April 25th, 2008 by Dr. Val Jones in Expert Interviews
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In my quest to bring the best possible health advice to the Revolution Health community I am actively pursuing interviews with credible sources. At the top of the list is America’s #1 doctor, the Surgeon General. I recently had the opportunity to sit down with Vice Admiral Richard H. Carmona, M.D., who served as Surgeon General from August 2002 to August 2006. He addressed a range of health issues facing Americans today. I am posting the interview in segments; the following post is part of that series.
Dr. Val: Obesity rates continue to rise each year. Does obesity lie at the core of the chronic disease crisis and if so, what can America do to reverse this trend?
Dr. Carmona: Obesity is absolutely at the core of the chronic disease crisis. When we look at the relationship of obesity to other diseases that plague society today (such as asthma, cancer, cardiovascular disease, and diabetes) obesity increases the incidence of each of them, and can even accelerate some of them. Losing weight is not about trying to emulate models in fashion magazines, it’s about being healthy.
If we could only address one major public health issue as a nation, I would focus on the obesity crisis. Weight loss could have the greatest impact in decreasing the chronic disease burden in America.
Dr. Val: So what can we do about obesity?
Dr. Carmona: That question is simple on the surface but incredibly complex when you begin to analyze it carefully. First of all we have to identify the variables that contribute to this problem, because it’s a multi-factorial issue. The socio-economic determinants of heath are inextricable from the health status of individuals and communities. That means that if you’re poor and have less education, you’re going to experience health disparities. You can’t afford to buy healthy food, you don’t live in a neighborhood where you can walk at night and get exercise, and so on. So understanding all the determinants of health to address obesity is important.
Let me describe just one significant variable contributing to the obesity epidemic: the sedentary lifestyles of children. Thirty years ago it was commonly believed that physical education in school was not important, because kids played during all the hours that they are out of school. Parents reasoned: ‘Why should I pay a teacher to have my kids play ball at recess? I’d rather have her teach them math and science.’ So there was a sweeping trend to discontinue physical education at school. Now, however, kids spend too much time on playstations rather than on play grounds – or they watch over 4 hours of TV a day. They’re sedentary at school and at home.
Other variables that influence obesity rates in kids include the accessibility to fast food, the increased rate of single parenthood, and the change in cultural traditions around meal time. For wealthier families, easy access to large volumes of food of every possible kind can create an environment where people overeat.
The solution to the obesity crisis is not “one-size fits all.” The approach to obesity must be tailored to the cultural and socio-economic sensitivities of the sub-population that you’re trying to reach.
Ultimately we need to change behavior – walk a little more, eat a little less, buy some healthy foods. But targeted interventions must be culturally sensitive and socio-economically relevant. For example, the government is funding programs to make healthy foods more accessible to underserved areas, and physical activity programs are being reinstated in schools. But the effects of these programs are not going to be seen for many years because it takes time for the culture to catch up. Also, the approach must be comprehensive. If we were able to get all of our children enrolled in a daily game of baseball (to increase their physical activity), that would not solve the problem of fast food and video games.
There needs to be a community approach, so that no matter where the child turns they’re getting positive reinforcement of healthy behaviors. That’s part of what I’m doing with the national non-profit health organization that I’m president of now – Canyon Ranch Institute.
***
The Surgeon General series: see what else Dr. Carmona has to say about…
Cost Savings Associated with Preventive Health
Consumer Directed Healthcare and Health Literacy
Complementary and Alternative Medicine
Preventing Chronic DiseaseThis post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 22nd, 2008 by Dr. Val Jones in Medblogger Shout Outs
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Welcome to Grand Rounds 4.31, Dr. Val’s edition of the weekly rotating carnival of the best of the medical blogosphere. There are many approaches to summarizing submissions to Grand Rounds, and I have chosen one that has never (to my knowledge) been used before.
That’s right – I’m taking my inspiration from the limbic system, and have organized the posts according to the dominant emotion they elicit from readers. And because Dr. Val was one of those annoying medical students who brought 10 different colored highlighters to study class, I will also label some of the posts with the following tagging system (in brackets) to offer advanced readers an additional nuance:
[:-)] = A post that demonstrates literary excellence
[{] = Early bird – an author who got his/her submission in early, which is really convenient for the host(ess)
[:-/] = Naughty – an author who forgot to submit an entry to Grand Rounds but who was included nonetheless
So without further ado, here’s the Grand Rounds that will make you laugh, cry, stomp your feet, and become enlightened in the process.
Amusing
The fun begins with the Clinical Cases and Images Blog, featuring a hilarious blogger “sweat shop” video to illustrate the heart attack-inducing stress that bloggers face on a daily basis. His post is called: “Death by blogging?”
Dr. Rob Lamberts from Musings of a Distractible Mind has some parenting tips (including pole vaulting avoidance strategies) in his post called “The Sins of the Father.”
Happy, the Happy Hospitalist offers his perspective of what it would mean if physician satisfaction surveys (rather than patient satisfaction surveys) mattered.
Allen Roberts of GruntDoc describes how one misspoken word can result in unexpected innuendo.
[:-/] Dr. Wes predicts an upcoming hospital “performance Olympics” after one patient receives a record fast, door-to-balloon cardiac intervention.
Touching
[:-)] Laurie Edwards of A Chronic Dose tells the touching and amusing story of how one sick young girl was ostracized at summer camp – and how new camps designed for chronically ill children are revolutionizing the camping experience. Her post is called, “Summer Camp: Sick Style.”
Barbara Kivowitz, from In Sickness and in Health, describes a husband who knows just the right thing to say in a stressful time. Her post is called “Mars/Venus Who Cares?”
Lisa Emrich, from Brass and Ivory describes what it’s like to experience a relapse of Multiple Sclerosis and an MRI to evaluate the progression of her disease. Her post is called “Surfing the Magnetic Tube.”
Dr. A from Doctor Anonymous wonders if peace and contentment come from accepting one’s lot in life. His post is called, “With Age Comes Happiness?”
Infuriating
ER Nursey relays the tragic story of a baby that died of a preventable illness. His mom decided not to vaccinate him against pertussis and was trying to treat the infection with “natural methods.” Her post is entitled simply: “Whooping Cough.”
[:-/] Abel Pharmboy at Terra Sigillata explains that since 1994, dietary supplements cannot be removed from the market until there is evidence for lack of safety, meaning that consumers must first be harmed before FDA is authorized to intervene. His post is called, “Must People Die Before DSHEA is Repealed?”
[:-/] David Gorski at Science Based Medicine takes a critical look at the claims of a popular alternative medicine practice: colon cleansing. His post is called, “Would You Like a Liver Flush with that Colon Cleanse?”
[:-)] John Crippen from NHS Blog Doctor explores the difference between a young doctor’s “gallows humor” and a senior physician’s deep and abiding concern for patients in this reflection on death certificates in Britain. The post is called “Ash Cash.”
A Canadian Medical Student and author of Vitum Medicinus tells the story of how a patient asked her doctor a question that she already knew the answer to, just to see if he was current in his knowledge of recent health news. The post is “What Trickery Is This?”
David Williams of The Health Business Blog points out the fallacies inherent in one writer’s attempt to vilify the health insurance industry. His post is called, “There is no Health Insurance Mafia.”
Enlightening
This large group of posts may be further organized by the topic of enlightenment. First up we have practical health tips.
Health Tips
[{] We begin this section with an anonymous psychiatrist blogger at How to Cope with Pain. She has captured my little Rehabilitation Medicine heart with her three-part series describing office ergonomics, therapeutic exercises, and how to avoid computer-induced postural strain. Her very practical post (that will be very useful to you readers) is called: “How to Sit at Your Computer to Avoid Pain.”
Ramona Bates at Suture for a Living explains what to do if you’re bitten by a cat – she does a wonderful job describing the treatment options and possible infections that can result. Her post is aptly named, “Cat Bites.”
Paul Auerbach at Medicine for the Outdoors teaches us everything we need to know about preventing and treating foot blisters caused by hiking/walking. His post has the shortest name of this Grand Rounds: “Blisters.”
Jeff Benabio at The Derm Blog offers a comprehensive analysis of the dangers of tanning salons with some tips for safe sun exposure. His post is called, “Is The Tanning Industry The New Big Tobacco?”
Nancy Brown at Teen Health 411 warns that outdoor tanning is also not safe. Her post is called “Sun Safety.”
Jolie Bookspan, The Fitness Fixer, tells the story of how a woman living in the Yukon learned that “doing exercises” doesn’t heal an injury if you go back to bad movement habits the rest of the day. The post is called, “Fixing Herniated Disk and Reclaiming Active Life.”
[:-/] TBTAM at The Blog That Ate Manhattan has practical tips for patients preparing for a new patient visit with an Ob/Gyn. Her post is called: “TBTAM’s Healthcare Team Tips for New Players.”
[:-/] Dr. David at Musings of a Pediatric Oncologist teaches us that HPV can predispose people to oral and throat cancers as well as cervical cancer. All the more reason to vaccinate boys as well as girls. His post: “HPV and Cancer Revisited.”
Kenneth Trofatter, at Fruit of the Womb offers a detailed analysis of when it might be appropriate to use Fondaparinux to reduce the risk of clotting in pregnant women. His post: “Use of Fondaparinux During Pregnancy.”
Joshua Schwimmer at Tech Medicine offers some tips for doctors. Practice makes perfect, and this new teaching mannequin has some nifty bells and whistles. His post is: “The iStan Medical Mannequin: it Sweats, Bleeds, and Breathes.”
More healthcare for dummies is offered by Jan Gurley of Doc Gurley Blog. Her post is called: “Playing Surgeon.”
Next up, a series of posts about Web 2.0 principles.
Web 2.0
Allergy Notes describes a small study in the BMJ demonstrating that text message reminders can improve compliance with asthma medication regimens. The post is called, “Text Messaging Can Help Young People Manage Asthma.”
[{] Sam Solomon of Canadian Medicine describes a new trend in Canadian medical research – using blog tools to analyze public opinion. His post is called, “Putting Clinical Depression under the Microscope and on the Blogosphere.”
Mic Agbayani at GeekyDoc, suggests that patient privacy is violated by YouTube when a video is posted of healthcare professionals laughing during a surgical procedure to remove a foreign body from the rectum. His post is called, “Patient privacy and YouTube.”
[:-/] Richard Reece at Med Innovation Blog explains that doctors get a bad rap when it comes to EMRs and IT in general. See his post: “Bad Rap on Physician IT Use Not Deserved.”
[:-/] A counter-point argument for the mandatory use of EMRs (at his hospital) is made by John Halamka at Geek Doctor. His post is called: “Accelerating Electronic Health Record Adoption.”
Health Policy and Medical Ethics
This is our largest and final subgroup of enlightening posts. You’ll find some great reasoning here (and Dr. Val is partial to reason).
First up we have the inimitable Sandy Szwarc of Junk Food Science. She takes a close look at the numbers and shows that the current Student Nutrition Policy Initiative is failing to stem the tide of childhood obesity and poor eating habits. Her post is called, “JFS Special Report: Major Findings on Childhood Obesity Programs.”
Amy Tenderich at Diabetes Mine has a terrific post about the need to revise the Americans With Disabilities Act. As a physiatrist, I cheer her on. Her post: “Disability and Diabetes Revisited.”
[:-/] Dr. Rich at The Covert Rationing Blog explains the financial incentives behind Medicare’s new “never event” initiative and how it will impact care for the elderly, obese, and those with bleeding disorders. His post is called, “Never Events? Never Mind.”
Bob Coffield at Health Care Law Blog writes that some argue that preventing disease does not decrease health costs. Bob disagrees, but isn’t sure if he can prove his case. His post: “Is prevention cheaper than treatment?”
[:-/] #1 Dinosaur of Musings of a Dinosaur explains that reducing expenditures in a patient’s last year of life requires perfect foresight into his or her life expectancy. His post: “End of Life Care Costs: A Logical Fallacy.”
Maurice Bernstein at the Bioethics Discussion Blog argues that, over the past 50 years, the ethics of medicine has changed more than any other aspect of it. Technological advances and the advent of medical consumerism have changed the way medicine is practiced. His post is: “50 Years of Medical Practice: Changes, Benefits, Costs, Dilemmas.”
Louise Norris at the Colorado Health Insurance Insider would rather be treated by a salaried physician who has no incentive to order additional and perhaps unnecessary tests and treatments. Her post: “More Care Does Not Mean Better Care.”
[:-/] Charlie Baker at Let’s Talk Healthcare offers a nice summary of a recent NEJM article about how to cut healthcare costs in the US. See his post: “Partners HealthCare Weighs In On Health Care Costs.”
[:-/] Kevin Pho at KevinMD has a series of posts called “My Take.” This one on legitimate malpractice lawsuits and anti-aging is very interesting.
Kerri Morrone at Six Until Me raises her voice for Type 1 Diabetes awareness. Her post: “My Raised Voice.”
[{] Ian Furst from Wait Time and Delayed Care wonders if visual cues could be developed to reduce patient wait times. His post is called, “Clutter of the Brain.”
And finally, an anonymous medical student at a blog called From Medskool argues that there is no primary care shortage, that incomes are fine, and that PCPs won’t abandon Medicare. Anyone wish to debate this with him? His post: “Four Myths of the Primary Care Crisis.”
***
And here’s a special message from next week’s Grand Rounds hostess, Jan Gurley:
Grand Rounds in medicine often means a morgue-cold auditorium, a sea of starched white coats, and staccato squeaks from irritable chairs. Doc Gurley is hosting April 29th’s Grand Rounds of the medical blogosphere with a more WWF-type approach: Grand Rounds Smack Down Week. Do you want to take on a behemoth topic with some chest-beating frenzy? Or just climb into the Internet ring wearing your most outrageous verbal-costume? Here’s your chance to go for it.
Thanks to all who sent me submissions, and many thanks to Nick Genes our fearless leader. Let me know how this Grand Rounds made you FEEL!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 13th, 2008 by Dr. Val Jones in True Stories
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I received a panicked call from my younger sister today. She is the mother of one-year-old identical twin girls, born slightly prematurely. During her pregnancy she had a problem with twin-twin transfusion syndrome and had to lie on one side for many weeks to ensure that both girls received an adequate blood supply. She delivered by Cesarean section and fortunately both girls have been doing well. That is, until a few hours ago.
My sister described an episode in which her daughter was in the bathtub and suddenly had one of her pupils become very large. It remained dilated for several minutes, which caused her to call her husband in to take a look. He confirmed that the eye was dilated and they decided to call me right away because they’d heard that a dilated pupil might have something to do with concussions or head injuries, though the little girl had not had any recent trauma to her head.
I tried to get a full history from them – they said she was acting “totally normally” – the usual peeing, pooping, eating checks were fine. They said she was sleeping well, not vomiting or lethargic, and that her pupil had now (after several minutes) returned to normal size. They said her fontanel was not bulging, and when I asked them to shine a light in her eyes they both constricted immediately.
My sister asked me, “what could this be?”
Ugh. I’m not a pediatrician, nor an ophthalmologist, but I do know that asymmetric pupils are usually an ominous sign. All I could think of was “space occupying lesion” but I didn’t want to scare my sister unnecessarily. All the other history sounded so reassuring (the child was well, with no apparent behavior changes, the eye had returned to normal, etc.) that I had to say that they should get in touch with the pediatrician on-call.
And here’s where things got confusing. My mother called me by coincidence just after I hung up the phone with my sister. She had been visiting with the babies for a full week, and slept next to their cribs during their vacation. I told my mom about the pupil issue, and she started relaying some potential “symptoms” that she had witnessed over the past week or so. She claimed that the baby had indeed vomited recently, that her behavior was different than her twin (more irritable and emotionally labile) and that her sleep patterns were also disrupted.
Now I was more concerned – was this early hydrocephalus or maybe even brain cancer? Would I be responsible for missing a diagnosis? I was thousands of miles away from the infants and trying to piece together a story from historians with different observations. So I called some pediatrician friends of mine and asked what they made of this. One said – “anisocoria is a concerning symptom in an infant, she needs a CT or MRI to rule out a tumor pressing on her eye nerve. She should go to the ER immediately.” The other said that since there were no other current symptoms, and the eye was back to normal, it should be worked up by an ophthalmologist as an outpatient.
What a bind to be in – I have some witnesses describing very concerning symptoms, others suggesting that everything’s fine except for a fleeting period of pupil size mis-match. I have dear friends suggesting everything from an immediate ER visit with sedation of the child and a head CT or MRI to watchful waiting and distant outpatient follow up. And I have my sister relying on my judgment (as a non-pediatrician) to tell her what to do.
Here’s what I did – I got my sister and her husband on the phone and explained to them that I take their observation of pupillary dilatation very seriously. I explained that this is not a normal event, and should be followed up by an expert to make sure that there’s no underlying cause of the eye symptoms. I also said that the fact that the baby is acting normally and the eye is no longer dilated are reassuring observations. I told them that they should keep a close eye on the infant, and that if they see any hint of recurrence of the pupil problem, or anything out of the ordinary like vomiting, inconsolability, lethargy, swollen fontanel, fever, or strange body movements or seizures, they should go to the ER immediately. In the meantime they should alert the doctor on-call to the situation and discuss everything with their pediatrician during her next available office hours.
I hope that was the right approach. I will not rest easily until the baby has been fully examined by an expert. Being a doctor carries with it a lot of anxiety and personal responsibility – at any time of the day or night your peace of mind can be uprooted by an abnormal finding relayed to you by friend, family, or patient. And if anything goes wrong – or if interventions are not achieved at an optimal speed and accuracy, this question will forever plague you: “Should I have done something differently?”
Who knew that my relaxing Sunday afternoon would be turned upside down by a dilated pupil?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 28th, 2008 by Dr. Val Jones in Expert Interviews
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Tanning salons are a $2 billion dollar industry in the U.S., and their bottom line has been damaged by the medical community’s warnings about the link between UV (ultraviolet) exposure and skin cancer. Recent studies have found that some Americans may have too little Vitamin D in their diets, and since the body can synthesize this vitamin when exposed to sunlight, the tanning industry is campaigning for the potential health benefits of UV exposure. Vitamin D helps to keep bones strong, and may provide protection from osteoporosis, hypertension, cancer, and several autoimmune diseases.
Now, in the interest of full disclosure – I did use tanning salons in my late teens and early 20’s. I knew it could be harmful, but (like a moth to a flame?) couldn’t resist the sweet lure of changing my “glow in the dark” skin to a light shade of cream (no melanin is no melanin, friends). So, I was more than curious to get an insider perspective on the tanning industry vs. medical professionals battle. I turned to a dermatologist whom I respect immensely: Revolution Health expert, Dr. Stephen Stone. I asked him the following questions:
1. Does exposure to ultraviolet light have health benefits?
Other than for treatment of disease (psoriasis for one, atopic eczema, cutaneous T-cell lymphoma, for example), the only known benefit is the production of Vitamin D in the skin – and adequate vitamin D can be obtained from food and supplements without the danger of UV exposure – and even in the worst climates, the sun is an adequate source of Vitamin D without resorting to tanning beds.
2. What amount of sun exposure is currently recommended?
There is no “recommended daily allowance” for sun exposure, and 15 – 20 min a day of unprotected sun on the arms (not total body) will allow peak production of vitamin D.
3. Are there alternatives for good health?
UV is not needed at all for “good health.”
4. What evidence is there that exposure to tanning beds increases the risk of skin cancers?
The US dept of HHS and FDA officially classify UV as a “known carcinogen” and there are numerous articles supporting this: Gandini et al., Meta-analysis of risk factors for cutaneous melanoma, European Journal of Cancer, Westerdahl et al., Risk of cutaneous malignant melanoma in relation to use of sunbeds, British Journal of Cancer (2000), Karagas et al., Use of tanning devices and risk of basal and squamous cell cancers, Journal of the NCI (2002).
5. How would you describe that risk?
Significant.
6. What do you think of the recent ad campaign sponsored by the tanning industry?
Same as I think of cigarette ads!
7. What is your take-home message to patients about tanning salons?
If the cancer doesn’t get you, think of the wrinkles! We focus on cancer, because that’s life and death, but no one can deny that the UV causes premature aging and wrinkles.
So there you have it, folks. Indoor and outdoor tanning are both harmful to your skin. Whether or not you get cancer, wrinkles are a sure result of excessive exposure to UV radiation (with a little help from our friend, gravity). So I’m going to keep up with my sunscreen (see Dr. Benabio’s blog post), get a skin check annually, and accept myself as the tanless wonder that I am. Or maybe I should create a pale people support group? Any joiners?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
