Archive for the 'General Health' category

The Next Step

Sep 29 2014 Published by under General Health

So I have been working with my standing desk for some time now. I have gotten comfortable with upright posture for most of my office duties, so I thought I would up my game and add physical activity.

Turns out an under-the-desk treadmill is $600 minimum. I'm not that ready for commitment. One website showed a standard treadmill that you could detach the handrails from, but I am not up for that sort of project.

StepperInstead, I spent $50 for a stair-stepper. It requires no power source. You can buy them at a variety of price points with various bells and whistles, but I went low-tech here. I have it set on the lowest tension.

It does take some time to get used to the stepping while you do stuff. I usually take calls without stepping, but I am able to write this blog post while I'm working my butt.

Only disadvantage I can see is that I am climbing a staircase to heaven but my Fitbit registers it as steps, not stairs. Oh, well, I'm burning extra calories.

So far I'm pretty happy with this investment. For the first time since I moved to Oklahoma I can easily get inm 10,000 steps without setting foot in the gym.

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Physician, Heal Thyself

Mar 31 2014 Published by under General Health

I had good intentions to blog last week. I had planned to fill out my #nephMadness bracket and blog about my choices. I had reviewed a topic, ready to discuss some medical science.

Then life interfered.

A bit over a week ago things were in their usual state of disarray for a Friday. I sat in my nurses' office, fiddling with the items on their table, including a wrist blood pressure cuff. I put it on and got a reading of 200/165. Yes, this is really high. After multiple readings with a variety of devices, including the gold standard (manual cuff and my nurse with a stethoscope), it became clear that I now have hypertension.

In retrospect, this should not have surprised me. After all, almost everyone in my family has developed high blood pressure at some point. I believe my mother's onset came during peri-menopause, a phase of life I now "enjoy."

I bought a cuff and picked up my first bottle of hydrochlorothiazide on my way home. The first few days got interesting since I had to fly to a meeting; gosh, diuretics do make you pee! By the end of the first week, my urine output was back to its usual amount. Today my blood pressure was 150/90. Not normal, but much improved and still decreasing daily, and all with a once-a-day drug that cost $3.51 for the first 30-day supply.

By the way, I felt completely fine. Even now that my pressure is down, I cannot point to a single symptom that would suggest my BP was high. Hypertension truly is a silent killer. Don't ignore it, and take your medication(s). It's important for your heart, your brain, your kidneys, and your life.

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Upright Update

Jan 24 2014 Published by under General Health, gizmos

After one week, I am pleased to report that I still love my VariDesk. I am still standing for 20 minutes and sitting for 10 when in the office, although occasionally I extend the standing period to 40 minutes. If I am eating lunch at my desk, I may give myself a 20 minute sit until I finish.

I can feel my new posture in the muscles in my back and flanks. Clearly standing engages them much more than sitting. I hope my plank time starts improving.

The other big change is that I have more trouble sitting still. In clinic today, while waiting for a student to finish interviewing a patient, I found myself standing and pacing while I read an article on my iPad. Sitting in that situation just feels wrong somehow.

I will update again after a month or so, but so far, so good. I would definitely buy my VariDesk again!

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A Standing Resolution

Jan 16 2014 Published by under General Health, gizmos

Like many of my readers, I once again resolved to improve my fitness in 2014. I actually did lose a few pounds in late 2013, and the scales remained stable over the holiday. Today I installed my latest device to assist the endeavor: a VariDesk.

Standing position (Click to Enlarge)

Standing position (Click to Enlarge)

This ingenious device provides a stable adjustable surface for your computer monitor and keyboard. When you need or want to sit (like when speaking with others seated in your office) the surface drops to 6 inches above your desktop. The keyboard can sit at a comfortable height just below the work surface on a keyboard area that pulls forward as needed.

When those pesky visitors depart, the return to standing work could not be easier. Two levers just under the work surface allow you to pull the desk up to the appropriate height and lock it in place.

My VariDesk, shown above, is the single monitor configuration. It weighs 41 pounds, and it can hold up to 35 pounds. The device also comes in a larger size for dual monitors that weighs 48 pounds. The single costs $275; the Pro configuration for two monitors runs $300. Both stands come fully assembled. Removing the packing material and setting up the VariDesk takes about 5 minutes.

In addition to the hardware, the company offers an app that lets you set the time you want to sit and stand. It then reminds you to change your position at the appropriate time. You can also enter your weight to estimate the calories you burn while standing.

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Not an eyesore (Click to Enlarge)

A whole parade of folks have toured my office this afternoon to see the VariDesk. I may have started a trend. In this case, that would be a very good thing.

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"The primary is just for check-ups" - Socioeconomic Status and Care Choices

Jul 18 2013 Published by under Access, General Health

In the US, un- and under-insured patients use the emergency department (ED) and inpatient services disproportionately. In part, this occurs because these facilities provide care for all who seek it, regardless of ability to pay. However, even in countries with universal health coverage, low socioeconomic status patients seek care with the same patterns.

Reigning in health expenses in the US includes efforts to shift non-emergency care from the ED and the inpatient ward to the outpatient setting. In the 1990's, many states experimented with Medicaid HMO's, assigning the poor to primary care clinics as part of the effort. Success was limited at best, and we now find those least able to pay seeking care in the most expensive venues.

 A recent study from the University of Pennsylvania explores reasons that those with low socioeconomic status (SES) use more acute care and less primary care than patients with high SES. They invited 64 adult inpatients of low SES based on Zip Codes to participate in structured qualitative interviews; 40 agreed to the study. Of these patients, 12 (Profile A) had 5 or more acute care episodes in the prior 6 months. The remaining 28 individuals (Profile B) had 4 or fewer hospital encounters over the same period. Patients of the two profiles had similar income, sex distribution, and ethnicity. The major difference between the two groups seemed to be the presence of  a social support network for subjects in Profile B.

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Click to Enlarge

The figure shows themes that differed between the two profiles. All patients identified ease of access and quality of care as reasons for choosing hospital-based services. Profile A patients reported more chaotic lives than those with fewer encounters; they experienced more trauma, dysfunction, substance abuse, survival insecurity, and problems with activities of daily living. Profile B patients also experienced barriers, including the need to be caregivers; however, their social networks also provided support as well as this burden. Finally, Profile B patients saw their health issues as concrete problems to be solved, rather than an intangible challenge.

The study provides an important first step in improving care for low SES patients by identifying themes that influence their care choices. Like all qualitative studies, it gives no results with a p value but provides data to generate new hypotheses and policies. The study population was also limited to urban, primarily African American patients; the rural poor we see in Oklahoma may identify different barriers. Further study is clearly needed.

The study is available here; this is the citation:

Kangovi et al. Understanding Why Patients of Low Socioeconomic Status Prefer Hospitals Over Ambulatory Care. Health Affairs 32 (2013): 1196-1203     DOI:  10.1377/hlthaff.2012.0825

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Ethics of Wellness and #247Health

Feb 22 2013 Published by under General Health

Since Science Online, I have been trying to summarize our session on Mobile Health, a discussion that raised more questions than it answered (like all good Science Online sessions). We started out with two major questions:

  1. How can we use smart phones and other mobile technology to improve health management?
  2. How can we harness this flood of data to learn more about health (and disease) without compromising privacy?

A number of ethical concerns came up, including who owns health data once it's logged? Who profits from data? How do we use these tools responsibly for mental health? Finally, how do we improve access if we do find that mobile health improves outcomes?

Yesterday I heard an interesting interview on NPR with Morgan Downey, an advocate for people with obesity and editor of the Downey Obesity Report. He discussed employee wellness programs:

Well, wellness programs come in two varieties: voluntary, participatory programs, where the employer may provide classes on smoking cessation or diet or lifestyle, maybe a membership in a gym - totally voluntary. And the rewards there are usually, you know, a baseball cap or tickets to a movie or a baseball game, or something like that.

The other type of program is a mandatory program where employees take a biometric, it's called - like blood pressure, for hypertension; like body mass index, for obesity - and set a target for what change they want to see. And if the employee meets the target, the employee would receive a benefit, an incentive. But if he or she doesn't, then they could be charged, in effect, up to 30 percent of their health insurance premium.

Click to enlarge

Click to enlarge

Corporate wellness programs are the new frontier and a prime method for generating profits in mobile health. The device I use, the Fitbit, clearly wants this market as shown in the picture. They promise that 88% of employees will take more steps with their tracking device; based on prior experiments with pedometers and other devices, I tend to believe this number. They then note that 69% of participants will improve their health. I have no idea what they mean by this statement. It could be some particular biometric parameter or merely a subjective reporting of health.

Given the number of hours we spend in the workplace, and the US employer-based insurance system, it makes sense that our bosses want us to improve our overall health. It is scary that what we pay for our benefits could depend on our performance in the gym.

Obesity treatment tops the list for most wellness programs. Certainly, excess body fat is associated with (and almost certainly causes) diabetes, cardiovascular disease, stroke, and other major causes of death and disability. Our treatment of obesity is not particularly impressive. A recent review of the medical evidence showed that most diets produced modest weight loss of 4-6 kg (8-13 lbs). All successful programs required calorie restriction of some sort, increased activity, and usually some sort of behavior modification. Most studies included less than 2 years of follow-up, so the long-term results are less clear. Modest weight loss can produce significant health benefits, even if the subject remains overweight. Will that accomplishment be sufficient for a corporate overseer? I have no idea. What if a participant regains the weight? Will there be financial penalties?

Right now I use my FitBit linked with a number of health apps to track my diet and exercise and other goals. I'm taking baby steps to my goals, but I am very glad that my employer is not following my efforts or linking my insurance rates to my success. I have enough to worry about with my job without making my fitness part of my career.

2 responses so far

More on #247Health for #scio13

Jan 21 2013 Published by under General Health

Click to Amazon

As Science Online draws near, I continue to gear up for the session on 24/7 Health. Another book on the topic, Jody Ranck's Connected Health: How Mobile Phones, Cloud and Big Data Will Reinvent Healthcare addresses the gee-whiz, look-what-we-can-do aspects of the topic but also takes a closer look at the limitations. Smart phones and home computers allow us to tract aspects of our health like never before. Doctors have more tools and access to immediate information. We are approaching a time when sequencing individual genomes will be affordable as well as feasible.

But what do we do with these data?

  • A number of twitter colleagues are currently participating in diet and fitness challenges, tracking runs and rides and calories and points. Will they accomplish more than those who have real-life, in-the-flesh work-out buddies?
  • Home appliances can now track heart rate and rhythm continuously. If a patient collects these data, how do I use the information? I have no idea at present.
  • Say a patient pays to have their genome sequenced. At this point in time, we simply do not know what most of it means, even in relation to known medical conditions or drugs. Sure, there have been some pharmacogenetics studies that produced useful information, but these represent a small portion of one individual's genomic made-up.

The revolution will require Big Data Services on many levels. First, only through the use of such analysis will we learn what the data mean. We cannot interpret one patient's genome until we have studied large populations to know what the results mean. We will need access to more than the gene sequences; accurate information about disorders, drug responses, side effects, and everything else we can consider will be needed to produce the brave new world of individualized medicine that we envision for the future.

As we have seen this week, there are risks involved. Even de-identified genetic data can be identified at some level. As Ranck states the problem:

Health care cannot afford the pervasive privacy policy conflicts of Facebook, nor can an overly rigid interpretation of HIPAA stand in the way of consumer sharing of data.

Finally, multiple streams of patient data will have to be crunched into a usable format. One of the chronic disorders that has led the tracking movement is diabetes. Smart phones allow patients to automatically log blood glucose levels and physical activity; integrated diet logs and insulin tracking can give a complete picture of the factors that influence glycemic control. If I am seeing this patient in the office for a quarterly visit, I really do not wish to manually sift through everything. I need a dashboard that can scan the record and point me to the times when something unexpected happened. The diabetes world is moving toward this endpoint; we are still awaiting these advances for other chronic diseases.

I'm looking forward to a spirited discussion of mobile health on Saturday, February 2, at Science Online. See you there, whether in real life or virtuallly.

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Healthier, One Month At a Time

Jan 03 2013 Published by under General Health

FitBit GalleryEvery time I glance at the FitBit App Gallery I find a new aid in my ongoing quest for fitness. I just started using Health Month, a game-based platform for habit change.

It began with a group of friends challenging themselves to improve their health:

Health Month, at least this geneological line of it, started on April 3rd, 2002 whenRick Webb got dumped by his girlfriend and he decided he wanted to lose some weight. In January of 2003 his friend Keith Butters joined in and another friend helped create the official set of rules. Over the next couple years the monthly ritual gained popularity at the Barbarian Group and amongst some friends in New York and Seattle. The draw of the event was more about doing something drastic and dramatic, with friends, as a form of penance for the previous year. Improving long-term health habits wasn’t so much the goal… proving that you could go 30 days without a drink (and justifying a spirit of over-indulgence the rest of the year) sort of was.

In 2008 livejournal community was born. In 2009, a Facebook Group was born. Then the bickering started. Were the rigid all-or-nothing rules of Health Month too black and white? Was it not healthy to eat some meat? Wasn’t yogurt a good kind of dairy? Isn’t dark chocolate supposed to be good for you? Was fat even a bad thing? Without a consensus about what was healthy and what was not, the group that originally started mostly as a self-dare became fragmented with worries about what true health actually was. Even though over 600 people signed up for the Facebook Health Month group in 2009, 2010 was pretty much a dud, and everyone did their own things.

In the meantime, I built an iPhone app related to learning more about how to eat locally called Locavore and a social game called 750 Words that was a private journaling social game of sorts. My brain was a mess of nutritional information and social gaming ideas. After my son, Niko, was born in May of 2010, I gave myself 90 days to either build something new or get a real job.

Health Month was (re-)born.

In its latest incarnation, the players define their health rules from some set lists as shown in this video:

So how do you score points?

After you commit to your rules, you start each month with 10 shiny new life points. The goal is to end the month with at least 1 life point. You lose a life point whenever you don’t stick to one of your rules, but don’t worry if you lose all of your life points — that’s what friends are for! Friends and other players of Health Month have your back when you need to be healed (this is a big part of why Health Month totally rocks compared to other health plans and services). This game is NOT about making you feel guilty. It’s about helping you discover what works for your current lifestyle (do more of that) and what doesn’t (skip it). Also, if you accidentally over-commit yourself and and lose all of your life points (I’ve seen some people go to -100 life points and more! Maybe there should be an award for being ambitious?), it just means you can take it a little easier next month. Life is long. Small improvements will make a bigger impact long term. And, by the way, you can still play the game if you are -100 life points… everything still works as usual.

Of course, those of us with a competitive streak can find friends and strangers with whom to compete. You can share your progress on all the usual sites, and it integrates well with a number of other fitness apps.

Click to Enlarge

Click to Enlarge

The other figure shows my progress so far this month. The yellow lizard notes my degree of difficulty. I have only set 3 rules and I rated them all fairly easy.

Health Month looks like a great way to progressively challenge myself to make small healthy regular changes to my routines. I just upgraded to the premium account (first 6 months for $20.13 instead of $30); if it helps my changes stick, I will renew in July and update here.

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Your Desk Is Killing You

Dec 22 2012 Published by under General Health

Click for website

Click for website

I have written before about integrating a standing desk  into my work routine (latest post here), but there are still tasks that I perform faster and better while seated. A new app that coordinates with my FitBit can help make a desk job healthier. FitBolt places a timer on your computer that alarms every half hour. You are directed to click on an extension to your browser which provides chair stretches, quick exercises, posture tips and other office fitness wisdom. Here's the introductory video:

The exercises  are rated for you on their difficulty and goofiness. The latter is particularly helpful if you have an office door to shut. You can click on the time below the blue arrowhead in the upper right corner which provides a timer for your activity. After you finish, click the arrowhead and the "I'm Done" button. If you have linked your FitBolt account to your FitBit account, any calories you burn in your office will be calculated and added to your daily total.

Sample stretch notice

Sample stretch notice

An account with notifications for stretches and exercises is free, although ads will pop up in some reminders. For $3 per month, you can get the ad-free version that also includes health reminders, posture and ergonomic tips, as well as diet pointers. While many of these points are well-known, the alarms at least get you to change position and remind you to move.

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With a Grain of Salt

The biggest improvements in human health occur with systematic changes. Clean water systems make a huge differences. Wide-spread immunization requirements conquered illnesses.

Success of Back-to-Sleep
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For a more recent example, I present Back-to-Sleep, a recommendation from the American Academy of Pediatrics in 1992. Placing most infants on their backs for sleep seemed to reduce the risk of sudden infant death syndrome (SIDS), also known as crib death. In October, about the time  my son came into the world, they began a blast of public health announcements to put infants on their backs unless your pediatrician instructed otherwise. The risks of positioning infants this way seemed minimal, and the costs negligible. The effects have been impressive, with a 50% reduction in deaths over a decade (see graph).

The message was simple and easily followed. Statistical modeling suggested a major effect from the intervention, and we see it in the data. Unfortunately, preventative measures for other disorders do not meet these criteria.

A recent article examines salt and public health, an area of intense debate.

Ronald Bayer, Daveid Merritt Johns, and Sandro Galea. Salt and Public Health: Contested Science and the Challenge of Evidence-Based Decision Making. Health Affairs 31:2738, 2012 DOI:  10.1377/hlthaff.2012.0554

The authors describe the issue at hand:

 For more than four decades, starting in the late 1960s, a sometimes furious battle has raged among scientists over the extent to which elevated salt consumption has adverse implications for population health and contributes to deaths from stroke and cardiovascular disease.

...

In 2011 two authors involved in the conduct of systematic reviews on salt declared, “It is surprising that many countries have uncritically adopted sodium reduction, which probably is the largest delusion in the history of preventive medicine.”3 Concurrently, a group of scientists long associated with studies on the harmful consequences of salt consumption wrote, “Denial and procrastination about dietary salt reduction will be costly in terms of avoidable illness and costs; it will also be ethically irresponsible.”4

The article discusses the evidence regarding sodium and blood pressure over the past 40 years, including systematic reviews of these data. Weighing both quality and quantity of data, the Cochrane group reported in 2011:

The second 2011 Cochrane report went further. After examining the potential impact of salt reduction on hormones and lipids in people with normal blood pressure, it concluded that the available evidence did not permit a conclusion as to whether low-salt diets improved or worsened health. It was possible, the authors concluded, that further research might be able to detect the beneficial impact of salt reduction, but “after more than 150 RCTs and 13 population studies without an obvious signal in favor of sodium reduction, another position could be to accept that such a signal may not exist.”55(p18)

Click for source

Clearly, many people with hypertension have salt-sensitivity and could benefit from reduced sodium intake; however, we cannot see the benefits when large general populations are examined. Just as clinicians have to make decisions about individual patients despite scientific uncertainty, policy makers must do the same for large groups. Several considerations must be weighed:

  • What are the benefits of reducing salt intake?

Those who have salt-sensitive hypertension have received the most attention in this debate; however, the reduction in blood pressure from sodium restriction alone amounts to only 1-2 mmHg in most people. Other populations might also benefit from global reduction in food salt content. Chronic kidney disease rates are rising as our population ages, and high salt intake complicates treatment of this group. High sodium intake can also induce kidney stones, and may be a major factor in this condition in the US.

  • Are there risks to health of reducing salt intake?

The answer here is about as clear. Some studies have suggested that patients with a number of chronic disorders may not fare as well with severe salt restriction. Just as there are biologically plausible hypotheses for the benefits of salt restriction, the activation of the renin-angiotensin-aldosterone system by low salt intake provides fodder for the other side. As the authors note, "medicine and public health are replete with examples of seemingly sound ideas that had devastating unintended consequences. One hundred percent oxygen for newborns can cause blindness. Extensive use of x-rays for screening purposes is associated with greater risk of cancer. The risk of unintended consequences grows dramatically when interventions are translated to a populationwide scale."

  • What is the cost of reducing salt intake?

The short answer: I have no idea. Salt initially served a preservative function in our food, but we no longer need it for that reason. However, people's palates have grown accustomed to its presence. Try a can of no-salt green beans sometime; they taste wrong, even when salted at the table. Manufacturers could begin cutting salt out of their processes and slowly getting us accustomed to its absence; some have started to do this with a variety of products. However, I have no idea what this change may cost at the factory or in the store.

The authors of the Health Affairs article do not solve this big hairy dilemma for us; they wrote this piece to demonstrate  "the role that judgment and values must play in evidence-informed policy making."

 As Roger Chou, a central figure in the conduct of systematic reviews for the US Preventive Services Task Force, has stated, “The evidence can tell us the likely benefits and likely harms, burdens and costs, but it does not directly tell us how to weigh all of these factors.”60(p10) Policy makers must ask: Are the burdens of public health interventions too great, and for whom? Are the expected benefits sufficient given the potential costs? These are not questions that can be answered in the absence of normative judgments.

As a doctor whose patients must often restrict salt intake, I know it would be in their best interest to systematically reduce salt in foods in the US. I do not know if it would benefit the general population enough to be considered successful on the same level as Back-to-Sleep.

The debate rages on. More data will be published.

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