit on out-of-pocket costs, providing protection against very high or sudden spikes in prices. For instance, California enacted a law limiting a consumer’s burden at $250 for a single prescription drug per month, or $500 for certain high-deductible plans. Second, they could more rapidly approve more generic versions of common drugs, currently a slow process. Third, they could allow limited importation of drugs from legitimate Canadian and European sources, which is currently illegal under U.S. law. Fourth, they could use their so called “march in” rights, that is, in cases of high prices of drugs developed in part from taxpayer money, the Department of Health and Human Services could force the company to allow another manufacturer to make a generic version that is cheaper for the consumer. Finally, the government should prohibit direct to consumer advertising of prescription drugs; other than New Zealand, we are the only nation that allows such promotion.

Perhaps the most potent means to control excessive pricing is through the enactment of a single payer system in the U.S., i.e. Medicare for all, which I have discussed before, http://www.mortontavel.com/2015/12/31/. This would allow the government to negotiate directly from a position of power with all pharmaceutical companies. This provides another good reason—of many—to move to the single payer format. Some have estimated that such an intervention could reduce drug prices by about 40%.

Finally, the consumer can fight back on a personal level. Ask your physician, before he or she writes a prescription, what the expected costs are likely to be, and if there are equivalent cheaper generics available. Although you could mention a given drug advertised on TV, do not insist that you receive it unless this is agreed upon by your own doctor. Also, there are many instances of older drugs, while not identical to the newer patented variety, are just as effective and far less expensive.

In all instances, consider shopping around for the lowest prices, which includes online sources such as GoodRx to learn a drug’s “fair price.” Prescriptions can be filled by legitimate sources such as HealthWarehouse.com. Be careful, however, since fraudulent sites abound, use only those operating within the U.S. and display the VIPPS symbol to show that it’s a Verified Internet Pharmacy Practice Site.

Unfortunately, the ultimate answer may lie with our government, which has to power to restrict such excesses, while, at the same time, must avoid stifling necessary research. This is a daunting task, but for those that believe that government should stay away from this problem altogether, be ready to suffer the consequences!

 

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Aren’t all mass shooters mentally ill?

gun and insanity

Here is what LIZA H. GOLD, MD, clinical professor of psychiatry at Georgetown University and contributing writer to the book “Gun Violence and Mental Illness” American Psychiatric Association Publishing, 2016, had to say in answer to this question..

On June 12, 2016, a man walked into an Orlando, Fla., nightclub and committed the worst mass shooting in U.S. history. When it was over, 49 people lay dead and more than 50 others were wounded. The shooter must have been mentally ill. Only someone with a serious mental illness would commit such a horrible crime, right?

Wrong! Evidence indicating that the perpetrator’s motives lay in his political/religious ideology and possible homophobia quickly knocked mental illness out of the debate about motivation behind this particular shooting. Nevertheless, media speculation about mental illness invariably accompanies mass shootings.

Mass shootings are the most sensational, gut wrenching, and widely publicized form of firearm violence. Nevertheless, statistically speaking, mass shooting homicides are the rarest form of firearm death. These incidents account for less than 1% of firearm mortality each year. About 33,000 people a year are killed by firearms. Firearm suicide accounts for about 65% of these deaths; the rest are overwhelmingly the result of interpersonal violence, not violence committed by a stranger with a gun.

All of us recognize the images of mass shooters who were in fact mentally ill, such as the young man with the dazed look and red hair in Aurora, Colo., and the chilling images of the Virginia Tech shooter posing with his weapons. Individuals in the first throes of psychotic illness are at increased risk of committing some type of violence as their functioning deteriorates, their thoughts become more disordered, and their lack of insight often leads to treatment refusal.

However, most mass shooters are not suffering from serious mental illness. As has been discussed in a recent article, mass shooters often hold “extreme overvalued ideas,” that is, nondelusional, strongly held beliefs, a concept that does not fit neatly into psychiatric diagnostic categories. As Dr. Tahir Rahman, an assistant professor of psychiatry at the University of Missouri, Columbia, and his colleagues wrote in a recent study: “An extreme overvalued belief is one that is shared by others in a person’s cultural, religious, or subcultural group. The belief is often relished, amplified, and defended by the possessor of the belief and should be differentiated from a delusion or obsession. The idea fulminates in the mind of the individual, growing ever more dominant over time, more refined, and more resistant to challenge. The individual has an intense emotional commitment to the belief and may carry out violent behavior in its service. It is usually associated with an abnormal personality.”. We used to refer to people who hold such beliefs as “fanatics.”

The line between psychotic delusions and extreme overvalued ideas is not always clear, but some markers and signposts can differentiate between the two. Psychiatric illness is suggested, for example, by the presence of other recognizable symptoms of mental illness, such as other delusions, hallucinations, or thought disorders. In addition, individuals with psychiatric illness demonstrate related functional impairment preceding and unrelated to the mass shooting. Finally, delusions are rarely shared by even two individuals; they are not shared by large groups.

Examples in which large groups of people share social, religious, or political beliefs and some believers resort to violence can be found throughout history: from Masada to 19th century abolitionists such as John Brown to 20th century animal rights activists and 21st century “sovereign citizens.” Finding groups that reinforce and validate extreme beliefs has become even easier in the age of social media.

However, fanatics often function adequately in society until something happens to trigger a choice to act violently. Absent a history of felonious violence, these individuals are not likely to be barred from owning firearms. More non–evidence based firearm ownership restrictions for those with mental illness are not likely to slow down or decrease the rising rate of mass shootings.

We do not have more people with psychosis in the United States nor do we have more people who hold extremist ideology. What we do have are more legally purchased, military-grade weapons in the hands of a civilian population than any other comparable country. An overwhelming number of mass shootings involve assault weapons.

One popular definition of insanity is doing the same thing over and over again and expecting different results. Only one intervention could make a difference in the increasing number of heartbreaking mass shootings. Military-grade semiautomatic weapons and their high-capacity magazines should not be available to civilians with or without mental illness or fanaticism. Moreover, as the Newtown, Conn., families are doing in their lawsuit against Remington Arms, the manufacturers who sell and market such weapons to civilians must be held legally accountable for valuing their profits over our lives.

So the next time you hear another politician harp on more vigorous control of mental illness as a means control gun violence, consider what the mental experts have to say on this subject, and vote accordingly!

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GMO UPDATE: WHEN “DO GOODERS” CAN BE “DO BADDERS”

       Cereal GMO         As I reported previously, (http://www.mortontavel.com/2013/06/21/) there is danger in labeling plants and foods as “genetically modified.” (GMO). Sadly, organizations with titles that sound helpful, such as Greenpeace, Consumer’s Union, Organic Consumers Association, etc., are actually pandering to irrational fears, to the detriment of a world that will, in the future, be desperately in need of adequate food supplies. They are urging governmental mandates to label all such foods as specifically modified in this fashion. In order to set the record straight, many distinguished scientists have come out with a powerful statement:

Nobel Laureates blast Greenpeace’s anti-GMO activities:.

More than 100 Nobel Prize winners have signed an open letter to promote the use of genetically modified plants and reject the views of its opponents. The letter states:

  • Global production of food, feed, and fiber is expected to have to double by 2050 to meet the demands of a growing global population.
  • Scientific and regulatory agencies around the world have repeatedly and consistently found crops and foods improved through biotechnology to be as safe as, if not safer than those derived from any other method of production.
  • Despite this, organizations opposed to modern plant breeding, with Greenpeace at their lead, have opposed biotechnological innovations in agriculture; misrepresented their risks benefits, and impacts; and supported the criminal destruction of approved field trials and research projects.
  • Greenpeace has led the opposition to Golden Rice, which has the potential to reduce or eliminate much of the death and disease caused by vitamin A deficiency (VAD), which causes 1 to 2 million preventable deaths each year, mainly among the poorest people in Africa and Southeast Asia.
  • VAD is the leading cause of childhood blindness globally affecting 250,000 to 500,000 children each year, half of whom die within 12 months of losing their eyesight.

The signers urge Greenpeace and its supporters to recognize the findings of scientific bodies and regulatory agencies and abandon their campaign against “GMOs” in general and Golden Rice in particular. They also urge governments of the world to oppose Greenpeace’s actions and accelerate farmers’ access to all the tools of modern biology, especially seeds improved through biotechnology. The Support Precision Agriculture Web site lists the laureates and more than 2,500 others who have joined the campaign so far.

The current move by several states to mandate labeling of all foods modified in this way sends a misleading message to the public, suggesting that these foods are somehow “tainted” or less safe. Nothing could be further from the truth!

    I, for one, wholly endorse the scientists’ initiative!

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Science Weighs In on High Heels

shoes

Obviously, what we wear on our feet affects how our bodies move. People who run barefoot, for instance, are more likely to land near the front of the foot with each stride than people wearing typical running shoes, who more commonly land on their heels.

But few other shoes affect the shape and functioning of the foot as dramatically as high heels do. According to a recent review of the available research about footwear, walking in high heels can alter the natural position of the foot-ankle complex, and thereby produce a chain reaction of effects that travel up the lower limb at least as far as the spine.

But while it’s clear that the feet and ankles of women who wear such heels over a long period of time are different from those of women who usually wear flats, the progression of theses changes has not been well understood.

A recent study published in The International Journal of Clinical Practice, researchers in South Korea turned to a handy recruit group: young women at the university studying to become airline attendants who were required to wear high heels to class, since they would have to wear them if hired by a Korean airline. With each passing year, from incoming freshmen to seniors, the women would have one additional year of heel wearing behind them, making it easy to track physiological changes.

The results were interesting. Compared with the freshmen, who were generally new to wearing heels, the sophomores and juniors displayed greater strength in some of the muscles around their ankles, particularly those on the inside and outside of the joint. Although this difference between new and experienced heel wearers suggested that wearing high heeled shoes may at first lead to adaptation and increased strength, the senior women, who had been wearing heels the longest, showed weakening of those same muscles, compared even with the freshmen, as well as much weaker muscles along the front and back of the ankle, resulting in dramatically worse balance. In fact, all of the upperclasswomen had worse balance than the freshmen, even as some of their muscles were strengthening. What appeared to have been happening is that the ratio of strength between the muscles on the sides of the ankles and those at the front and back became increasingly unbalanced over years of wearing heels, contributing to ankle instability and balance problems and eventually to a decline in the strength even of those muscles that had been stronger for awhile.

This finding is worrisome because strength imbalances in the muscles around a joint, especially those around the ankle, are known to increase injury risk in other muscle groups, such as those in the hamstrings or upper leg.

So should women give up wearing high-heels altogether? If it’s possible, I would respond with an emphatic yes! However, if such shoes are unavoidable, wearing should be minimized as much as possible. Moreover, people who often must wear high heels should strengthen their ankles whenever possible with simple heel lifts, where one stands barefoot and then rises onto the toes repeatedly; and heel drops, during which one stands on the edge of a stair, slowly lowering the heels over the edge.

Whenever possible, slipping off heels while sitting at one’s desk should be done, since wearing the shoes, even when not moving can alter the resting length of the muscles and tendons around the ankle, which could destabilize the joint and increase the risk of injury.

Also never run purposely in heels. The impact forces created are concentrated over a small region of the foot in high heels, creating regions of very high pressure, often resulting in foot pain. Additionally, balance and biomechanics are compromised, making running in heels a very inefficient way to move.

In conclusion, whoever invented high heels should themselves be required to wear them 24-7; perhaps then they would learn to be careful of what they had wished for!

 

 

 

 

 

 

 

 

 

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NRA REACHES YOUR DOCTOR’S OFFICE

gun home

As a physician, I had always prided myself on being free to advise patients about all health issues, including risks that could endanger their personal well-being and that of their families and loved ones. This meant that I could inquire not only about immediate risks such as smoking and diet, but, among others, about whether a patient was using his/her seat belt when driving, or exposing family members to the toxic effects of secondary cigarette smoke in the home. I was also free to inquire whether a given patient had a firearm at home, because of the potential dangers involved. In that regard, evidence shows that the presence of a gun in a home increases by threefold the risk of death for all household members, especially by suicide, when compared with homes free of guns. Even worse, this risk rises to fivefold greater for children residing in homes possessing firearms. Thus these dangers are so great that it is incumbent on physicians to counsel patients about risks of home firearms and to recommend countermeasures, which include use of safety devices and meticulous storage of weapons, or better yet, total removal of guns from the household.  This is so important that all major physicians’ organizations, including the AMA, have recommended that physicians discuss firearm safety with their patients.

So can such responsibilities be forbidden? Outrageously, Florida’s Firearm Owners’ Privacy Act was enacted in 2011 in response to concerns raised by some patients whose physicians asked them about gun ownership. The law prohibits physicians from intentionally entering information into a patient’s record about firearm ownership that “is not relevant to the patient’s medical care or safety, or the safety of others.” Thus physicians my not ask about firearm ownership unless they believe “in good faith” that “such information is relevant to the patient’s medical care or safety, or the safety of others.”  Physicians who violate this law may be “disciplined” (whatever that means). Whew! How disingenuous can a law be?

Now several physicians and their organizations are rightly suing the Governor of Florida, claiming that the law violates the First Amendment. Subsequently, a 3-judge panel of the Florida Court of Appeals voted to uphold the Act. Although the legal interpretations were mixed, this court believed that physician counseling may be so persuasive as to deter patients from exercising their second amendment right to own guns. But they got it wrong! This amendment doesn’t protect anyone from hearing information about the risks of firearms. As a matter of fact, some limited studies suggest that gun owners counseled in this way are more likely to change storage and handling practices, thus reducing the odds of gun-related catastrophes.

This case is still being contested, and the associated First Amendment issues are apt to be major. Missouri and Montana already have laws similar to Florida’s, which have been (not surprisingly) strongly supported by the NRA.  In 2011, the West Virginia legislature even considered a law that defined physicians’ questions about gun ownership as gross negligence.

If the Florida law is upheld, additional states may then enact similar restrictions, endangering physicians’ ability to counsel patients about gun safety. Even more egregious, this could lead to more invasive regulation of physician counseling; for instance, several states already require doctors to provide women—often against their wishes—with medically questionable information prior to abortions. All such laws threaten to compromise the physician-patient relationship, which relies on truthful and confidential communication in order to arrive at shared health goals. These laws unduly reflect the invasion of a physician’s ability to speak truthfully in the effort to protect a patient’s own health as well as that of their families.

Perhaps the NRA is creating more mischief than merely protecting the Second Amendment!

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