Why Christmas Still Matters

Why Christmas Still Matters

Dr. Dennis J Teehan, Jr.

The meaning of Christmas has changed over the past few decades.  Christmas is a religious holiday, but the spiritual essence of the holiday has become matched, if not exceeded, by a culture of commercialism and consumerism.   This has undoubtedly changed how Americans and Christians throughout the world celebrate it. 

Hand and hand with this is the obvious reality that as a general rule Americans and people everywhere are increasingly questioning their faith.   People are exploring their ideas about God and re-examining their values in ways that make many less by-the-book pious.

As America redefines it’s faith the question remains of what happens to the most important holiday in Christianity and it’s traditionally Judeo Christian fundamentals.  I think it safe to say as America goes through a spiritual re-configuration that there is a small vacuum at the core of Christmas, and for now this vacuum has been filled with a culture of rabid commercialism.

I for one believe that Christmas still matters.  Not just in terms of electronics, video games and gift certificates or a cultural experience but as a spiritual and existential holiday of great importance to the  human story.

I am a Christian, but I am also a doctor and a scientist.  Count me as among the group of Christians who are questioning dogma, but to me the literal truth of the Christmas story is less important than the ideas that it represents.     It is not some distant event that makes Christmas and Christianity what they are, but  acred psycho spiritual themes.

Christmas should not only be viewed only as a religious holiday celebrating a 2000 year old event, but rather as an intimate celebration of ideas that reside in each of us.  The values that Christ preached when he was alive are as important to our survival and success as a species today as they were then (if not more so):  social justice, compassion,  caring for each other.  These are the only way for human beings to create a better world, which is what Christ, and countless other teachers, have preached to us for millenia.  

The ideas and themes carry a message that resonates with so many souls because they powerfully and wonderfully embody so much of the human experience.  They are not unique to Christianity or even religion, but show up everywhere, in every culture and every story ever told.   And these sacrosanct ideas are wonderfully epitomized in the story of Christ and his birth.  

The story of Christ represents something in each of us.   What more sacred an idea there is to the human experience than the notion that each one of us has a Christ in us?  (Or a Buddha?  Or a Mohammed for that matter). That each of us born into this world carries these ideas with us every day as we move through our lives and experience the joy and sorrow of existence.  That each of us is a manifestation of an infinite God and that each soul which individuates from the infinite sea of consciousness might remember that all things ultimately come from one source

The values that Christmas represents (joy, giving, compassion and mercy) all tie back to that one very sacred notion:  that each individual can by honoring our highest self be a part of creating a better world.   On a deeper level this is an acknowledgement that all life forms are interconnected and that an act of kindness to another and the world is in actuality an act of kindness to one’s self.  What could be more sacred or divine than that?

As we move through the Christmas season and experience what it has become and how it has changed, try not to forget the relevance and  intimacy of the Christ story to all souls everywhere.  Regardless of religion, the themes of Christ story are critical to the human experience.    At it’s core is the idea that all things are one.  And that, and not ruthless commercialism, is what makes Christmas sacred, important and divine to all humans.

Why Is So Much Research Wrong: Looking at The Flaws In Randomized Controlled Trials?

There is a lot of "junk science" happening in the world today.  

The average American is bombarded on a daily basis with the results of scientific studies as presented through the untrained and generally unqualified pulpit of the mainstream media.   Television, Social Media, Newspapers and Magazines.  The  output is dizzying, and much of the research is either poorly done or improperly represented. 

 Even a simple research question like "Is taking a multivitamin beneficial for  health" has been the subject of several conflicting reports in recent years that offer completely opposite answers from credible studies done at credible institutions. 

It can be extremely hard to make sense of all this information  for even the most trained and educated professional.   For those without a scientific back round putting all this together can be downright confusing.

Take it from someone with  training in statistics, epidemiology and evaluating scientific research:  there is a lot of garbage science happening out there.   Much of it is actually happening at world class institutions.
  

The reasons for this are many, but at the heart of the problem is one simple fact:  Doing science is really, really, really hard!  The simple fact is that it is extremely challenging in our universe of space, time and matter and our world of financial and logistical challenges and barriers  to answer any research question definitvely without somehow corrupting the findings along the way.

For example, let's say we wanted to know if Chemical X released into air by Corporation Z causes lung cancer in humans.  Sounds simple right? We have many study designs we could use, but the most pristine way to answer this question would be to do what is called a Randomized Controlled Trial.  In that study design we would take a sufficiently large group of individuals and assign each person them in one of two groups. We can then expose one of our two groups to Chemical X and another to a placebo solution that resembles chemical X but is in fact known to be harmless.

 By randomly assigning each member of our large number of study subjects to one of of our two groups inferential statistics tells us that each separate group is likely to have similar amounts of demographic and potentially confounding traits (i.e age, smoking, socioeconomic status, etc).  For that reason our results will have the best chance to be free from confounding factors.   Our study subjects can not know which agent they get (chemical X or placebo), which is a technique known as blinding. 

Think of some of the problems that even this method would cause.  Most cancers take decades to develop.  If the time it takes for Chemical X to cause a lung cancer was 30 years imagine the financial cost of following our patients for 30 years? It would cost tens of millions of dollars in today's dollars, a daunting amount for even the most well financed research institution.   So cost is one major strike against doing the RCT, even if it is the best method. 

Think of the logistical challenges.  Even scientists rarely stay at the same institution for an entire career, so who will conduct our trial? 

 Furthermore certain patients would get lost over the 30 years and be unavailable to be included in the studies final results.  It is unlikely that this would be random and there is a certain type of patient more likely to get lost to follow up.   Most likely patients with job difficulties, social or family problems would be more likely to relocate to a place where follow up was difficult or impossible.

Patients from certain geographic areas may  be less likely to follow up.   For example, let's imagine some of the study patients live in a wealthy neighborhood close to the study where the access to medical care is better.   Another group of patients lives in a much poorer neighborhood 30 miles away.  Who, over the course of our long study, would be more likely to follow up?  Could, by mere geography, we be introducing a key form of inadvertent bias into our study?

Or perhaps patients who develop stress or mental health problems may be less likely to comply with rules of study.  This is another way we could introduce bias into our findings .   Imagine if we inadvertently excluded our poorest or most mentally ill subjects simply because they were less likely to follow up. They are the ones most likely to smoke, live in bad neighborhoods, have exposure to environmental toxins, have poor nutrition and poor access to care.  This could certainly bias our results in many different ways.      

 Certainly some of our patients may die of other causes during our 30 year study, and we would not obviously have as much follow up for them as for the healthy ones who survive until the studies end.    We would intrinsically be excluding the sickest patients at baseline from our study.  Think of how this could influence our results.    

You could try to solve some of these problems by only following a smaller group, but most lung cancers are exceedingly rare.  If we only follow 100 patients in each group and our exposed group has 6 cases and our unexposed has 4 cases,  can we say with confidence that those 2 extra cases of the 100 were caused by chemical x, verus mere random chance alone?  Mind you in this example, those 2 extra cases amount to a 150% increase relative risk!  The realities of inferential statistics demand that a big group is usually essential in these types of studies with rare outcomes so that we can exclude the possibility that the observed differences between groups is not merely due to statistical chance, so small groups are generally not reliable.   

Also consider the ethical problems this would cause.    Is it obviously not right to give people an agent that scientists suspect may be carcinogenic.  What if we decided to only give Chemical X to adults given informed consent?  We would be excluding children from the study.   Could this not substantially alter the results?  What if Chemical X is most carcinogenic in childhood. 

How would we assess the outcome of lung cancer in our randomized controlled trial anyways? The only reliable way to detect a lung cancer would be to diagnose a mass with a CT scan and then a biopsy the mass when it was detected.  Is it ethical to give thousands of people a CT scan every few years?  Studies have shown that ionizing radiation is a known carcinogen with a clear dose response relationship (meaning the more radiation you give, the higher the cancer rate).   

Of course most masses that develop in peoples lungs are NOT cancerous, but every patient with a mass would need a biopsy for definitive diagnosis in our study.   As you  might imagine, sticking a needle in peoples lungs, even under the most controlled conditions, can cause all sorts of medical complications.  Undoubtedly a few of our thousands of study subjects over the 30 years would suffer serious or life threatening complications.  Even if we could get such a procedure approved by an Institutional Review Board,  we might likely have to exclude our sickest patients from these dangerous biopsies ( People with limited cardiopulmonary function).   We may have introduced another methodological error likely to corrupt our statistics!

Furthermore, how would we even assess exposure to Chemical X.   It is nearly  logistically impossible to ask thousands of people to carry monitors for Chemical X for a lifetime.   Could we rely on medcial records?   Geography? Air Quality Testing?   Environmental Records?  (We will touch more on this in my next column, about other study methods). 

Imagine another dilemma. Let's say that Chemical X indeed causes lung cancer after 20 years of exposure, but it also causes asthma first. Imagine that the most sensitive individuals to Chemical get severe asthma (which would ultimately lead to getting lung cancer) and would be able to infer that they were getting Chemical X (remember they are blinded to whether they get chemical X or Placebo) from the fact they have developed asthma (and not the Placebo.)    Maybe this would cause them to drop out of study.  Maybe it would cause them to seek medical attention sooner and be more likely to be diagnosed?  How could each influence our results?

Or what if we weren't studying a toxic chemical but a potentially beneficial drug.   Imagine a study design where our blinded subjects got either placebo pills (usually a harmless sugar pill) or a powerful medicine with a possible therapeutic effect.   The medicine, as opposed to the placebo, would be likely to cause side effects.  Patients who inferred they were getting the actual drug versus the placebo would no longer be blinded.  

This may prompt them to change their behavior.  They could seek other treatments or medical attention, not try other treatments, change other habits or behaviors or just simply be more vulnerable to powerful placebo affects (which studies show explain up to a third of the observed in research studies).  This would especially be a concern if the outcome we were investigating was subjective, like depression or anxiety or pain.   Some psychologists argue that the very minute efficacy of anti-depressant medicines in studies is due to this effect and not any real anti-depressant properties of the medicines.

All these questions, and many, many  more, arise during the process of conducting a study design (randomized controlled trial) known to be our most pure method of conducting research.  My point of this article is that here are literally dozens of places where even a randomized controlled trial could run into trouble, and produce results that are wrong, distorted or vulnerable to manipulation.  It should therefore be no surprise that our science often changes by the study.

When we look to answer a seemingly simple question like "Does Chemical X cause Lung Cancer?" it is easy to imagine the hundreds of potential places that our "clean study" may become polluted.  Conducting science in a universe of space, time and matter is nearly impossible even under the best of circumstance. 

Numbers Don't Lie When It Comes To Vaccinations

Millions of people watched a youtube video a few years ago of a former Washington Redskins Cheerleader and beautiful young woman who was walking like a chicken supposedly as a result of getting the flu vaccine a few weeks earlier.  No one ever was able to prove that this isolated instance was indeed related to getting the vaccine, but undoubtedly this video influenced the perceptions of many who watched it.  

Conversely there is no dispute from anyone that about 1/1000 children who get measles infection will suffer from a rare and devastating neurological disease called Subacute Sclerosing Pan Encephalitis.  The virus will trigger an inflammatory response in the body of infected kids that will attack their brains and almost all of those who suffer this complication will experience severe permanent neurologic damage if not death.   Were it not for measles vaccination, tens of thousands of children in the world in the last few decades would have suffered severe debilitating neurologic compromise.  

Of course, we will never know who the names of the children whose brains were saved, but we can say for certainty that this is but one of the many known bizarre, debilitating and not all that rare complications from the many diseases we vaccinate against.

Even death is a not at all an uncommon complication from the germs that are commonly vaccinated against.   Flu season is fast approaching and the Influenza virus will kill approximately 35,000 American this year of all age groups, just like it does every year . 

I feel like there is so much misinformation and faulty logic out there about vaccines that I felt compelled to address it in this blog.  Many have been influenced  by counterculture horror stories of vaccines that are founded on flawed logic and fantasy.  I politely offer the patients I see with this perspective the vaccine and give them my “strongest recommendation” to get it based on my analysis of the risks and benefits.    

Yet still many say no in spite of my effort to convince them.

 The reason I make this recommendation this is clear to me:  I took an oath to do no harm and based on the best available scientific evidence, which I spent the better part of my life gaining the skills to assess, there is no disputing that Vaccines have saved millions upon millions of human lives.  

Population Medicine is a tricky game.  The goal is to identify problems and then implement population based changes that ultimately cause more good than harm.    This is not always easy and the history of medicine has been littered with mistakes.  But  numbers don’t lie:  Hundreds of Millions of people are alive today because of vaccines.  

For someone to convince me as a physician to stop recommending vaccines they would have to prove, scientifically, that vaccines do sufficient harm to outweigh the benefit from the innumerable lives vaccination has saved.    It can be easy to lose sight of the HUNDREDS OF MILLIONS of lives vaccines have saved when we hear isolated horror stories of the dangers.    

The truth about vaccines is pretty straight forward:  No physician, nurse or public health professional has ever suggested that vaccination of any kind does not have risks associated with it.    In fact every person who gets a vaccine does so only after getting informed consent about the risks of vaccinations.  There is no disputing that people have died from the consequences from vaccinations.

But the risks and toxicity of the germs they prevent is, simply put, much, much, much greater.  Influenza, Mumps, Measles, Diptheria, Polio, Rubella and the other bugs we vaccinate against are nasty stuff.  They cause problems beyond simply making people feel unwell for a few days.   They attack the body and cause dangerous and bizarre syndromes (like SSPE) in some unfortunate individuals.   They infect hearts, brains, nervous systems and kidneys which often causes serious consequences and death.

To illustrate the dangers of the germs we vaccinate against consider the following example.   The most well known complication of flu vaccination is a syndrome called Guillane Barre Syndrome.   GBS is a rare ascending paralysis that is triggered when something introduced to the body produces an “autoimmune” response to some of our nerve cells.  It is usually short lived and self limited but can occasionally be serious and even more rarely fatal.  It occurs in 1 in every several hundred thousand people who get flu vaccine. 

I know this sounds scary but here is the catch:  Flu vaccine is not the only thing that causes GBS.  It turns out the actual flu virus that you may get from your neighbor, relative or somewhere in the community also can and will cause GBS.  In fact studies show that people are far, far more likely to get GBS from  actual flu infection than they are from flu vaccination and that people who get GBS from the actual flu virus as opposed to the vaccine typically have a much more serious and complicated course.  

In fact many of the risks of vaccination are things that are caused in greater likelihood and severity by the actual germs we aim to vaccinate against.  So if you are worried about getting GBS this winter, your best bet is to get the flu vaccine not take your chances with the highly virulent and much more immunogenic wild type flu strains circulating through our communities.  

The moral of the vaccine story is that everything in life has risk associated with it.   There is no such thing as a “risk free” path in any endeavor and certainly not when it comes to health and medicine.   That a vaccine has risk to it should put in good company: most of the things we do in daily life carry a risk of harm.  In fact most of the routine things we do in daily life carry a much greater risk of harm than flu vaccination with much less clear, tangible benefit.  Have you taken notice of the tremendous risks associated with driving a motor vehicle lately?

The logical error most people make  is not in their admittedly accurate identification of the risks associated with flu vaccination but in their failure to acknowledge the benefits of vaccination and their failure to accurately consider the risk of non-vaccination.  This is a math problem and to come to the correct answer you have to accurately consider all the variables, not just the most visible ones.  

That flu vaccine has risks or has definitely harmed people is not sufficient to disqualify it from being a good idea.  

One of the funny and unfortunate truths of population medicine:  we will never be able to place a definite name or face on the people  who population based preventive interventions like vaccines save, but for the unfortunate few we harm there is always a name, a face a story and maybe even a youtube video.

While these stories resonate in our mind good medicine is like a good baseball manager who “plays the percentages” to maximize his team’s chance of a desirable outcome. It's strictly a numbers game.  In this case the numbers do not lie:  vaccines save way more lives than they take or harm.  

One Physicians Take: Why I Support The Affordable Care Act

When it comes to the Affordable care act Americans seems to be divided.  A substantial proportion of our country remains opposed to Obama's attempt at health care reform but I, as a practicing physician, can't seem to figure out why. 

 In the year 2011-2012 I made it through a Masters in Public Health at a University where some of the faculty actually advised the Obama Administration, and I earned that degree yet somehow I learned next to nothing about the ACA.  Recently the debate on the ACA has turned up a notch when I realized I knew precious little about the law besides what I had regurgitated from blurbs on the TV news I decided it was time to inform myself.

What I realized is that while The ACA may not be perfect and it will undoubtedly cause some problems in the short term, it is an essential step for fixing our broken, inefficient and under performing health care system.

I may not have learned a lot about the ACA in my MPH, but what I did learn a lot was how our current health care system works, the role of health and wellness in society and  the importance of health and productivity to the solvency and economic potency of our nation. An unhealthy nation can not survive and we as a people are becoming increasing less healthy. It almost entirely traces back to a lack of preventive care and lifestyle related illness.    I also learned a lot about where our health care system fails, a place most Americans choose not to look at until they or a loved one is sick, and how it costs us deeply both morally and in the pocket book. 

If I had to summarize the current American Health Care system in one saying it would be "Spend the most, Get the Least."   To me this is a slogan that most Americans are blissfully ignorant to.  Any person who dares to utter that we have "the best health care system in the world" is, to put it politely, just painfully and unequivocally misinformed. 

To understand the problem in the current health care system and why the ACA is essential you need to understand a few principles about health care in America. 

(1)  First and foremost is that America spends the most on health care of any country in the world by far, and it isn't even close.  It is estimated that the United States spends about 18% of its annual Gross Domestic product on health care averaging out at over $8000 per citizen per year.  This is by far tops among the 34 industrialized democracies that are members of the Organization of Economic Cooperation and Development.   Second on the list is Norway who spends 12%, or approximately 33% less than the United States.  Those horrible single payer systems in Canada and the United Kingdom, long derided in the States for their expense and inefficiency, spend 11.4% and 9.6% of their GDPs on health care, billions upon billions of dollars less than the US and consistently outperform the United States on most objective measures of quality.

(2) In spite of our high health care bill, we are providing inferior care to the population. It seems like a logical and basic idea that when one spends the most on something they should in return get the most back.   Unfortunately when it comes to health care in the United States the complete opposite is true.   In fact when public health scientists have studied how the United States performs on measures of quality versus other industrialized nations we either come in last or near last. For example, we have the highest infant mortality rate of any industrialized nation.  In some parts of our country, like on  Indian Reservations or in poor urban areas, the infant mortality rates are comparable to some of the poorest nations in the world in Africa.   When we look at measures of managing chronic disease in terms of quality and quantity of life our sick people do worse than the sick people in other countries.  For example, a diabetic in any other industrialized nation is likely to live longer and better than a diabetic in the United States.  

 We could say the same for any number of other chronic diseases like heart disease, lung disease, cancer and HIV.  Why should America's sick people have less years and less quality years than those, say in France, Germany or Japan, when we spend more on health care than those nations.  What are spending all this money for? 

In fact in the year 2000 we set a series of goals for our nation called "Healthy People 2010."   We met almost none of those goals, despite spending the most on health care of any country in the world in that decade. 

(3)   We decided long ago in this country that no sick person will go without medical treatment. THE ACA IS NOT ABOUT PROVIDING UNIVERSAL HEALTH CARE TO AMERICANS. Here is a revelation that I bet most Americans do not realize: WE ALREADY HAVE UNIVERSAL HEALTH CARE IN THE UNITED STATES. The ACA is about providing universal. or near universal, health insurance to Americans.   Walk into our emergency rooms and you will see the masses if indignant people who use the emergency rooms in our country for the care of routine medical problems.  No one get's turned away from out hospitals and we already take care of everyone:  We just do it in the most expensive and inefficient way possible.

  

When you understand those 3 principles (that we spend the most, get the least and we are currently taking care of everyone in the most expensive least efficient way possible) than you understand why health care reform in this country is essential to the future of our civilization. We can not continue like this. Our sick and our healthy people deserve better.

So why do I support the ACA?  

The ACA is about shifting the focus to preventive care and care in the community.  It is about paying 70 dollars for a flu shot, instead of paying 70000 for 4 day hospital stay for the flu.  It is about paying for 500 dollars for prenatal visit and labs for a mother. instead of millions for a case of neonatal Hepatitis.  It is about paying 5000 for a colonoscopy, instead of millions for a case of colon cancer.  In fact under the ACA all preventive services will be covered by insurance providers. This is essential.  

In order to do this the ACA tries to ensure that as many people as possible have insurance.  This directly saves costs by ensuring people have access to physicians in the community  for preventive services (vaccines, cancer screening, other disease screening) and the management of chronic diseases.  For example a patient with worsening COPD can see their doctor and get an inhaler to treat their problem for a total cost of a few hundred dollars, instead of waiting until their problem is out of control and they are forced to go to the emergency room of a hospital and costing the system tens of thousands of dollars. 

One provision of Obama Care that is essential is the "Individual Mandate."  This requires that all Americans have health insurance or face a tax penalty.  The reason for this is simple:  Because every one of us will get sick eventually, all of us must pay into the system. This really isn't about individual rights: It is about basic economics and fairness:  You have to pay into the system to get something back from it.  Simply put:  Everyone can't get something for nothing.  

The law also will expand Medicare to 16 million more Americans and allow children to stay on their parents insurance until age 26 again in the spirit of keeping people insured for the same reason: Uninsured people are expensive. Furthermore, the ACA requires that no insurance company can turn someone away if they are already sick, or stop covering someone because they got sick.  

Another essential provision of Obama Care is the "Employer Mandate"  This requires that all small businesses over 50 employees must provide their employees with insurance or face a tax penalty.  In exchange for providing insurance, these companies will benefit from a significant tax credit.   While this undoubtedly will affect some small businesses adversely, it is worth mentioning that only 4% of Americas small businesses are businesses that are over 50 people that don't already provide insurance to their employees.  

The major goal of the ACA is to provide health insurance care to the 50 million Americans who are uninsured and the reason for this is simple.  All 50 million of these individuals are going to get sick eventually. It is unavoidable.  And if they haven't bought into the system then the rest of us will have to pay for them.   If they don't have access to affordable care and preventive care in the community then we will pay a lot for them in expensive hospitals and emergency rooms, often times when their illness is too advanced to cure.  At that point we should factor in the cost of their lost productivity into our calculations of losses and gains.  What might cost mere dollars to fix ends up costing thousands or millions.

America is becoming a nation ravaged by poor health (mostly because of lifestyle related illness) and it is severely impairing our ability to remain strong and productive.  I don't postulate that the ACA is a perfect law, but it is going to help.  There are going to be problems with it.  Some businesses will be adversely affected and some people will lose their jobs. Others may lose their insurance.   But the net gains will far exceed the losses so we have to endure the problems.   What I am confident of is that in the "big picture"  health care reform is essential to the survival of our civilization.

In spite of the initial costs and difficulties I believe the ACA will ultimately save The United States a lot of money, but we can debate all day about the economics  However, besides all the weighing of tangible pro's and cons, in a civilization that spends money all over the globe on all kinds of things, isn't protecting the health of it's citizens simply the moral thing to do?  Is there a more noble expense for the richest country in the world?  Is it not wrong that babies in this country are dying of preventable diseases every day because they can't get to doctors and old men who could live another ten years live don't get to see their grandchildren grow up because they can't get a doctor?  This is not just an economic issue, this is a moral one.

Every generation has to face challenges and sacrifices.  Our grandparents generation had to fight a viscous war overseas to save the world from a tyrant and protect our safety and liberty.  Today what threatens us, and costs us lives by the thousands, isn't a foreign invader but an unhealthy lifestyle and an inefficient health care systems.  The net amount of suffering and loss caused by this is massive.   One of our generations tasks is to make America a healthier place and to reform this broken, inefficient system for the betterment of the future to ensure the next generation of Americans has access to health care.   We are going to have to make short term sacrifices to ensure it.

I  am rooting for the ACA because I believe it is a big step towards doing that and, at the very least, I hope Americans take the time to learn about the ACA and the rationale behind it from unbiased sources before they make up their minds. 

The Only Way We Can Honor Monday's Victims: Looking at Risk and Suffering.

This week’s terrorist attacks in Boston brought many emotions out from people in the city, the nation and the world.  In the aftermath I was amazed and humbled by the courage, compassion and integrity show by millions of citizens, health care providers and law enforcement officials.  May God bless the victims.

In addition to those emotions the attacks this week made me think a lot about risk in a more rational way.  The public health professional in me can not help but look at things from the big picture side and make a tangible analysis of the benefits and the harms in any situation.

Of the 600,000 or so individuals who watched the Marathon in person last Monday only a very small percentage were harmed by the attacks. Obviously one was too many, but extrapolating that further hundreds of millions and millions of Americans who have attended public gatherings in the past ten years in major cities have gone largely unharmed until Monday.  Public events are extremely safe in terms of ratio of injuries and illness to hours of exposure time.  Most of us are going to do things in the next week (like drive a car, take an opiate medicine or antibiotic, go skydiving, go for a bike ride or eat a cheeseburger) that are much, much more likely to cause harm to ourselves or a loved one than terrorism.

If it is not tangible risk of harm that pushes our fear button then what is it?  It is a well known psychological phenomenon that human beings assess risk and danger more on emotional than rational terms.  It is why people like me are irrationally scared to fly (one of the safest things a person can do according to a huge body of numbers) while I routinely drive on freeways or go running alone in the woods and never even think about the much greater dangers.   Evolution programmed us to assess danger based on the hills and valleys of our psyche and not on the cold, hard numbers because when we were still animals in trees such impromptu calculations were all we had.

Terrorism is frightening not because it is likely to kill us, but because of the mental and emotional imagery it creates and what that symbolizes.  Dozens of people in America will have limbs amputated in the next few weeks from car accidents, but the unfortunate ones who suffer from an explosion in the heart of a major city, during a major event and with the eyes of the world watching provide terrifying imagery that stimulates our primitive fear.   One million reckless drivers in pick up trucks driving 75 miles an hour while talking on their mobile phones for an hour every day for a year will create far, far more amputations, brain injuries, deaths and overall suffering than the horror on Monday did, but most of us will never see the imagery that results from these harmful actions and even if we do it lacks symbolic triggers that make our brains tune in to fear.

3 people died from the bombs on Monday and it was awful, but 37,000 people (most of them young) die in cars every year.  What about the 500,000 who die of cardiovascular disease? The 51,000 that die of  influenza? Or the  31,000 people, about 85 people per day, that die in gun violence in 2010 (or the 73,505 who had gun injuries)? 5 Michigan Football Stadiums of children (about 500,000) worldwide go blind from Vitamin A Deficiency every year and according to the CDC 70% of them die within one year.  Who even worries about Vitamin A deficiency around here?

Are those deaths any less meaningful? Any less senseless?  Any less preventable?   Are most of those people any less human or innocent?

On Monday to see that many young and innocent people killed or maimed at once was gruesome and unfair.  I too got afraid and emotional, but I could not help noticing how people justifiably reacted to this tragedy while ignoring so much preventable suffering that we consider routine.

If we assessed risk and suffering based on actual data, we would also get sentimental about motor vehicle accidents, the obesity epidemic, nutrition, influenza or any number or things.  This is not to triviliaze the horror of Monday or to de-value the symbolic currency of attacks on “our” nation by “outsiders”, but merely to suggest that the best way to honor the victims of undue human suffering is take action to prevent further human suffering. In contrast to terrorism, it is a suffering that happens in a silent but equally devastating way every day in our world but it is every bit as real.  If you were one of the millions motivated by seeing the injustice and horror of lives cut short Monday than in addition to the USA chants, the tough words, the posts on Facebook, and the flag waving and honor the victims in the best and only way possible:  Live in a way that respects every life, every second of every day.  

Live to respect life.

Start with driving, because statistics show driving is one of the most dangerous things Americans do on a daily basis.  From now on drive humanely.   As a physician I am amazed by the savagery and brutality I see on our roads and highways every day.  Do people not realize when they turn the key to their ignition they are engaging in a behavior that kills tens of thousands of human beings (mostly young) each year and seriously injures many more?

 After Monday, If you agree that it is horrible to see young people killed or injured then please drive safely tomorrow.    You may not be a “terrorist” but if you drive drunk, text on your phone or drive recklessly you are contributing to a problem that is going to kill and maime more people than Monday’s attacks did. If in honor of Monday’s victims we pledged to drive safe, sober and avoided distracted driving we would save dozens of lives in this country a day!  What better way to honor the victims than by reducing or eliminating the suffering of others?

 Vaccinate your children. Don’t take drugs.  Give money to charity at home and abroad.  Exercise.  Feed yourself and your family healthy food (Do you realize how many thousands of children are going to die or get disabled from the Diabetes epidemic rising in our nation?).  Don’t play around with guns in the home.   These are some the things that contribute to the killing and maiming of innocent people on a massive scale but lack the grandoise imagery that gets our attention.  Honor Monday’s attack victims and all those who suffer not just by waving the flag or singing sentimental songs at sporting events (don’t get me wrong all that is well and good)  but by living consciously.

 As the old saying goes “Be the Change You Want to See In the World.”  On Monday we were all confronted with horror and we are programmed to respond to the frightening imagery.  If you were moved by what you saw than the best response is to take actions to reduce and prevent human suffering of all kinds in everything we do.  In that way we best honor the tragedy we saw last week.  
 

The Problem With Recent Call by Scientists to Regulate Soda

The recent public declaration from over 51 public health agencies asking the Food and Drug Administration to use it's a regulatory power  to impose restrictions on the maker of sugary beverages is a major step in the right direction for America’s Plague: The Obesity Epidemic. 

America's growing public health crisis with obesity, diabetes and cardiovascular disease is no joke.   It is not only going to result in a tremendous human toll in terms of premature sickness and death, but it is also going to cripple us financially in terms of direct medical care and the indirect cost of lost productivity.  Yet while this declaration is an excellent start I believe the major contributor to America’s upcoming plague of lifestyle related illness is not even addressed in it:  The poisonous foods that serve as the foundation of the American Diet. 

As I've written about in the past there really is no major difference between carbohydrates in terms of how your body processes them: a carb is a carb is a carb.  The difference between a healthy carbohydrate and a poisonous one is not so much the carbohydrate itself but rather the packaging the carbohydrate comes in.

High fructose corn syrup is so devastating because it has been highly processed. The carbohydrates have been taken out of their natural casing and made available for extremely rapid digestion by the human body.   With all the natural casing and fiber (which slows digestion and therefore keeps blood sugar and insulin levels low) gone, the end result is that your body can easily digest the carbohydrates in high fructose corn syrup and your blood sugar spikes quickly. 

Your pancreas then releases a hormone called insulin that helps break down the sugar and turn it into fat. The combination of high blood sugar and corresponding high blood insulin leads to a widespread consequences throughout the body.  Organ systems impacted include the brain, the kidneys, the liver and also increased fat storage.   Most importantly, it appears that both high blood sugar and high insulin spikes scar the inside walls of blood vessels leading to the development of scabs (called plaques) in the arteries.  This is what causes cardiovascular disease.  

What the declaration fails to address is that any carbohydrate that is easily metabolized by the body will cause a similar spike in blood sugar and insulin and ultimately cause obesity and heart disease. Most of the foods that form the cornerstone of the American diet fall into that category.  It does not have to be high fructose corn syrup or sugar. Any carbohydrate that has been processed so that the natural casing and fiber has been disrupted will lead to a spike in sugar/insulin and is in effect the same as consuming sugar or high fructose corn syrup.

America has a love affair with these foods.  Bread, Rice (all rice white or brown that is taken out of the natural husk is in fact a culprit), Juices, Pasta, Baked Goods, Cereals and many, many more.  These foods are pretty much the equivalent of eating table sugar or corn syrup in terms of how they impact your body once absorbed.

Further adding to the problem is that many foods marketed as health foods are actually foods that spike blood sugar and insulin and are basically poisonous to human beings. Some examples of this are many commercially available “wheat breads” that are the same as bleached wheat flour, many cereals, like Special K or Rice Krispies, marketed as healthy choices but actually are in effect like eating table sugar, Brown Rice that has been removed from it’s husk and is as unhealthy as traditional white rice and many, many others.

The only way you can learn which carbs are actually healthy is to look up their measurement on a scale called “The Glycemic Load” which objectively measures how much different foods raise blood sugar.  My favorite website to do this on is self.com n(google nutrition data at self.com)

America’s problem with diabetes, obesity and cardiovascular disease is directly related to it’s addiction (and yes it is an addiction just like any drug) to all refined and processed carbohydrates.  Most of our diets are not based on soda!  For most of us our diet is pretty much based on refined carbohydrate and it is pretty much impossible to entirely avoid them even when we try.  Even the USDA food pyramid, which advises 9 servings of whole grains a week does little to distinguish between low (healthy) and high (unhealthy) glycemic carbs. 

 

If you remember one thing from this blog it should be this:  Carbohydrates that have been highly processed and refined are poisonous to human beings no matter where they come from (even if they are "organic!).  Going after sugary beverages is a start, but the real cornerstone of the American Diet are the “High Glycemic” junk carbohydrate food sources like Bread, Bagels, Pizza Dough, Cakes, Cookies, Pastas, Rice, Cereals, Muffins, Baked Goods and many, many more that are in effect very similar to eating sugar or high fructose corn syrup.    

PrevMedTIPS QUICK HITTER: CONSIDER ME A SKEPTIC ABOUT STUDY LINKING BEING OVERWEIGHT WITH LONGER LIFE

A recent study released in this weeks JAMA has found an association between being moderately overweight and having longer life.   I would like to believe that being mildly overweight conveys a mortality advantage over being skinny because so many Americans (including me until 2 years ago!) fall into that category but consider me in the group of skeptics.    From reading the study it seems to me that this study has a major flaw in it's methodology that could explain these results. 


This study found a relatively modest (6%) mortality benefit to being moderately overweight.   As anyone who has ever worked in medical field knows often times when people are very sick they get very skinny.   Many, many diseases cause profound weight loss especially at the end of the road.  People who suffer from cancer, AIDS, heart disease, drug and alcohol problems, hematologic disease, renal disease, gastrointestinal disease , dementia, immunological disease and many, many medical problems can lose weight as their disease progresses.  In order for this study to be meaningful the authors would have had to have provided sufficient and rigorous statistical corrections to account for this fact.  Unfortunately this was not possible based on the study methods.  

This study relies on data from numerous other smaller studies pooled together to make it's conclusions.   Not all of the studies that the authors included in their data pool were able to correct for the presence of chronic underlying disease.  Some of these studies were and some were not.  And as readers we have no idea how many were and how many weren't or what if any methods were used.  We are left to trust that the authors of all these individual papers sufficiently corrected for the presence of chronic disease when possible, used the right statistical methods to do so and corrected for the diseases most likely to confound the results.  Obviously this is a huge area of uncertainty and a huge leap of faith for us to accept this puzzling conclusion of modest effect.

Because many of the papers did not correct at all we can be sure that at least some skinny, very sick people with chronic disease found their way into the study.   Was this enough to explain all of the results?  The truth is we may never know.  To me it seems very plausible that the modest association observed between moderate obesity and mortality could be at least partially explained by what effectively amounts to a confounding variable that impacts both the exposure (body weight) and the outcome (mortality rate) aka the presence of chronic disease.  


On the other side of the coin if even if these findings are somewhat skewed it does raise a point I often convey to patients which is the distinction between body weight (which is based on how many calories we eat and burn) vs metabolic/cardiovascular health (which is based more on what we eat and if we exercise).  Even if the mortality benefit observed is "white noise" being slightly obese is hardly a death sentence. The truth is the likely effect of being slightly overweight on death risk is somewhere around mildly harmful to none to, as this study argues, slightly beneficial.  The overall take home message is that slight obesity does not neccesarily mean completely unhealthy.

 While I question these findings, I think it is possible to skinny and unhealthy and that it is possible to be healthy and overweight.  The real trick is to exercise, eat right and to keep proven cardiovascular risk factors under control (smoking, hypertension, cholesterol, diabetes).  I still maintain that being a normal body weight is probably better than being overweight even after this study, but we can add this skewed study as a reminder that when it comes to mortality the big money is in  cardiovascular risk not neccesarily weight.