Medication Pricing: Tips for the Individual

Posted on April 13, 2018 by admin

Not surprisingly, prices vary greatly among pharmacies for many medications. The retail cash price variation could be as much as 45 times more from one pharmacy to the next, even within the same zip code, which is both outrageous and incomprehensible.

Worse yet, pharmacists may not be allowed to tell you if a drug is cheaper when you don’t use your insurance. That’s because pharmacists may be bound by “gag clauses” — imposed upon them by corporations known as Pharmacy Benefit Managers that set prices for drugs. The only workaround is for a consumer to ask the pharmacist specifically if there is a lower price.

You deserve better–especially when it comes to something as expensive and important as prescription medications.

Sometimes you could save money by not using your insurance, and instead looking for coupons online, shopping around, and paying cash. To find these savings, Consumer Reports has developed some specific questions that you can ask your local pharmacist. They’ve created an easy, downloadable card that you can print out and keep in your wallet with the three key questions to ask your pharmacist to help get you the lowest prices on drugs possible.

Asking the pharmacists directly doesn’t guarantee a cheaper price, but keeping pharmacists under gag clauses should not work. We need to demand transparency, accountability, and fair drug prices for everyone!

To learn more about pharmaceutical pricing, here is some information provided by GoodRx, a firm based in Santa Monica, Calif., that offers deep discounts on some medications. The company sends discount cards to physicians’ offices, but they can be obtained directly from the company’s website, (www.GoodRx.com) and an app. It advertises that it is about transparency, and if you’ve ever tried the company’s site or app, the service it offers is remarkable and simple to use. You plug in the medication you’re interested in, include the dose and quantity you’d like, and add your ZIP code, then a list of pharmacies with the GoodRx discounted prices is generated for easy comparison shopping. It tells you how far each pharmacy is from your current location and provides the discount codes; the phone, fax, and hours of operation for the pharmacy; and a link to a map with driving directions. And if driving to multiple pharmacies to get the best price on multiple medications seems too difficult, in what is just short of miraculous technology, the app allows people to enter in all their medications and shows the comparative prices for the bundle. In short, GoodRx is to medication pricing what Trivago is to hotel rates. The technology is impressive, and it’s worth noting that the founders of GoodRx previously worked in top positions at Facebook.

GoodRx offers “up to 90% discount” on the cash price of medications through its app, website, or discount card – all of which can be gotten for free. This triggers two questions: 1) Who pays for this difference in the medication cost, and 2) How does the company, with 95 employees, make any money?

Medications are made by a pharmaceutical company or, for generics, there may be many manufacturers. The medications are sent to a pharmaceutical distributor, such as McKesson, and it, in turn, sells and delivers the products to pharmacy chains, as well as to smaller, independent pharmacies. The pharmacies pay an acquisition cost for medications then set a price for these medications that are considerably – or even astronomically – higher than the acquisition price. This is the cash retail price, or in medicine, what is called the Usual & Customary (U&C) cost of the medication. The price may be neither usual, customary, nor reasonable, and it’s not necessarily the price the pharmacy expects to recoup on sales.

Every major insurance company contracts with a pharmacy benefits manager (PBM), for example, Caremark, Express Scripts, and Optum, to negotiate the cost of medications with each major pharmacy chain. Physicians are familiar with PBMs, who intercede by requiring preauthorization procedures for certain medications or by instituting stepwise requirements before they will allow pharmacy benefits toward the purchase of medications. When the PBMs negotiate with the pharmacies, they will negotiate for a discount off the pharmacy’s U&C charge for medication, perhaps a discount as much as 75% or 80%. The discount is not negotiated on a per-medication basis but as an across-the-board average, so for one medication, the insurance price may be 2% discount from the U&C cost, and on another medicine it may be 95%. There is a dramatic variation, more than you’d ever expect.

GoodRx gathers prices from many places, including partnerships with a number of PBMs. In addition to providing discounted prices for insured customers, the PBMs also include in their negotiations a slightly less-discounted price for cash-paying patients who present with a GoodRx card or coupon. You might be surprised to learn that discounted prices can often be less than the typical patient copay. For patients with high deductibles or when the copay is higher than the cost of the medication, it will often be less expensive for patients to use a GoodRx discount instead of their insurance. In cases of non-covered medications, GoodRx could be especially beneficial. And whether patients use either their insurance or a GoodRx discount, part of the cost of the prescription includes an administrative fee that goes to the PBM. When GoodRx cards are used, the PBM pays GoodRx part of that fee.

One example of an enormous cost discrepancy was provided a couple years age by Provigil (modafinil), a drug that promotes daytime wakefulness. Thirty pills cost just under $35 at Costco, while all other pharmacies were charging close to $1,000. Costco seems to base their prices on their acquisition costs and then raises them a certain percent. It’s one way to provide a fair price, but that doesn’t necessarily mean they always have the lowest price. They are one of the major pharmacies that list their drug prices on their website.

So what was in it for the PBMs? Why would Express Scripts be motivated to negotiate a discount in price for cash-paying customers outside of the insurance networks, and how did partnering with GoodRx benefit them? The answer, in part, lies with the fact that the GoodRx website and app allow patients to comparison shop and go to pharmacies with lower prices. If patients use their insurance, the insurance company is paying less; if they don’t use their insurance because they learned the cash cost is less, then the cost burden has shifted from the insurance company entirely to the patient.

So what’s in it for the pharmacies? Why would they be willing to accept less money from a patient bearing a discount card? Pharmacies want to honor their contracts with PBMs, and the U&C prices are set high to enable negotiation so that they still make some profit. Most people couldn’t afford to pay the high U&C, but they can’t lower them for individual cash-pay customers because that would violate their agreements with PBMs, Medicare and Medicaid. With the GoodRx price, they still make a profit, and people in drugstores buy other items as well. Pharmacies are usually happy to work in this manner, for they get more patients; moreover, in certain areas, a prescription that costs over $15 may never be picked up. Many pharmacies are frustrated; they want a fair price where they can make a profit, and every year, 200 million prescription orders are left at pharmacies, and the medicines are never picked up. Non-adherence to medication comes at an enormous cost in this country – roughly $300 billion in medical expenses. Making medications more affordable is one way to circumvent this problem.

Although GoodRx has only 95 employees, how do they generate sufficient income? A portion of the PBM’s administration fees go to GoodRx, some comes from advertising revenue, and finally, GoodRx provides technology for the PBMs and charges for this service.

So here are some suggestions to acquire better drug prices before risking bankruptcy!

HOW THE EPA THREATENS OUR CHILDREN WITH BRAIN DAMAGE

Posted on April 5, 2018 by admin

As reported recently in the New England Journal of Medicineⁱ, plans had been drawn up by the Obama administration’s EPA by 2015 to totally ban the “organophospate” insecticide chlorpyrifos in agricultural and all other uses. Already dating back to 2001, this toxic substance was being phased out because of its danger to humans, especially children. Predictably, however—to the glee of the chemical industry—this plan was scrapped in 2017 by incoming EPA director Scott Priutt, despite evidence of human toxicity presented by agency’s own scientists.

Harmful effects of chlorpyrifos on the developing brain are not surprising, given that this chemical was first introduced as a poison nerve-gas during World War 2, and then later adapted by the chemical industry for use as insecticides. Studies in animals and humans have disclosed that these toxins are capable of widespread disruption of nervous tissue—especially the brain. One study disclosed that exposure during pregnancy resulted in reduced cognition in children by the time they reached the age of 7. Evidence also established that, following exposure to very young children, irreversible cognitive and behavioral defects are likely to develop later in life. Especially worrisome was a previous study in children in which brain damage was found by MRI images in those most highly exposed to these agents, and the areas most afflicted sub-serve vital brain functions that include social behavior, attention, receptive language, emotion, and inhibitory control.

Nor do adults escape free of bad effects, for occupational exposure to this substance has been clearly linked to Parkinson’s disease, and other neuro-degenerative diseases cannot be excluded.

The EPA is required by federal law to ban or regulate a chemical if it cannot prove with reasonable certainty that the chemical is safe. In the case of chlorpyrifos, it has failed to provide this certainty, and, as a result, it is likely putting an entire generation of young brains in harm’s way. Given this administration’s cavalier attitude toward public safety in general, our entire population—children as well as adults—are likely exposed to clear danger. Regardless of whether or not Pruitt remains in his present position, successors appointed by Trump are as likely to be as bad or worse.

What else can we look forward to from such reckless leadership! Should the EPA receive a new name: “Environmental Destruction Agency” ??

i Rauh VA, Polluting developing brain—EPA failure on chlorpyrifos. N. Eng.J. Med; 2018; 378:1169-1171.

ARE THERE ANY MEANS’ TO ENHANCE MEMORY?

Posted on March 30, 2018 by admin

Many signs of memory loss can be disconcerting, as exemplified by misplaced car keys, forgotten names of people and streets, etc. We all go through such lapses, especially as we age. So it’s no surprise that many of us, according to the Nutrition Business Journal, sales of supplements touted as memory boosters nearly doubled between 2006 and 2015. But, unfortunately, scientific studies thus far have yielded little evidence that any of these products is of any benefit for preventing or delaying memory lapses, mild cognitive impairment, or eventual dementia as we age.

So let’s take a look at what is known about some of the popular “memory enhancers.”

Fish oil: Some studies have disclosed that diets high in omega-3 fatty acids, as found in fatty fish, may have a lower risk of dementia; however, similar benefits are not provided by supplements. A 2012 review of data on thousands of older adults found that those who took omega-3 supplements had no fewer dementia diagnoses or better scores on tests of short-term memory than those who took a placebo.
B-vitamins: These also have failed the test. A 2015 review of studies disclosed that supplementation with B6, B12, and/or folic acid failed to show any increase in short or long-term mental capabilities.
Ginkgo Biloba extract, made from the dried leaves of a ginkgo tree, touted after decades of research, have failed, through modern science, to demonstrate any benefits.
Other supplementation, hyped for memory enhancement: A 2017 Government Accountability Office report analyzed hundreds of ads promoting memory enhancing supplements online, and they found at least 27 products making illegal claims about treating or preventing diseases such as dementia. Unfortunately, even legal claims that suggest supplements will improve, boost, or enhance your memory, supply no data to justify them. These products are loosely regulated, and some may even contain undisclosed ingredients or inappropriate prescription drugs.
One example supplement, of many, is that of Prevagen, highly touted by Quincy Bioscience, for its ability to allow one to “experience improved memory, a sharper mind, and clearer thinking.” See my post: http://www.mortontavel.com/2015/10/22/ According to the company, apoaequorina, a protein first discovered in jellyfish, can help protect brain cells by binding to excess calcium, which might otherwise damage or destroy these cells—noting that calcium can result in memory impairment. However, no studies have shown that apoaequorin, when taken orally, reaches the bloodstream or brain. Three studies have ostensibly been performed, only one of which was published in a medical journal, and the latter lacked adequate statistical comparison of results between the group taking Prevagen and those taking placebo, making it impossible to draw conclusions from this study. Thus, regarding scientific verification of efficacy, we are left in the dark. Moreover, the FDA has claimed that the key ingredient, apoaequorin, is not acceptable in a dietary supplement without further rigorous testing. Regarding potential toxicity, the FDA accused the company of not reporting to the government adverse events like seizures, strokes, and worsening symptoms of multiple sclerosis that had been reported to them as being associated with the use of Prevagen products. According to the FDA, reports about this product to the company have also included chest pain, tremors, fainting and other serious symptoms. In fact, they found that the company received more than 1,000 incidents and product complaints about Prevagen between May 2008 and December 1, 2011, and only investigated or reported two events. Because of the glacial pace of litigation, however, sales go on, and we can do little about it but wring our hands and alert as many as possible about these dangers! Unfortunately, this is but one of many such products misleadingly labeled as “supplements” and not drugs.

DOES ANYTHING WORK?

If you wish to enhance your brain power, three measures are worth trying:

1) Exercise your brain in reasoning and memory challenges—learning a new language, for instance—might help delay or slow decline. A ten year trial found that such training through various “brain games” can help increase cognitive processing speed and sharpen reasoning skills, hopefully forestalling or preventing later deterioration.

2) Exercise your body: In 2011, one study estimated that one million cases of Alzheimer’s disease in the U.S. were due to a sedentary lifestyle. Several other studies have found that physical activity—walking, weightlifting, etc. may delay or slow cognitive decline, but not prevent it.

3) Control blood pressure. Lowering blood pressure to normal levels can dramatically reduce the risk of heart disease and stroke, which are risk factors for memory loss and dementia. So everyone should have their pressure checked, follow its level, and comply with treatment directives for its control.

Unless I could alter everyone’s hereditary predispositions to dementia, I can only offer the limited dos and don’ts as described above. But, above all, don’t take any supplements!

THE MANY HEALTH BENEFITS OF FIBER

Posted on March 23, 2018 by admin

Fiber is a dietary component that is justifiably gaining attention these days. Not only does it promote good health but it may even extend longevity. In a recent study reported in the Journal of Gerontology, older people who ate fiber-rich diets were 80% more likely to live longer and stay healthier than those who didn’t. The study followed over 1,600 healthy adults for 10 years and found that high daily fiber intake of 29 grams or more had reduced incidence of cancer, heart disease, and diabetes, and they also retained better overall cognitive, physical, and cardiovascular function.

So what is fiber anyway? It is a carbohydrate found in plant foods: beans, fruit, grains nuts, and vegetables. Surprisingly, it isn’t a nutrient that is broken down and absorbed, and that’s what makes it so beneficial. There seem to be several ways it exerts its anti-aging magic:

Reduces body cholesterol by blocking intestinal bile acids that promote fat absorption. A recent large review found that high fiber intake led to a 7.7 mg/dl reduction in total cholesterol and a 5.4 mg/dl drop in LDL (“bad”) cholesterol
Prevents diabetes. Another recent study found that people who got less than 20 grams of fiber per day had a 50% greater risk of developing diabetes (type 2) than those who got 31 grams or more per day. The reason? Fiber slows the absorption of carbohydrates into the blood stream, meaning that blood sugar levels rise more slowly and the pancreas has more time to react through its production of insulin
Better weight control. Fiber adds bulk, allowing you to feel more satiated and to
stay full longer.
Lowers colorectal cancer risk. A recent report by the world Cancer Research Fund found that eating fiber-rich whole grains daily could lower colorectal cancer risk by 17%.
Reduces inflammation. Chronic inflammation has been linked to many diseases such as arthritis, some cancers, and even Alzheimer’s disease. Although the mechanism is uncertain, this may result from the polyphenol and magnesium content of fiber, which confers anti-inflammatory properties.
Protects joints. Possibly through its anti-inflammatory actions, fiber seems to reduce the risk of arthritis. A recent study published in the Annals of the Rheumatic Diseases found that those whose daily fiber intake averaged 20 grams had a 30% lower risk of degenerative knee arthritis than those who ate about 8 grams daily. Furthermore, those who consumed about 25 grams per day had a 61% lower risk compared with those who consumed about 14 grams.
Promotes “good” intestinal bacteria. Through fermentation of fiber, the enhancement of “good” bacteria may have far reaching effects such as strengthening the immune system and helping to control inflammation, although such properties are still under much investigation.
HOW TO GET ENOUGH FIBER

Although some packaged foods are fortified with various fiber additives, it’s best to get the most fiber from foods naturally rich in these substances. But overall, the more fiber consumed daily, the better. Below, for starters, is a list of good candidates, the rest is up to you. Women should try to eat at least 21 to 25 grams of fiber a day, while men should aim for 30 to 38 grams a day. Read nutrition

labels to find out exactly how much fiber is in your favorite foods.

Fruits	Serving size	Total fiber (grams)*
Raspberries	1 cup	8.0
Pear, with skin	1 medium	5.5
Apple, with skin	1 medium	4.4
Banana	1 medium	3.1
Orange	1 medium	3.1
Strawberries (halves)	1 cup	3.0
Figs, dried	2 medium	1.6
Raisins	1 ounce (60 raisins)	1.0

Grains, cereal and pasta	Serving size	Total fiber (grams)*
Spaghetti, whole-wheat, cooked	1 cup	6.3
Barley, pearled, cooked	1 cup	6.0
Bran flakes	3/4 cup	5.5
Oat bran muffin	1 medium	5.2
Oatmeal, instant, cooked	1 cup	4.0
Popcorn, air-popped	3 cups	3.6
Brown rice, cooked	1 cup	3.5
Bread, rye	1 slice	1.9
Bread, whole-wheat	1 slice	1.9

Legumes, nuts and seeds	Serving size	Total fiber (grams)*
Split peas, boiled	1 cup	16.3
Lentils, boiled	1 cup	15.6
Black beans, boiled	1 cup	15.0
Lima beans, boiled	1 cup	13.2
Baked beans, vegetarian, canned, cooked	1 cup	10.4
Almonds	1 ounce (23 nuts)	3.5
Pistachio nuts	1 ounce (49 nuts)	2.9
Pecans	1 ounce (19 halves)	2.7

Vegetables	Serving size	Total fiber (grams)*
Artichoke, boiled	1 medium	10.3
Green peas, boiled	1 cup	8.8
Broccoli, boiled	1 cup	5.1
Turnip greens, boiled	1 cup	5.0
Brussels sprouts, boiled	1 cup	4.1
Sweet corn, boiled	1 cup	3.6
Potato, with skin, baked	1 small	2.9
Tomato paste, canned	1/4 cup	2.7
Carrot, raw	1 medium	1.7

“DRUG” ADVICE WORTH REMEMBERING

Posted on March 15, 2018 by admin

As I have stated, there is no justification for allowing prescription medicine to be advertised on TV: http://www.mortontavel.com/2017/03/28/. Why would anyone think of trying one of those medicines after listening to the laundry list of warnings of dangerous side effects? Moreover, if they posted their sticker prices, even more people would be turned off.

So, here is one with better results, more tolerable side effects, and definitely cheaper!

Do you have feelings of inadequacy?

Do you suffer from shyness?

Do you sometimes wish you were more assertive?

Do you sometimes feel stressed?

If you answered yes to any of these questions, ask your doctor or pharmacist if Cabernet Sauvignon is right for you.

Cabernet Sauvignon is the safe, natural way to feel better and more confident. It can help ease you out of your shyness and open you to world attention.

You will notice the benefits of Cabernet Sauvignon almost immediately, and, with a regimen of regular doses, you will overcome obstacles that prevent you from living the life you want.

Shyness and awkwardness will be a thing of the past. You will discover talents (and maybe some handicaps) you never knew you had.

WARNINGS

Side effects may include the following:

dizziness, nausea, vomiting, incarceration, loss of motor control, loss of clothing, loss of money, delusions of grandeur, table dancing, headache, dehydration, dry mouth and a desire to sing Karaoke and play all-night Strip Poker, Truth Or Dare and Naked Twister.

The consumption of Cabernet Sauvignon may make you think you are whispering when you are not.

The consumption of Cabernet Sauvignon may cause you to tell your friends over and over again that you love them.

The consumption of Cabernet Sauvignon may cause you to think you can sing, when you can’t (at least on key).

The consumption of Cabernet Sauvignon may create the illusion that you are tougher, smarter, faster and better looking than most people.

THE UNFORGETTABLE BOTTOM LINE

“LIFE IS A CABERNET OLD CHUM”!

Don’t take me too seriously! But can you recognize some parallels out there?

STEM CELLS: A TRUE PANACEA OR A TRENDY HOAX?

Posted on March 8, 2018 by admin

You may have been bombarded recently by hype about the magical healing power of stem-cell treatments. But before doing so, we offer some sobering information:

An investigation published recently in a major medical journalⁱ involving 368 Web sites that combined stem cell with various buzzwords and practitioner names associated with “complementary and alternative medicine” has disclosed the following:

243 sites marketed stem cell therapies and 116 marketed other interventions where stem cells were mentioned in the description of the treatment or its effects. The other interventions included platelet-rich plasma injections and others.
The stem-cells used for transplantation were said to be derived from fatty tissue, bone marrow, blood, umbilical cord, and other sources, e.g., placenta, amniotic fluid, and embryonic stem cells.
20 sites advertised plant cell-based treatments and products such as skin creams.
The most common advertised treatment targets were: bone, joint, and muscle pain/injury; various diseases or maladies; cosmetic concerns; non-cosmetic aging; and sexual enhancement.
80% of the sites were for clinics in the USA; the rest were located in 17 other countries.
The practitioner types mentioned on the 368 sites included medical doctors (161), naturopaths (63), chiropractors (61), acupuncturists (36), midwives (33), homeopaths (27) and massage therapists (13). Some sites mentioned more than one and some sites listed none.
Hyperbolic language was found on 32% of the sites.
Only 31% of the sites mentioned the regulatory status of the intervention, and only 33% noted that the therapy was unproven.
Only 19% of the sites stated there was limited evidence of efficacy of the intervention and 13% said there was evidence of inefficacy.
Only 25% of the sites mentioned general risks of the interventions.

The investigators concluded:

Many clinics seem to be engaging in misrepresentation of science (pseudoscience), which can seriously obfuscate public discourse, mislead the public and make it difficult to discern real science from marketing claims that merely reference scientific sounding terminology. The marketing of unproven stem cell therapies has the potential to harm patients and to harm the reputation of stem cell science. It is incumbent on regulators and policymakers to take a proactive approach to managing the risks associated with the growing private market for stem cell-related interventions. Also, addressing misleading marketing practices is an important part of this strategy.

What real science has shown about stem cells ⁱⁱ

Stem cells are special cells with the potential to repair damaged tissue and organs, and they have been used in injections and tissue transplants in attempts to heal injuries and to treat various diseases. There are several types of stem cells, each possessing differing powers. Those that come from human embryos can turn into any kind of cell, and in theory, repair any organ or tissue in the human body. By contrast, those stem cells taken from fully developed tissues, called “adult stem cells” can only turn into the type of tissue from which they came, a feature that limits their use considerably.

Access to embryonic stem cells is federally monitored, but adult stem cells, which can be extracted from a patient’s own body, are subject to relatively few federal regulations. As a result, physicians and other non-licensed practitioners have been unimpeded in using them to treat a wide range of conditions without demonstrating that they are safe or effective. In fact, stem cell treatments are widely accepted only for two broad medical indications–to help treat a handful of blood disorders that include leukemia and some forms of anemia, and in certain cases to help burn victims.

The FDA has acknowledged the problem of under-regulated stem cell treatments and says it is taking steps to strengthen oversight of this burgeoning industry. Regulators have issued warning letters to numerous stem cell clinics for violating laboratory and manufacturing standards, and have ordered at least one company to stop selling any of these products. In the future, agency approval would be required for some stem cell therapies in a fashion similar to approval of prescription drugs. Clinics where patients are harmed would be subject so enforcement actions that could include increased inspections and possible product seizures. However, critics counter this proposed action by stating that those measures fall short of what’s needed to protect consumers, stating that such practitioners need to be prevented from selling dangerous untested treatments before they harm people, not after. Although much active research is taking place, the average consumer should be wary of any of these various schemes, even if emanating from recognized clinics such as Mayo Clinic, Northwestern University and the University of California, all of which have been accused of stem-cell over-hype in some instances.

So before anyone considers subjecting him/herself to a stem-cell treatment of any kind, obtain as much information as possible, especially from a well-recognized licensed medical practitioner involved in the same field of endeavor.

i Murdoch B et al. Exploiting science? A systematic analysis of complementary and alternative medicine clinic websites’ marketing of stem cell therapies. BMJ Open 8(2), March 2, 2018.

ii Interlandi J. Could this call save your life? Consumer Reports, March, 2018, pp 37-41.

FIREARM VIOLENCE AND REVEREND BAYES

Posted on March 1, 2018 by admin

Reverend Thomas Bayes (1702–1761) was an English clergyman who happened to be a fine mathematician, which was undoubtedly his first love. He formulated a theorem bearing his name, which allows for the mathematical calculation of probabilities of outcomes based upon certain preexisting conditions. Bayes’s formula remains pertinent to this day and is used by contemporary health professionals, psychologists, economists, physicists, and engineers. We medical practitioners apply this principle almost daily in evaluating the meaning of test results (Tavel, 2012). Now, however, this idea can be applied to politics.

The idea that Bayes introduced was conditional probability, i.e., the likelihood of a given outcome when prior baseline characteristics are already known. Nearly all methods of detection employ means that are not 100% accurate, and this means that any given model of prediction will omit outcomes that will eventually occur, as well as prediction of outcomes that fail to materialize. Thus Bayes provided a mathematical means to derive the actual probability of a later outcome after two variables are applied.

First let’s apply this idea to flying in a commercial airliner. Statistics show that such air travel is approximately 60 times safer than car travel. So why are so many of us afraid of airplanes? The answer can be described in terms of conditional probabilities. The probability of dying in an air fatality is the product of two different probabilities—the probability the airplane will crash, and the probability that, in the event of a crash, the passenger will die. The first probability is extremely low—virtually zero. The second probability is one (100%)—that the individual person will die if there is a crash—and that’s the probability that scares many people. But according to Bayes’s concept, the chance of mortality is a result of the product of these two variables—the chance of a crash, which is almost zero—times the chance of death. So, when the multiple is calculated—nearly zero times one—the answer remains almost zero. This very low conditional probability should provide much comfort to all air travelers.

Now let’s apply this same principle to the detection of mental disorders in our attempt to ward off mass firearm violence in schools, public gatherings, etc. According to the National Institute of Health, the prevalence of major mental illness in the U.S. is approximately 4.2% of the entire population, meaning that about 10.4 million people harbor serious mental disorders. During the past six years, there were 43 individuals responsible for mass firearm attacks. Even if one assumes that this entire group of 43 was mentally ill, which is unlikely, it would constitute an infinitesimally small percentage (.000004) of all those suffering from mental illness. Applying Bayes’ theorem, unless we had a fail-safe (100%) method of detecting individual would-be killers from this large group of mentally ill, our ability to find a likely killer remains at nearly zero, which represents the proverbial needle in the haystack. Moreover, all mental health professionals freely admit that it is virtually impossible to predict accurately which of those with known mental disorders will perform such acts of violence. Compounding this problem even further, laws in this nation generally preclude forced detention of mentally ill individuals who have not yet performed any act of violence. What this means is that, given these extremely daunting numbers, detection and treatment of those with suspected mental illness in the effort to ward off gun violence is a virtual impossibility, notwithstanding the pronouncements by many politicians.

It all boils down to a simple bottom line: Major efforts must be aimed primarily at sensibly limiting everyone—whether or not mentally ill—from obtaining firearms capable of mass destruction. Reverend Bayes, among many others, would be gratified!

REFERENCE

Tavel, ME, “Snake Oil is Alive and Well: The Clash between Myths and Reality. “Reflections of a Physician”. Brighton Press, Inc. Chandler, Arizona, 2012

Good Fats and Bad Fats: Where do we Stand Now?

Posted on February 16, 2018 by admin

Most of you have by now heard recent media stories that claim to debunk long-established beliefs that saturated fats do not cause heart disease and that the vegetable oils that we’ve been encouraged to use instead may actually promote it.

But the best-established facts on dietary fats say otherwise. How well polyunsaturated vegetable oils hold up health-wise when matched against saturated fats like butter, beef fat, lard and even coconut oil depends on the quality, size and length of the studies and what foods are eaten when fewer saturated fats are consumed.

So before you succumb to wishful thinking that you can eat with abandon well-marbled steaks, pork ribs and full-fat dairy products, you’d be wise to consider the findings of what is probably the most comprehensive and untainted review of the dietary fat research yet published. It can be found in a 26-page advisory prepared for the American Heart Association and published last June by a team of experts led by Dr. Frank M. Sacks, professor of cardiovascular disease prevention at the Harvard School of Public Health. The report helps to explain why the decades-long campaign to curb cardiovascular disease by steering the American diet away from animal fats has been less successful than it might have been and how it inadvertently promoted expanding waistlines and an epidemic of Type 2 diabetes.

When people cut back on a particular nutrient, they usually replace it with something else to maintain their needed caloric input. Unfortunately, in too many cases, saturated fats — and fats in general — gave way to refined carbohydrates and sugars, the so-called SnackWell phenomenon that prompted fat-wary eaters to overindulge in high-calorie, low-nutrient foods. Most people do miss their unhealthy fats and, in the latest rage, many have latched onto coconut oil in the mistaken belief that its main highly saturated fat, lauric acid, and other nutrients can enhance health rather than undermine it.

As documented in the new advisory, misleading conclusions that saturated fats do not affect the risk of developing and dying from cardiovascular diseases have largely resulted from studies that failed to take into account what people who avoided saturated fats ate in their place. Several of the otherwise well-designed trials involved too few participants or did not last long enough to reach a scientifically valid conclusion. It can take up to a decade or longer to show that consuming healthier fats can produce a decline in cardiovascular deaths, and few well-controlled clinical trials last that long.

Some studies may have failed to show a benefit from reducing saturated fats because participants substituted margarine and other partially hydrogenated vegetable oils containing trans fats that were later shown to be even more damaging to blood vessels than animal fats. This was a problem in the Sydney Heart Study, conducted from 1968 to 1973; the experimental group was given margarine high in trans fats, resulting in more cardiovascular events than among those who continued to eat lots of saturated fats like butter.

On the other hand, the results of four “core” trials conducted in the 1960s, lowering saturated fat and replacing it with vegetable oil rich in polyunsaturated fat, primarily soybean oil free of trans fats, lowered coronary heart disease by 29 percent, similar to the benefit from taking a statin to reduce cholesterol.

In later studies, the most important influence on the results was the types of foods study participants ate in place of saturated and other fats. For example, in a study of 252 British men who had suffered heart attacks, following a low-fat, high-carbohydrate diet reduced cholesterol levels by a meager 5 percent and had virtually no effect on future heart attacks. The carbohydrates they ate were mainly refined, low-fiber flours and sugars that promote weight gain and diabetes, two leading risk factors for heart disease. In North America and Europe, the effect of lowering saturated fat was essentially negated by people’s consumption of more “refined grains, fruit juice, sweet desserts and snacks, sugar-sweetened beverages, and other foods” that hardly promote good health.

Unfortunately, there have been no trials to date testing the cardiovascular benefits of replacing dietary fat with “healthful nutrient-dense carbohydrates and fiber-rich foods such as whole grains, vegetables, fruits and legumes that are now recommended in dietary guidelines. The most recent studies conducted that analyzed the effects of specific nutrients showed that when 5 percent of calories from saturated fats were replaced by an equal number of calories from polyunsaturated fats, monounsaturated fats (like olive and canola oils) or whole-grain carbohydrates, the risk of coronary heart disease was reduced respectively by 25 percent, 15 percent and 9 percent. Furthermore, when polyunsaturates and monounsaturates replace saturated fats, death rates decline from cancer, dementia and lung diseases as well as from heart disease and stroke. In other words, if you are truly concerned about preserving good health overall, focus on a Mediterranean-style diet heavy on plant foods and unsaturated vegetable oils, with whole grains, fruits and vegetables as the main sources of carbohydrates.

Thus information stemming for the best research is straightforward: consume few saturated fats like butter, full-fat dairy, beef and pork fat, and coconut, palm and palm kernel oils and replace them with natural vegetable oils high in polyunsaturates — corn, soybean, safflower, sunflower, peanut, walnut and grapeseed oils. Also healthful are canola and olive oil, rich in both monounsaturates and polyunsaturates.

Based on the National Health and Nutrition Examination Survey, almost half the calories in the American diet come from carbohydrates, and of those 80 percent are from refined starches, sugar and potatoes. Sadly, the average American diet is not very healthy, to say the least.

Although dairy fat as not optimal, it is not nearly as good as plant fats, but not quite as bad as other animal fats. Thus you don’t have to totally abandon cheese, but dairy foods should be limited to one serving every one to three days, not thee servings a day.

As for coconut oil, it may be the nutritional fat du jour but it has not been proven to be healthful. It is fine to use on your body as a moisturizer for skin or hair, but not necessarily in your body, although consuming small amounts is unlikely to be harmful.

So here we are again back to square one, but now with with important qualifications as noted above!

EVER THOUGHT OF LIVING FOREVER? WELL, DON’T!!

Posted on February 7, 2018 by admin

This was the intriguing subject of an article by Dara Horn¹ appearing recently in the New York Times. In it, Horn describes how several billionaires have sunk lots of money into projects called “life extension,” or “end aging forever.” These aspirants seem to be composed of mainly billionaire men, possibly owing to the likelihood that women would prefer not to be around with the likes of such man for such a lengthy period. These men seem to believe that interminable life does not “violate the laws of physics.” Ironically, they seem to have gained some support from a woman, Elizabeth Blackburn, who received the Nobel Prize for her work on telomeres, which are protein caps on chromosomes (cellular elements) that may be a key to understanding aging. But Professor Blackburn admits that her important research, while allowing for a better understanding of aging, does not suggest living to one’s hundreds, stating that “everyone’s cells become old and eventually we die,” which suggests that her research may allow a better chance for us all to live a long and healthy life.

But in the extraordinary unlikely event that eternal life could be achieved, what would be its practical implications? First, as suggested by the billionaires, it would extremely costly and likely limited to the very affluent, sowing the seeds of severe social unrest. As a result, those who possess limited resources would be left “out in the cold,” and likely and foolishly demand that immortality be covered by medical insurance. But suppose eternal life were to become cost-effective. This planet would then be overcrowded so severely that all resources would be exhausted and new births all but prohibited. The environment would take a severe drubbing with global warming, disastrous environmental desecration, inundating sea water levels, and insufferably high temperatures.

Then there is the matter of evolution: Human development, lacking generational replacements, would be halted, thus preventing us to from becoming a better and more adaptable species. (We could certainly use some betterment, at least in politics!) At the same time various animal species would presumably continue to evolve, and maybe some of our higher relatives might equal or pass us up, resulting in a planet of apes?—or dolphins?

So, as enticing as eternal life may seem to each of us, it is simply not to be, not now and not forever!

But now we get practical and examine the issue of present longevity.

This is also an even more intriguing subject, and while there are obviously no clear answers, it brings up two important questions: 1) How long would we survive if all presently known diseases were eradicated? 2) How far could science take us, provided we have emerged victorious over these diseases? So let’s look at each question separately.

Life Expectancy in the Absence of Disease

In 1900, average life expectancy in the USA was approximately 47 (women living about 2 years longer than men). By 1998, the average had risen to around 76 (women doing better by about 5 1/2 years. But note from the chart below that we made most of this progress between 1900 and around 1970. The early rapid progress was primarily attributable to our victory over infectious diseases, which was halted temporarily by a drop in mortality in 1918 resulting from the influenza epidemic (note in the chart) . Since 1970, the curves are rising more slowly because of the more formidable challenges than posed by the various non-infectious diseases.

Now our biggest killers are related to cardiovascular diseases, (heart disease and strokes) caused primarily to arteriosclerosis (hardening of the arteries), and cancers of all types. Based upon the numbers, if we could wipe out cardiovascular disease and cancer, we could allow most folks to live out a maximum number of years based upon our current understanding of human physiology.

Causes of Death in the USA in 2010

Heart disease: 597,689
Cancer: 574,743
Chronic lower respiratory diseases: 138,080
Stroke (cerebrovascular diseases): 129,476
Accidents (unintentional injuries): 120,859
Alzheimer’s disease: 83,494
Diabetes: 69,071
Kidney Diseases, nephrotic syndrome, and nephrosis: 50,476
Influenza and Pneumonia: 50,097
Intentional self-harm (suicide): 38,364

Based upon published information together with my medical knowledge, I believe that we could reach an average age of 100-110, provided that at least these two major disease categories, mentioned above, could be eliminated.

In the case of cardiovascular diseases, we have the answers now, provided that the various lifestyle problems and predisposing conditions could be corrected. They include improper diets, obesity, smoking, hypertension, lack of exercise, and others of lesser importance. It’s generally conceded that prevention offers a far more effective strategy than do medications and surgical procedures to reduce mortality. Thus treatments of all types are only of limited importance. A recently reported counter trend slight fall in lifespan is likely not indicative of a major trend shift, but if sustained, would be likely due to poor lifestyle choices, especially advancing obesity.

Cancer provides a formidable challenge, possibly because it is likely multi-factorial in cause and often extremely difficult to treat with our current methods. With advances in our understanding cell biology, including DNA makeup and manipulation, together with controlling immune reactions, we are likely to solve this riddle within the next few years—probably not soon enough in my judgment.

How Far Could Science Take Us Next?

The answer to this question takes us into the realm of science fiction, but, for what it is worth, here are my thoughts.

Despite the great advances in such areas as organ transplantation, cell mechanics, surgical procedures, and many others, I believe that the maximum life expectancy will remain capped in the area of 110. I say this because, as noted in the chart below, we are already beginning to level off, and despite many advances in organ transplantation and other potential treatments, various targeted methods and replacements cannot support the entire body, such as muscles, bone, brain and others. Thus the entire body continues the inexorable process of aging. For this reason, we are likely to be restricted by such limitations in lifespan as determined by evolution.

The assumptions stated above are merely that, but in order to advance beyond these limits we would need extreme and game changing advances that are not possible to foresee at this time. But who knows?

In the meantime, be careful what you wish for!

Violet line = Females. Black line = Males.

1Horn D. The men who want to live forever. N.Y. Times, January 28, 22018. p. 9

CONSUMING RAW WATER: ANOTHER NUTTY IDEA!!

Posted on February 1, 2018 by admin

You may have recently heard that drinking “raw water” is the latest health panacea. Advocates are claiming great health benefits to be derived from this source, among which are the elimination of that nasty fluoride, the acquisition of beneficial probiotic bacteria, and lord knows what else! And paying big money to boot! Their claims seem to fall in line with those zealots who are touting raw milk, an equally nutty claim that I have covered in a previous post: http://www.mortontavel.com/2013/12/03

Our municipal water is filtered for a reason. Untreated water may contain bacteria, viruses and parasites. Resulting health problems can range from mild gastrointestinal discomfort to diarrhea, dehydration and death. The bacteria that cause cholera, typhoid, dysentery and others can thrive in “natural” water, meaning raw water could provide a long trip to the toilet at best—and the hospital or morgue at worst. Water contains radon in many areas of the U.S., and 25,000 people die each year from radon exposure and consumption. Since raw water isn’t treated or tested, you may be ingesting potentially damaging levels of naturally occurring radon, as well as other unidentified chemicals and bacteria.

Proponents of raw water insist that their supply comes from pure springs that have no traces of diarrhea-inducing diseases, and they feel that the water’s natural probiotics and lack of fluoride outweigh the risk of contamination. But fluoride in water has never been found to be a risk to health, The Centers for Disease Control showed that tooth decay is down in the 70 years since routine fluoridation started. As for probiotics, it’s true that tap water filters out bad microbes like giardia, but also takes away less harmful bacteria that could be good for gut flora. Sadly, however, the probiotics in raw water won’t necessarily help fend off any diseases, and even though some research suggests that probiotics may be beneficial to health, one can obtain these microbes in a far safer fashion from products such as cultured yogurt.

I would simply conclude by asking a simple question: Would you be willing to drink raw water that might be no different from that attained from either a third-world country or your own toilet bowl? If so, go ahead at your own risk; in any event, your local hospital or funeral director will be more than willing to assist you.

ENERGY DRINKS: WHAT EVERYONE SHOULD KNOW

Posted on January 25, 2018 by admin

They are all over the place, brazenly claiming to keep you revved up, energized, and alert. But controversy is now raging over these products, for several deaths have reportedly followed their use and more problems keep surfacing. So we need to explore the facts about these drinks.

First, how do they accomplish this energy infusion? I can answer with a single word—caffeine! We all know it is the active ingredient in coffee. An 8 ounce cup of coffee contains about 100 milligrams of caffeine. By contrast, a 16-ounce Starbucks Grande contains about 330 milligrams. That’s why most people drink coffee in the morning: It’s a helpful “waker-upper” to get them started and ready to attack the day with a head of steam.

Although caffeine can make you feel more alert, boost your mental and physical performance, and even elevate your mood, it can also make you jittery, keep you from sleeping, cause rapid pulse or abnormal heart rhythms, and raise blood pressure. Safe limits of caffeine consumption are still being studied, but data suggest that most healthy adults can safely consume up to 400 milligrams per day; pregnant women, up to 200 milligrams; and children, up to 45 to 85 milligrams depending on weight.

The content of caffeine in the various “energy” products is not always listed, but from what we know, caffeine content varies greatly, ranging from about 6 milligrams to as much as about 250 milligrams per serving.

Various scientific groups have for years urged the Food and Drug Administration to require disclosure of caffeine levels on these products, but the agency says it lacks the authority to do so. Also, some energy drinks include additional ingredients such as taurine, L-carnitine, and high amounts of B vitamins, such as niacin and vitamin B6, ingredients that are not of real benefit, but they may present additional problems.

Now comes more bad news about these drinks: More than half (55.4%) of young people who have ever consumed an energy drink have experienced at least one adverse reaction, according to a study published recently in a medical journal.
The research was conducted online among over 2,000 adolescents and young adults (age 12 – 24) in Canada. Most (73.8%) reported having ever consumed an energy drink, and, of these, 55.4% reported experiencing at least one adverse reaction. The most commonly reported reactions were rapid heartbeat (24.7%), difficulty sleeping (24.1%), headache (18.3%), nausea/vomiting/diarrhea (5.1%) and chest pain (3.6%). About 3% of respondents who suffered an adverse event had sought or considered seeking medical help for an adverse reaction. Those who reported having ever consumed an energy drink were almost three times more likely to report an adverse event than those who reported having ever consumed coffee. According to the authors, the current findings are consistent with those of Health Canada’s Expert Panel on Caffeinated Energy Drinks, which concluded that, although the probability of serious adverse events is low, given the high volume of use, the risk of adverse events is considered to be a public health issue.
Previously, a 2015 study published in the Journal of the American Medical Association concluded that drinking a single energy drink may increase cardiovascular risk, and the drinks have been associated with cases of brain hemorrhage, acute hepatitis, and vitamin B6 toxicity. Disconcertingly, a 2017 study published in Journal of Medical Toxicology found children under the age of six accounted for almost 45% of energy product exposures reported to poison control centers in the U.S.

Conclusion: My advice: Stick to coffee, considering the caffeine limits cited above. Forget the “energy drinks.” They are not only a waste of money but also a danger to health!

TRUMP’S MEDICAL “CHECKUP”: IS HE REALLY IN EXCELLENT HEALTH?

Posted on January 15, 2018 by admin

We physicians are often asked to conclude two things from a regular “checkup” of someone who has no symptoms to suggest present disease: 1) What is the likelihood that one is harboring an unrecognized but hidden disease? 2) What is the likelihood that disease will develop in the future?

In the absence of complaints, information from a physical exam seldom discloses unrecognized diseases, and routine laboratory screening tests seldom add much of additional value. Thus the results of Trump’s exam tell us very little about any present physical diseases, especially in the absence of psychological testing. But can his findings tell us anything about his chances of impending future health disasters? Based upon his lifestyle choices and family history, his greatest chances of future diseases are cardiovascular events (heart attacks, stroke, etc.) and dementia (Alzheimer’s disease).

With regard to cardiovascular risk (our largest killer by far), using the various charts supplied by the American Heart Association and others, which include age, sex, blood pressure, and certain blood tests, Trump’s chances of developing serious cardiovascular events within the next ten years are approximately 15%. At his age, less than 10% is considered reasonably low.

But additional factors must be added that include his coronary artery calcium score of 133 (on CT scans), a number that means he already has asymptomatic cardiac vascular disease. The calcium score directly correlates with the risk of overt future cardiac events. People with higher scores have greater plaque burden on the linings of these arteries, carrying a higher risk for cardiac events regardless of whether symptoms are present. For asymptomatic individuals, a calcium score of 0 indicates absence of detected calcium and an extremely low likelihood (<1%) of any coronary arterial disease. The odds ratio (ratio of events in an interest group vs. events in a baseline population) of developing symptomatic cardiovascular disease is 3:1 for people with scores of 1 to 80 (where the zero score group is the baseline population), 8:1 for people with scores between 80 and 400 (Trump’s group) and nearly 25:1 for people with scores above 400. In fairness, Trump is taking “statin” drug and aspirin to minimize this risk, but, nevertheless, the dangers are clearly present.

What may be more damming, however, is Trump’s widely publicized poor diet with obesity (yes, folks, despite his denials, according to the published charts, he is obese), and lack of regular exercise, factors that, while difficult to quantify, when coupled with the presence of coronary calcium, would raise his overall odds of serious cardiovascular events to at least 20-30% over the next ten years (three years obviously being a substantial portion of this number). Obesity, per se, raises his odds significantly for developing various cancers: https://www.cancer.gov/about-cancer/causes-prevention/risk/obesity/.

But what if we add his chances of present mental disorder or future dementia? Based upon his family history (his father suffered from Alzheimer’s disease), it is entirely possible that Trump himself already is manifesting its early phases or, at least, has greater chances of developing dementia soon in comparison with the general population. Despite Trump’s examining physician’s recent claim that his “cognitive ability” is normal, it is widely acknowledged that there is little correlation between cognition (intelligence) and insanity. This information, coupled with Trump’s erratic behavior, should mandate an immediate and comprehensive neuropsychiatric examination, which, sadly, is likely to be denied.

Does this information justify the declaration by the White House that Trump is in “excellent health”? For the present, maybe so, maybe not. But for the future, I’m taking no bets, and neither should you!

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