MORE SUPPORT FOR A HEALTHY LIFESTYLE (DID WE NEED ANY?)

A VIEW FROM THE OFFI CE

MORE SUPPORT FOR A HEALTHY LIFESTYLE

(DID WE NEED ANY?)

 

 

LIFESTYLE RISK FACTORS PREDICT DISABILITY AND DEATH IN HEALTHY AGING ADULTS [THE 15TH MAJOR LIFESTYLE STUDY]: For the development of my "Formula for Health" I had collected 13 major observational studies and 1 RCT to support the synthesis of lifestyle essentials into just 5 lifestyle factors. These were cited in my Editorial in American Family Physician in 2010. Now it is time to add a new observational study to the list.(1)

        "[The] [p]ositive health effects of maintenance of normal weight, routine exercise, and nonsmoking are known for the short and intermediate term." These investigators studied the effects of these risk factors into advanced age. They collected data from 2,327 college alumnae aged 60 years of more who were followed annually (1986-2005) by questionnaires addressing health risk factors, history, and Health Assessment Questionnaire disability. Mortality data were ascertained from the National Death Index. Low-, medium-, and high-risk groups were created on the basis of the number (0, 1, > 2) of health risk factors (overweight, smoking, inactivity) at baseline. The medium- and high-risk groups had higher disability than the low-risk group throughout the study (P , 0.001). Low-risk subjects had onset of moderate disability delayed 8.3 years compared with high-risk subjects. Mortality rates were higher in the high-risk group (384 vs 247 per 10,000 person-years). The authors conclude: "Seniors with fewer behavioral risk factors during middle age have lower disability and improved survival. These data document that the associations of lifestyle risk factors on health continue into the ninth decade."

COMMENT: We already knew this, at least for elderly Europeans (aged 70-95 years) from the HALE Study which looked at 4 factors (not smoking, Mediterranean diet, exercise, and some consumption of alcohol. The benefits observed in the HALE study were truly dramatic-- 61-64% reductions in coronary and peripheral vascular mortality, 36% reductions in cancer (of all causes), and a 60% reduction in all-cause mortality. [It's OK to gasp.]

        So how much more data will it take before something like the "Formula for Health" becomes the cornerstone of all primary care--from cradle to grave? (Of course, it is NOT a data problem. Those who could be persuaded by data WERE persuaded a long time ago. For the rest, the data are irrelevant. It will probably take until ALL of the MONEY runs out to pay for procedures, tests, and medications before we give primary prevention a chance.

REVIEWING THE "FORMULA FOR HEALTH": DOES ADVICE TO EXERCISE WORK?  Of course, it does, but it's hard to prove. For this reason the USPSTF has dismissed physician counseling for exercise to the trash bin of "insufficient evidence," which I have always considered unfair. "The USPSTF found insufficient evidence to determine whether counseling patients in primary care settings to promote physical activity leads to sustained increases in physical activity among adult patients. Controlled trials of physical activity counseling in adult primary care patients were of variable quality and had mixed results. There were no completed trials with children or adolescents that compared counseling with usual care practices." [Not updated since 2002]  While we have to make concessions to the fact that the studies are few, small, often uncontrolled, and generally use suspicious "self-reported" amounts of exercise as outcomes, the remarkable thing is that a few minutes of physician or practice time, whether face-to-face or by phone or by class, makes a difference; the trend among studies is phenomenal. And, all of the lifestyle studies with their more global perspective identify exercise as a key component of a healthy lifestyle that is associated with the dramatic improvements in outcomes as mentioned above.

        The British are far more pragmatic and ultimately more fair, and with good reason. The BMJ has just published a systematic review of physical activity promotion based in primary care and found that it significantly increases physical activity levels at 12 months.(2) A prior meta-analysis of cohort studies found that self reported achievement of the official UK exercise goal (150 minutes of moderate intensity activity each week) was associated with a 19% reduction in the rate of all cause mortality, compared with sedentary behavior.(3) In the UK only 39% of men and 29% of women achieve this goal (2008).  A Cochrane review of interventions to promote physical activity in community dwelling adults showed a moderate effect on self reported physical activity and cardiorespiratory fitness at a minimum of 6 months of follow-up.  In addition, similar brief interventions have previously been shown to reduce smoking and alcohol use. One of the major problems with previous studies on exercise are that reviews included non-randomized trials and trials with short follow-up duration. Since the USPSTF recommendation (2002), however, there have been several large trials of physical activity promotion based in primary care with outcomes data after at least 12 months. It is time to take a fresh look. [Shame on you, USPSTF!]

        These investigators found a total of 15 relevant randomized controlled trials with 8745 subjects. Most interventions took place in primary care, included health professionals in delivery, and involved advice or counseling given fact to face or by phone (or both) on multiple occasions. In the 13 trials presenting self-reported physical activity, there were small to medium positive intervention effects as 12 months (OR, 1.42). The number-needed-to treat for one additional sedentary adult to meet internationally recommended levels of activity as only 12 (7-33). These are very positive results.

        Here are some other noteworthy aspects of the data to consider:

1. The authors could find no unpublished studies on brief interventions to promote exercise. Funnel plots of their pooled data did not suggest any publication bias.
2. A planned subgroup analysis showed significantly larger intervention effects on self reported activity in studies where control participants received no intervention than where they received a lesser comparator intervention. This analysis suggests that the observed positive effect on exercise levels may be underestimated as it appears that the comparator interventions themselves had positive effects. "The additional percentage of participants who reported meeting international activity recommendations at 12 months, compared with baseline, was 11-47% in participants allocated to receive an intervention, and 8-47% in those allocated to receive a comparator intervention. The corresponding range for those allocated to receive no intervention was from -2% to +19%. These findings suggest that briefer interventions, as used in the comparator groups, might achieve effects that are similar to those of more intensive interventions." 
3. Only one study reported an objective measure of physical activity level as an outcome, and in this study it was not significantly different. The authors call for more studies with an objective measure of outcome.
4. Only one study found a significant intervention effect on adverse events, reporting a relative 11% increase in falls and a 6% increase in injuries among intervention participants.
5. Since follow-up was limited to only 12 months in most trials, the effect of the exercise intervention of diabetes, cardiovascular events, or mortality could not be assessed.   

COMMENT: The USPSTF has been way too timid. They are missing the forest for the trees. Promoting exercise should be consider one of the absolute core activities of primary care practice. It's not. The USPSTF could be helping. It is not.

WALKING TO SAVE YOUR MIND: The Japanese have conducted a trial to evaluate the efficacy of a municipality-led walking program under the Japanese public Long-Term Care Insurance Act to prevent mental decline.(4) These data are from the program in the city of Takasaki. One hundred fifty community members aged 72.0 =/- 4 were randomly divided into intervention and control groups. A walking program was conducted once a week for 90 minutes for 3 months. The program encouraged participants to walk on a regular basis and to increase their steps per day gradually. The intervention was conducted in small groups of approximately six in order to obtain possible benefits in both exercise and social interaction. Cognitive function was measured using 9 tests in 5 domains: memory, executive function, word fluency, visuospatial abilities, and sustained attention. Quality of life, depressive state, functional capacity, range of activities, and social network were also assessed as well as motor function. There were significant differences between the intervention and control group in word fluency related to frontal lobe function (P=0.01), quality of life (P=0.002), functional capacity including social interaction (P < 0.001), and motor function (Timed Up and Go Test; P=0.002). COMMENT: As opposed to the "do nothing" attitude of the USPSTF, this is the kind of program we should be starting in our practices. Get every staff member (including a stint for yourself!) to lead a group at different hours during the day. I had a resident a few years ago (my esteemed Chief Resident at Santa Rosa, Dr. Serena Brewer, Touro graduate) who designed a project to do just this in a residency clinic setting. It would even reimburse well (if a provider spent some face-to-face time with each patient). You know what doomed it in this setting? The supporting hospital's fears of potential legal liability in the case that a patient might slip and fall. Sigh. We have to do better than this.

HOW OFTEN SHOULD I EXERCISE, DOC? The answer from Joseph Alpert, MD [Editor-in-Chief of American Journal of Medicine] is "Only on the days you eat."(8) His full answer is: "Our DNA heritage with its highly complex biochemical and physicological processes is appropriate to a very active lifestyle, not a modern 21st centruy couch potato, fast-food existence. Consdequently, we should make every effort to include elements that resemble the Paleolithic lifestyle [of our ancestors] in our modern daily existence. My lifestyle includes daily exercise, lots of fruits and vegetables in the diet, and avoidance of heavily engineered snack food. Of course, I also do not smoke tobacco nor do I consume large quantities of alcohol. I recommend these liefstyle elements to all my patients. When friends or family ask, 'How often should I exercise?' my answer is always 'Only on the days you eat.' That seems to get the message across." COMMENT: It's a shame that he didn't mention relaxation or stress reduction. But perhaps that is not an option for the Editor in Chief of American Journal of Medicine. 

ANOTHER ASIAN STUDY: AS LITTLE AS 15 MINUTES OF EXERCISE EACH DAY MAY PROLONG LIFE: A prospective cohort study from Taiwan examined the association between physical activity and mortality.(5) In this study, people who did as little as 90 minutes of exercise each week (who would ordinarily be considered physically inactive) were analyzed as a separate group. Around 12.5% (28,311 of 226,493 subjects) of those who exercised at all did so for about 15 minutes of 6 days a week. The study followed up for an average of 8 years more than 400,000 people who underwent regular health check-ups. Compared with people who exercised very little, those who did not exercise at all had a 17% higher risk of dying from any causes, and an 11% higher risk of dying from cancer. Each extra 15 minutes of daily exercise was linked with a 4% reduction in the risk of dying from any cause, and a 1% lower risk of cancer related death. The results held in both sexes, regardless of age, smoking and drinking habits, and overall risk of cardiovascular disease. The authors conclude that, at age 30, men who exercised for 15 minutes each day on average could expect to live 2.6 years longer than their peers who did not exercise at all; women could expect 3.1 years of extra life. Among 30 year olds who met the recommendations for physical activity--30 minutes exercise on 5 days a week--men could expect to live 4.2 years longer and women 3.7 years longer, compared with their physically inactive peers.

1.  Chakravarty EF et al. Lifestyle risk factors predict disability and death in healthy aging adults. Am J Med 2012; 125: 190-197.

2. Orrow G. et al. Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials. BMJ 2012; 344:e1389 doi: 10.1136/bmj.e1389 (March 26, 2012).

3. Woodcock J et al. Non-vigorous physical activity and all-cause mortality: systematic review and meta-analysis of cohort studies. Int J Epidemiol 2011; 40: 121-38.

4. Maki Y et al. Effects of an intervention using a community-based walking program for prevention of mental decline: a randomized controlled trial. J Am Geriatr Soc 2012 Mar; 60(3): 505-10. doi: 10.1111/j.15

5. Wen CP et al. Minimum amount of physical activity for reduced mortality and extended life expectancy: a prospective cohort study. Lancet 2011; 378: 1244-53.

A COCKTAIL FOR LONGEVITY & HEALTH

A VIEW FROM THE OFFICE

DIET & LONGEVITY: A NEW APPROACH

GLASSES UP! A COCKTAIL TO ROUND UP YOUR LIFE:  As you know (perhaps ad nauseam) my approach to maximizing the lifespan (i.e., reducing all-cause mortality) is to follow The Formula for Health: 0 cigarettes, 5 servings of fruits & vegetables a day, 10 minutes of relaxation a day, maintaining a BMI < 30, and getting 150 minutes of exercise each week. Now these researchers have done me one better. They offer a cocktail of 30 ingredients to delay aging and extend the life span.(1) The data are preliminary but very positive (i.e., in mice). The thesis makes perfect sense. We have learned that health is always multifactorial and never attributable to a single factor. The reason that the Okinawans live so long is that there diet has little meat but contains more than 15 different kinds of fruits and vegetables each day. These investigators have further refined the nutrition essentials to go beyond a simple one-a-day multivitamin (which, prior to this I enthusiastically supported).

        This nutrient cocktail was developed by Dr. C. David Rollo and colleagues at the McMaster University in Canada. It was not a simple ad hoc formulation, but was strategically selected to address the five key mechanisms of aging. 

THE 5 KEY MECHANISMS OF AGING

oxidative stress

inflammation

mitochondrial dysfunction

insulin resistance

loss of membrane integrity

  

"No single mechanism alone accounts for any one specific disease process. Instead, all five mechanisms interact with one another to produce both general aging and specific conditions that limit activity, cognitive function, and ultimately lifespan...All animals, from worms to insects to humans, change in very similar fashions as they succumb to the five key mechanisms of aging."  Dr. Rollo and colleagues studied the impact of these nutrients on laboratory mice because of their short normal life span." (A mouse is considered 'old' by age 2 years.) They sought to study measures that would apply equally to mice and humans. They chose to focus on how much the aging animals moved and how their cognitive function changed with time. 

        "As they grow older, all animal species move about less and less each day, spending more and more time at rest or in sleep. Reduced mobility is an excellent marker of aging, because it is closely linked to overall metabolic rate, feeding, fat storage, brain neurotransmitter levels, mitochondrial function, and cardiovascular and skeletal muscle systems...[L]loss of mobility in humans is associated with muscle wasting, bone thinning, and other changes that increase the risk of other negative outcomes such as fractures, pneumonia, and skin infections. Cognitive function also declines with age in all animal populations. Younger animals typically learn faster, requiring fewer repetitions to master a task. They can also bring up important memories faster and more accurately, allowing them to find food, escape threats, and protect other members of their species. Studies show that preserving cognitive function into older ages is associated with longer life spans."

       In the study, the 30-ingredient cocktail was soaked into small pieces of bagel. For the longevity study they used both normal mice and a special strain that demonstrates accelerated aging as a result of excessive sensitivity to all five aging mechanisms. Compared with control animals, the supplemented mice of the accelerated aging strain lived 28% longer. Supplemented normal mice survived 11% longer than controls. For the mobility component of the study the investigators placed the mice in a system of transparent chambers, where they were given food, water, and an exercise wheel; they recorded the amount of time each animal spent moving about the enclosure over a 24-hour period. "Normal, unsupplemented mice showed a progressive decline in activity; by 24 months their mobility was roughly half that of younger normal animals. By 24 months of age, supplemented normal mice were moving roughly three hours more per day than were unsupplemented animals. No other treatment has ever been found that ameliorates declining mobility to this extent."

        Dr. Rollo's group also measured biochemical markers that might explain the difference in mobility. Supplemented older mice had increased activity of the neurotransmitter dopamine (decreased dopamine levels are associated with loss of movement in aging humans and in Parkinson's disease). They also had increased measures of mitochondrial activity, "suggesting that supplemented animals simply had more energy as they aged." Finally, they measured decreased levels of protein corbonyls--altered molecules that reflect the impact of glycation and oxidation on cells and tissues.

        To assess cognitive outcomes they  tested the mice on a water maze that required the animals to find and remember the location of a platform submerged just below the surface of a pool filled with waters. This test is an indicator of both learning skills and memory. They repeated this test each day for 5 days. At first all of the animals had difficulty finding the platform taking an average of 81 seconds. By day 5 young mice had learned and remembered enough to find the platform 43% faster than on day 1. "Older unsupplemented mice, however, showed no significant improvement in the time it took them to find the platform, indicating age-related impairments in learning and memory. But with supplementation, old mice showed a level of learning almost identical to that of young mice; in fact on day 5 they took an average of 46% less time to find the platform than they did on day 1. In other words, supplemented old mice showed the same ability to learn and remember new tasks as did young animals." In the related biochemical observations they noted that brain mitochondrial activity fell steadily with age in the untreated mice, while supplemented animals showed a steady increase in this measure of brain energy supply; mice with higher brain mitochondrial activity proved to be significantly better learners than those with lower mitochondrial activity; and brain weights, which normal decrease with age, were higher in supplemented male mice by 7%, and in females by 11%, compared with brain weights of control animals.

        The editors of Life Extension Magazine (free 3 month trial subscription available at this link:  http://www.lef.org/magazine/mag2012/may2012_Nutrient-Cocktail-Delays-Aging-Extends-Life-Span_01.htm) summarize the article as follows:

1. "Aging is a complex, multifactorial process, but five major mechanisms are now known to account entirely or in part for most human age-related diseases.
2. Dr. Rollo and colleagues have developed and tested successfully in mice a 30-nutrient supplement mixture designed to attack all 5 mechanisms of aging.
3. Tested in mice, the supplement mix extends life span by up to 28% while improving the aging animals' mobility and cognitive function.
4. All 30 ingredients are known to be safe and effective in human beings.If this mixture, or one like it, has similar effectiveness in humans, one could expect an 80-year-old to add nearly 9 years of life with youthful levels of activity and cognition."

Anyone interested?

And, of course, here is the prize. The 30 ingredients of the cocktail are:

TABLE OF NUTRIENT COCKTAIL INGREDIENTS
NUTRIENT	MECHANISM OF AGING AFFECTED
	Oxidant stress	Inflammation	Mitochondrial function	Insulin resistance	membrane integrity
B vitamins (B1, B3 (niacin), B6, B12,and folate.	x		x	x
Vitamin C	x
Vitamin D		x		x
Acetyl-L-carnitine	x		x
Alpha-lipoic acid	x	x	x	x
Aspirin		x
Beta-carotene				x	x
Bioflavonoids	x	x
Chromium picolinate				x
Garlic	x	x	x	x	x
Ginger root extract	x	x	x	x	x
Ginkgo biloba	x
Ginseng	x	x	x	x	x
Green tea extract	x	x		x
L-glutathione	x
Magnesium	x			x
Manganese	x			x
Melatonin	x	x
N-acetyl cysteine	x
Potassium	x			x
Rutin	x	x
Selenium	x	x	x	x	x
Vitamin E	x
Cod liver oil (omega-3)		x			x
Coenzyme Q10	x	x	x
Flax seed oil		x			x

COMMENT:  In my opinion this list makes complete sense. Over the years in my newsletters I have reviewed favorably 28 of the 30 ingredients as having important preventive benefits; the only ones that are new to me are rutin and manganese. The table above suggests particularly potent health benefits from garlic, ginger, selenium, and ginseng. 

        One of the important trends in medicine is the evolution of the 'polypill' principal. The original 'polypill' published by Wald & Law in the British Medical Journal 2004 consisted of a recommendation for universal consumption, starting at age 50, of an aspirin, folic acid, a statin, and 3 antihypertensive agents (regardless of baseline blood pressure) in half their usual starting doses. The imputed benefits were a greater than 80% reduction in heart disease and stroke. Then came the healthy lifestyle literature starting with the Hale Study focusing on a recipe of no smoking, regular exercise, a Mediterranean diet (which contains a lot of the ingredients above), and any intake of alcohol; the reported benefits for these elderly subjects over 10 years were a 60% reduction in mortality over, a 64% reduction in coronary heart disease, a 61% reduction in cardiovascular disease, and a 60% reduction in cancer. On the lifestyle front, I further refined a healthy lifestyle to my "Formula for Health" with the imputed benefits listed below:

This article takes the evolution of this concept yet one more step farther. Expect to see much more of this in the future.

WHAT IS THE BEST WAY TO DISPOSE OF OLD MEDICATIONS?  This is an important and very practical concern. The 'experts' have previously led us to believe that to dispose of medications with minimal damage to health and the environment, they should all be dropped off somewhere (like your local pharmacy) to be incinerated. The exception to this was a previous FDA recommendation that the following medications could be flushed down the toilet:

Abstral, tablets (sublingual)	Fentanyl
Actiq, oral transmucosal lozenge *	Fentanyl Citrate
Avinza, capsules (extended release)	Morphine Sulfate
Daytrana, transdermal patch system	Methylphenidate
Demerol, tablets *	Meperidine Hydrochloride
Demerol, oral solution *	Meperidine Hydrochloride
Diastat/Diastat AcuDial, rectal gel	Diazepam
Dilaudid, tablets *	Hydromorphone Hydrochloride
Dilaudid, oral liquid *	Hydromorphone Hydrochloride
Dolophine Hydrochloride, tablets *	Methadone Hydrochloride
Duragesic, patch (extended release) *	Fentanyl
Embeda, capsules (extended release)	Morphine Sulfate; Naltrexone Hydrochloride
Exalgo, tablets (extended release)	Hydromorphone Hydrochloride
Fentora, tablets (buccal)	Fentanyl Citrate
Kadian, capsules (extended release)	Morphine Sulfate
Methadone Hydrochloride, oral solution *	Methadone Hydrochloride
Methadose, tablets *	Methadone Hydrochloride
Morphine Sulfate, tablets (immediate release) *	Morphine Sulfate
Morphine Sulfate, oral solution *	Morphine Sulfate
MS Contin, tablets (extended release) *	Morphine Sulfate
Nucynta ER, tablets (extended release)	Tapentadol
Onsolis, soluble film (buccal)	Fentanyl Citrate
Opana, tablets (immediate release)	Oxymorphone Hydrochloride
Opana ER, tablets (extended release)	Oxymorphone Hydrochloride
Oramorph SR, tablets (sustained release)	Morphine Sulfate
Oxecta, tablets (immediate release)	Oxycodone Hydrochloride
Oxycodone Hydrochloride, capsules	Oxycodone Hydrochloride
Oxycodone Hydrochloride, oral solution	Oxycodone Hydrochloride
Oxycontin, tablets (extended release) *	Oxycodone Hydrochloride
Percocet, tablets *	Acetaminophen; Oxycodone Hydrochloride
Percodan, tablets *	Aspirin; Oxycodone Hydrochloride
Xyrem, oral solution	Sodium Oxybate

        By this time, fortunately, we have the benefit of a little experience with such guidelines and thoughtful review.(2)  The problem remains that American homes are filled with unused prescription drugs. "Each year we squirrel away 200 million pounds of pharmaceuticals we don't need anymore." Flushing or trashing drugs was the traditional means of disposal for decades, but in recent years take-back programs have been encouraged. The DEA has organized four nationwide take-back events since 2010. The most recent, in late April, collected more than 500,000 pounds of unwanted medications.        Flushing has fallen out of favor for all but a handful of drugs (see above) because of concerns about water contamination. Also we have data from Sweden that participation in take-back programs tends to stagnate at around 40%. New research, however, from the University of Michigan concludes that trashing drugs may be the most environmentally-friendly option. The researchers looked at the overall environmental impact of 3 disposal methods--flushing, trashing, and incineration. They analyzed how much of the drugs would enter the environment, emissions impacts from transportation, water treatment, and burning of waste materials. Their results show that flushing allows the highest levels of drugs to enter the environment by far, and creates more pollution than trashing. Drugs collected by take-back programs are incinerated, which means that none of the medicines themselves enter the environment, but these programs produce much greater emissions of green house gases and other pollutants than either flushing or trashing. This is mostly because consumers have to travel to a drop-off point and then the collected drugs are shipped somewhere else for incineration. The investigators suggest that home disposal is beneficial because we already have an infrastructure for collecting household trash. If our take-back programs are no more efficient than the Swedish programs, then our take-back program produces three times as much pollution while allowing about the same amount of drugs ultimately to reach the environment as home disposal in the trash. COMMENT: This suggestion makes a lot of sense. While the intention of take-back programs was to spare the environment, unless you take a more global perspective, you may be doing more harm than good. I, for one, appreciate being able to put my drugs back in the trash.

REFERENCES:

1.  Life Extension Magazine. May 2012. Nutrient 'Cocktail' Delays Aging and Extends Life Span.

 This article was brought to my attention by reader Phawda Moore.

2. NPR.org/blogs/health. Trash can may be greenest option for unused drugs. accessed 9:53 am, May 18, 2012.

IS PATIENT SATISFACTION A GOOD THING FOR PATIENTS?

A VIEW FROM THE OFFICE

IS PATIENT SATISFACTION A GOOD THING FOR PATIENTS?

     Almost all health care organizations are obsessed by patient satisfaction as an outcome measure. But think about it. Does a satisfied patient necessarily mean that the care was either good or effective? Patient satisfaction is well known to reduce law suits (if they like the doctor they are less likely to sue him/her), but it is also well known that patients who have liked their doctor over time are less likely to sue even if an egregious mistake was made. Patient satisfaction is really just a subjective measure of a brief interaction. It is more sensitive to process problems like long waits, rude staff, doctor in a hurry, etc., which cumulatively can undermine the quality of care. But actually there is very little a patient can discern about whether his/her doctor was right, efficient, or cost-effective in his/her care. So is it enough just to measure the subjective quality of the experience? Do we have to give up on trying to understand anything about the 'quality' of the care?  These questions are worth much further thought. This recent article provides that and comes to a surprising conclusion.(1)

    These authors conducted a prospective cohort study of 51,946 adult respondents to the 2000-2007 national Medical Expenditure Panel Survey. Patient satisfaction was assessed using 5 items from the Consumer Assessment of Health Plans Survey. The positive correlate of patient satisfaction (in the highest quartile group) was a lower odds of any emergency department visit (OR 0.92; 95% CI, 0.84-1.00), which is a good thing. On the other hand, however, this group had higher odds of an inpatient admission (OR 1.12), 8.8% higher total health expenditures, 9.1% higher prescription drug expenses, and higher mortality (OR 1.26, 95% CI, 1.05-1.53).

    These findings are not completely out of line with limited prior research. Among a vulnerable older population, patient satisfaction had no association with the technical quality of geriatric care;(4) other evidence suggests that satisfaction has little or no correlation with Health Plan Employer Data and Information Set (HEDIS) quality metrics.(2,3) [Original References 3, 7, and 8] There are other data to suggest that physicians whose compensation is more strongly linked with patient satisfaction are more likely to deliver discretionary services (e.g. advanced imaging for acute low back pain).(5)

     It is not certain what is going on here. Physicians may be just trying to keep patients happy by ordering tests, medications, and hospitalizations that are not really necessary. On the other hand, sicker patients may develop closer long-term, more satisfied, relationships with physicians who order appropriate tests and services. But the 26% greater mortality in this study strongly suggests that this is not an idle or trivial question to pursue. We don't want to kill our patients with kindness.

   The authors comment: "In the ideal vision of patient-centered care, physicians deliver evidence-based care in accord with the preferences of informed patients, thereby improving satisfaction and health outcomes, while using health resources efficiently. However, patient-centered communication requires longer visits and may be challenging for many physicians to implement...Relaxing patient satisfaction incentives may encourage physician to prioritize the benefits of truthful therapeutic discourse, despite the risks of dissatisfying some patients."

SHOULD ORAL HEALTH BE A PART OF HEALTH CARE?

 

 

 

DOES ORAL HEALTH HAVE A PLACE IN PRIMARY CARE?

 

HOW IMPORTANT IS ORAL HEALTH IN PRIMARY CARE?  This is a primordial gripe of mine--that in the US the people who set up health care have not noticed that oral health (i.e., teeth) are important to health. Existing statistics show that 33% of the entire US population is edentulous by age 60, all of which is easily preventable. This great neglect of oral health starts from the first day of medical school when students are taught how to do physical exams--"Open your mouth. Say "aaahhhh", and then they look at the uvula (an anatomic structure of no clinical significance) and the tonsils (which are irrelevant if the patient is not symptomatic with sore throat). Each and every time one of us does this part of the exam we are looking right past the teeth. Dental health turns out to be very easy to assess. If we hadn't been taught systematically to ignore it, it is something that we would do just because it was obvious.

     Whenever studies have been done to evaluate the most important components of a routine physical exam, the teeth and gums are always in the top 5 high-yield targets, both for pediatrics and adult medicine. (I mean, think of it; most of a comprehensive routine physical exam is pure wasted effort--but NOT the teeth!)  So when was the last time, when you asked the patient to "Open up and say 'aaahhhh'," that you actually noted the status of the teeth and gums. Make an effort. It matters. Only if you catch these problems early can you manage them without dental referral. We, as primary care physicians, are the ones who get the biggest opportunity to see teeth and give instruction and advice that would be accepted.

 

The Secrets of the Oral Health Exam

 

1. Look for holes. Holes are not supposed to be there. Holes are easy to spot. If there is any question whether it is a hole or not, it is not a hole. Big holes are left by missing teeth, which are extremely obvious. Every physical exam should describe the approximate (%) of teeth that are either carious or missing.

 

2. Look at the gums (right up front--your nose is almost bumping into them when you look at the uvula). Health gums should have nice, sharp, steep interdental pink tissue (papillae). The first sign of gum disease is that the tips of these become blunted and the height of the papilla becomes lower as the gums recede. This is a very early sign at a stage where it is still quite correctable with good hygiene. In the more advanced stage the entire gum recedes from the bottom of the exposed part of the teeth and you start to see the roots. Every physical exam of the head and neck should include a description of the height of the interdental papillae and the relative placing of the gum line across the normal neck of the teeth.

 

      People who have either of these findings should receive dental care. But, ay, there's the rub. Most of our patients will not have insurance for dental health. It is not regarded as part of general health coverage. We can get you a gastric bypass surgery but not a simple teeth cleaning. We sit back and wait for this time bomb to go off, and then the patient presents to the emergency room as the only place they can get any care for their acute dental pain. I am amazed at the number of patients I treated for recurrent tooth abscess with antibiotics. They take the antibiotics and a pain medication, but are unable to see a dentist for definitive treatment so they just come back in when it hurts again. And it goes on and on. What we need is a study that shows that good dental care saves general health costs down the road. I have never seen one. If you have, please let me know.

 

     Recently I got an email from a reader, Adam Jason, who has a special interest in this problem. He has prepared an infographic available on the web. I share it with you here by permission. It is a worthy reminder of an important health and primary care issue.

 

  

Emergency Room Dentists:

The High Costs of Life or Death Dental Care (Infographic)

Posted on April 10, 2012 by Jason (Frugal Dad)

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It’s hard to believe but we seem to have forgotten about our teeth. We’ve been looking into the costs of America’s famously straight, white smiles. Instead of facts on cosmetic dentistry, we’ve come up with some troubling statistics on rapidly rising trend: emergency room dental visits. It turns out that dental care is suffering right along with general healthcare.
Our latest graphic explains the costs and causes of this overall decline in preventative care. Dental care is really an investment against future costs, but we can’t blame the uninsured for avoiding costly cleanings and checkups. It’s a costly gamble to forego dental insurance. Routine checkups at the ER will get astronomical fast, not to mention the terrifying costs behind contracting a serious dental disease or injury.
Going along with the infographic, it comes down to reform. Insurance-wise, it seems that dental costs need to be reduced in order for more employers to provide coverage. On an individual scale, it seems a more extensive dental hygiene regimen could really help Americans with or without insurance.

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About Jason (Frugal Dad)

Jason founded FrugalDad.com in 2007, back when being frugal was still unpopular. My Google Profile+

 

 

 

 

 

 

 

   350

parts per million of atmospheric carbon compatible with a familiar, sustainable planet Earth

 

HOW TO SAVE YOUR MIND WHEN ALL ABOUT YOU ARE LOSING THEIRS

A VIEW FROM THE OFFICE

HOW TO SAVE YOUR MIND

     Your mind is a terrible thing to lose, and the fact is that you don't have to. I am often asked, "What can I do to prevent Alzheimer's disease?," and it turns out there is a nice, simple, effective answer, but it takes a lot of work. The answer is exercise. Chapter One of John Medina's book, Brain Rules, makes this point very nicely.

     Research shows that overall the greatest predictor of successful aging was the presence or absence of a sedentary lifestyle. The primary benefit of exercise is to the heart and vascular system, but it also has a very specific benefit for brain function. "When couch potatoes are enrolled in an aerobic exercise program, all kinds of mental abilities begin to come back online. Positive results were observed after as little as four months of activity."

   
     "A lifetime of exercise can result in a sometimes astonishing elevation in cognitive performance, compared with those who are sedentary. Exercisers outperform couch potatoes in tests that measure long-term memory, reasoning, attention, problem-solving, even so-called fluid-intelligence tasks (the ability to reason quickly and think abstractly, improvising off previously learned material in order to solve a new problem).

      But how much activity does it take? The encouraging answer is, "Not much." "If all you do is walk several times a week, your brain will benefit. Even couch potatoes who fidget show increased benefit over those who do not fidget." The effect is so significant that your lifetime risk for general dementia is literally cut in half if you participate in leisure-time physical activity. "Aerobic exercise seems to be the key. With Alzheimer's, the effect is even greater: Such exercise lowers the odds of getting the disease by more than 60 percent." "You have to participate in some form of exercise just twice a week to get the benefit. Bump it up to a 20-minute walk each day, and you can cut your risk of having a stroke...by 57%."

     Exercise is also a powerful treatment for depression as it influences the neurotransmitters serotonin, dopamine, and norepinephrine. "For both depression and anxiety, exercise is beneficial immediately and over the long term. It is equally effective for men and women, and the longer the program is deployed, the greater the effect becomes. It is especially helpful for severe cases and for older people."

     In fact, "the benefits of exercise seem nearly endless because its impact is system-wide, affecting most physiological systems. Exercise makes your muscles and bones stronger, for example, and improves your strength and balance. It helps regulate your appetite, changes your blood lipid profile, reduces your risk for more than a dozen types of cancer, improves the immune system, and buffers against the toxic effects of stress. By enriching your cardiovascular system, exercise decreases your risk for heart disease, stroke, and diabetes. When combined with the intellectual benefits exercise appears to offer, we have in our hands as close to a magic bullet for improving human health as exists in modern medicine."

      How did exercise become so important in the history of the survival of our species. The answer is pretty simple--once upon a time, it was necessary. Our prehistoric ancestors in the homo species (erectus and sapiens) walked about 10 to 20 kilometers a day for men and about half that for women in the pursuit of food. That's 12 miles a day. In addition the species was steadily expanding its range--by about 25 miles per year. Survival required constant motion, quick reflexes, and quick thinking. What's unfortunate is that survival (in good health) still requires that even when it is not obvious.

     If you've drifted away from this healthy habit over the course of your life, don't despair. The Atherosclerosis Risk Factors in Communities Study (ARIC) has shown that even long-term couch potatoes with no healthy habits who convert to not smoking, exercising 20 minutes a day, eating 5 servings of fruits and vegetables a day, and getting their BMI to less than 30, enjoy a 40% reduction in mortality over a period as short as 4 years. It's really amazing that it only takes 4 years of good habits to make up for a lifetime of bad habits. You can do it.

     So, why not take advantage of this simple secret. It's easy to do. Dr. Medina offers two simple suggestions: (1) Wear your gym clothes all day. Eliminate the barrier to exercise that changing clothes imposes. Employers should encourage this. (2) Adapt yourself during your PC time managing email or surfing the web by doing it while on a treadmill. Dr. Medina says it took him only 15 minutes to become fully proficient on the laptop keyboard while walking at a 1.8 mile per hour pace. My additional suggestion is to find a way to capitalize on our preference, nay, need for, regular rituals. Create either four 5-minute ritual walks for your every day routine--walking to the store or post office, exploring a neighborhood park, walking from the parking lot to work or up several flights of stairs, etc., or create two 10-minute rituals. Whatever works for you--it just needs to add up to 20 minutes a day every (or almost every) day. And, either before your walk or right after, consume a fruit or vegetable (a smoothie or a glass of V8 juice), and then relax. Hey, you've got the whole lifestyle challenge beat according to the "Formula for Health", assuming you're not smoking and your weight (read "BMI") is heading down to 30 or below.

     You could even organize a neighborhood outing for 10-15 minutes every day after work. Invite the local kids and their parents to join you for a walk or ride. Making this kind of activity communal is the single best contribution you can make for your community. It will be immensely rewarding.

     And remember, you don't need to get Alzheimer's disease. It is essentially completely preventable.

REFERENCE:

Medina J. Brain Rules: 12 Principles for Surviving and Thriving at Work, Home, and School. Pear Press. 2008.

Brain Rules: 12 Principles for Surviving and Thriving at Work, Home, and School [Paperback]

John Medina (Author)

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NOTE: I will be in Portola this weekend for the Saturday morning clinic. I hope to see you there!