News You Can Use AAOM December 2013 Online Journal DL Harshfield MD MS Director of Integrative Imaging College of Integrative Medicine- coimed.org Little Rock, Arkansas
More Than a Billion People Taking Statins?: Potential Implications of the New Cardiovascular Guidelines The American College of Cardiology/American Heart Association (ACC/AHA) guidelines on assessment of cardiovascular risk1 and on treatment of blood cholesterol, which included recommendations for primary prevention with statins,2 came under intense criticism immediately with their release. Main concerns focused on flawed methods (problems with the risk calculation),3 ethics (conflicts of interest),4 and inferences (too many people offered treatment). With potentially more than 1 billion people caught in the statin dilemma, there should be hundreds of thousands of interested participants for such trials. With expanded target populations and more affordable generic prices, the cumulative global sales of statins may approach $1 trillion by 2020. Lipitor sales alone exceeded $120 billion between 1996 and 2011.
More Than a Billion People Taking Statins?: Potential Implications of the New Cardiovascular Guidelines New recommendations on hypertension management in older people released. • The New York Times (12/19, A23, Kolata, Subscription Publication) reports that “new guidelines suggest that people over 60 can have a higher blood pressure than previously recommended before starting treatment to lower it.” The guidelines committee, “composed of 17 academics, was tasked with updating guidelines last re-examined a decade ago.” The recommendations were “published online on Wednesday in The Journal of the American Medical Association.” • The AP (12/19) reports that “the panel completed its work earlier this year, around the same time that the National Heart, Lung and Blood Institute announced that it was getting out of the guidelines business and turning the job over to the American Heart Association and American College of Cardiology.” • The Wall Street Journal (12/19, A2, Winslow, Subscription Publication) points out that neither the American College of Cardiology nor the American Heart Association vetted the document, nor did the NHLBI. • The Los Angeles Times (12/19, Kaplan) “Science Times” blog reports that “rather than aim for a target blood pressure of 140/90 mm Hg, the target will be relaxed slightly to 150/90 mm Hg, according to” the “new guidelines.” The guidelines’ authors “emphasized that they were not changing the definition of high blood pressure.” Instead, “they are recognizing that data from randomized clinical trials do not show that using drugs to nudge down systolic blood pressure from 150 to 140 provides any health benefit.” • Bloomberg News (12/19, Cortez) reports that individuals aged “60 and older were focused on in the guidelines because they ‘are a unique population and we are concerned about the number of medications that may be required,’ said Paul James, the lead author of the article.” • According to the Boston Globe (12/19, Kotz), “a number of cardiologists...complained that the new guideline was not issued by any major medical group or government entity.” • Harlan Krumholz, MD, discusses the guidelines in the New York Times (12/19) “Well” blog. Also covering the story are CNN (12/19, Willingham), MedPage Today (12/19, Neale), and HealthDay (12/19, Thompson).
Population Medicine ESC/ESH Blood Pressure Guidelines • Currently we have European Society of Cardiology/European Society of Hypertension guidelines stating that blood pressure should be less than 140 mm/Hg for all. • Now, if you go through the guidelines it talks about how those over 80 years...are exempt, but why do we have to have this "for-all" approach? • That is just not working, it's not right; it's basically the structure of guidelines that doesn't respect the individuality of what's unique about us biologically, physiologically, and anatomically -- our environment, everything.
Population Medicine Demand for Specialists Will Outpace Primary Care by 2025 • The demand for adult primary care services will grow by 14% in the next 12 years, according to a study published online November 4 in Health Affairs. • However, with an aging population and expanded medical coverage, demand will grow even more markedly for specialized services. http://content.healthaffairs.org/content/32/11/2013.abstract
Population Medicine To estimate future demand, the investigators took into account numerous factors, including: • In just 12 years, the US population will have increased by 9.5%, and the population aged 65 years and older will grow by 45%, according to US Census Bureau projections. • The population with Parkinson's disease is projected to increase by 68% between 2010 and 2030. • By 2025, the elderly population with Alzheimer's disease is expected to increase 40%, according to the Alzheimer's Association. • The National Cancer Institute projects 18.1 million more cancer survivors by 2020 (up 30% from 2010). • The proportion of elderly Americans with chronic disease rose from 86.9% in 1998 to 92.2% in 2008. http://content.healthaffairs.org/content/32/11/2013.abstract
Population Medicine Oprafication of Medicine • Another part of the story that seems to have had a big impact in the United States is the Oprah effect of creating monsters. • There are 3 physicians that she brought to the forefront: • Mehmet Oz, • Andrew Weil, and • Deepak Chopra. • And it seems like all 3 of them had a big amplification of their impact -- if not even the beginning of their stardom -- with Oprah.
Population Medicine Oprafication of Medicine What Oz and Chopra and Weil all have in common is this notion of medicine as a guru, sort of, "Listen to me." And medicine is not that. Science is viewed by some as distant, technological, and cold. If you remember the TV show Star Trek, but there was the doctor on that show -- Bones McCoy. He would take this scanning device, and he would scan up and down, look on that device, and that was the diagnosis. It was immutable. It was clear. There wasn't any question about it, and that is just not medicine. What people like Oprah, and like Oz, Chopra, and Weil, do is imbue their medicine with a kind of spirituality. It becomes a matter of them and their personality rather than the data, which is always a little dangerous.
Population Medicine People will say you can't trust science because, for example, one study will show one thing, and then that study will be shown to be incorrect. But that that is good: That means that science is self-correcting. We can take a textbook and throw it over our shoulder without a backward glance as we get more and more information, but to some people that mutability and fluidity is viewed as disconcerting. They want something that is surer, and these people provide that in their books. You look at Andrew Weil's books. He tells you how to be a friend, he tells you how to make low-fat salad dressing, he tells you how to live your life -- and that is attractive.
Population Medicine Alternative Medicine and Celebrities Siddhartha Mukherjee is a Rhodes Scholar wrote a wonderful book on cancer, The Emperor of All Maladies . He trained at Cambridge and then Harvard. He has an expertise and experience in cancer. He wrote a Pulitzer Prize-winning book that really explained cancer for the general public. And yet he is not the person the media go to when they are trying to explain cancer; it is Suzanne Somers. And who is she? She was Chrissy on Three's Company. She was the promoter of the ThighMaster. That is what recommends her to the population as an expert in cancer, but it has always been true. I don't see that changing.
Population Medicine • The paper in the New England Journal of Medicine on a big Italian study that showed that fish oil didn't do anything for preventing heart disease. • And there were recent studies that showed that at least the antioxidant part of omega-3 fatty acids actually could increase your risk for such things as cancer. /viewarticle/803823 /viewarticle/808139
Population Medicine 'Our' Brains on Coffee • The New York Times, June 6, 2013: "This Is Your Brain on Coffee" -- why drinking 3 cups a day may be good for us. • Well, does that take into account that at least 20% of people carry an allele where the metabolism of caffeine is markedly reduced, and that risk allele has indeed been linked to a higher risk of heart attack? • Why should there be a recommendation now that all of us should be drinking 3 cups of coffee a day?
Population Medicine Salt Guidelines • Then in May of this year there was a big Institute of Medicine report regarding what should be the salt guidelines. • And this got all sorts of organizations rankled -- the American Heart Association [for instance] -- about what should be the salt recommendations for everyone. • This is crazy stuff, because we know that there are some people who are remarkably salt-sensitive and will have a blood-pressure response to a salt load, and then there are many others who are what essentially appears to be salt-resistant, as they can have as much salt in their diet as possible and it's not going to have an effect on their blood pressure.
Population Medicine The Confusion Over Vitamin D There is a lot of confusion about what should be a population level of vitamin D that is good for people. Suddenly we are all vitamin D deficient, and the level has changed and now the normal range has been revised so that everybody seems to be vitamin D deficient. Certainly, vitamin D is of value for the child who is exclusively breastfed. The mother doesn't get outside very much. The child doesn't get outside very much. Absolutely, vitamin D is of value there. Otherwise, regarding bone thinning -- the use of vitamin D plus calcium – the data just aren't clear and are certainly not compelling, 10 years from now we are going to look back and ask, "What is this vitamin D craze?" and be past it.
Population Medicine The antiaging industry • $6 billion-a-year industry • The notion that we can in some ways turn back the clock has been something that has been attractive to us ever since the days of Ponce de Leon. • We are always looking for the fountain of youth, and we do live longer than we used to, but the reason that we live longer than we used to has everything to do with the way that we live and nothing to do with the way that we age.
Population Medicine The antiaging industry • We have had vaccines. • We exercise more. • We are more careful about our diet, about eating more fruits and vegetables. • We try to avoid stress. • All of that has contributed to our living longer, and this entire antiaging industry has really contributed nothing to why we live longer.
Population Medicine Dietary Supplement industry $34 billion-a-year industry. 54,000 dietary supplements on the market. The problem with the industry is that it is unregulated. The Cartel of vitamin supplement companies came together in Santa Barbara and put out a big campaign with Mel Gibson [featured in commercials]. Senator Orrin Hatch (R, Utah) [and his role in the Dietary Supplement Health and Education Act of 1994 (DSHEA). The politics and the background that has prevented the US Food and Drug Administration (FDA) from having oversight of this enormous area of health and medicine.
Population Medicine Dietary Supplement industry a lot of people making a lot of money, including big pharmaceutical companies. Pfizer bought Alacer recently, which is probably the biggest maker of megavitamins in the United States. Hoffmann-La Roche has been a player in the megavitamin and supplement game since the 1930s.
Population Medicine Dangerous Side Effects of Little Consequence Now there are more than 20 studies to show that if you take large quantities of vitamin A or vitamin E or beta-carotene, which is a vitamin A precursor, you actually increase your risk for cancer and increase your risk for heart disease.
Population Medicine Meditation and the Placebo Response The placebo response and the physiology of the placebo response is physiologically based. We need a word that is different from "placebo," because when people hear that word, they think it is dismissive -- that it is just all in their heads.
Population Medicine Theranos Wellness Centers Rebooting of laboratory medicine, and if there ever was a portion of medicine that probably needed creative destruction, this was it Wellness centers are next to the pharmacy inside of these retail locations. There is a tremendous amount of knowledge in the pharmacist, and so we have trained and certified phlebotomists or other appropriately state-certified personnel. But we are also leveraging the expertise of the pharmacist in being able to provide a care framework for the patients who come in to do their tests. And that is something that we think is a wonderful application of the talent that exists in these pharmacies with respect to being able to have that level of oversight and care.
Population Medicine Theranos Wellness Centers We can take a tiny sample and do not need dedicated tubes of blood for each type of test that we run. We can, on a given ‘painless’ finger stick sample, automatically run to other assay methodologies that traditionally would require a separate draw, which means that if something is out of range, we can, on the same sample, run tests that a physician would like to have ordered to better figure out why it's out of range. For example, in the morning a patient could come to a wellness center and we could draw a sample. The physician could say on their requisition that if this is out of range, automatically run this other test. And that afternoon, when the physician sees the patient, they have all of that information
Population Medicine 23andMe • At this time, we have suspended our health-related genetic tests to comply with the U.S. Food and Drug Administration’s directive to discontinue new consumer access during our regulatory review process. • Current 23andMe customers who received health-related results prior to November 22, 2013 will continue to have access to that information. However, no new health-related updates will be provided to your account. • Customers who purchased kits before November 22, 2013 will still receive health-related results. • We are continuing to provide you with both ancestry-related genetic tests and raw genetic data, without 23andMe’s interpretation.
Population Medicine The Out-of-Hospital Experience • The structural icons of medicine are undergoing reassessment. What do we do with hospitals and clinics in a digital medicine world. • We should start delivering healthcare "farther and farther" from the hospital setting and "even out of doctors' offices.“ • Over 70% of patients would prefer a virtual rather than a physical office visit. • A large Intel poll of 12,000 consumers found that most believe that hospitals as we know them today will be "obsolete in the near future."
Population Medicine Tracking the Human Body The FDA approval of smartphone ECGs and digitized pills heralded the beginning of many more novel digital ways that we will be tracking patients in the future. A watch that passively and continuously captures blood pressure from every heartbeat is just around the corner. We don't even know what "normal" blood pressure is when it can be assessed 24/7, throughout the night, and during any time of stress, and this is representative of what the era of wireless sensor tracking will bring.
Detecting objects as small as protein molecules using multispectral imaging “Raman scattering provides information on the ways molecules vibrate, which is equivalent to taking their fingerprint. It’s a bit like a bar code,” said Martel. “Raman signals are specific for each molecule and thus useful in identifying these molecules.” A nanoprobe, consisting of a dye encapsulated in a carbon nanotube (credit: Universite de Montreal)
New Insights into the Dementia Epidemic • Described in the early 1980s as “The Silent Epidemic,” dementia in the elderly will soon become a clarion call for public health experts worldwide.
The Sunshine Act A provision of the Affordable Care Act (ACA) seeks to expose financial dealing between industry and physicians and discourage conflicts of interest for the latter.
The world will always be governed by self-interest: we should not try to stop this: we should try and make the self-interest of cads a little more coincident with that of decent people. --Samuel Butler
Will disruptive innovations cure health care? Harvard Business School, Boston, USA.It's no secret that health care delivery is convoluted, expensive, and often deeply dissatisfying to consumers. But what is less obvious is that a way out of this crisis exists. Simpler alternatives to expensive care are already here--everything from $5 eyeglasses that people can use to correct their own vision to angioplasty instead of open-heart surgery. Just as the PC replaced the mainframe and the telephone replaced the telegraph operator, disruptive innovations are changing the landscape of health care. Nurse practitioners, general practitioners, and even patients can do things in less-expensive, decentralized settings that could once be performed only by expensive specialists in centralized, inconvenient locations. But established institutions--teaching hospitals, medical schools, insurance companies, and managed care facilities--are fighting these innovations tooth and nail. Instead of embracing change, they're turning the thumbscrews on their old processes--laying off workers, delaying payments, merging, and adding layers of overhead workers. Not only is this at the root of consumer dissatisfaction with the present system, it sows the seeds of its own destruction. The history of disruptive innovations tells us that incumbent institutions will be replaced with ones whose business models are appropriate to the new technologies and markets. Instead of working to preserve the existing systems, regulators, physicians, and pharmaceutical companies need to ask how they can enable more disruptive innovations to emerge.If the natural process of disruption is allowed to proceed, the result will be higher quality, lower cost, more convenient health care for everyone.