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When I eat out at a restaurant I’m inevitably asked whether or not I’d like bottled water with my meal. My answer usually depends upon the city I’m in – New York water tastes great, so I ask for tap water in Manhattan. The water in DC tastes like a swimming pool (at best), so I usually order bottled water at Washington restaurants.
But little did I realize that the water I’ve been drinking (whether from DC, NY or even from the bottle) has small traces of pharmaceutical chemicals in it. A new investigation conducted by the Associated Press suggests that most major urban water supplies are laced with tiny amounts of prescription drugs. How do the drugs get in the water supply?
Remember that water cycle you (or your kids) studied in grade school? Well, the “underground phase” is where the action happens. Drugs that we swallow pass through our bodies and some is released in our urine and stool. We flush that down the toilet and the fluid debris is treated in a sewage plant and then the water portion is released back into the water supply. Sewage plants and water filters are not designed to remove trace chemicals like heart medicines and anti-depressants, so they remain in the drinking water. Kind of disturbing, right?
Well, the good news (if there is any) is that the amounts of chemicals in the water are pretty small – we’re talking parts per trillion. Just to put that in perspective, that’s more than 1000 times smaller than the minimum amount needed for therapeutic effect from the fluoride added to the water system. And the concentration is far below the therapeutic threshold in the bloodstream for these drugs. But how do we know that tiny amounts of drug exposure isn’t harmful in some cumulative way?
Research into the potential long term effects of these chemicals in the water supply has focussed mostly upon the presence or absence of the drugs, and the concentrations at which they’re present. Animal studies (such as the “feminization” of fish exposed to environmental estrogens) and cell culture research suggest that exposure to larger concentrations of these drugs can cause negative outcomes, but to my knowledge there are no long term studies of the potential impact of very small concentrations on human health. But before we become outraged at this apparent lack of investigation, let’s think about why it’s so difficult to gather this kind of information.
First of all, concentration-wise, pharmaceuticals represent a small fraction of the thousands of man-made chemicals in the environment, including everything from pesticides to personal care products. So it’s very difficult to prove a cause and effect for any one drug’s influence – we are each exposed to a very dilute cocktail of chemicals in our daily lives, whether through the water we drink, the food we eat, or the air we breathe. How can we tease out the potential damage of one chemical over another?
Secondly, it’s pretty likely that any potential harm (from chemicals at such small doses) would take many years of exposure before a clinically measurable threshold is reached. It’s very difficult and expensive to study large groups of people over time – and it’s hard to know what their lifestyle choices may contribute to their overall chemical exposure. Over time people change jobs, change what they eat or drink, change where they live… the complex interplay of environmental factors make it hard to interpret exposures and effects.
And finally, how do we know what outcomes to look at? It’s possible that these small doses of pharmaceutical products could affect our bodies in fairly subtle ways – which again makes it difficult to measure. It’s hard enough to study cancer rates in populations, but how would we study differences in physical or mental performance? Or slight changes in mood or heart function?
Since there’s no easy way to prove a connection between drugs in our water system and our general health and wellbeing, we are likely to be left with far more questions than answers. I think we all agree that we’d rather not be exposed to trace amounts of any chemicals in our water supply, but unfortunately the cost of filtering all potential contaminants from the water is exceedingly high. Reverse osmosis (a process currently used to reclaim fresh water from the sea) can cost as much as $1-18/gallon depending on the system in place and the country using it. While reverse osmosis could guarantee a chemical-free drinking water supply, we couldn’t afford to supply it to all Americans. And in the end, it’s still unclear if solving that part of the puzzle would improve our overall health.
I hope that we’ll find ways to reduce the chemical load on our environment, and that advanced water purification technology will become more affordable in the future. Unfortunately, trace amounts of chemicals, drugs, and pesticides are more ubiquitous than we’d like to believe. The impact they may have on our health is difficult to measure, and largely unknown at this point. Perhaps the bottom line is that we’re all connected to one another through our environment – so that granny’s heart medicines may yet live on (albeit in trace amounts) in your bottled water. All the more reason for Americans to pull together to live healthy lifestyles, control our weight, and try to prevent the diseases that are requiring all these drugs in the first place.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
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I’ve wrestled with this question for many years: “When is weight loss surgery an appropriate option?” I used to do weight loss research prior to working at Revolution Health. My studies focused on using “natural” methods to reverse type 2 diabetes – in other words, weight loss via diet and exercise. My study subjects were all obese, and most had struggled with weight for decades.
At some point during the trial, people would often ask: “Can’t I just have surgery for this and not have to struggle so much?” And I would gently remind them that surgery was no picnic, and to try diet and exercise first. “But it’s so hard!” they would say. I would acknowledge their difficulties and offer lots of empathy, and firmly encourage them to stick with their diet. In the end I found that only half of my study subjects could manage to stay on the diet for months at a time. So what should the other half do? Give up and let their diabetes ravage their bodies?
My friend and colleague Dr. Charlie Smith rightly points out that weight loss surgery can dramatically improve the health of people who have been unsuccessful at losing weight through diet and exercise. Heart disease, diabetes, and cancer rates were dramatically improved for morbidly obese people after weight loss surgery. So there is a clear benefit for some people to have the procedure.
However, the caveats should not be overlooked. First of all, weight loss surgery does not guarantee long term weight loss. It’s possible to gain back all the weight lost if eating behaviors are not changed. The human stomach is amazingly stretchy, and even if it’s surgically reduced in size, with repeated overeating it can eventually stretch to accommodate large meals again. Secondly, some types of weight loss surgery (like gastric bypass) can affect the body’s ability to absorb critical vitamins. Without enough of these nutrients, one can end up severely anemic, and osteoporotic just to name a few serious side-effects. And finally, the surgery itself is quite dangerous, carrying with it a potential risk of death as high as 1 in 200!
So weight loss surgery can be life-threatening, and is not a quick fix for a long term problem. However, morbid obesity itself is so dangerous (with the increased risk of heart disease, diabetes, and cancer) that it may require this extreme intervention to actually save lives. For people who have more than 100 pounds to lose, and have sincerely tried diet and exercise without success for a prolonged period, then weight loss surgery may be an appropriate option. For those whose lives are not at risk because of severe obesity, it doesn’t make sense to undergo such a risky procedure.
Are some people successful at losing a large amount of weight and keeping it off without surgery? Yes! The National Weight Control Registry keeps a list of thousands of Americans who have lost at least 30 pounds and kept them off for at least 6 years. What’s their secret? You guessed it – regular exercise and a calorie controlled diet. Some other things that these “successful losers” have in common: 1) they eat breakfast 2) they have a cardio machine at home 3) they weigh themselves regularly.
If you’d like to meet a group of people who are working towards long-term weight loss success, feel free to join my weight loss support group. We have weekly challenges, tools and trackers, a vibrant discussion group, and free medical insights to help you along your way. Weight loss is really hard to achieve by yourself. It takes encouragement, support, and a community of like-minded folks who are determined to make a difference. You can do it!… and I’d be honored to support you along the way.
P.S. There’s a special group forming at Revolution Health for folks who need to lose 100 or more pounds. It’s called “Overweight But Not Giving Up.” Check it out.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
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I must have a really trustworthy face. No matter where I go, absolute strangers ask me for directions, they request that I watch their belongings, hold their place in line, they even ask me to help with their kids. I am continually astonished by the uninvited inquiries that I receive walking down the street, on the train, or even in foreign countries. I guess people think I’m both harmless and likely to know how to help them. They are right about the first part, and not quite as right about the second.
Just a couple of days ago I was settling into a train seat when the woman in front of me peaked over the head rest and asked if I’d mind watching her bags while she left to go to the restroom. I happily agreed to do so, wondering what I’d actually do if someone tried to take her bag. And as I mused about how on earth I’d won her absolute confidence without even making eye contact, I began to think about the idea of trust. How do patients decide whom they trust with their medical care?
I’d like to think that trust is earned – and many times it is – but there’s also something more primitive about it than that. Without knowing a person for long enough to judge his or her character, we often draw conclusions nonetheless. How successful are we at these snap decisions? Well, we might be quite good at it. I was amused to find an online test where you may judge the sincerity of a person’s smile just by looking at a 4 second video clip. Some of the models were asked to smile convincingly, and others were told a joke or were caused to laugh by some genuine means. Most people figure out which smile is contrived and which is natural most of the time. See how you do.
And so, when it comes to finding a primary care physician, or a doctor that you trust with your medical care, should you rely on your gut instincts or is there a better way to assess their competency?
I’ve wrestled with the idea of online physician ratings for a couple of years. Part of me thinks that it’s impossible to capture all the qualities of a good physician in some simplified form filled out by non-medical professionals. But another part of me wonders if a large collection of different experiences might add up to an opinion trend that’s on the mark. Whether or not you’re a fan of physician ratings, they are here to stay. Perhaps the best we can do is offer as many ratings as possible so that the average might provide high level, helpful information. Revolution Health has a free physician rating tool. Check it out.
How do you know whom to trust? Do you rely on your instincts or the referral of someone you know? Would online physician ratings be helpful, harmful, or simply limited in their utility?
Let me know… and if you see me on the street, yes, I’d be happy to watch your bags.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
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I’ve been wrestling for some time about whether or not it’s appropriate to blog about celebrity news (particularly health issues). On the one hand it seems like an invasion of privacy – what gives me the right to speculate on their health? Shouldn’t I leave the poor celebs their privacy, hen pecked as they are by the media? Yet, on the other hand, when the country is abuzz about an important health issue, there is a “teachable moment” in which doctors can perhaps influence patient lifestyle choices for the better, or encourage some preventive screening if needed.
I did decide to blog about Heath Ledger’s sad passing, and thought it might be important for people to know about autopsies and how they work. Although I had mixed feelings about the post, it was one of my most popular in a long time. So that led me to conclude that I shouldn’t shy away from celebrity news. Nonetheless, I confessed my squeamishness to a friend of mine, and his answer was so insightful that I thought I’d share it with you:
The other way I think
of it is this: health is really personal. Almost everyone who writes about
health does it from the perspective of a personal story – the most common health
blogs are health blogs by patients / survivors about their own experience, the
next most common is by doctors talking about patients. You could have written
yesterday’s entry [Heath Ledger] about the death of a friend or a patient under unknown
circumstances. The problem is that a blog that begins every time with, “I had a
friend who had ALS…” is very concrete to you – you know the friend – but not
concrete to the reader – they don’t know your friend. The use of celebrities
creates a shared vocabulary – people we all “know” that we can converse about.
Put another way, in an
era before blogs, where health conversations were held around kitchen tables and
over the back fence, there was probably less discussion of celebrity health
because the discussants all shared a common stock of people about whom to chat:
Doris down the street has breast cancer; Trudy two doors down has a pregnant
teen; Francine on Maple Street has a mom with Alzheimer’s. The internet and
blogs are an attempt to create a similar conversation with people all over the
country – the planet – who don’t know any people in common. Celebrities are the
only folks we can all discuss, because they are the only folks we all
What do you think? Is it ok to blog about celebrities? Should I do more of it? Less of it? Does my friend have a point? Please share your thoughts.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
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I had a really great conversation with iHealthBeat reporter Kate Ackerman recently. She summarized our conversation in an online article
and I’ve copied some of it here. Please check out the full article for the entire interview.
Consumer Demand Fueling Online Health Care Market
by Kate Ackerman, iHealthBeat Associate Editor
As patients increasingly turn to the Internet for health care information and online tools to manage their health, many companies, both new and old, are stepping up to meet the consumer demand.
It is still too early to tell which companies will be successful and how the Internet-savvy health care consumer will transform the patient-physician relationship, but the trend has captured the interest of many health care insiders.
Val Jones, senior medical director of Revolution Health and author of a blog called “Dr. Val and the Voice of Reason,” spoke to iHealthBeat about the online health care market, physician concerns about patients relying on the Internet and the role of medical blogs.
A recent Harris Interactive survey found that the percentage of U.S. adults who looked for health care information online increased from 72% in 2005 to 84% in 2007. Why do you think more and more consumers are turning to the Internet for health information?
I think it’s partially because more and more consumers are turning to the Internet for information, period. Online information is incredibly convenient, served up lightning fast and has revolutionized how we research everything from buying toasters to finding a doctor. Of course, health is much more serious and complicated than purchasing products, so consumers should be very wary of the source of their health information.
Do you see a generational divide in the people using Revolution Health?
We primarily appeal to everyone between the ages of 20 and 60, though women conduct more health searches than men. The only age gaps are related to the medical subjects being researched. Clearly, not too many 20-somethings are reading about menopause, and not too many 50-year-olds are reading about college stress. Otherwise, all of our community tools and groups are fair game for people of any age. We have 60-year-olds blogging and enjoying discussion groups, and 20-year-olds posting forum questions too. It’s wonderful to see the generations interacting online and learning from one another.
New York orthopedist Scott Haig in November wrote an essay in Time Magazine complaining about patients who research their symptoms, illnesses and doctors online before seeking treatment. What are the downsides to patients searching for health care information online?
I think Dr. Haig’s essay has been somewhat misinterpreted because he was focusing on a specific patient with a serious disorder. My favorite quote from Dr. Haig’s article is that “the role of the expert is to know what to ignore.” I think the major downside for patients searching for health information online is that it can be difficult to figure out what’s contextually relevant to them. Aside from that, the next major downside is that there are snake-oil salesmen out there preying on the frustrations that we all have about our broken health care system and promising “miracle cures” and fueling mistrust in doctors.
What can be done to ease concerns from physicians, like Haig, about consumers relying on the Internet for health information?
Educated patients are a pleasure to work with, but misinformed patients require lots of extra help. The hours we spend every week dispelling urban legends and Internet-fueled medical myths is really mind-boggling. Physicians are naturally protective of their patients and don’t want them to be duped or misled.
From Google to Microsoft, companies are beginning to recognize an opportunity in the online health care market. Is there enough room for all of these companies? What will make successful ventures stand out from the rest of the pack?
There’s as much room as consumer demand will fuel. However, only the largest and most innovative companies will ultimately survive long term. While we’re all waiting for the government to create standards for health information and the creation of interoperability rules, successful companies will meet the needs of today’s consumer. Small but practical tools and innovations will keep the companies solvent while we work toward the holy grail of a common health information platform for all the stakeholders.
Medical blogs seem to have taken off in recent years. Who do you think the intended audience is?
Actually, while there are an estimated 70 million blogs out there, only a few hundred doctors are blogging. That’s a huge discrepancy, and I don’t think we’re even at the beginning of the wave of medical blogging that will inevitably occur as doctors enter the Web 2.0 world. The first pioneers of the medical blogosphere are writing mostly for their peers, though patients find their blogs very engaging and read them as well. Very few medical bloggers write specifically for consumers.
What are your predictions for the online health care market in 2008 and beyond?
With decreasing access and increasing patient loads, I think we’re going to see the consumer-driven health care movement take center stage. Patients are going to need to “do it themselves” a lot of the time (meaning manage their own health information, teach themselves about disease management and make financial plans to take care of their own needs if the government cannot afford to do so).
Another trend I have my eye on is the retainer medicine movement. As primary care physicians continue to be squeezed out of existence by decreasing Medicare reimbursements, they are beginning to join an “off-the-grid” group of providers who simply do not accept insurance.
As more PCPs create retainer practices, I think IT solutions will really take off. Online tools that simplify their practices and speed up their patient communication will be welcomed and encouraged.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.